1. health and fitness
2. disease
3. aids and hiv

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:
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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’.
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Use of ‘Self’ in the Counselling Process
Session Overview:
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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:
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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.
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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.
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 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:
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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?
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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”.
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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.
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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
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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
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Understanding counseling as a skill and
core competencies
Session Overview:
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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
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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.
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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.
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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
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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.
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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)
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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?
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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.
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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)
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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
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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.
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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
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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.
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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
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Understanding Marginalization and Vulnerability in
the context of HIV/AIDS
ges
Session Overview:
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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
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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.”
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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
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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)
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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.
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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]
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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.
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 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.
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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.
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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
------------------------------------
-------------------------------------------------------
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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
------------------------------------
-------------------------------------------------------
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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?
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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.
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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.
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[Source: TARSHI (2006).Basics and Beyond: A Manual for Trainers, India]
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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
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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.
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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
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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.
----------------------------------------------------
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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
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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
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Time
allowed:
:
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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.
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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).”
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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
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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
:
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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
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 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.
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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
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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)
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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
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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
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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.
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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.
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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
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(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)
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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
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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
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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
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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
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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
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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
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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
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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
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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)
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• 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:
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“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
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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)?”
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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.”
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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)
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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.”
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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.)
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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
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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.
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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.
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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.
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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.
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 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.
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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.
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 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.
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 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.
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 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.
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 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
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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:
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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:
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 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
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 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
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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
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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
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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)
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