Behavioral Counseling using Brief Interventions

Brief Interventions Module:

Goals: To use “brief interventions” to counsel and educate clients about HIV disease course, health maintenance, and disease management.

Objectives:

1) Define and describe counseling for behavioral change

2) Define the communication skills needed for effective counseling

3) Describe and utilize the steps of effective counseling using brief interventions

Procedure:

1) Brainstorm what is counseling and what is not counseling

2) Lecture using slides

3) Break group into pairs and conduct role plays using the following scenarios and the principles of counseling

4) Debrief reviewing principles of counseling

SCENARIOS FOR LESSON:

1) You are the nurse on duty and Ajit is admitted to your ward. He is a 35 year old alcoholic who was tested for HIV 3 years ago and learned he was positive. He has never been sick until now. He was admitted to the hospital two days ago for pneumonia. He has tried to stop using alcohol in the past but his wife recently died and he began drinking again.

2) You are the nurse on duty and Rajesh is admitted to your ward. He is a 20 year old male construction worker who was last hospitalized 1 year ago with TB. At that time he was tested for HIV and learned he was positive. He states that he is aware that he is HIV positive but has not revealed it to anyone because he is afraid he will lose his job. He states that he continues to have unprotected sex with his wife and a girlfriend. He does not know if either woman has HIV.

Counseling skills:

1) Empathizing: seeing the world through the other person’s eyes. Example: “My boyfriend keeps asking me to have sex with him and I feel embarrassed and angry.” Response: “So you often feel irritated, uncomfortable and pressured by him. That must be difficult for you.”

2) Active Listening: Involves paying attention to a client’s verbal and non-verbal messages and listening in a way that conveys respect, interest and empathy.

3) Using open ended questioning in probing:

These are questions that require more than one word answers. They usually begin with words such as “How”, “What” or “Why”
Open ended questions encourage clients to express their feelings and share information about their situation. Probing is using
questions to help clients express themselves more clearly. Probing is necessary when more information is needed about a person’s feelings or situation. The following are probing phrases:

“Can you tell me more about that?”
“How do you feel about that?”
“Why do you feel you are at risk for HIV?”

4) Using closed-ended questions:

These are questions that require a one-word answer. They are used sparsely for information gathering.

The following are examples:

“How old are you?”
“Have you been to our hospital before?”

5) Focusing: Sometimes a client will try to address all of their problems at once. It is important to stay focused on the topic in a time limited setting. Attempt to redirect the patient in an understanding manner.

6) Affirming: Congratulating or complimenting the patient on the positive actions they have taken.

Example:
Patient: “I’ve recently started using condoms each time I have sex.”
Counselor: “That is a really positive step in protecting yourself against STIs and HIV, well done!”

7) Correcting Misperceptions: Providing correct information to the patient in a sensitive way that does not put the patient on the defensive. Acknowledge misinformation and correct it.

8) Summarizing: Presents the main points to the client. It aids in clarifying, helping the patient gain perspective and ending the session.

Principles of Counseling:

The following principles of counseling are derived from an ancient Indian theory of communication – Sadharanikaran, based on the Natyashashtra. These principles are especially suited to the Indian context as they draw upon the complexities of Indian culture.

1. Compassion (atmiyata). Compassion towards the patient/client is absolutely essential for counseling to be effective. The principle of compassion is a prerequisite for meaningful communication to occur between two people.

2. Communication style should be equal. This principle states that counseling is not effective if communication is top down, i.e. if the session is dominated by the health provider and there is not much scope for the patient/client to participate. The counselor’s communication style should be based on an equal basis between him/her and the client. For example the counselor/nurse should maintain the same communication style irrespective of the patient. Nurses should be very sensitive to patients who belong to marginalized groups such as commercial sex workers, laborers etc.

3. Social Influence. It is very important for the health provider to understand the high levels of social influence which operate in a patient’s life. These social influences to large extent determine a patient’s behavior. For example, an HIV positive mother does not wish to breastfeed her baby. But the social pressures on her are so heavy that she has to breastfeed her child. The health provider must take into consideration these social influences when counseling the patient. For example, patient’s social network can be drawn upon to provide support to a patient. Peer pressure is another form of social influence and the counselor should try to assess the level of peer pressure operating on the patient.

4. Positive Emotional Response. The counselor should create a positive climate and not increase the fear level of the patient. The patient’s emotional response should be managed in a manner which calms his/her feelings. The counselor must learn how to tackle the patient’s negative feelings or hostility and maintain a friendly and open atmosphere.

The steps of counseling

. • Build rapport with patient

. • Assess the patient’s situation (ask questions)

. • Identify the behavior that needs to be changed

. • Identify reasons why the behavior can be changed

. • Identify barriers

. • Discuss benefits of the behavior with the patient

. • Discuss the options

. • Assist to integrate the new behavior into the patient’s routine

. • Talk with family members if required

. • Summarize

KEY POINTS

. • Counseling involves: trust and respect; empathy; listening; verbal and non-verbal communication; problem solving; empowering the patient to make decisions and confidentiality.

. • Counseling skills are: empathizing, active listening, open ended questions and probing, closed-ended questions, focusing, affirming, clarifying, correcting misperceptions, and summarizing.

. • Risk reduction is a key element counseling and brief intervention.

. • The role of the nurse is to “plant the seed,” and to provide an
environment for the patient to speak freely.

. • Principles of counseling are: compassion, equal communication style, understanding how social influence affects a patient, evoking a positive emotional response.

. • These interventions are meant to be brief. A nurse can counsel patients in stages and can build rapport throughout his/her hospitalization.

. • Be sure to assess the patient’s willingness to adopt the new
behavior.

. • Be reminded that what you think the patient should do and what the patient thinks he/she should do may be different. There is no correct answer!

. • The steps of counseling are: Build rapport with patient, assess the patient’s situation (ask questions), identify the behavior that needs to be changed, identify reasons why the behavior can be changed, identify barriers, discuss benefits of the behavior with the patient, discuss the options, assist to integrate the new behavior into the patient’s routine, talk with family members if required, summarize.

Nursing Action:

1. Listen to the patient and assess his/her needs

2. Target a single behavior to change in one counseling session

3. Empathize and be non-judgmental

4. Encourage the patient

5. Develop with the patient a plan for change

6. Maintain equal communication between health worker and patient