INTRODUCTION

There are many definitions for counseling. Counselling is the means by which one person helps
another through purposeful conversation. It involves a series of problem solving interviews
It is a process in which two people meet to explore personal problems and to identify solutions.
As far as individual counseling is concerned there are certain common features the same has been
given below:
1. Two people are present
2. The process leads to action on the part of the client
3. Counsellor is a person who listens
4. Client can be trusted to find their own solutions
5. Personal growth of the client usually occurs
6. Resolution of problems is an expectation

Counseling is a dynamic and purposeful relationship between two people, who approach a mutually
defined problem with mutual consideration of each other to the end that the trouble one or less
mature is aided to a self determined of his problem. ( Wress 1962).

There are some essential elements of counseling as mentioned below:

1. Essential Elements of counseling
a. Empathic Relationship
b. Counsellor and Client related well
c. Counsellor sticks closely to client’s problems
d. Client feels free to say what they like
e. An atmosphere of mutual trust and confidence
f. Rapport is essential

TECHNIQUES OF COUNSELING:

a. Ventilation
b. Explanation
c. Reassurance
d. Healthy diversion by physical and mental activities
e. Recreation
f. Improving problem solving skill
g. Change of attitudes/Life style
h. Encourage Healthy Defence mechanisms – sublimation
i. Altruism
j. Humour
i. Reinforcement
j. Getting others’ support

UNWED MOTHERS

Unwed mother is a woman who has become pregnant without legal justification of physical
intimacy between man and women

1
 Factors contributing to unwed pregnancy

 Younger age
 Low Socio-Economic status
 Single or teen parents
 Rape
 Prostitution
 Sexual abuse
 Contraceptive failure
 Lack of knowledge regarding safe sexual practices

The possible scenarios these girls might encounter.

 The girls with difficulties can seek assistance, Promise, support

 Pregnant and subsequently, abortion

 Pregnant, carry to term and raise child with or without financial help or help from father of
child.
 Pregnant, carry to term and eventually give up child for adoption.

Contact Counsellor
.
organisation handles and
through phone advises face to Girl attends counselling and
helpline/ internet face counselling gets referrals to shelters/clinics/
or by visiting to understand hospitals. Counsellor also tries
family service situation to resolve any emotional issues
centers.

Girl evades counselling and

seeks help on her own.

Counsellors try to give

Seeks help from Counsellors assigned referrals for medical or
neighbourhood to assist girls. financial as required.
clinic/polyclinics

2
Consequences of unwed motherhood

 Being an unwed mother, a female has to overcome a number of sociological as well as

psychological difficulties in her life.
 According to a research conducted by a Colombo-based lawyer, “The single women both at
home and at work place have to face many problems from men young and old.
 Furthermore the responsibility of a child born outside marriage rests soley on the mother.
 The lack of support from family relatives, society etc makes her living hard
 Social stigma of being an unwed mother leads some women to attempt to commit suicide
 In Indian culture it is humiliation to the entire family and leads to social isolation for a
longer period of time may develop
 Unwed mother used to treat very badly by the family and society.
 Lacks of support leads financial crisis
 Lacks of appropriate care for mother and child
 Serious health problem, mal nutrition , lack of health checkups
 Leads to serious mental problem also, like depression or postpartum psychosis

Socio – emotional problems of unwed mothers and their children

.
 Social stigma related to unwed pregnancy
 Violence
 Financial burden
 Social isolation
 Anxiety
 Stress
 Low self esteem
 Substance abuse
 Depression
 Post traumatic depression
 Adjustment disorders
 Suicidal tendencies

Counseling of unwed mothers

Objectives
 Identify the psycho social problems faced by the unwed mothers
 Identify the problems acts as a hindrance on the path of their development.
 Identify the emotional problems faced by the children of unwed mothers
 Provide emotional support to unwed mothers and their children
 Identify domestic, work place violence which cause physical and emotional disturbance

3
The counseling service includes

 Assessment of the basic needs like food, water, shelter to unwed mothers etc
 Social needs ( housing , financial needs , education, employment)
 Assessment of the support system
 Existing coping skill techniques
 Assess signs of domestic violence
 Assess signs of anxiety and depression
 Assess the legal support available.

Awareness regarding

 welfare measure and legal help ( NGO’s, welfare schemes and developmental program in
the urban / rural areas)
 safety measures (regarding risks factors like unsafe pregnancy leading to HIV/AIDS, and
sexually transmitted diseases)
 measures to avoid domestic violence( how to protect themselves from crime)
 legal protection, land rights, welfare schemes like short stay homes shelter homes for
destitute available in rural and tribal areas
 rehabilitation for those who are the victims of violence. Eg.physical , sexual
 safer sex practices and knowledge them regarding the risks involved in unprotected sex
 dangers like false promise to marry and associated crime related to this
 women protection acts
 training programs available in community to make unwed mothers economically
independent.
 Community resources, mental health services, and women and child welfare services crisis
cells and rehabilitation services available in the community.

Support system to unwed mother

Support system to unwed mother is more available in western societies than traditional one. For east
few decades the government provides free food, free medical support, jobs to earn income, proper
education facilities to unwed mother child.

Legal rights of unwed mothers

Establish paternity; unwed mother has to right to raise the case in the court to establish paternity
for her child against men who she is expected that he is father of her child .

Support & Custody of child

Once paternity is established, the mother can demand the support from the father to raise her child.
The support can be in the form of money or in some other form

4
Even if paternity is established still has the right to undertake the custody of her child if she wants
it.

PREVENTION

Peer Education ;

 peer education should be implanted to provide education to those who are not able to go to
school
 education regarding sexual and regarding sexual and reproductive health can be provided to
them by forming a group of peers

Sexual Education

 well designed and well implemented sexual and reproductive health education can be
provided to young people , so that they can engage in a safe and responsible sexual behavior
 supply of contraceptives
 method of using contraceptives

Depromoting the prostitution

 prostitution mostly result in unwed mother.

 Banning of the prostitution by law

Role of nurse counsellor

As educator;

 Nurse should play a vital role in providing sex education to youngster to prevent occurrence of
unwed mother.
 Nurse can provide knowledge to youngster about the evil effect of being unwed mother.
 Educational programs for the school children
 Sexual awareness program, contraceptives using methods
 Community education program for the risk group

As an advocate

 The rights of unwed mothers and can protect her from further exploitation.
 She must inform the mother about her the legal rights which are provided by government to
them so that mother can take benefit of them.
 Educate regarding the importance of the health of the mother and child.

As a supporter

 Nurses must provide free services to the mothers which are provided by government
agencies to help them

5
  Problem solving skills and coping skills
 Vocational rehabilitation
 Legal support

As a researcher

 As a researcher, she should conduct research in the best preventive measures to avoid the
occurrence of unwed mothers in the society

COUNSELING FOR END OF LIFE

End of life:
It is the concluding phase of normal lifespan although life can end at any age

Physical changes at end of life:

 Sensory changes: its mainly due to decrease oxygenation and circulatory change. Hearing
& touch: decreased perception of pain, touch & sensation. Taste & smell: Decreases with
disease progression, blurring of vision, blinking reflex absent.
 Integumentary system: cold, clammy skin. Wax like skin due to loss of muscle tone,
cyanosis on nose, nail beds, knees due to decrease oxygenation and circulatory changes.
 Cardiovascular system: pulse rate increases and slows down later& becomes weak, blood-
pressure decreases, elevation in the body temperature due to changes in hypothalamic
function, and delayed absorption of drugs.
 Respiratory system: increased respiratory rate, Cheyne stroke respiration, death rattle
irregular breathing.
 Urinary system: urinary output decreases due to loss of ability to form urine, incontinence
of urine & unable to urinate.
 Gastrointestinal system: slowing of digestive tract, accumulation of gas due to decrease
gastric motility and peristalsis which lead to constipation.
 Musculoskeletal system: gradual loss of ability to move, difficulty in speaking &
swallowing, maintaining body posture, due to weakening of muscular system because of
metabolic changes.
Psychological changes at the end of life:

 A variety of feelings and emotions affect the dying patient and family at the end of life. most
patients and family struggle with a terminal diagnosis and the realization that there is no cure
 Grief: it is a emotional and behavioral changes to loss , it is a positive coping mechanism which
also helps in individual wellbeing

STAGES OF GRIEF

6
 Denial:
Denial is usually only a temporary defense for the individual. This feeling is generally replaced
with heightened awareness of situations and individuals that will be left behind after death.
Example - "I feel fine."; "This can't be happening, not to me."
 Anger:
Once in the second stage, the individual recognizes that denial cannot continue. Because of anger,
the person is very difficult to care for due to misplaced feelings of rage and envy. Any individual
that symbolizes life or energy is subject to projected resentment and jealousy.
Example - "Why me? It's not fair!"; "How can this happen to me?"; "Who is to blame?"

 Bargaining:
The third stage involves the hope that the individual can somehow postpone or delay death.
Usually, the negotiation for an extended life is made with a higher power in exchange for a
reformed lifestyle. Psychologically, the person is saying, "I understand I will die, but if I could just
have more time..."
Example - "Just let me live to see my children graduate."; "I'll do anything for a few more years.";
"I will give my life savings if.

 Depression:

During the fourth stage, the dying person begins to understand the certainty of death. Because of
this, the individual may become silent, refuse visitors and spend much of the time crying and
grieving. This process allows the dying person to disconnect themselves from things of love and
affection. It is not recommended to attempt to cheer an individual up that is in this stage. It is an
important time for grieving that must be processed.

Example - "I'm so sad, why bother with anything?"; "I'm going to die . . . What's the
point?"; "I miss my loved one, why go on?"

 Acceptance:

This final stage comes with peace and understanding of the death that is approaching. Generally, the
person in the fifth stage will want to be left alone. Additionally, feelings and physical pain may be
non-existent. This stage has also been described as the end of the dying struggle.

Example - "It's going to be okay."; "I can't fight it, I may as well prepare for it."

Ethical, legal and communication issues at end of life:

1.Assessing decision making capacity

An assessment of decision making capacity can and should be performed by the primary physician;
determining decision capacity for a specific medical intervention requires neither legal intervention
nor psychiatric expertise.

7
On the other hand, decisions about competence are judicial determinations that involve ruling on
the patient's global decision making ability. Competency determinations are necessary when
evaluating the capacity of a person to make non-medical decisions, such as financial matters.
Patients and families struggle with many decisions during the terminal illness and dying experience.
Many people decide that the outcomes related to their care should be based on their own wishes.

2. Legal documents used in end of life care:

 Advance directives: Advanced care directives are specific instructions, prepared in advance,
intended to direct a person's medical care in the event that he/she is unable to do so in the future.
 Durable power of attorney : A legal document that allows an individual to appoint someone
else (proxy) to make medical or health care decisions, in the event the individual becomes
unable to make and/or communicate such decisions personally.
 Medical power of attorney: it‘s a term which describes a document used for listing the person
to make health care decisions when the patient is unable to make decisions for self.

3. Organ and tissue donation:

 Any body part or the entire body may be donated.
 The decisions to donate organs or to provide anatomic gifts may be made by a person
before death .and family permission must be obtained at time of donation.
The physicians must be notified immediately when organ donation is intended because some tissues
must be used within hours after death
4.Euthanasia:
Refers to the practice of ending a life in a painless manner. Many different forms of euthanasia can
be distinguished, including animal euthanasia and human euthanasia, and within the latter,
voluntary and involuntary euthanasia. Voluntary euthanasia and physician-assisted suicide have
been the focus of great controversy in recent years.

Palliative, hospice and spiritual care at the end of life:

 Hospice:
 Hospice is a concept of care that provides compassion, concern, and support for the dying.
 It exists to provide support and care for the persons in last phases of incurable diseases so that
they can lead their life comfortably.
 Hospice care is given by a medically supervised interdisciplinary team professionals and
volunteers.

Hospice care is family-centered care -- it involves the patient and the family in making decisions.
Care is provided for the patient and family 24 hours a day, 7 days a week. Hospice care can be
given in the patient's home, a hospital, nursing home, or private hospice facility. Most hospice care
in the United States is given in the home, with a family member or members serving as the main
hands-on caregiver.

8
Hospice care also tends to your spiritual needs. Since people differ in their spiritual needs and
religious beliefs, spiritual care is set up to meet your specific needs. It may include helping you to
look at what death means to you, helping you say good-bye, or helping with a certain religious
ceremony.

Family conferences:

Through regularly scheduled family conferences, often led by the hospice nurse or social worker,
family members can stay informed about your condition and what to expect.
Family conferences also give you all a chance to share feelings, talk about expectations, and learn
about death and the process of dying. Family members can find great support and stress relief
through family conferences. Conferences may also be done informally on a daily basis as the nurse
or nursing assistant talks with you and your caregivers during their routine visits.

COUNSELING FOR END OF LIFE

It is a skilled consultation between professional and patient in which each draws on the expertise
and knowledge of the other in order to assist the patient with any physical, psychosocial or spiritual
issues he would like to explore at the final stages of illness. The expertise and knowledge of the
counselor exists as a result of training and experience, self awareness, and awareness of the culture
and value system. The expertise of the patient lies in his knowledge of his own body, his past life
experience and acquired skills and wisdom and his knowledge of his culture, history and belief
system

Counseling offers the dying person much the same that it offers anyone – a supportive relationship
in which the individual has opportunities to work on significant personal concerns. The unique life
situation of the dying person place limits on the process of therapy and demands greater modesty on
the part of the therapist regarding possible outcomes. Regardless of the theoretical orientations
therapist working with dying patients rely first and foremost on communication. Therapy is best
used as a forum for exchanging information , educating expressing fears and discussing needs.

GOALS OF COUNSELING WITH DYING OR TERMINAL ILLNESS PATIENT

The major goals of the therapy with dying patient can be summarized as follows

 To allow open communication with patients regarding their conditions, and to provide
honest, factual information about those conditions.
 To facilitate the expression of the important emotions and to help patient to manage the
emotions as well possible under the circumstances.
 To provide a relationship in which patients can experience support in the confrontation with
death.

9
  To intervene between patients and other significant people such as family, friends and
medical staff during the time of the terminal illness.

TERMINAL ILLNESS COUNSELING Vs TYPICAL COUNSELING

 Terminal illness counseling more time limited and focused than typical counseling
 Goal of the terminal illness counseling is more modest.
 Recognizing the limits of possible change is an essential feature of therapy with the dying.
 The treatment of the dying patient often requires careful coordination with variety of medical
, nursing and pastoral professionals

COUNSELING APPROACHES- 4 main types

 Psychodynamic
 Humanistic
 Behavioural
 Family therapy

PSYCHODYNAMIC APPROACHES

The psychodynamic approaches are primarily concerned with the emotional conflicts and defense
mechanisms of individual. Special issues of conflict and defense arise in the dying person, and this
approach addresses them in the hope of resolving the psychic crisis to the fullest extent possible.
Dying is the ultimate crisis of ego development and as such is associated with intense infra psychic
turmoil. The fear of death may precipitate a breakdown of previously integrated ego functioning, and
result in an attitude of despair and disgust.

COMMON DEFENSE REACTIONS by the terminally ill patient

 Denial
 Displacement
 Projection
 Regression

MAJOR GOAL OF PSYCHODYNAMIC THERAPY

 To help the person recognize, confront, and replace the defenses which run counter to a
emotionally healthy attitude toward death.
 In the process it may be necessary to try to work through some long standing problems and
fixations which are intensified by the death crisis.
 Dynamic therapy with dying patient is not directed as much toward the goal of insight, as it
is with others goal is mainly short term changes not longterm

10
Managing counter transference of the therapist

Another significant concern which has been addressed by the psycho dynamic approach is counter
transference, emotional reaction of the therapist. The three potential negative results of counter
transference are
 The therapist unwillingly support patient’s denial of death by avoiding the issue
 The therapist regress to a helpless position in doing therapy with the patient
 The therapist engages in an anxious avoidance of the patient and his concerns.

The therapist must be particularly careful to avoid letting personal fears and conflicts over death
interfere with helping the patient.

HUMANISTIC APPROACH BY FEIGENBERG

More than other approach the humanistic view of therapy clearly integrates a philosophy of human
nature which death plays an essential role. Existentialism is a philosophy which has had a significant
effect on the humanistic approach, and in this philosophy of living the good life demand a
confrontation with reality of death. death awareness helps us to clarify our values and purpose of the
life and motivates us to live our lives with fullness and meaning. Death is the absolute existential
threat , and it forces us to acknowledge the limit of our life plans and face nothingness.

Goal of humanistic therapy

 To help the dying patient lives as full a life as possible in the face of death
 Without giving false hope or reassurance
 Mobilize the patient’s will to live
 To encourage the expression and growth of the self
 To facilitate the patient’s self actualization

Main features of the humanistic therapy

 Patient centered approach

 It emphasis building strong, supportive and empathic relationship with client
 It allows the client to set the pace of the treatment
 It enables the client to actively and positively participate in the process of dying

BEHAVIOURAL APPROACH

In this approach educating the client to more adequate coping skills to help deal better with death
crisis. Impending death is terribly stressful situation , and it produces extreme emotional reactions

11
like anxiety and depression which inhibit patients are partially manageable through some standards
behavioural thechniques.

Goal

 To provide some coping skills so that the patients can reduce discomfort and gain a
measures of control over life.
 To acquire productive coping skills will not only enable the patient to manage negative
feelings of helplessness but also improve self esteem by providing a sense of competence
and self efficacy

FAMILY APPROACH

The impending death of the family member places entire family in a state of crisis. Death present a
threatening situation for each members of the dying person’s family. the degree of disturbance in the
family depends on many factors such as role of the dying members, the stage of development of the
family and the quality of the relationships among family members.

A family system approach conceives of the entire family, not just the dying person, as the recipient
of therapy. This approach seeks to provide the family unit the opportunity to learn to deal with the
tragedy. Family generally experience a range of intense emotions regarding dying patients, including
anger guilt , fear and depression. Some therapist will continue treatment beyond the death, offering
grief counseling for the survivors.

Advantage of the family approach

It offers an experience that may enable everyone to accept the facts and to work together to enhance
the quality of life for the dying person.

It provides emotional comfort for the patient and family members. Many worries about loss of
control and loss of dignity as their physical ability decline. It is also common for the patient to fear
being abandoned/ fear of becoming burden for the loved ones.

How to provide emotional comfort

It can be given in several different ways by the caregivers/ family members. This is to help them to
enhance their self esteem and dignity.
As with the physical symptoms, every patient’s emotional needs in the final stages of life also differ.
However some emotions are common to many patients during end of life care.

o Keep the patient company; talk to the patient , read to him or her watch movies together or
simply sit and hold their hand.

From a therapeutic stance this is the ideal awareness context and a goal of therapy.

12
Open awareness is not necessarily easy to attain, and attempts to establish this type of relationship
may prematurely overwhelm the defenses of the dying person and provoke significant emotional
distress.

Advantages of open awareness

o Patients and families can benefit by honest sharing of their experiences regarding death and
can prepare themselves more fully for it.

o Patients is able to make plans and arrangements necessitated by death Eg; funeral plans,
writing a will.
Specific illness like Cancer

Specific terminal illness like cancer create unique medical, psychological, social problems for the
patients. Though there are many diseases which kill people , only a few have received special
attention by those working with the dying

Need For Counseling in cancer victims are more than any other terminally ill group.

Some of the features of terminal cancer which set it apart from the other illnesses are its prolonged
course, periods of remission, and its stigma. Because cancer may be a progressively debilitating
disease, cancer victim can anticipate a long often painful struggle , associated with aversive medical
treatments. For many cancer patients disease involves a rollercoaster ride from remission to relapse,
which is enormously stressful.

Therapist working with cancer patient will focus on the cycle of optimism and despair which
accompanies changes in the symptoms of the disease.

Stress and pain management techniques that are helpful in enabling patient to get through the more
noxious periods of medical treatments, eg; chemotherapy.

Behavior therapy techniques such as desensitization and relaxation training have been very useful to
help the cancer patient learn to control the anticipatory stress and nausea related to chemotherapy.

Counselor can help them to ventilate their feelings, help them to fulfill the unmet needs if any,
resolve the conflicts between others and also for seeking financial assistances.
REFERENCES
1. Nieuwmeyer S, Hosking M counseling the terminally ill can we prepare for death? SA Fam
Pract 2006 ; 48 (6) 20-22
2. Michel herson William Sledge Encyclopedia of psychotherapy
3. Joseph Culkin psychotherapy with dyiing patients, www sunnysufflok.com
4. PhilipA. Pecorino Counseling for end of life care 2002
5. Palak mathur, social and cultural stigma, unwed mothers palak mathur word press.com
6. Group counseling with the single mothers www collections cannada.com
7. Improving out reach and suppoet to unwed mothers www. Beyondresearch.sg

13
14
 COUNSELING FOR THE HIV /AIDS PERSON

The key aims of HIV counseling are:

 To prevent HIV transmission by providing information about transmission risks (such as unsafe sex
or needle sharing);
 To assist people in developing the personal skills needed to negotiate safer practices;
 To provide psychological support to people who are infected with and affected by HIV In
improving their emotional, psychological, social, and spiritual well-being; and
 To support clients in treatment adherence

Who can provide HIV counseling?

 Nurses, Doctors, Social workers, and other care providers who have been specially trained in
HIV counseling;
 full-time counselors (including psychiatrists, psychologists, and family therapists) who have
been trained in HIV counseling;
 community-based workers whose work consistently entails appropriate handling of
confidential information and emotional issues; and people living with HIV and AIDS .

Where is HIV counseling provided?

Counseling communication skills

Body language

15
  Good eye contact with clients especially when we are talking about sensitive
issues.
 Sitting “with” the client, and not behind a desk
 Sitting a culturally appropriate distance from them and facing them
 Sitting in a relaxed but professional way ( not too formal, not too casual)

 Not looking at our watch, or taking phone calls or doing other distracting things
whilst the client is talking

Non-verbal skills
 Not responding to the clients in a way that shows our frustration or
displeasure e.g. grunts, sighs or groans.
 Not giggling or sounding surprised when a client says something that
embarrasses us
 Talking in a calm manner ( not too bossy or directive)
Paraphrasing involves restating, in your own words, the essence of what the client
has said.
The client says, “I feel so helpless. I can’t get the housework done, get the children to
school on time, or even cook a meal. I can’t do the things my wife used to do.” Then
the counsellor says, “You are feeling overwhelmed by having to do things you did not
have to do in the past when your wife was alive.”
Reflecting emotions is similar to paraphrasing except that the focus is on the
emotions expressed by the client
e.g. the client says, “I don’t know what to do. Before he died I promised my
husband that I would take care of his mother for the rest of her life. But I no longer
have the energy. I cannot seem to get myself sorted out to do anything. He knew that
his mother and I did not get along and that the situation would be miserable. Why did
he die and leave me in this mess?’ The counsellor reflects, “You seem to be feeling
very low and helpless right now, but at the same time you seem to be feeling guilty
and angry about your promise to your husband.”

Consider how to ask questions

Closed questions: Can be answered with only a one word response “Yes or No”

e.g. “Do you practice safer sex?“ This could give us misleading information. The
client may say yes but what they think is safe sex may be different to what we
consider safe.
Leading questions: Tell the client what we would like to hear

16
 e.g. “You always use a condom don’t you?” Clients who are asked these types of
questions may give you inaccurate answers.

Open questions

Start with “how” “what” “where”

e.g. “Many clients have trouble using condoms what are some of the problems you
have?” These questions allow the client to explain or describe a situation.

Use silence – do not talk too much

Silence is important because it gives the client as it time to think about what to say,
the chance to experience his or her feelings, the ability to proceed at his or her own
pace, time to deal with ambivalence about sharing, and freedom to choose whether
or not to continue.
Elements of effective counseling

 Ample time
 Acceptance
 Accessibility
 Consent
 Consistency and accuracy(follow National HIV guidelines)
 Confidentiality
 Ethical ,Socio cultural considerations

Types of HIV counseling

1. HIV prevention counseling: HIV transmission risk reduction

2. Pretest counseling
3. Post-HIV test counseling
4. Ongoing counseling for people affected by HIV
5. Treatment adherence counseling
6. Pediatric counseling
7. Partner counseling

1.HIV prevention counseling: HIV transmission risk reduction

 The counselor assists infected and uninfected clients in identifying and exploring the
difficulties involved In reducing transmission risk behavior.

17
  Provision of information to the more therapeutic evidence-based strategies that can include
 motivational interviewing,
 structured problem solving,
 Interpersonal and brief psychotherapy for risk reduction,
 cognitive behavioral therapies,
 relationship counseling, and infant-feeding counseling.
 Prevention counseling is employed in pre-HIV test and post-HIV test counseling and in
counseling across the disease continuum.

2. Pretest counseling

 Confidential Counseling that will enable an individual to make an informed choice about being
tested for HIV. (According to WHO)
 and must be free of coercion.
 The potential benefits and risks associated with testing.
 The possible psychosocial, legal, and health implications of knowing the client’s serostatus.
 Assess the client’s capacity to cope with the possibility of a positive HIV antibody test,
provides information on HIV, and engages in prevention counseling, mainly to reduce
transmission risk behavior
 Review the client’s risk of infection
 Help the client understand why the test is needed
 Explain the test and clarify its meaning
 Psychologically prepare the client for a potential HIV positive result
 Explain the limitation of the test and various results that can be obtained
 Informed consent

3.Post-HIV test counseling

 If the client tests positive for HIV antibodies, post-test counseling must make it easier for him
or her to adapt to life with HIV and STI infection.
 Suicide presents a significant challenge to counselors. (suicide may occur as an impulsive
response to the emotional turmoil to diagnosis, second period of high risk occurs late in the
course of the disease when complications –Physical, psychological, social.
 Post-HIV test counseling is typically provided by the counselor who conducted the pretest
counseling.

Key counselling issues in post-diagnosis follow-up and support

Assessment of impact of the diagnosis. The ability of the client to manage the impact
of the diagnosis must be regularly reviewed. The intent is not only to improve the
quality of life of the client but also to facilitate adherence to transmission prevention,
drug dependency, and HIV clinical treatments.

Problem solving. Clients often require more than just information to resolve their
problems. Often they will need assistance in planning and rehearsing new behaviours.

18
For some individuals diagnosed relatively late in the disease, especially those with
years of chronic substance use, there may be co-morbid or HIV- related CNS
complications that can impair cognitive functioning, making the client unable to
initiate and adhere to a prevention and treatment programme. Such complications
commonly affect these areas of cognitive functioning: planning and organization,
speed of information processing, verbal fluency, short- term memory, and eye-hand
coordination.

Mental health.
Mental health problems are common among substance users who are HIV-positive.

ALTERED MENTAL STATES IN HIV/AIDS PATIENTS

Early: -
 Grief
 Stress
 Anxiety
 Depression(suicidal behavior)

Late: -

 Delirium
 Depressive Syndromes
 HIV Associated Dementia

19
According to some estimates, 25%-50% of drug users also have co-morbid mental
health problems. Some drug and alcohol users have a long history of mental illness
without proper diagnosis or treatment. In a number of cases drug or alcohol use may
represent the client’s attempt to manage symptoms of an undiagnosed, pre-existing
mental illness. The provision of appropriate mental health support–psychiatric
(antidepressant therapy) as well as psychological (e.g., cognitive behaviour therapy)–
is an essential component of drug treatment services.

HIV-related neurological complications. Some studies suggest incidence of HIV

encephalitis in the brains of 56% of HIV-positive drug users, compared with only 15% of
HIV-positive non-users. Other studies indicate that clients with a history of injecting
drug use who present with slowed psychomotor activity have a more rapid
progression and show abundant macrophage activation within the CNS. But the
degree to which substance use contributes to progression from minor neuro-
cognitive disorders such as minor short-term memory loss to dementia remains
unclear.

Decisions regarding treatment

Clients may have misconceptions about both HIV and drug dependency treatments
offered, and may also need to discuss their fears and concerns. Some may need to
engage the support of friends or family. Assistance may have to be provided to
facilitate this.

Ongoing counseling for people affected by HIV

 Psychosocial issues confronting both infected and affected individuals change throughout
the course of the illness.

Treatment adherence counseling

 Psychological, Physical, and practical barriers to treatment adherence.

 Non-adherence can lead to inadequate suppression of bacteria and, in the case of HIV, viral
replication.
 Includes knowledge of both the disease and the medications and their side-effects.
 It helps the patient set goals, develop positive beliefs and perceptions, and increase self-
efficacy in maintaining treatment.

Pediatric counseling

Counseling must be available for any child undergoing HIV testing, including post-test
counseling for the child and the parent(s) or caretaker(s). Counseling children infected
or affected by HIV and AIDS requires the following skills:
● assessing maturity for understanding the benefits and risks of testing and for
providing consent;
● age-appropriate communication;

20
● disclosure;
● the process of informing a child of his or her HIV status;
● counselling for adherence to HIV medication;
● ability to talk to children about death;
● assessment of sexual abuse and rape;
● parent or caretaker counselling; and
● ongoing psychosocial counselling.

COUNSELING CHILDREN INVOLVES:

● creating a friendly and private environment
● establishing a relationship with children and gaining their confidence and trust;
● helping children to tell their story;
● listening to children in an active manner;
● giving children correct and appropriate information at his or her level of
development;
● recognizing that the HIV test may raise different issues for children of different
ages;
● giving honest answers without hiding information, even if difficult;
● helping children to make decisions;
● preparing older children and adolescents for safe sexual (or injecting practices), to
prevent co-infection with another strain of HIV, and onward transmission of HIV to
their sexual or injecting partners; and
● helping children to recognize and build on their strengths to develop a positive
attitude towards life.

The foundation for a relationship between a counsellor and a child is good

communication. Children should never be forced to tell their ”story”–there may be
good reasons when children cannot communicate about something. To help children to
communicate freely, a counsellor can use one or more of the following creative and
non-threatening tools:

 drawing;

 storytelling;

 drama and role-plays; or plays.

 Profound impact on the lives of children and their families

21
  Provide support to children, assisting them in coping with separation and loss issues related
to the parents’ or the child’s own illnesses.
 Other common presentations seen in children with HIV infections are behavioral
disturbances, cognitive and motor impairment, and poor treatment adherence.
 To ease his or her entry into substitute-care settings
 To give emotional support to children who have experienced not only the death of parents
but also societal rejection or discrimination.

NURSE’S ROLE

Assessment

 Observe all dimensions of human response.

 Create a psychologically safe environment by assuring the client of confidentiality
 Refraining from judging or giving specific advice and allowing sharing thoughts and feelings.
 Don’t expect client to follow steps in grieving process.
 Assess degree of impairment within context of client’s life and experiences.
 Assess the cultural practices, rituals of client after loss.
 Explore 3 critical components in assessment
 Perception of the loss
 Support
 Coping Behaviors

On the basis of subjective and objective assessment data nursing diagnosis are made.

1. Risk for dysfunctional grieving

2. Risk for spiritual distress
3. Ineffective coping
4. Altered perception of loss

Grieving / Dysfunctional Grieving /Anticipatory Grieving :

 Identify the effects of his or her loss.

 Seek adequate support.
 Apply effective coping strategies in expressing & assimilating dimensions of human response to
loss in his or her life.
 Assess client’s stage in the grief process.
 Develop trust, show empathy, concern, unconditional positive regard.
 Allow the client to express feelings.
 Explore client’s perception and meaning of the loss.
 Allow adaptive denial
 Use effective communication
 Offer presence and give broad openings
 Use open-ended questions
 Establish rapport and interpersonal skills by:

22
 Attentive presence
 Therapeutic touch
 Respect for client’s unique grieving process
 Respect for client’s personal beliefs
 Being trustworthy
 Client has discussed about loss.
 Verbalized feelings.
 Expressed anger appropriately.
 Participates in the spiritual practices as before.
 Participates in social activities.
 Provide crisis management
 Manage the risk for suicide

Perception of loss

 Assess clients stage in the grief process.

 Develop trust, show empathy, concern, unconditional positive regard.
 Allow the client to express feelings.
 Explore client’s perception and meaning of the loss.
 Effective communication skills can be useful in helping the client in adaptive denial move toward
acceptance
 Provide continuing support(support group)

Social support

 Assess the support system availability.

 Help client to reach out and accept support.
 Give opportunity to review strengths.
 Encourage self care.
 Use simple, nonjudgmental statements
 Refer to a loved one by name.
 Refer to the other support groups.

Spiritual needs

 Assess the level of distress and plan interventions accordingly

 Be accepting and non judgmental.
 Encourage ventilation.
 Ensure that client is not left alone.
 Contact the spiritual leader if required

23
24
25