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

2. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Contents Introductions Introductions Theoretical models I have found useful Theoretical models I have found useful Issues for people with HIV Issues for people with HIV Assessment and how to handle certain clients Assessment and how to handle certain clients

3. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Introduction to course Aim of training To educate and inform participants about aspects of HIV and mental health To educate and inform participants about aspects of HIV and mental health To help you discuss own experiences of dealing with clients with mental health and emotional support issues To help you discuss own experiences of dealing with clients with mental health and emotional support issues To do some elementary experiential training to help volunteers deal with and relate to people with specific emotional support needs To do some elementary experiential training to help volunteers deal with and relate to people with specific emotional support needs

4. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Introduction to people! Name Name Why are you a counsellor? Why are you a counsellor? Why you work in HIV Why you work in HIV One thing you like doing that’s nothing to do with HIV One thing you like doing that’s nothing to do with HIV

5. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Pair exercise “My bad day, and what I did about it” “My bad day, and what I did about it”

6. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Part one – some theoretical models I have found useful Stress and stressors Stress and stressors Fight, flight and freeze Fight, flight and freeze The Kübler-Ross adaptation model The Kübler-Ross adaptation model The Gestalt cycle The Gestalt cycle Predispositions: the Reichian character structures Predispositions: the Reichian character structures

7. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk A side-journey into STRESS “ The state arising when the individual perceives that the demands placed on them exceed (or threaten to exceed) their capacity to cope, and therefore threaten their wellbeing.”* “ The state arising when the individual perceives that the demands placed on them exceed (or threaten to exceed) their capacity to cope, and therefore threaten their wellbeing.”* Stress is not mental illness Stress is not mental illness Stress is a normal part of life Stress is a normal part of life Stress has physical effects Stress has physical effects The result of stress depends on what you do with these physical effects: The result of stress depends on what you do with these physical effects: To energise you To energise you To give you ideas To give you ideas To make you angry To make you angry To shut you up To shut you up To make you depressed To make you depressed To make you ill To make you ill * Paul Martin: The Sickening Mind: Brain, Behaviour, Immunity and Disease. ISBN 978- 0006550228 * Paul Martin: The Sickening Mind: Brain, Behaviour, Immunity and Disease. ISBN 978- 0006550228

8. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Stress Event value Death of spouse 100 Divorce60 Menopause60 Separation from living partner 60 Jail term or probation 60 Death of close family member other than spouse 60 Serious personal injury or illness 45 Marriage or establishing life partnership 45 Fired at work 45 Marital or relationship reconciliation 40 Stress scale top 10

9. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Fight, flight – or freeze Sympathetic and parasympathetic nervous systems Sympathetic and parasympathetic nervous systems React automatically to stress React automatically to stress Sympathetic excitatory, parasympathetic inhibitory Sympathetic excitatory, parasympathetic inhibitory Usually the sympathetic nervous system responds to a stressor Usually the sympathetic nervous system responds to a stressor Adrenaline (epinephrine) mobilises the “Fight or flight” reaction Adrenaline (epinephrine) mobilises the “Fight or flight” reaction When fight or flight is impossible the sympathetic and parasympathetic nervous systems both fire at once When fight or flight is impossible the sympathetic and parasympathetic nervous systems both fire at once Acetylcholine (and NO) normally produces relaxation Acetylcholine (and NO) normally produces relaxation In the presence of sympathetic arousal it produces dissociation – the “Freeze” reaction – like an animal playing dead In the presence of sympathetic arousal it produces dissociation – the “Freeze” reaction – like an animal playing dead Dissociation lies behind many adjustment disorders and ‘stuck’ states – see below Dissociation lies behind many adjustment disorders and ‘stuck’ states – see below

10. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Adaptation to loss and change from On Death and Dying by Elisabeth Kübler-Ross

11. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk The Gestalt Cycle: adaptation and moving on

12. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Four primary emotions Happiness Happiness Anger Anger Fear Fear Sadness Sadness Confusion Confusion

13. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Five primary emotions - stuck Happiness stuck ⇒ manic defence, denial Happiness stuck ⇒ manic defence, denial Anger stuck ⇒ pathological rage, blame, self-harm, suicide Anger stuck ⇒ pathological rage, blame, self-harm, suicide Fear stuck ⇒ anxiety disorder, panic attacks, phobias, PTSD, OCD Fear stuck ⇒ anxiety disorder, panic attacks, phobias, PTSD, OCD Sadness stuck ⇒ depression, dysthymia, irritability, physical symptoms Sadness stuck ⇒ depression, dysthymia, irritability, physical symptoms Confusion stuck ⇒ more confusion (compound dissociation, fugue, DID, amnesia) Confusion stuck ⇒ more confusion (compound dissociation, fugue, DID, amnesia)

14. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Predisposition – the Reichian character structures Different structures vulnerable to different stress Schizoid – child hated or ignored Schizoid – child hated or ignored “Life means nothing unless I am in control” “Life means nothing unless I am in control” Oral – child loved inadequately (e.g. PND) Oral – child loved inadequately (e.g. PND) “Life means nothing unless I am loved” “Life means nothing unless I am loved” Symbiotic – child loved to exclusion of others Symbiotic – child loved to exclusion of others “Life means nothing unless we are in love” “Life means nothing unless we are in love” Narcissistic – child used to make parents feel good Narcissistic – child used to make parents feel good “Life means nothing unless I am adored and special” “Life means nothing unless I am adored and special” Masochistic – child over-disciplined or controlled Masochistic – child over-disciplined or controlled “Life means nothing unless I do it myself” “Life means nothing unless I do it myself” Histrionic – child used to create drama and fights Histrionic – child used to create drama and fights “Life means nothing unless it is (sexually, emotionally) exciting” “Life means nothing unless it is (sexually, emotionally) exciting” Rigid – child brought up with rigid social expectations Rigid – child brought up with rigid social expectations “Life means nothing unless I am a success” “Life means nothing unless I am a success”

15. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Issues for people with HIV HIV is a chronic stressor – you’re always aware of it HIV is a chronic stressor – you’re always aware of it It may at certain times also be an acute stressor – risk encounter, HIV diagnosis, AIDS diagnosis, rejection (sexual or family), discrimination, stigma It may at certain times also be an acute stressor – risk encounter, HIV diagnosis, AIDS diagnosis, rejection (sexual or family), discrimination, stigma

16. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk HIV-specific issues Physical: HIV illness, dementia Physical: HIV illness, dementia Drug side effects: efavirenz, also possibly AZT etc Drug side effects: efavirenz, also possibly AZT etc New diagnosis New diagnosis Stigma and isolation Stigma and isolation Long term survivors: ‘Lazarus effect’: I’m not special any more Long term survivors: ‘Lazarus effect’: I’m not special any more Work and career Work and career Loss and bereavement Loss and bereavement Sex, love, disclosure, rejection Sex, love, disclosure, rejection Body changes/image Body changes/image Life issues that may have led to HIV: depression, addictions, abuse Life issues that may have led to HIV: depression, addictions, abuse

17. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Why mental health is important in HIV

18. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk How common I: North Carolina

19. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk How common II: London 2002

20. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Assessment: what do you notice…? Appearance/behaviour: unkempt, restless, eccentric Appearance/behaviour: unkempt, restless, eccentric Rapport: are they with you? Eye contact? Rapport: are they with you? Eye contact? Speech: slow, fast, easy, reluctant, comprehensible Speech: slow, fast, easy, reluctant, comprehensible Mood: euphoric, depressed, anxious, irritable, labile, blunted, incongruent Mood: euphoric, depressed, anxious, irritable, labile, blunted, incongruent Thought: block, incoherence, delusion, obsession Thought: block, incoherence, delusion, obsession Cognition: ability to understand and have concepts Cognition: ability to understand and have concepts Body and perception: dizzy, spaced-out, cold sweat, heart, headache, noise Body and perception: dizzy, spaced-out, cold sweat, heart, headache, noise Insight: self-awareness, including the awareness that something is wrong (if it is) Insight: self-awareness, including the awareness that something is wrong (if it is) And most important… And most important… HOW ARE YOU FEELING ? (countertransference and embodied countertransference) HOW ARE YOU FEELING ? (countertransference and embodied countertransference)

21. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk What do you cover? “Famous first words” (and actions) “Famous first words” (and actions) Presenting problem Presenting problem Family history Family history Relationships Relationships Family relationships Family relationships Current life setting: work, money, housing etc Current life setting: work, money, housing etc Psych. History/medication Psych. History/medication Medical history including HIV Medical history including HIV Drink/drug issues/dependency Drink/drug issues/dependency Any suicide history/ideation? Any suicide history/ideation? Sex risks/dysfunction Sex risks/dysfunction What are their hopes for counselling? What are their hopes for counselling? What do they expect counselling to be like? What do they expect counselling to be like? Practical issues e.g. times/frequency/duration/fees/contact Practical issues e.g. times/frequency/duration/fees/contact “If this worked, what would you be like?” “If this worked, what would you be like?”

22. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Depression and its risk factor, suicide A story…Mr Pig A story…Mr Pig Inner experience and meaning of depression: shutdown Inner experience and meaning of depression: shutdown Language to watch out for: overt/sleep/going away/switch off/can’t cope Language to watch out for: overt/sleep/going away/switch off/can’t cope Depressed people are helpless, hopeless…and annoying! Value their anger! Depressed people are helpless, hopeless…and annoying! Value their anger! How NOT to help a depressed person How NOT to help a depressed person Don’t reassure ⇒”You don’t understand” Don’t reassure ⇒”You don’t understand” Don’t reason ⇒”Yes, but…” Don’t reason ⇒”Yes, but…” Don’t sympathise ⇒ “You see? It’s hopeless” Don’t sympathise ⇒ “You see? It’s hopeless” Don’t get angry ⇒”You see? You hate me too” Don’t get angry ⇒”You see? You hate me too” Action and distraction work best Action and distraction work best

23. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Anxiety and its risk factor, panic A story…Tim and my dog A story…Tim and my dog Inner meaning and experience of anxiety states: the adrenalin trap Inner meaning and experience of anxiety states: the adrenalin trap Fight, flight – and freeze Fight, flight – and freeze How NOT to help anxious clients How NOT to help anxious clients Do NOT reason with the fears Do NOT reason with the fears Do NOT argue with the irrational Do NOT argue with the irrational Do NOT reassure Do NOT reassure Physical relaxation techniques usually don’t work: person ‘spaces out’ Physical relaxation techniques usually don’t work: person ‘spaces out’ Ask: “If you weren’t worrying about this, what would you be worrying about?” Ask: “If you weren’t worrying about this, what would you be worrying about?”

24. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Anger and its risk factor, violence A story…Dave C. A story…Dave C. Inner meaning and experience: frustration and isolation Inner meaning and experience: frustration and isolation Language and behaviour to watch out for Language and behaviour to watch out for How to handle angry clients How to handle angry clients Stay calm Stay calm Sit down Sit down Match them with energy but not with anger Match them with energy but not with anger Make sure they can really see you – they may be in Trauma – an angry person is a frightened person Make sure they can really see you – they may be in Trauma – an angry person is a frightened person Understand they need to be heard Understand they need to be heard Pre-set limits if you can: no violence/destruction/safe words Pre-set limits if you can: no violence/destruction/safe words

25. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Knowing who you can’t work with A story: “I am a medical experiment” A story: “I am a medical experiment” Knowing when you can’t work with someone is a very personal decision, based not only on your professional experience but your life issues Knowing when you can’t work with someone is a very personal decision, based not only on your professional experience but your life issues Signs: no contact/relationship, no insight, delusion, extreme countertransference, client’s issues mirror ones you currently have, client triggers trauma/memories Signs: no contact/relationship, no insight, delusion, extreme countertransference, client’s issues mirror ones you currently have, client triggers trauma/memories Strong reactions aren’t always bad! Strong reactions aren’t always bad! Dislike, boredom, annoyance, anxiety, sadness, attraction (especially sexual!), urge to touch…if you feel these then a) You feel what others feel b) You’re probably feeling what they’re feeling (even if they don’t know it). Dislike, boredom, annoyance, anxiety, sadness, attraction (especially sexual!), urge to touch…if you feel these then a) You feel what others feel b) You’re probably feeling what they’re feeling (even if they don’t know it).

26. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Bully/victim/rescuer The roles people play… The roles people play… …and the roles they try to get you to play …and the roles they try to get you to play Projective identification Projective identification A story: autistic Rob and his dreams A story: autistic Rob and his dreams His therapists always started as rescuers and ended as bullies His therapists always started as rescuers and ended as bullies

27. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Boundaries and confidentiality The client who wants to be your friend The client who wants to be your friend The client who tells you shocking things The client who tells you shocking things When to break confidentiality When to break confidentiality Imminent harm to self or others Imminent harm to self or others Always have a professional contact Always have a professional contact You are not there to suffer or be punished… You are not there to suffer or be punished…

28. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Groups and peer groups Isolation is the biggest single predisposing factor for mental illness Isolation is the biggest single predisposing factor for mental illness If you are a group facilitator, many of the same issues will come up with individuals – complicated by group dynamics If you are a group facilitator, many of the same issues will come up with individuals – complicated by group dynamics Models: directive, non-directive: open, closed, slow open Models: directive, non-directive: open, closed, slow open You are there to interpret the group process, not to counsel individuals. The group will do that You are there to interpret the group process, not to counsel individuals. The group will do that

29. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Some workshops that could be adapted Prevention/safer sex: Healthy Relationships. Prevention/safer sex: Healthy Relationships.See; www.cdc.gov/hiv/topics/research/prs/resources/factsheets/healthy-relationship.htm Living with HIV: The Positive Self Management Programme (the ‘Living Well’ course). Living with HIV: The Positive Self Management Programme (the ‘Living Well’ course). See www.livingwelluk.com/ and http://patienteducation.stanford.edu/programs/psmp.html www.livingwelluk.com/ http://patienteducation.stanford.edu/programs/psmp.htmlwww.livingwelluk.com/ http://patienteducation.stanford.edu/programs/psmp.html Self-confidence and getting more from life: The AIDS Mastery. See www.aidsmasteryokc.org/ Self-confidence and getting more from life: The AIDS Mastery. See www.aidsmasteryokc.org/www.aidsmasteryokc.org/

30. Taiwan Counselling Workshop – Gus Cairns – 07 September 2007 www.ferguscairns.co.uk Any questions?