Indira Gandhi

National Open University School of Social Work

BSW-130
Prevention of
Substance Abuse

Block

4
COUNSELLING IN HIV AND FAMILY MATTERS
UNIT 1
STIs and HIV/AIDs Counselling
UNIT 2
Family and Premarital Counselling
UNIT 3
Counselling on Sexuality and Sensitive Issues
UNIT 4
Existing Trends in Counselling Services in India
Expert Committee (Original)
Prof. P.K. Gandhi [Link] Sehgal Prof. [Link]
Jamia Millia Islamia Indore School of Social Work, University of Delhi
New Delhi Indore New Delhi

Dr. D.K. Lal Das Dr. Rama V. Baru Prof. A.A. Khan
R.M. College of Social JNU, New Delhi IGNOU, New Delhi
Work, Hyderabad

Dr. P. D. Mathew Dr. Jerry Thomas Dr. R.P. Singh

Indian Social Institute Don Bosco IGNOU, New Delhi
New Delhi Guwahati

Dr. Alex Vadakumthal Prof. Surendra Singh Dr. Richa Chaudhary

CBCI Centre, New Delhi Vice Chancellor B.R. Ambedkar
M.G. Kashi Vidyapeeth University of Delhi
Varanasi Delhi

Prof. Gracious Thomas Prof. A.B. Bose (Retd.) Prof. Prabha Chawla
IGNOU, New Delhi SOCE, IGNOU, New Delhi IGNOU, New Delhi

Prof. A.P. Barnabas (Retd.)

IIPA, New Delhi

Expert Committee (Revision)

Prof Sushma Batra, Dr. Sangeeta Sharma Dhaor, Dr. Saumya,
Department of Social Work, Dr. Bhim Rao Ambedkar College, School of Social Work,
University of Delhi University of Delhi IGNOU

Prof. R.R. Patil, Prof. Gracious Thomas, Dr. G. Mahesh,

Department of Social Work, School of Social Work, School of Social Work,
Jamia Millia Islamia IGNOU IGNOU

Prof. Beena Anthony Reji, Prof. Rose Nembiakkim, Dr. Sayantani Guin,
Aditi Mahavidyalaya, School of Social Work, School of Social Work,
University of Delhi IGNOU IGNOU

Course Preparation Team (Original)

Unit Writers
1. [Link] D'souza
2. Prof. Chitrajan Andrada
3. Prof. Gracious Thomas
4. Prof. Gracious Thomas

Content Editor Block Editor & Programme

Prof. Stephen Mavely Coordinator
Prof. Gracious Thomas
IGNOU, New Delhi
 Course Preparation Team (Revised)
Unit Writers
1. [Link] D'souza
2. Prof. Chitrajan Andrada
3. Prof. Gracious Thomas
4. Prof. Gracious Thomas

Content Editor Programme & Course

Dr. Sheeba Joseph Coordinator
Bhopal School of Social Sciences Dr. Sayantani Guin,
Bhopal School of Social Work, IGNOU

PRINT PRODUCTION
Counselling in HIV and Famil
Matters INTRODUCTION TO BLOCK 3
The last block of the course on “Prevention of Substance Abuse” is on
“Counselling in HIV and Family Matters”. There are four units in this block.
Unit 1 deals with “STI and HIV / AIDS Counselling”. Apart from discussing the
main features involved in STD counselling, this unit also deliberates on the
nature of HIV/AIDS counselling, types of HIV related counselling and ethical
issues involved in HIV counselling. Unit 2 is on “Family and Pre-marital
Counselling”. The topics discussed in this unit include selection of marriage
partners, and pre-marital counselling. Unit 3 is about “Counselling on Sexuality
and Sensitive Issues”. In this unit, some of the sensitive topics discussed
include: guidelines for talking about sensitive topics, sexual myths and
misconceptions, sexual coercion and violence and some of the sexual
problems. Unit 4 deals with the “'Existing Trends in Counselling Services in
India”. In this unit, information is provided about training facilities, places
where counsellors work and the scope for social work counsellors.

This block will help the learner to acquire knowledge on certain important
concepts and processes involved in counselling services. Many people
involved in HIV/AIDS related work are called upon to provide counselling to
their clients. Some of them may have training in communication and
counselling while several others may have hardly any formal training in
counselling. It is presumed that this course will be highly useful to the learners
who intend to enter into the field of counselling services.

4
 STIs and HIV/AIDs
UNIT 1 STIs AND HIV/AIDS COUNSELLING Counselling

Contents
1.0 Objectives
1.1 Introduction
1.2 STI Counselling – Main Features
1.3 HIV/AIDS Counselling – Its Nature and Purpose
1.4 Types of HIV/AIDS Related Counselling
1.5 Ethical Issues in HIV/AIDS Counselling
1.6 Let Us Sum Up
1.7 Suggested Readings

1.0 OBJECTIVES
The purpose of this unit is to provide you with a basic understanding about STI
and HIV/AIDS counselling. It is aimed at orienting you to the issues involved in
counselling someone vulnerable to STI/HIV infection or already having an STI
and/or HIV/AIDS.
After reading this unit you should be able to:
 understand the main features of STI counselling;
 understand the purpose of HIV/AIDS counselling and the different types of
HIV related counselling;
 get oriented to the ethical issues involved in HIV/AIDS counselling; and
 develop an understanding of the qualities required of an STI and HIV/AIDS
counsellor.

1.1 INTRODUCTION
STIs and HIV/AIDS have emerged as major public health problems in India. It
is estimated that there are 40 million new cases of STIs in the country every year
(NACO 1998). The prevalence rates are up to 10 percent in urban areas and 7
per cent in rural areas (NACO 1998). India also has the largest number of HIV
infected persons in the world. The epidemic is no longer confined to groups with
high-risk behaviour; but has moved well into the community. It is also becoming
increasingly visible in rural India. As the number of persons living with HIV/
AIDS increases rapidly the acute and complex psychosocial and economic burden
of the disease on the individual, family and the community is becoming evident.

Relationship between STIs and HIV

The predominant mode of transmission of both STIs and HIV is through sexual
intercourse. The same risk behaviour for a STI also puts the person at risk for
HIV/AIDS. STIs, especially ulcerative STIs and discharges, promote the
transmission of HIV. Studies have shown that in persons with HIV infection,
STIs may be more severe and resistant to treatment. With longer lasting symptoms
the facilitation of STIs and HIV infection is much easier, furthering the already
rapid spread of the AIDS epidemic. Thus, control and management of HIV/AIDS
have become major components of the National AIDS Control Programme.
Counselling has been recognized by the programme as having to play a very
important role in the prevention of STIs and HIV besides providing psychosocial
support to those already affected.

1.2 STI COUNSELLING – MAIN FEATURES

STIs are not discussed openly because of the shame, stigma and discrimination
associated with them. They are in fact referred to by some people as ‘private’ or
‘secret’ diseases. It is wrongly believed that STIs happen to “bad” people or
women in prostitution. Due to these reasons persons, with STIs do not seek
treatment. However, STIs can not only cause much pain and discomfort but also
have many damaging consequences. Counsellors need to be sensitive to these
perceptions. They need to demonstrate acceptance and a non-judgmental attitude
to clients. Every attempt should be made by them to safeguard the privacy and
confidentiality of their clients.

When counselling someone with a STI, the following points should be attended
to:
 What STIs are, and how they are contracted?
 The common symptoms and signs of STIs in men and women. Counsellors
need to emphasise that there may not always be symptoms; or, they may be
so slight that they do not bother the patient. Women especially, often do not
have any symptoms at all. However, without treatment, the patient is and
will remain infectious and can unknowingly pass on the disease.
 Myths about STI (myths regarding the mode of spread as well as means of
cure)
 Consequences of not treating an STI, especially for pregnant women.
 The relationship between STIs and HIV.
 Where a person can go for further information and tests: primary health
centres, STI departments in government hospitals/STI Clinics,
dermatologists (specialists in skin and sexually transmitted diseases),
gynaecologists, family physician (who may treat and/or refer) etc.
 Diagnosis and treatment. The importance of early treatment and compliance
needs to be stressed to ensure complete cure. STI patients should be
counselled to take all medication as prescribed even if the symptoms
disappear or they feel better.

How STIs including HIV can be prevented.

The following guidelines can be provided to clients:
If you are unmarried:
It is best to abstain from sex. By indulging in sex with anyone other than one’s
own spouse, you will be involving in risk behaviour, which may endanger your
life. HIV/AIDS is also an STI and there is no known cure for it at all till today.
Even the use of condoms does not guarantee full protection and safety. Therefore,
have sex only with one faithful sexual partner, who never indulges in sex with
anyone else, and does not have an STI.

If you are married

Keep safe by staying with one faithful sexual partner. If you have sex with many
partners, there is a great risk that one of them might harbour an STI and infect
you. Therefore, stick to one faithful partner, i.e. your spouse.

Partner Notification

Counsellors need to encourage the clients to inform the person/s that s/he has
had sexual contact with about the risk of STI infection. The sexual partners
could have the STI too, even if there are no symptoms. If clients find it difficult
to tell the sexual partner/s, then the counsellor could provide the necessary support
to do so. This issue has to be very sensitively handled so as not to cause any
irreparable damage.

Partner notification should always be done with the permission of the client,
except in the case of a client infected with HIV who has not informed the sexual
partner of his/her status and continues to have unprotected sex. Under such
circumstances, the counsellor may inform the partner responsibly.

1.3 HIV/AIDS COUNSELLING – ITS NATURE AND

PURPOSE
HIV/AIDS counselling has two general objectives:

1) To provide psychosocial support to those already affected; and

2) To prevent HIV infection by changing life-style/behaviour.

In order to achieve these objectives, counselling seeks to enhance self-
determination, boost self-confidence, and improve family and community
relationships and the quality of life. HIV/AIDS counselling, therefore, also means
providing support to families and loved ones, so that they, in turn, can help to
encourage and care for people with HIV infection.

For whom is HIV/AIDS counselling useful?

In context of HIV/AIDS, counselling is recommended for the following:
 Persons already identified as being infected with HIV, or as having AIDS,
and their families;
 Those being tested for HIV (pre- and post-testing);
 Those planning their future and seeking help because of past or current risk
behaviour; and
 Those not seeking help but who practice high-risk behaviour.
With these priorities in mind, the types of situations in which counselling is of
value might include the following:
 Persons with AIDS or other diseases related to their HIV infections;
 Persons experiencing difficulties with employment, housing, finances,
family; etc. as a result of HIV infection;
 Persons considering being tested for HIV;
 Persons who have been tested for HIV (whether or not they are infected);
 The family and friends of persons who are infected with HIV;
 Health workers and other professionals who come into regular contact with
persons infected with HIV;
 Persons who choose not to be tested despite past or present risk behaviour;
and
 Persons who are unaware of the risk of HIV infection involved in the specific
behaviours they have, or are engaged in.

Where can it be provided?

HIV/AIDS counselling can take place in any setting where there is, or could be,
a discussion about HIV/AIDS. Such settings include wards in hospitals, centres
for sexually transmitted diseases, antenatal and postpartum clinics, family
planning clinics, blood donation centres and sites, drug de-addiction centres,
prisons, community health schools, places of worship, outpatient clinics, and all
health outreach or community-based programmes. There will inevitably be other
types of settings that should be considered for this purpose.

However, the counsellor should pay attention to the specific setting in which the
client or family is seen. Each of these settings will call for different responses
from the counsellor. Each will influence responses from those being interviewed.
A supportive, helpful relationship cannot develop if the counsellor does not
acknowledge both the gravity of the problem and the context within which
discussions about it take place. For example, trying to ask questions about sensitive
personal topics in a crowded clinic waiting room obviously calls for an approach
quite different from asking the same questions in a private place. Attention to
context is important in any form of counselling, but is particularly important in
counselling with relation to HIV infection because of the severe stress and stigma
associated with the condition.

Who should provide it?

In addition to doctors, nurses, psychologists, psychotherapists and social workers,

other people can readily be encouraged and trained to provide counselling support.
Counsellors need not be professional health-care providers. Teachers, health
educators, laboratory personnel, religious and community leaders, youth group
workers, traditional healers, and members of self-help groups can undertake both
preventive and supportive counselling.

Why is it necessary?

Being diagnosed as having, recognizing the possibility of or suspecting the

existence of HIV infection or AIDS, all have profound emotional, social,
behavioural, and medical consequences. The type of personal and social
adjustment required in the context of HIV infection often has implications for
family life, for sexual and social relations, for work and education, for spiritual
needs, for legal status, and for civil rights. Adjustment to HIV infection involves
constant stress management and adaptation. It is a dynamic, evolutionary, and
lifelong process that makes new and changing demands of individuals, their
families and the communities in which they live.

During the course of HIV infection, a broad range of physical needs and problems
are likely to be experienced. These are not necessarily constant and will
progressively become more serious and difficult to handle. They call for increased
and different resources, both from those who are HIV infected and from the
persons looking after them.

Check Your Progress I

Note: Use space given below for your answer.
1) What are the main issues to be covered in counselling someone with
an STI?
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1.4 TYPES OF HIV/AIDS RELATED
COUNSELLING
Preventive Counselling
Preventive counselling is very important for
 those seeking help because of past or current risk behaviour and planning
their future,
 those not seeking help but who practice high risk behaviour; and
 those not involved in any risk behaviour currently so that they may be aware
of HIV/AIDS.

Further, in some places, facilities for testing are not readily available. Where this
is so, every effort should be made to emphasize preventive counselling, especially
the need for behavioural change where there has been high-risk activity, and the
maintenance of low-risk behaviour where changes has been brought about.
Preventive counselling would include risk assessment, risk re-education
counselling and information on HIV/AIDS. Counsellors’ function more as health
educators who provide clear and simple information, clarify misinformation and
assist in decision-making and implementation of behavioural changes.

The goals of preventive counselling are to help the client:

 Personalize his or her risk of HIV infection by recognizing that it is a personal
threat; and
 Assess his or her current and past risk of HIV infection.
At the beginning of the counselling session, it is important to:
 Discuss the importance of assessing the risk of getting HIV with a view
to preventing the disease.
 Explain that, in order to do this, explicit sexual behaviour and substance
use, including behaviours, which may be culturally considered taboo
subjects, must be discussed.
 Explain that the purpose is not to make assumptions about or judge a person’s
behaviour, but rather to prevent the person from becoming sick or
transmitting HIV/AIDS to others.
 Explain the necessity of reviewing all forms of risk behaviour with each
individual.
 Explain the specific area of HIV risk assessment.
 Assess the client’s knowledge of how HIV is transmitted and clarify any
misinformation.
 Ask the client to assess his or her current and or past high-risk behaviours.
 Ask the client to assess his or her risk of HIV infection while discussing
any concerns and clarifying misconceptions.
 Summarize the discussion about the client’s risk of HIV infection, leading
to discussion about risk reduction.
 Acknowledge openly the discomfort and embarrassment the client may feel
in discussing explicit sexual behaviour and substance use. Reassure them
that these are normal reactions.
 Explain that the client will be asked to reveal very personal and explicit
information that is not normally discussed with others, and that
confidentiality will be maintained.
The chief points to cover while talking about risk reduction are:
 Recognize that HIV transmission is avoidable.
 Identify behaviour changes that will reduce the client’s level of risk of
contracting or transmitting HIV.
 Plan behaviour changes. Changing sexual and drug use behaviours is
difficult. These are step-by step changes, which call for time, effort and
commitment.
 Develop strategies to overcome potential obstacles in implementing and
sustaining new behaviours.
 Evaluate the success attained, and reinforce positive changes. If the client
is available for follow-up, it is worthwhile to see how much change has
occurred and to encourage the positive action that has been undertaken.

i) Pre-Test Counselling

The Aim of Pre-Test Counselling

Counselling before the test should provide individuals who are considering
being tested with the information on the technical aspects of screening and
on the possible personal, medical, social, psychological, and legal
implications of being found either HIV-positive or HIV-negative. The
information should be given in a manner that is easy to understand and
should be up-to-date. Testing should be seen as positive act that is linked to
changes in risk behaviour.
The decision to be tested should be an informed decision. Informed consent
implies awareness of the possible implications of a test result. In some
countries, the law requires explicit informed consent before testing take
place; in others, implicit consent is assumed whenever people seek health
care. There must be a clear understanding of the policy on consent in every
instance, and anyone considering being tested should understand the limits
and potential consequences of testing.
Testing for HIV infection should be organised in a way that minimizes the
possibility of information disclosure or of discrimination. In screening, the
right of the individual must also be recognized and respected. Counselling
should actively endorse and encourage those rights, both for those being
tested and for those with access to records and results. Confidentiality should
be ensured in every instance.

Issues in Pre-test Counselling

Pre-test counselling should be centred on two main topics: first, the person’s
personal history and risk of being or having been exposed to HIV (box 1),
 secondly, the client’s understanding of HIV/AIDS and previous experience
in dealing with crisis situation (box 2).

In assessing the likelihood that the person has been exposed to HIV, the
following aspects of his or her life should be taken into account.

Box 1: Assessment of Risk

 Frequency and type of sexual behaviour and specific sexual practices;
in particular, high risk practices, such as vaginal and anal intercourse
without using condoms, unprotected sexual relations with commercial
sex workers, and drug infection.
 Being part of a group with known high HIV prevalence or with known
high-risk life-styles, e.g., injecting drug users, male and female
commercial sex workers and their clients, prisoners, and homosexual
and bisexual men.
 History of blood transfusion, organ transplant, or administration of blood
or body products.
 Exposure to possible non-sterile invasive procedure, such as tattooing
and scarification.

Box 2: Assessment of Psychosocial Factors and Knowledge

 Why is the test being requested?
 What particular behaviour or symptoms are of concern to the client?
 What does the client know about the test and its uses?
 Has the client considered what to do or how he/she would react if the
result turned out to be positive? What if it was negative?
 What are the client’s beliefs and knowledge about HIV transmission
and its relationship to risk behaviour?
 Who could provide (and is currently providing) emotional and social
support (family, friends, others)?
 Has the client sought testing before; and, if so, when, from whom, for
what reason, and with what result?

This initial assessment should make it possible to discuss the likelihood of the
client’s understanding:

a) The meaning and potential consequences of positive or negative result; and

b) How change in behaviour can reduce the risk of infection or transmission

to others.

Pre-test counselling should include a careful consideration of the person’s ability

to cope with a diagnosis and the changes that may need to be made in response
to it. It should also encourage the person being counselled to consider why he or
she wishes to be tested and what purpose the test will serve.
12
When the counsellor enquires about personal history, it is important to remember
that the client:
 may be too anxious to fully absorb what the counsellor says;
 may have unrealistic expectations about the test;
 may not realize why questions are being asked about private matters and,
therefore, be reluctant to answer; and
 may not be willing to change behaviour irrespective of the result.

During pre-test counselling, it is also important that the client be told that current
testing procedures are not infallible. Both false-positive and false-negative results
occasionally occur, although supplemental (confirmatory) tests are very reliable
if an initial test is positive. These facts must be clearly explained, together with
information about the “window period” during which the test may be unable to
assess the true infection of the person.

In summary, pre-test counselling should:

 Determine what that person understands about HIV and AIDS;
 Provide factual information as needed;
 Discuss potential implications of positive and negative test result;
 Explain and obtain informed consent;
 Review the test procedure;
 Assess the person’s ability to cope with a positive result; and
 Establish a relationship as a basis for post-test counselling.

ii) Post-Test Counselling

Post-test counselling is very important especially if the test result is positive.
However, a negative test result does not mean that the need for post-test
counselling is less important HIV testing can have three possible outcomes:
i) A negative result;
ii) A positive result; or
iii) An equivocal result.
Counselling after a Negative Result
It is very important to carefully discuss the meaning of a negative result (whether
this was expected or not). The news that the result was negative is likely to
produce a feeling of relief, of euphoria; but the following points must be
emphasised:

1) Following possible exposure to HIV, the ‘window period’ must have elapsed
before test results can be considered reliable. This means that, in most cases,
a minimum of at least three months must have elapsed from the time of
exposure before a negative test can be considered to mean that infection
did not occur. A negative test result carries greatest test certainty if at least
six months have elapsed since the last possible exposure.
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 2) Further exposure to HIV infection can be prevented only by avoiding high-
risk behaviours. Safer sex and avoidance of needle sharing must be fully
explained in a way that is understood and permits appropriate choices to be
made.

3) Other information on control and avoidance of HIV infection, including

the development of positive health behaviours, must be provided. It may
be necessary to repeat such explanations and for the counsellor to practice
together methods of negotiating these with others, in order to assist the
client in introducing and maintaining the new behaviours.

Counselling after a Positive Result

People diagnosed as having HIV infection or disease should be told as soon as

possible. The first discussion should be held in private and under conditions of
confidentiality, and the clients should be given time to absorb the news. After a
period of preliminary adjustment, the client should be given a clear, factual
explanation of what this news means. This is not a time for speculation about
prognosis or estimates for time left to live, but for acknowledging the shock of
the diagnosis and for offering and providing support. It is also a time for
encouraging hope – hope that achievable solution can be found to the resulting
personal and practical problems. Where resources are available, it may also be
justifiable to talk about possible treatments for some symptoms of HIV infection
and about the efficacy of new antiviral drugs. Important practical information
for people with HIV infection must be provided.

After a positive result, the counselling relationship may enter a new phase. Crisis
counselling will always be necessary, and usually problem-solving counselling
also. The pre-test assessment can be used to determine the best way to tell the
client about the test result. How the news is accepted will depend on the person’s
personality, psychological circumstances, previous knowledge of HIV, and
cultural attitudes towards AIDS. The clients must be told how to contact the
counsellor during periods of severe stress. There should be some discussion of
what may happen if employers or others learn that the person is HIV infected.
All the information previously given about safer sex, prevention of transmission,
and maintaining health must be repeated. Follow-up visits must be arranged,
often on a routine basis.

Counsellors must always stress the individual’s responsibility for changing

behaviour to avoid infection or to limit, if not eliminate, the risk of transmission,
and the lifelong nature of the infection and of the risk of infecting others.

How the news of the HIV infection is accepted often depends on the following:

1) The person’s physical health at the time. Persons, who are ill, may have a
delayed reaction. Their response may appear only when they have grown
physically stronger.

2) How well prepared the person was for the news. People who are completely
unprepared may react very differently from those who were prepared and
perhaps expecting the result. However, even those who are well prepared
may experience the reactions described in this unit.

14
3) How well supported the person is in the community and how easily he/she
can call on friends. Factors, such as job satisfaction, family life and cohesion,
and opportunities for recreation and sexual contact may all make a difference
in the way a person responds. The reaction to the news of HIV infection
may be much worse in people who are socially isolated and have little
money, poor work prospects, little family support and inadequate housing.

4) The person’s pre-testing personality and psychological condition. Where

psychological distress existed before the test result was known, the reactions
may be either more or less complicated and require different management
strategies than those found in persons without such difficulties. Post-result
management should take account of the person’s psychological and/or
psychiatric history, particularly as the stress of living with HIV may act as
a catalyst for the re-appearance of earlier disturbances.

In some cases, news of HIV infection can bring out previously unresolved
fears and problems. These can often complicate the process of acceptance
and adjustment and will need to be handled sensitively, carefully, and as
soon as possible.

5) The cultural and spiritual values attached to AIDS, illness, and death. In
some communities with a strong belief in life after death or with a fatalistic
attitude towards life, personal knowledge of HIV infection may be received
more calmly than in others. On the other hand, there may be communities
in which AIDS is seen as evidence of antisocial or blasphemous behaviour
and is thus associated with feelings of guilt and rejection.

Counselling and support are most needed when reactions to the news of
HIV infection or disease appear. Some reactions may initially be very intense.
It is important to remember that such responses are usually normal reactions
to life threatening news; and as such, should be anticipated.

The following are some common shock reactions to diagnosis or infection:

 Numbness/stunned silence/disbelief;
 Confusion/distractibility/uncertainty about present and future circumstances;
 Denial (“It can’t be true”/ “Don’t worry; things will be fine”);
 Despair (“Oh my God, everything is ruined!”);
 Anger towards health staff, loved ones etc., over the impact on life and
circumstances;
 Fear of pain, death, disability, loss of bodily/mental functioning, loss of
confidentiality/privacy;
 Guilt over the association of infection or illness with sexual activity, or
with being gay or a drug user;
 Acute and severe anxiety;
 Emotional instability (moving quickly and unpredictably form tears to
laughter and vice versa);

15
  Sadness and morbid concern about the future, work, lover/spouse, family,
health;
 Suspicion about the actions and behaviour of staff/loved ones/helpers; and/
or
 Relief at knowing what caused the recent illness.
In conjunction with these, there are a number of behavioural reactions to shock:
 Crying – episodic and often unpredictable,
 Anger and irritability – towards anybody, often ‘sparked off” by trivial and
unimportant events, (may be physical and/or verbal);
 Withdrawal – distancing from present issues and circumstances, reluctance
to become involved in conversation, activities or plans for treatment;
 Self-denigration – description of the self as “deserving this plague,”
“worthless,” “unclear and dirty.”
 Checking the body for signs of further infection or physical deterioration;
and
 Questioning – for reassurance and/or further information

The following points need to be repeatedly emphasised:

a) HIV infection is not AIDS. Prognoses vary; but every infected person should
be encouraged to live a normal, social and economic life unless AIDS-
related symptoms do not permit this. Since normal living requires the support
of others, those concerned may need regular counselling to anticipate and
cope with the new needs.
16
b) A person who is HIV positive should take care of his/her general health.
The presence of other infections, such as other sexually transmitted diseases
or any illness, will affect the immune response and may hasten the
development of AIDS. The counsellor must stress the need to avoid exposure
to illness as a measure to prolong life. The counsellor must explain how the
risk of infections can be avoided through general home hygiene and the
prevention of other sexually transmitted diseases, emphasising the need to
practice abstinence or to remain faithful to one’s own spouse.

c) Spouses and partners will need support. Telling them that HIV infection
has been found is difficult, and considerable support for this may be needed
from the counsellor. Bringing spouses or partners in for counselling to
prevent transmission and, where indicated, referring them for testing is a
frequent counselling goal.

d) Spouses and partners must be protected against infection. The use of

condoms may not be acceptable in some cultures and religions. Objections
to them, and the positive and negative consequences of using them, need to
be discussed.

e) A person who is HIV positive should be advised not share his syringes,
needles, or other skin-piercing instruments.

f) He must be told not to donate blood, plasma, body organs, or other tissues.

g) Avoid pregnancy. HIV infected women who are pregnant should know about
the great health risk to the unborn children and potential health hazard to
themselves, and be provided with counselling services. HIV infected men
should discuss the hazard of pregnancy with their partners. Given the present
situation where provision for adequate care and treatment of HIV infection
does not exist, an HIV infected woman should be discouraged from opting
for pregnancy.

h) The issue of breast-feeding needs to be discussed with mothers. Counsellors

need to keep themselves abreast with the latest information on this topic.
In summary after a positive test result, post-test counselling should:
 Ensure that the person understands what a positive HIV test result
means;
 Discuss how they feel about being infected;
 Provide support to help the person deal with these feelings;
 Discuss their plans for the immediate future;
 Establish a relationship with the person as a basis for future counselling;
 Schedule appointments for medical evaluation and follow-up
counselling;
 Counsel partner(s), if possible; and
 Refer the person to local community services, if possible.

17
 Counselling after an Equivocal Test Result

A test result may be equivocal for a number of reasons; for instance, there may
have been insufficient time for full seroconversion to take place since the possible
exposure to HIV occurred (the “Window period” previously mentioned). In such
circumstances, there are two main issues for the counsellor to consider:

I) The test used to determine whether the person is infected with HIV. The
first test most commonly used is ELISA, which is 100 per cent sensitive
with specificity approaching 99.5 per cent, so that a negative result can be
regarded as a definite indicator that the person is not infected, except for
tests carried out during the “window period.” Correspondingly, a positive
result suggests the possibility of HIV infection. The usual procedure then is
to retest, again using ELISA with specificity of 100 per cent. The results of
such supplemental testing can either be positive, strongly indicating HIV
infection, or negative indicating no infection. In situations where the presence
of HIV infection is to be confirmed, a third ELISA with a specificity of 100
per cent may be carried out on seropositive with the first two ELISA tests.
If it is positive, it strongly indicates HIV infection. If it is negative, it is
indeterminate. The reasons may be as follows:

 The person has developed non-clinical signs of HIV infection more

quickly than might normally be expected;

 A related HIV virus is present;

 A cross-reaction is occurring with a non-viral protein and the reaction

is simulating those associated with the HIV core protein.

The following options are then available:

a) To use alternative methods with the aim of obtaining a reliable result,

e.g., by using combinations of techniques so as to exclude false-positive
results;

b) Not to carry out further testing. Where the result is indeterminate and
either the results of further testing are being awaited or further testing
is not possible, it is not possible to say with any degree of assurance
that the person is HIV-infected. The counsellor should then advise the
person to present himself again after three months for repeat testing. It
is important to remember that, in areas with low levels of HIV infection,
the risk of finding a false-positive result is greater than in those where
background rates of HIV infection are high. Thus, where there are many
people with AIDS in the community, it is more likely that a positive
ELISA result is accurate. For more information, you may read Unit 4
of Block 2 of the Basic Course on HIV/AIDS.

II) Prevention and support while waiting for an unequivocal result. The period
of uncertainty following equivocal or indeterminate test result may be three
months or longer after the last instance of potentially high-risk exposure or
the previous test for HIV infection. It is then important for counsellors to
emphasise essential prevention messages regarding sexual and drug-use
activity, body fluid and tissue donation, and breast-feeding. The person
18
will need to undertake the precautions recommended for HIV positive persons
until proven otherwise. Just as importantly, however, the uncertainties
associated with this period may lead to acute and severe psychosocial
difficulties, and the counsellor must be prepared to assess and manage such
issues or to make appropriate referrals, if necessary, in every case.

Ongoing counselling for sero positive and terminal persons:

 Keep in touch with development in all spheres of the client’s life;

 Acknowledge information shared earlier;

 Deal with issues of sudden disruption in normal life;

 Provide support where client feels loss of control over life;

 Help client face situations where HIV positive status has to be disclosed,
for example, when visiting a dentist;

 Help client face situations where HIV positive status has to be disclosed
for example when visiting the dentist;

 Help client overcome hostility, indifference and prejudice of others;

 Re-establish coping skills and feeling of self-worth;

 ‘Teach client how to take care of self, as much as possible, as well as

how to protect others;

 Pay regular home-visits if a client is agreeable, and maintain

confidentiality;

 Build up a relationship with the client’s family;

 Always stress on hope and positive living;

 Stress on improving quality of life;

 Change client’s perception of HIV infection, making him understand

the difference between a terminal illness and a chronic disease which
may go on for years;

 Teach the client how to relax, e.g., meditation techniques;

 Encourage the client to participate in giving support to others and in

preventive work. Also encourage social activities with others as well
as individual hobbies;

 Support the process of anticipatory grief;

 Involve the client in planning of the future;

 Encourage participation in a self-help group;

 Help the client to accept death;

19
  Encouraging the client to concentrate on past achievements rather than on
failures;
 Encourage belief in a spiritual approach to coping.

Check Your Progress II

Note: Use space given below for your answer.
1) What are the issues that must be dealt with in counselling a person
with a negative test result?
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1.5 ETHICAL ISSUES IN HIV/AIDS

COUNSELLING
When someone seeking to be tested gives no history of high-risk behaviour, the
counsellor should enquire into the reasons why testing is sought, and offer
preventive and supportive counselling. The counsellor may discourage people
who do not want to know the test result from taking it, but should make it quite
clear to them that they must behave as if they were seropositive in order to prevent
infection of themselves or transmission to others.

Mandatory Testing

Mandatory testing may be carried out only for certain medical purpose and not
for identifying the infected individuals for ulterior motives. This risk must be
weighed against the cost to and consequence for social order and the civil rights
of compulsory testing. Counselling should encourage motivation and voluntary
action to bring about behaviour change. Mandatory testing should extend only
to blood and blood products, organs, breast milk, and other tissues in order to
avoid the risks of HIV transmission to the recipients of these products.

Informed consent is another difficult issue. Where health care workers usually
behave in any authoritarian manner, it may be tempting to “order” person to be
tested. Counsellors know, however, that people are more likely to respond
positively to information and counselling if they themselves take part in decision-
making. As far as possible, therefore, counsellors should ensure that, before any
test, the client understands the procedures, their limits and the possible
psychosocial consequences of being tested. Whether they are likely to be
seropositive or only want to be reassured, clients must be told what the test
involves, to whom the result may be communicated and the possible repercussions
on themselves.
20
In some places, the counsellor may be required to ensure that a client gives
written informed consent for certain medical procedures. The counsellor should,
therefore, make the following points very clearly:
 No test can tell whether someone has, or will, develop AIDS;
 The tests available detect antibodies to HIV in the blood;
 The presence of HIV antibodies (except for passive maternal antibodies in
the case of uninfected infants of HIV-infected mothers) is proof only of
HIV infection; it does not prove that the person is suffering, or will suffer,
from HIV-related diseases;
 It is impossible to tell from a positive HIV test when the person was infected
or for how long. This point is important and needs to be discussed with
clients so as to make sure that they understand that HIV infection may have
occurred before an existing relationship began and does not necessarily
imply that the current partner has been unfaithful. It could also be other
risk behaviour or exposure;
 Whether the test is positive or negative, behaviour must often be changed,
either to remain negative or to protect others against HIV infection;
 A negative result does not rule out infection. If there has been risk behaviour,
the test should be repeated three months after exposure has occurred, to
allow for the “window effect;” and
 Some kinds of behaviour and practices are dangerous to the HIV-infected
person because they lead to exposure to other infections, including sexually
transmitted diseases.

Trust in terms of confidentiality is one of the most important factors in the

relationship between the counsellor and the person being counselled. It enhances
that relationship and improves the chances that the person (or even the group)
will act decisively on the information provided. Given the possibility of
discrimination, ostracism, and personal discrimination when an individual is
diagnosed as having HIV infection, it is all the more important that confidentiality
be guaranteed. The counselling relationship must be based on the understanding
that whatever is discussed will remain confidential until and unless the client
decides to share that information with someone else. A breach of confidentiality
is unethical.

Sometimes, in a hospital, the counsellor may not be in position to guarantee

confidentiality, before a test for example. He must tell the client about this and
discuss the implications. Protecting confidentiality may be very difficult in clinics
or health services where there is little privacy, or where offices are kept open for
ventilation purposes.

There may be some instances where the counsellors or other health workers feel
that confidentiality may need to be broken, e.g., a decision made to notify the
sex partner of an infected person even when the client has refused them permission
to do so. The most common conflict for counsellors is that between observing
complete confidentiality and informing the family or other intimates, in their
own or the public’s interests. Also, what is the counsellor to do when a HIV
carrier or AIDS patient continues to put other people at risk? The counsellor
 must be aware of, and consider these difficult issues and be familiar with the
legal and ethical rules which guide them.

Confidentiality is valued differently in different places. In some cultures, for

example, a person may have a relationship with someone else who has a culturally
assigned role as a caregiver or confidant. Anyone who fails to reveal something
to this person violates an important cultural norm.

Counsellors must be aware of the limits of medical confidentiality in a particular

culture. The ideal is total confidentiality of test result and respect for privacy.
Where the rights of individuals are highly valued, it is easy for counsellors to
explain the need for confidentiality. In community or group-oriented cultures,
counsellors will have to adapt their concept of confidentiality to cultural
expectations and traditional norms.

In such and similar situations, the health care provider will be required to make a
decision consistent with medical ethics and the relevant law of the country. In general,
where confidentiality is preventing the adoption of appropriate individual measures to
avoiding the spread of HIV, it may be necessary to reconsider whether it should be
maintained.

Partner Notification

This issue is linked to confidentiality and has also been discussed in the section on STI
counselling. There may be some instances where the counsellor or other health care
workers feel that confidentiality needs to be broken, for example, to notify the sex-
partner of an infected person when the client refuses to do so and continues to involve
in high risk activity. In such cases, the counsellor will be required to make a decision
consistent with medical ethics and the relevant legislation.

Check Your Progress III

Note: Use space given below for your answer.
1) What are some of the points, which the counsellor should inform the
client about before giving consent for carrying out medical procedures?
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1.6 LET US SUM UP

In this unit on STI and HIV/AIDS counselling, we have discussed the main
features of STI counselling, and the ethical issues involved in HIV/AIDS
counselling. The aim of this unit is only to help you to understand the purpose of
HIV/AIDS/STI counselling and to know some of the desirable qualities for an
STI and HIV/AIDS counsellor.

22
1.7 SUGGESTED READINGS
TISS (1994), HIV/AIDS Prevention and Counselling: Manual for Grassroots
Level Workers, Cell for AIDS Research Action and Training, Department
of Medical and Psychiatric Social Work, Tata Institute of Social Sciences.

WHO (1994), HIV/AIDS Counselling, A Guide for Trainers, World Health

Organization, Regional Office for Southeast Asia, New Delhi.

NACO (1994), HIV/AIDS/STI Counselling Training Manual, National AIDS

Control Organization (Ministry of Health and family Welfare)
Government of India, New Delhi.

Thomas, Gracious (1997), Prevention of AIDS: In Search of Answers, Shipra

Publication, New Delhi.

23
Counselling in HIV and Family
Matters UNIT 2 FAMILY AND PREMARITAL
COUNSELLING

Contents
2.0 Objectives
2.1 Introduction
2.2 Selection of Marriage Partners
2.3 Why Does One Marry?
2.4 Sex in Marriage
2.5 Counselling on Family Planning
2.6 Rights and Responsibilities
2.7 Let Us Sum Up
2.8 Suggested Readings

2.0 OBJECTIVES
The purpose of this unit is to provide you with an understanding of the importance
and different aspects of pre-marital and family planning counselling.
At the end of this unit you will be able to:
 understand pre-marital counselling and its significance;
 become conversant with the various issues related to pre-marital counselling;
 understand family planning and its significance; and
 be sensitive to the larger context in which family planning decisions are
made.

2.1 INTRODUCTION
Traditionally, in India, a wedding is a big event. Everybody looks forward to it.
Young boys and girls are anxious to get married. Their parents are anxious to get
them married off, and relatives and friends look forward to the celebrations. The
time, effort and money spent on wedding preparation are amazing. There are
negotiations between the two marriage parties about dowries, gifts, and wedding
expenses. There are discussions about the auspicious time and date for the
wedding, the number of guests to be invited and the various customs and rituals
to be followed. It is a busy and important time for the whole family. At a wedding,
a family shows off its guests, shows off its wealth, and shows off the bride and
the groom. The status of the family is based on display at the wedding.

While all these preparations are made for the wedding and its celebrations,
comparatively little or nothing is done to prepare the bride and the groom for
living their lives as married partners. The would-be-bride and groom are expected
to pick up messages about their roles and responsibilities from some verbal and
nonverbal communications causally given by parents, relatives and friends. There
24
is hardly any information given on sexuality; and the little that the groom and
bride-to-be may receive is inadequate and inaccurate. No guidelines are given
on building up a relationship, forming a compatible partnership, coping with
conflicts, or where to turn for help when needed. Parents and educational
institutions are equally guilty of neglecting the most practical aspects of an
enlightened education, i.e., guidance and instructions for living a happy and
harmonious life.

A marriage, even at the best of times, experiences many challenges. Today, with
rapid social and economic changes, it faces greater pressures. More and more
marriages are experiencing strife and legal separations and divorces are on the
increase. The pain and anguish caused by divorce and marital strife prove to be
extremely costly to society in both human and financial terms. In this context, pre-
marital counselling has a very important role to play.

2.2 SELECTION OF MARRIAGE PARTNERS

By Arrangement

In traditional Indian families, the parents or relatives of the bride and the groom
arrange their marriage. Often, it is possible that the bride may meet the groom for
the first time on the wedding day! The partners are total strangers and start their
lives together on the wedding night!

Many Indian families, especially in urban settings, will let the boy and the girl
meet in the presence of adults. The atmosphere is often tense for the young people.
They are made to dress attractively and given instructions to make a good
impression. Both the boy and the girl know that they are on display. The parents
25
 and/or the prospective marriage partners will decide if the match is suitable. If
they all agree, the match is made and wedding preparations begin. If the match is
not approved, the parents will arrange more meetings till a suitable match is
found. If this search for the marriage partner goes on for a long time, it is bound to
have a very negative effect on the marriageable person.
These types of marriages are considered as arranged marriages:
 When parents, relatives, friends arrange the marriage;
 When professional matchmakers are involved in arranging the marriage;
 When marriage proposals are sought through advertisements.

In many cases, astrologers are consulted and horoscopes of the would-be-bride

and groom are matched according to religious customs.

By Choice

Some families will permit the boy and the girl approved by the families to meet
and get acquainted. During this period of getting to know each other, the young
people decide whether or not they want to get married. With more opportunities
available for boys and girls to meet outside their homes, they get attracted to
each other and fall in love. The individuals then decide to get married and may
or may not take the consent of their parents.

What do parents look for in a good match?

i) The external appearance of the boy or girl, that is, height, skin, colour,
physique, attractive face, long hair, etc., takes a high priority in the choice.
Physical disability, however minor, such as, lips in speech, squint eyes,
sometimes even wearing spectacles, often become the cause for rejecting
the boy or the girl.

ii) Economic status of the family plays an important role: dowry settlement
from the girl’s parents, family income of the boy, property and business of
both families are considered vital.

iii) Education and job security of the boy, and in our current context, also that
of the girl are considered seriously in middle and high-income group
families.
iv) Health of both;
v) Home-making skills of the girl; and
vi) Matching of horoscopes is yet another consideration.

In poor and less literate families, in villages and slum communities, these criteria
hardly have any importance. Religion, caste and social status certainly carry
much more weight.

What do young people look for in a good match?

The most attractive thing for both boys and girls of marriageable age is the physical
appearance of the partner. A survey of young people in an Indian city revealed
26
that the things boys find attractive in girls are: long hair, good complexion, a tall
and slim body, a fair skin, attractive eyes, full breasts, a pleasing smile, a sweet
giggle, being easy to talk to etc.

The things girls find attractive in boys are: good height, a good physique, broad
shoulders, physical strength, good looks, a sense of humour, good dress sense
etc.

Basically, young people from rural or urban areas are attracted to physical traits
and outward behaviour in people of the opposite sex. They often look for the
heroes and heroines they admire in films. Basing one’s choice of a life partner on
any of the above factors alone does not guarantee a happy married life.

What should one look for in a good marriage partner?

The maturity and health of a partner are important factors in a successful marriage.
Similarities between partners can help a marriage to start on a firm foundation.
These similarities can be divided into four groups:
i) Basic orientation of life with regard to values, views on religion, goals, and
convictions;
ii) Ideas about marriage in relation to fidelity, sex, children, and in-laws;
iii) Personal factors such as age, education, social and economic status; and
iv) General factors, which include cultural, social, and political backgrounds.

More details on this subject are given in the basic and elective courses on family
education.

Courtship
The period of courtship is the most romantic time in a person’s life. This is the
time between the agreement to get married and the marriage. The courting couple
looks forward to their meetings with each other. They dress with great care and
try to please each other. They are on their best behaviour and strive to make an
impression on each other. This behaviour takes time and priority over all else.
Hence the essential issues which two people should talk about before marriage
are often left out.
The time of courtship should be used by a couple to find out the attitudes, values
and similarities as well as the differences between them. The issues that could be
discussed profitably during courting are:
i) Expectations of each partner: about their roles vis-à-vis each other. How
does the couple propose to divide/share their professional responsibilities?
Does the couple or any one of the partners subscribe to traditional role
definitions? How will these influence expectations?
ii) Religion, especially in case of mixed marriages (inter caste, inter-cultural
and inter-religious marriages). Couples in these cases need to discuss issues
of family support, feelings and coping in the absence of support; religion
the children will follow in the case of inter-religious marriages, etc. Very
often these issues are left to be tackled after the couple gets married; and
that can lead to a whole lot of conflicts that could have been easily avoided.
iii) Housing for the young couple: where the new couple will stay, advantages
and disadvantages of living in a joint or a nuclear family, financial resources
to buy a house, etc.

iv) Relatives (in-laws): expectations of in-laws regarding the daughter-in-law,

e.g., continuation of job, when to have the first child, etc.

v) Dependents (parents, siblings): to whom will the couple handle the

responsibility towards dependents, especially the wife’s responsibility
towards her own parents.

vi) Interests and hobbies: Flexibility of both partners to pursue interests jointly
and separately. No matter how intimately bonded the couple is, each partner
should have the freedom and space to pursue her/his interests individually.
The couple should not be so enmeshed that each partner loses her/his
individual identity. Such a situation would not be healthy for the marriage.

vii) Economics: the couple’s current and future financial status. Is there sufficient
income to support the marriage? If so, from what sources? If support from
either the bride’s or groom’s family is involved, the question of how this
affects such relationships must be posed. Who will have primary
responsibility for the household accounts? If not already covered in previous
discussions, how was the decision made as to who would manage the
household finances and how comfortable are both parties with that decision?

viii) Household chores and division of work: especially if the wife is going to
continue with her job.

ix) Number of children and when to have them: depend on the age of the couple,
financial resources, support available, access to services such as crèche
facilities, etc.

x) Family planning: how the couple will share family planning responsibilities,
choice of family methods, religious beliefs about family planning, etc.

xi) Friends if from different social backgrounds: respect for each other’s friends,
freedom to pursue friendships, how one would relate to one’s spouse’s friend
whom one may not particularly like.

xii) Career of the woman: if she is working or plans to work after marriage.

xiii) Decision making and conflict resolution (Discussed below in detail).

The entire relationship developed during the courting period should be based on
honesty and trust. Withholding information or deceiving one’s partner may make
the aggrieved partner sour and disappointed.

Readiness for Marriage or Maturity

The legal age for marriage is 18 years for girls and 21 years for boys. Despite this
law, many young boys and girls are married before reaching puberty. In rural
areas this practice is still prevalent although the tradition is gradually changing.

Boys and girls have to be biologically, emotionally and socially mature in order
to take on the responsibilities of marriage. Biologically a boy may be capable of
fathering a child by the age of 14 to 16 while a girl can bear a child by the age of
12 to 14. However, they are not yet emotionally and physically ready, especially
girls, to become parents. It creates serious health issues for the females.

Check Your Progress I

Note: Use space given below for your answer.
1) What should one look for in a good marriage partner?
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2.3 WHY DOES ONE MARRY?

There are some questions that should be considered by young people who are
contemplating marriage as marriage entails a lifelong commitment. The answers
will differ from individual to individual.
1) Do I wish to marry because I need a spouse to further may career or to fulfil
my ambitions?
2) Do I wish to marry in order to have someone to look after my house, my
parents, or me?
3) Do I wish to marry in order to have a dowry to support me financially?
4) Is my desire to get married due to my need for a child who will bear my
name?
5) Do I wish to marry in order to get away from an unhappy home or to cure
my loneliness?
6) Am I prepared to share a sexual relationship with another person?
7) Will I marry only if I am deeply in love with the person?
8) Do I wish to marry because my parents want me to marry?
9) Do I wish to marry because my younger sister or brother is already married?
10) Do I wish to marry for companionship?
Some Considerations and Anxieties
1) What do I want out of life for myself?
2) Can I handle a marriage and a job? Do I have time and energy for both?
3) Do I expect my spouse to make my life happy?
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4) Will I prove that I am a man or woman by getting married?
5) Do I want to give my spouse the love he or she needs? Is loving easy for
me?
6) Can I afford to support a spouse?
7) How would a spouse interfere with my growth and development?
8) In case of a second marriage – Have I dealt sufficiently with the pain of
death or divorce?
9) Am I ready to have a child? Do I want to have children at all?

The expectations that the couple bring with them into their marriage differ and
this is likely to affect their relationship with each other. Unless they can come to
some agreement on the major issues, serious conflicts can occur and threaten
their life together. For this, the couple needs to be able to communicate effectively
with each other. The couple should be able to communicate feelings, ideas, goals
or images for the future. The importance of the quality of communication should
impress upon the couple. Communication is a learned skill and should not taken
for granted.

Working Towards a Happy and Harmonious Marriage

Some points that can help an individual to keep marriage fresh and vibrant are:
— Knowing your partner
— Accepting rather than trying to change the partner.
— Changing with time. Both the partners change as they go through life and
have to keep adjusting to this change in each other.
— Dealing promptly with minor problems; solutions have to be worked out
rather than putting the blame on each other and bearing grudges.
— Giving each other room to develop by not invading the each other’s privacy,
and by not being possessive or jealous.
— Planning the future together.
— Acknowledging the marriage commitment.
— Accepting the in-laws from both sides.
In order to bring fun into a marriage some of the following points will help:
— Drop your inhibitions.
— Be spontaneous.
— Be playful.
— Surprise each other by doing something unexpected and pleasant.
— Learn to laugh together.
— Bring joy to your sex life.
— Be loving throughout your married life.
— Respect each other

Fun is important. Marriage needs an atmosphere of light-heartedness.

Resolving Quarrels and Conflicts

Quarrels and conflicts are natural to any healthy relationship. A marriage spent
in denial of this issue of conflict resolution is bound to result in repression or
internalization of feelings, denial, unresolved hostility, ulcers, and in quite a real
sense, the death of the marriage. In the marital relationship, these may arise due
to:
 Difference of perceptions about things,
 Lack of trust,
 Jealousy of partner’s achievements, popularity etc.,
 Interference of In-laws,
 Sexual disharmony due to lack of information, unrealistic expectations about
performance, inhibitions, insensitivity, sexual role stereotypes etc.,
 Differing backgrounds, namely; religion, financial status, social standing
etc.,
 Conflicting value systems, and
 Dowry demands.

Minor Adjustments of day-to-day Living

Different psychological facets are present in individuals. Couples need to

understand how they characterize themselves in terms of being essentially
dominant or submissive: are there instances in their experience of one another in
which one pattern prevails while at other times, on other issues, the opposite
may be the case?

Another set of categories, which may be helpful to evaluate, is whether they see
themselves as primarily rational, intuitive, sensing and feeling types of persons.
There are not right or wrong answers to this. These insights can be used to help
the couple understand each other better so that they are able to relate effectively
and meaningfully with each other.

A couple should seek to ensure that the minor adjustments of day-to-day living
do not become serious on-going battles. This could be achieved through the use
of ‘fair-fight’ rules:

i) Keep to one topic and don’t bring up past grievances.

ii) Get the fight over as soon as possible.

iii) Don’t battle in public.

iv) Don’t say hurtful things to each other. Words once spoken cannot be taken
back.

31
v) Never hit each other.
vi) In case the situation gets volatile, take a break. Cool down, pick up the
threads, and resolve the issue as soon as possible.
vii) Don’t threaten to end the relationship.
The major issues may not be so easy to settle unless:
a) Both compromises,
b) Both learn to change, and
c) Both seek help of other family members or friends, or of a counsellor.

If the problems go unresolved, both partners live in an unhappy marriage. In

extreme cases this may result in mental and physical ill health, escapist measures
like alcoholism, extra-marital relations, separation, divorce, or even suicidal
attempts.

Remember

You get out of marriage what you put into it. Marriage is a partnership, not an
ownership. It is a two-way street of respect based on trust, time, talk, and touch.
The biggest risk and chance one take in life is in marriage. A good marriage is a
union of heart, mind, soul and body.

Adjustment in Marriage

Adjustment in marriage is a lifelong process. The type and extent of adjustment

changes from stage to stage. The early stages of adjustment are more dramatic for
the woman than for the man. She has to adjust to and cope with several things.
The woman has to adjust with:
 The fact of leaving her parental home and moving into a new and often a
strange home.
 Interacting with new members of the family (husband and in-laws).
 The routines of her new home.
 Her new role as a wife, daughter-in-law and sister-in-law.
 The new experience of physical intimacy.
 Developing an adult image, she has to drop the carefree ways of her parent’s
home and has to be restrained, dutiful and obedient.
 Handling both home life and work (if she is working outside the house).
The man’s adjustments are comparatively few. He has to adjust to:
 Sharing his life with his spouse.
 Sharing physical intimacy with his spouse.
 The fact that his spouse may hold a job outside the house.

If his wife has a job outside the house, it could mean that she spends more time
outside the home than in it. She earns a substantial salary, which gives her greater
independence and status in society. She interacts with people whom he may not
know. She is confident and self-assured.

If the husband suffers from poor self-esteem, this could threaten his ego and
pride, especially if the wife is insensitive and makes him feel incompetent.
However, as more and more women are taking up jobs outside the home, men are
learning to adjust. This often leads to a more democratic relationship between
the sexes.

Check Your Progress II

Note: Use space given below for your answer.
1) What are some of the adjustments a woman has to make in her husband’s
home?
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2.4 SEX IN MARRIAGE

Sex is an essential ingredient of marriage. The satisfaction or dissatisfaction in
sex life can contribute to the attitudes and behaviour of both partners towards
each other. The earlier belief that men are more sexual and have more urges than
women is no longer accepted as true. Scientific research has shown that both
men and women have strong sexual urges, and it is the responsibility of both to
satisfy each other’s needs and respect each other’s moods and feelings.
Sexual activities are not only meant for procreation. They contribute to pleasure,
entertainment, sharing of love, and help the couple to remain in intimate
relationship. They are also a means of expressing love for each other and
communicating most intimately. Both partners, therefore, should:
— Feel comfortable with each other.
— Understand and respect each other’s needs.
— Talk about the feelings of pleasure and pain that the sexual activity causes.
— Let their sexual activities be private and undisturbed.

Preparation for Sexual Relationship: The Wedding Night

The couple needs to be prepared for a happy and satisfying sexual relationship.
It has been observed that, at times, there is no consummation of marriage because
of lack of knowledge about the facts of life, anxiety, fear, or romantic ideas
about the wedding night, leading to disappointments and frustration. The first
wedding night experience can be very traumatic and may have a long-term impact.
 For most Indian couples, the “wedding night” or what is popularly known, as
“suhaag raat” is very important. In most cases this is the first night together for
most couples who are inexperienced in relationship. For all practical purposes,
this is the first night in world they offer themselves to each other both in mind
and body. It is the beginning of the long journey of marital and family life, the
primary unit of any society.

What usually happens to married couple on their wedding night? In most cases,
they are both tired. They are ignorant, have inadequate information, or have
misconceptions about the sexual experience. Both are strangers to each other.
Both feel they have to live up the wedding night fantasies depicted in the movies.
Individually, both the man and the woman may have their own fears and anxieties.
Previous history of sexual abuse in either partner could have its influence as
well.

Women
 There is the emotional tension of leaving the parental home.
 There could be fear of pain and bleeding at the first intercourse.
 There could be anxiety about pregnancy and childbirth
 There could be apprehension about her in-laws.
 There could be clashes between the in-laws on dowry issues, gifts, etc.
causing tension especially in the young bride.
 There could be inhibitions about sex.
Man
 There could be anxiety about sexual performance.

Consequences and Effects

If the groom is aggressive or inconsiderate, he may force a sexual intercourse on

the wife, which may prove to be a traumatic experience for her. If the groom is
unable to perform at the expected level, or if there is failure, then he himself
could get disappointed and lose confidence in himself. This may affect his future
sex life specialty if his wife is not cooperative and understanding enough. She
may question his virility, which may further damage his self-confidence. It is
possible that, due to ignorance about proper sexual postures or due to fear of
pain and bleeding, despite the effort to have sexual intercourse, the marriage
does not get consummated.
 To ensure a more relaxed and less anxious beginning of sexual relationship,
the married couple should:
 Have premarital counselling;
 Develop mutual understanding; and,
 Avoid trying to consummate the marriage at all costs on the wedding night.

There is nothing wrong if the couple decides on their own to postpone their first
sexual intercourse after marriage till both of them are physically and emotionally
34
relaxed, instead of rushing into fulfil the common expectation of the wedding
night. This can only occur if a proper dialogue is established. They must find the
time and privacy to talk about this issue. The parents should ensure that the couple
get opportunity for proper orientation on all these small but very important aspects
in marital life.

Pre-marital Counselling

An important thing to consider in pre-marital counselling is whether any of the

partners has experienced any sexual trauma in her/his history such as rape,
molestation, incestuous advances etc. It needs to be recognized that past sexual
trauma can easily constitute a physical and psychological impediment to marriage
if not resolved. If the response is affirmative, the counsellor should help the
partner to sort out his/her feelings, or refer them to someone who is skilled in this
area. Also important to explore is whether either partner has resolved issues
about sexual identity, i.e., whether he or she is attracted to a person of the same
sex, opposite sex, or both. If these issues are unresolved, they could have serious
implications for the marriage. A person, who is inclined to or is in a homosexual
relationship, may not be in a position to exercise her/his right to be in a same sex
relationship for various reasons; and so, may enter into marriage as a cover up. If
the person has maintained a sustained physical or deep psychological or emotional
attachment to a person of the same sex, specific counselling is imperative to
determine the possibility of commitment to an exclusively heterosexual marital
love relationship.

Check Your Progress III

Note: Use space given below for your answer.
1) What usually happens to married couples on their wedding night?
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2.5 COUNSELLING ON FAMILY PLANNING

Family planning means planning how to improve the quality of family life. It
includes:
 Taking decisions on regulating and spacing child births;
 Choosing suitable methods of contraception;
 Helping childless couple to have children;
 Counselling of both parents and would-be parents; and
 Developing parenting skills, social skills and family budgeting skills.
 Thus, family planning is much wider than is normally thought. It does not merely
mean avoiding having children or merely taking decisions about the practice of
contraception. Planning a family aims at improving the quality of life by regulating
family size so that each child comes when it is wanted, and gets the love, care,
security, and nurturing needed for her/his total development, especially in the
context of developing self-worth.

If a couple would like to raise a family and yet maintain a reasonable standard of
living, a small family is the best way to do this. A small family means that parents
are able to devote more time, energy and resources on each child, thus giving
each offspring a better chance to develop his/her potential than would be possible
in a large family.

Having a small family would also mean having enough time to devote to each
other, and to be able to enjoy family life without always having to worry about
making ends meet.

Family planning is a very serious business and calls for decisions to be taken by
both partners. The need for family planning can be understood in terms of the
family life cycle, and family needs and resources. Couples who have decided to
delay having a first child or to space their children need to choose the method of
contraception, which is best, suited to their needs.
Choice of method may be influenced by:
— Knowledge about different methods;
— Availability and accessibility of family planning services;
— Experience of a particular contraceptive method (For instance, if use of
Copper T causes excessive bleeding, infections or comes in the way during
sexual intercourse, the woman may discontinue its use.);
36
— Number of children they wish to have (For instance, permanent sterilization
is the method of choice if the couple wishes to have no more children.);
— Health of both partners (For instance, a woman who suffers from high blood
pressure or diabetes should not use the oral pill. If either of the partners has
a sexually transmitted disease, the use of a condom is advised while awaiting
a cure.); and
— Religious sanctions: whether the religion the couple belongs to permits the
use of certain contraceptive methods.

Such a decision, however, can be made properly if only both the partners have
proper knowledge of how the different methods work, their advantages and
disadvantages.

Contraceptive methods fall into the following categories viz. Natural methods,
spacing methods, and permanent or surgical methods.
1) Natural family planning methods
i) Abstinence (refraining from sexual intercourse)
ii) Coitus interruptus
iii) Rhythm method
2) Spacing methods
i) Barrier methods
ii) Condoms (for males and now also for females)
iii) Diaphragm
iv) Chemical spermicide to be used locally in the vagina
v) Hormonal devices (IUD)
vi) Oral pill
vii) Injectables
viii)Implants
ix) Intrauterine devices (IUD)
3) Permanent or surgical methods
i) Vasectomy for the male.
ii) Tubal ligation for the female (A thread, wire, fillet or the like, tied
tightly around the fallopian tubes to constrict them, thereby obstructing
the passage of the ovum)
iii) Tubectomy for the female

Abortion is not a family planning method but is available on demand if a

contraceptive fails.
Remember, every contraceptive method has a failure rate which increases with
incorrect method of use. The failure rate of the natural methods is the highest,
whereas that of the surgical and hormonal methods is the least. The couple
should also understand that using contraceptive pills after every sexual
intercourse will lead to severe health issues in females.

Check Your Progress IV

Note: Use space given below for your answer.
1) What are some of the common aspects influencing couple in choosing
any of the family planning methods?
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2.6 RIGHTS AND RESPONSIBILITIES

At the International Conference on Population in Mexico City, held in August
1984, the following recommendation on family planning was adopted which
was accepted by 157 countries:

All couples and individuals have the basic right to decide freely and responsibly
the number and spacing of their children, and to have the information, education
and means to do so. Couples and individuals in the exercise of their rights should
take into account the needs of their living and future children and their
responsibilities towards the community.
Hence, every family planning client has the right to information about:
— The benefits and availability of family planning,
— The correct use of family planning methods and how each works,
— The advantages and disadvantages of different family planning methods,
— The immediate side effects of family planning methods,
— The long-term consequences of family planning methods, and
— The availability of medical guidance.
Counselling services should facilitate the client in several ways such as:

Access To obtain services regardless of sex, creed, colour, marital

status or location.

Choice To decide freely whether to practice family planning and

which method to use based on the available information
Safety To be able to practice safe and effective family planning
Privacy To have a private environment during counselling or
services
Confidentiality To be assured that any personal information will remain
confidential.
Dignity To be treated with courtesy, consideration and
attentiveness
Comfort To feel comfortable when receiving services
Continuity To receive contraceptive services and supplies for as long
as one needs them
Opinion To feel free to express views on the services offered.

Conversely, all family planning clients also have the responsibility to:
— Be honest about their medical history.
— Follow instructions carefully on how to use the family planning method
selected.
— Ask if they do not understand.
— Go back to the family planning clinic if they feel any side-effects or for
supplies when needed.
— Tell the clinic staff of any complaints or suggestions they have about the
clinic services.

Family planning choices of couples do not occur in a vacuum. A number of

larger contextual factors such as socio-cultural practices (for instance, son
preference), religious beliefs, gender power, dynamics, economics, etc., have a
major bearing on such decisions. Though a woman bears the responsibility of
contraceptive use and the burden of repeated pregnancies, family planning
decisions are controlled to a large extent by her husband and family. Their
involvement in family planning counselling is, therefore, vital. To be more
effective, family planning counselling needs to go beyond contraceptive use,
spacing and limiting of births to addressing issues of decision making, sexuality,
intimacy, violence between couples and responsible male involvement. It needs
to address the issue of equitable gender relations.

2.7 LET US SUM UP

In this unit on Family and Pre-marital Counselling, we have discussed a wide
range of topics such as selection of marriage partners (by arrangement or by
choice), readiness for marriage or maturity, reasons for marriage, adjustments in
marital life, sex in marriage, pre-marital counselling, the role of counselling of
family planning, and the rights and responsibilities involved in a marital life
recommended at the International Conference on Population in Mexico City in
1984.

39
 2.8 SUGGESTED READINGS
TISS (1994), HIV/AIDS Prevention and Counselling: A Manual For Grassroots
Level Workers, Cell for AIDS Research Action and Training, Department
of Medical and Psychiatric Social Work, Tata Institute of Social Sciences.

WHO (1994), An Orientation to HIV/AIDS Counselling, A Guide for Trainers,

World Health Organisation, Regional Office for Southeast Asia, New
Delhi.

NACO (1994), HIV/AIDS/STI Counselling Training Manual, National AIDS

Control Organisation (Ministry of Health and Family Welfare)
Government of India, New Delhi.

Thomas, Gracious (1997), Prevention of AIDS: In Search of Answers, Shipra

Publication, New Delhi.

40
 Family and Premarital
UNIT 3 COUNSELLING ON SEXUALITY Counselling

AND SENSITIVE ISSUES

Contents
3.0 Objectives
3.1 Introduction
3.2 What is Sexuality?
3.3 Guidelines for Talking about Sensitive Topics
3.4 Sexual Myths and Misconceptions
3.5 Sexual Coercion and Violence
3.6 Sexual Problems
3.7 Let Us Sum Up
3.8 Suggested Readings

3.0 OBJECTIVES
The aim of this unit is to sensitize you to the complex issues involved in
counselling a client on sexuality and other sensitive matters, and the appropriate
attitudes that need to be developed by counsellors working in this area. At the
end of the unit we hope you will:
 understand the concept of sexuality;
 get sensitized to issues of normality and abnormality in sexuality;
 get oriented to different kinds of sexual behaviours and their risks in terms
of STIs and HIV/AIDS;
 develop a basic understanding of issues related to sexual orientation;
 understand some sexual myths and misconceptions;
 get a basic understanding of issues related to sexual coercion and violence;
 develop some level of comfort in discussing sensitive issues; and
 begin exploring your own views and values on sexuality with a view to
developing appropriate attitudes.

3.1 INTRODUCTION
It is essential to be able to discuss sex and sexuality openly and comfortably
when working in the field of HIV/AIDS since almost nine out of ten persons in
India are infected through sex. It is impossible to talk about AIDS without talking
about sex. Some of the myths, misconceptions and incomplete information about
sex and sexuality influence our ability to effectively prevent HIV transmission.
Unfortunately, many counsellors find it difficult to get over being shy, embarrassed
and put off dealing with the sexual issue; at other times, they are judgmental and
label a sexual behaviour as not normal. Counsellors will need the essential 4 C’s
41
 – compassion, care, communication and counselling to be effective. To be able
to counsel effectively, it is also important to have a basic knowledge of sexuality
and the range of sexual behaviours that people practice.

3.2 WHAT IS SEXUALITY?

Sexuality refers to gender – male or female – but has been relegated to imply
“doing” something, such as having an intercourse or orgasm; or to the vagina, the
penis, and the genitals. Sexuality is a more complex phenomenon, which is difficult
to define but perhaps easy to understand. Sexuality refers to the total sexual makeup
of an individual. Self-esteem, body image, social roles and relationships are just
few of the determinants of our sexuality. It includes sex, sexual behaviour and
sexual intercourse. It is expressed in many physical ways. It is not confined to
sexual intercourse; but includes touching, talking, embracing, fantasizing, kissing,
caressing, even just holding hands. In addition to covering the physical aspects,
sexuality also encompasses feelings, attitudes, values and preferences. It involves
also a lot of caring and sharing. The World Health Organisation (WHO) defines
sexual health as the integration of physical, emotional, intellectual and social
aspects of sexuality in a way that positively enriches and promotes personality,
communication and love. Understanding sexuality is important for healthy sexual
behaviour.

What Exactly is Normal?

Today, it is recognized that there are many variations of sexual behaviour. No

two people behave exactly the same way sexually. On the other hand, we all like
to think that how we act and how we think about sex is “normal”. In reality,
culture, tradition, society and our own emotions and experiences have conditioned
our thinking. For example, when we think of homosexuality, a range of emotions
and judgements are expressed by different people about it:
 “They are unnatural;”
 “They should not be tolerated;”
42
 “It is abnormal;”
 “They should be ostracized;”
 “It is alternative sexual behaviour;” and
 “Homosexuals are as good as heterosexuals.”

Whatever may be the beliefs or personal views; counsellors must be non-

judgmental in viewing the client as a person requiring compassion, understanding
and help to adopt healthy attitudes to sex and sexual mores.

Certain criteria to evaluate what is “healthy” in a sexual relationship could be:

 There should be consent between the husband and wife to engage in what
gives them mutual satisfaction;
 The sexual activity should not cause physical or mental harm;
 It should be a private affair, not public; and
 The activity should not be exclusive (for example, one partner insisting
that only masturbation should be done). It is important to remember that
vaginal insertion is the usual and necessary condition for procreation.

Spectrum of Sexual Behaviours

The spectrum of sexual behaviours between two individuals is wide. Although

our society has given sanction for sex only between husband and wife, it is a
known fact that people do involve in pre-marital and extra-marital sex. Generally,
any sex outside marriage is considered to be ‘immoral.’ Further, there is no set
pattern as far as the type of sexual activities in which one can be involved.
Counsellors need to have adequate knowledge about them and their probable
risks in terms of STIs and HIV/AIDS infection.

Some activities are mentioned below:

Abstinence: Keeping away from sex. Culturally, in India and in most other parts
of the world, people in general and a good number of young people believe that
sexual intercourse should be done only within marriage. Virginity is still prized.
Consequently, those wishing to practice abstinence should be encouraged. They
should be made aware of the positive aspects of abstinence and the great values
associated with confining sex within the bounds of marriage.

Masturbation: Means stimulating one’s own genitals to reach orgasm. Most males
masturbate with their hands, while some rub their penis against the surface of
the bed, or use some object to bring about arousal. Females also masturbate in
the same way. Masturbation is still a taboo topic. However, masturbation has
been considered as one of the satisfactory and harmless ways to achieve sexual
release. However, it may produce ‘guilt feelings’ in those who are riddled with
many misconceptions regarding it. Many others, while rejecting the myths, the
taboos and the ‘do’s’ and ‘don’ts’ about masturbation, may still feel anxious,
uncomfortable or guilty about it. It is important that, while attempting to change
a client’s behaviour, he/she must be made to understand the views of the two
schools of thought on the subject:
43
1) The ‘School of Ethical Thought’ argues that masturbation is a selfish sexual
activity through which one looks for personal satisfaction, pleasure, release
of tension etc. It is argued that the primary purpose of sex is procreation and
for expression of love between a husband and a wife. The husband has the
right over the body of his wife; and the wife has the right over the body of
her husband. If individuals look for sexual satisfaction through self
masturbation, then the primary duty of providing sexual satisfaction to the
spouse gets diminished. This will ultimately lead to avoiding sexual
intercourse, or limiting it which will have far reaching consequences on the
‘husband-wife relationship’. In course of time, values such as concern for
the spouse, his/her satisfaction, love for one another, self-giving, loving-
kindness, thoughtfulness, attraction towards him/her etc. will get diminished.
This is bound to result in defeating the very purpose of marriage, family life and
sex in one’s life.

2) The ‘School of Safe-Sex Thought’ argues that masturbation is a harmless

activity and may be practiced as a “safe sex” activity instead of indulging in
high-risk behaviour like pre-marital and extra-marital sex. They argue that
the only harm it does is development of “guilt feelings”. The proponents of
safe-sex practices say that masturbation can help in avoiding pregnancy and
infection with HIV/AIDS/STIs. This practice has been recommended as
one of the ‘safe sex’ practices by several psychologists and institutions
(including governments) who are involved in the prevention and control of
HIV/AIDS all over the world.

It is for the individual to choose what in best for him/her for a satisfactory life.

Kissing: It is the pleasurable touching of one’s lips against another’s. Deep kissing
is pressing the mouths together with the lips parted, which allows for one’s tongue
to play in the others mouth. Although, theoretically, deep kissing carries a slight
risk of transmission because HIV infection can be carried through saliva, the
chances of transmitting the virus are virtually nonexistent even if blisters or cuts
are present in the mouth of either partner. Partners also derive pleasure as well
as satisfaction and intimacy through kissing on other parts of each other’s body.

Oral Sex: It is the stimulation of the genitals with the mouth. Transmission of the
HIV virus is possible through oral sex because of the chance of coming in contact
with the vaginal fluid or semen. Fellatio is when a man’s penis is stimulated
through the mouth of another man or a woman. Cunnilingus is when a woman’s
clitoris and vaginal area are stimulated through the mouth of another woman or
man. Persons involved in both same sex and heterosexual activities often practice
oral sex.

Anal Sex: It is the insertion of the penis into the rectum of a woman or a man.
This is risky in terms of HIV transmission for the recipient, because the lining of
the rectum is thin and can tear exposing white blood cells directly to the semen.
Even without tearing, HIV virus can pass through the mucus membrane lining the
rectum. Men who have sex with men or between heterosexual partners practice
anal sex.

Vaginal Penetration: It is the insertion of the penis (or any other object) into the
vagina of the woman. This can be a high-risk activity because, when the vagina
is penetrated by the penis, HIV-infected semen can pass through the mucus
membrane lining the vagina and enter the white blood cells of the woman.
Conversely, if a woman is infected, the HIV virus in her vaginal secretions can
enter the man through the mucus membrane of the head of the penis. Withdrawal
of the penis before ejaculation does not reduce the risk of HIV transmission.
However, sexual intercourse between a mutually faithful couple is certainly a
‘safe sex’ practice which needs to be encouraged.

Sexual Orientation

A person’s sexual orientation, that is, whether a person is emotionally and sexually
attracted to a person of the same sex, opposite sex or both, is a fundamental part
of the person’s overall identity. It also plays a large part in determining a person’s
intimate relationships. In the context of HIV/AIDS, an understand of the client’s
sexual orientation is important for purposes of assessment of sexual behaviours
and risk perception to self and partners.

Heterosexuality: People who are emotionally attracted to and chose to share

their bodies sexually with persons of the opposite gender are called heterosexuals
(i.e., man-woman relationships). Generally speaking, these male-female
relationships are more common among people. In the context of HIV/AIDS in
India, the spread of HIV infection is highest among the heterosexual group who
are also involved in sex outside the marriage.

Homosexuality: Persons who choose to share their bodies sexually with persons
of the same gender are called homosexuals. In a male-male relationship, the
person may be termed gay. In a female-female relationship, the person is known
as a lesbian. Why some prefers homosexual behaviour is still being debated. The
term “alternative sexuality” is becoming a more acceptable term. It is to be noted
that attitudes towards homosexuality are changing, although there is still a great
deal of antagonism towards homosexuals, as well as contempt, anger and
misunderstanding among the general public. Health professionals are now coming
to accept homosexuality more as a sexual variation than as an illness. Sometimes,
homosexual experiences may be situational like when it happens in prisons,
boarding schools, colleges and hostels. The person may participate voluntarily
or be even forced when he or she usually prefers to avoid indulging in any sexual
activity. Homosexual behaviour is dangerous when penetrative anal sex and oral
sex occurs. Fine injuries or ruptures around the anus and mouth help the meeting
of HIV infected blood or semen with the blood of the uninfected partner. Oral
sex, which is a popular sexual activity among the homosexuals, can be unsafe if
a partner has oral, vaginal or penile lesions. Often, behaviours like “cruising”,
where a person goes out to find an unknown partner or stranger in a train, or
exhibition etc., can be very unsafe behaviours. The dangers associated with such
behaviours should always be explained to the client. Sex between lesbians can
be unsafe in terms of HIV/AIDS risk if there is an exchange of body fluids or
sharing of unsterilised sex objects (used for penetration) with more than one
partner.

Bisexuality: Bisexuals are persons who frequently indulge in both homosexual

and heterosexual activities. They are persons who are sexually attracted to or
have intercourse or other sexual activities with both men and women. A number
of homosexuals are unable to stand up to societal disapproval or family pressure
to marry; and, may thus enter into a bisexual role. Studies also suggest that
45
homosexuals in India sometimes maintain a bisexual existence, the heterosexual
side being their public posture to gain social acceptance. There are also men
who perceive themselves to be heterosexuals but occasionally have sex with
other men, which they consider to be “masti.” Often, such practices are not viewed
as risky in terms of HIV infection. However, they can be dangerous not only for
themselves but also for their sexual partners.

On Counsellors and Sexuality

A few words for counsellors on sexuality is essential which will help them during
the process of counselling:
— They should be comfortable and familiar with the terminology of human
anatomy, physiology and sexual behaviour;
— They should understand the basic underlying processes of reproductive and
sexual physiology;
— They need to appreciate the range and variety of sexual expression in the
human culture;
— They must recognize the social implications of human sexual behaviour and
the relative nature of these implications in different societies; and
— They have to work at being able to deal candidly with their own sexuality in
relation to themselves and others; and,
— They should be persons who reflect on the related moral and ethical
dilemmas.

Check Your Progress I

Note: Use space given below for your answer.
1) Briefly highlight the argument of ‘school of ethical thought’ on
masturbation.
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3.3 GUIDELINES FOR TALKINGABOUT

SENSITIVE TOPICS
It is necessary for the counsellor to obtain an understanding and history of the
behaviour, which may have exposed the client to HIV infection or AIDS. This
means that he must be able to gather and interpret information about very private
– and sometimes illegal or socially condemned – behaviour. There is no simple
formula for getting people to talk about topics such as their own sexual activities,
drug injecting or responses to infection from blood transfusions. Effective
discussion of sensitive topics will depend in large part upon the ability of the
counsellor to:
 gear his/her communication to the emotional and intellectual level of the
client;
 make the client feel safe, secure and accepted by establishing a supportive
relationship; and
 demonstrate his/her own ease in talking about topics usually avoided in
ordinary social life or in medical consultations.

Whatever approaches counsellor uses, this will require skill, tact and sensitivity
towards the client. With some clients, counselling can be a process, which
develops gradually and may need to be eased into slowly. Early on, a rapport
will need to be established, together with an overall atmosphere that helps the
client to develop a feeling of safety and trust, without which the counselling
process will not be completely successful. The counsellor’s style must, therefore,
be reassuring, confident and direct, but considerate of the client’s feelings and
fears and acknowledging the client’s difficulty.

Guidelines

The following specific guidelines on talking about sensitive topics will be useful
to counsellors:

 Ask direct questions so as to be clear about what is worrying the client, and
what he or she wants and expects from the counsellor.

Example: “What do you want from me (this clinic, hospital, etc) right now?
What made you decide to come here now?” (Anticipate a certain degree of
embarrassment at discussing sex; point out that you realize that people do
not usually discuss it in such depth.)

Example: “We do not usually talk very openly about sex in our country.
But, now, since you believe you may have been at risk of infection, you and
I must determine the degree of risk. To do that, I have to ask some very
specific questions. Most people feel a bit embarrassed by these questions,
and you too may feel the same. For example, I need to know how many
sexual partners you have had over the past six months.”

 Explain clearly why you must inquire into sexual practices and drug injection
habits, namely, that it is in order to determine precisely what the client
needs to do to prevent becoming infected or passing the infection on to
others.

Example: “HIV is transmitted in a number of quite specific ways. You

know that sharing needles is dangerous for you and for others. What can
you do to keep yourself free of infection, or to protect other people?”

 In such interviews, the counsellor should use formal expressions first (e.g.,
vaginal intercourse). If it is not understood, the slang expression should be
47
 used and the client should be asked which one he or she prefers. The client
must not feel that the counsellor is making any moral judgment on any sexual
behaviour or other risky behaviour. (The counsellor should check frequently
to make sure that the client understands what is being said; for instance, by
asking the client to repeat in his or her own words what the counsellor has
been saying.)

 Cultural factors influencing sexual behaviour.

It is important to note that, in some cultures, the absence of penetrative sex

is the same as not having had sex at all – suggestions for safe sexual practices
may, therefore, not be well received in such cultural and religious settings.
In these cases, it must be reiterated that the only complete safe behaviour is
a monogamous long-lasting relationship in which neither partner is infected
with HIV. In our society, this monogamous relationship is only between
the husband and the wife.

The counsellor should anticipate that some of this information might be

met with embarrassment, laughter, turning away, or even anger depending
on the cultural context. On religious grounds, for example, a person might
become angry with a counsellor who mentions masturbation and, perhaps,
safe sex. As always, the counsellor should respect the client’s beliefs, but
point out that everyone is entitled to complete information, whether or not
a decision is made to act on it.

3.4 SEXUAL MYTHS AND MISCONCEPTIONS

Some of the common myths and misconceptions that counsellors may encounter
are mentioned below:
I) Nocturnal emissions make boys weak: Loss of semen through a “wet dream”
or nocturnal emissions (involuntary ejaculation during sleep) is perfectly
normal, and a harmless occurrence. It does not make one weak. A male
client may suffer from guilt, shame or anxiety when such dreams occur.
Counsellors must make their clients understand that nocturnal emissions
are perfectly normal.
II) The size of penis equivalent to masculinity or virility: The size of the penis,
either when it is flaccid or when it is erect, is no indication of a man’s
masculinity or ability. It is a myth that a long penis is necessary for adequate
sexual pleasure. In the woman, primarily, it is the labia, the clitoris and the
outer one-third of the vagina that are sensitive to sexual touch. As such, the
size of the penis is not an important factor.
III) A drop of semen is equal to 20 drops of blood: Semen has no relationship to
blood and its loss causes no weakness to the body. Semen is meant to be
released from the body. Dissipation of semen does not devitalize a man,
nor promote ageing, or lead to seminal bankruptcy.
IV) Masturbation is harmful: It is a common sexual activity practiced by both
males and females. It does not affect sexual functioning. Masturbation does
not lead to acne, insanity, impotence, homosexuality, mental retardation,
reduction of the size of the penis or changes in the angle of the penis as
may be commonly believed.
V) Using a Copper “T” or having undergone a tubectomy or vasectomy for
birth control also protects from HIV: This is not true. Use of Copper “T”
may actually increase the rate of transmissions, especially infection of the
reproductive tract.

VI) Condoms are the only form of birth control and safety measure to protect
from HIV transmission: This is not true. There are other methods of family
planning. Similarly, condoms do not provide full safety either from HIV
transmissions or pregnancy.

VII) STIs can be cured if the infected man has sex with a virgin: STIs require
medical treatment. Sex with a virgin will only pass on the infection to that
innocent girl, very often a girl child.

VIII) A girl cannot get pregnant if a boy doesn’t ejaculate or “come” inside her:
Even if a boy does not ejaculate inside a girl’s vagina, it is still possible that
the pre-seminal fluids, which contain sperm, can cause pregnancy. If the
boy is infected with HIV, the girl also will be at risk because the fluids
could contain the virus.

IX) Coitus should be avoided during pregnancy: Coitus during pregnancy is

permissible unless the doctor advises otherwise for medical reasons.
However, the sexual activity should not be uncomfortable for the pregnant
woman. In case of pain, vaginal bleeding or a past history of abortion,
coitus must to be avoided. It is necessary to consider the wishes of the
pregnant woman particularly during certain periods of pregnancy when it
could affect the safety of the child.

Check Your Progress II

Note: Use space given below for your answer.
1) Write briefly about any three guidelines on talking about sensitive
topics, which will be useful to counsellors.
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3.5 SEXUAL COERCION AND VIOLENCE

Many sexual behaviours, particularly rape, incest, and abuse of children, are
universally prohibited. Yet they occur with some frequency and often leave the
survivor severely traumatized. Every form of violence is a manifestation of power
and threatens the individual with physical or psychological violation and limits
his or her ability to make their own life choices. They can have debilitating
mental (depression, low self-esteem, anxiety, suicidal thoughts, etc.) and physical
health consequences (physical injury, STIs, HIV, and in some cases, death). Many
types of sexual behaviour are punishable by law since they infringe on another
person’s right to safety and security. The law, however, may not deal adequately
with the degree to which sexual abuse violates the individual’s (usually a women’s
or a child’s) personhood, mental or physical integrity, or freedom of movement.

Rape: Rape refers to forced sexual relations often with actual or threatened
violence. Often the rapist’s motivation is not to enjoy sexual pleasure but to
express anger, hostility, power, or aggression, either towards the victim personally
or towards a class of people whom the victim represents.

There are many myths in society regarding rape that helps to romanticize it,
especially in films. The truth is that rape is a forced sexual act. It can affect a
person of any age, of any sex, and at any place. Most rape victims are women.

According to section 375 of the Indian Penal Code (IPC) a man is said to commit
‘rape’ when he has sexual intercourse with a woman under any of the following
six circumstances:
 First – Against her will
 Secondly – Without her consent
 Thirdly – With her consent, when her consent has been obtained by putting
her or any person in whom she is interested in fear of death or hurt.
 Fourthly—With her consent, when the man knows that he is not her husband,
and that her consent is given because she believes that he is another man to
whom she is or believes herself to be lawfully married.
 Fifthly – With her consent, when, at the time of giving such consent, by
reason of unsoundness of mind or intoxication, caused or administered by
him personally or through another person.
 Sixthly – With or without her consent when she is under sixteen years of
age.

The IPC considers rape to occur only when a man assaults and has intercourse
with a woman. It does not cover the rape of a man. While the very idea seems
unbelievable, it is true that a male can be coerced into having sexual relations.

Unfortunately forced sexual intercourse between a husband and a wife is not

considered to be rape, according to the IPC, unless the wife is under sixteen
years of age. The final version of section 375 of the Indian Penal Code, which
emerged after deliberations in the Select Committee, is a crystallized form of
Clause 359 of the Macaulay’s Draft Penal Code. Section 375, the provision of
rape in the Indian Penal Code (IPC), has echoing very archaic sentiments,
mentioned as its exception clause- “Sexual intercourse by man with his own
wife, the wife not being under 15 years of age, is not rape.”

As per the Indian Penal Code, the instances wherein the husband can be criminally
prosecuted for an offence of marital rape are as under:
1) When the wife is between 12 – 15 years of age, offence punishable with
imprisonment upto 2 years or fine, or both

2) When the wife is below 12 years of age, offence punishable with

imprisonment of either description for a term which shall not be less than 7
years but which may extend to life or for a term extending up to 10 years
and shall also be liable to fine.

3) Rape of a judicially separated wife, offence punishable with imprisonment

upto 2 years and fine

4) Rape of wife of above 15 years in age is not punishable.

In 2005, the Protection of Women from Domestic Violence Act, 2005 was passed
which although did not consider marital rape as a crime, did consider it as a form
of domestic violence. Under this Act, if a woman has undergone marital rape,
she can go to the court and obtain separation from her husband. This is only a
piecemeal legislation and much more needs to be done by the Parliament in
regard to marital rape.

Statutory rape is a special category of offence in which the law considers rape to
have occurred when, even though the abused individual may have consented,
the latter was younger than a legally defined ‘age of consent.’ Here the ‘consent’
is invalidated by the fact that the victim of the rape is not old enough to make
sexual decisions maturely. Under the IPC, this age bar is set at 16 years of age.
Such a law is meant to protect minors.

If a woman has been raped, the most important step is to get help immediately.
The initial response would be to go home, take a bath (to wash off the acute
sense of violation she feels) and just try to forget the whole sordid event. But in
this case, one’s instincts are not necessarily right.

The best place to go, even if there are no obvious injuries, is a hospital emergency
room. For emotional support and comfort, she could call a trusted friend, someone
who will not blame her for getting raped but, on the contrary, would be very
supportive.

Despite a strong desire to wash herself, she should avoid doing so until after the
medical procedures are completed. This is in case she decides to take legal action
later against the perpetrator. The medical procedures consist of:
 A pelvic examination, or a rectal examination; and
 Examination and treatment of any external injuries.

Later a VDRL test will help diagnose the presence of an STI. Prophylactic
treatment by antibiotics for the prevention of sexually transmitted diseases can
then be taken.

A woman who has been raped must also accept that the rape will affect her both
physically and psychologically. The immediate responses can range from
numbness and disbelief to extreme anxiety, fear and disorganisation. The woman
will probably feel physical pain, depression, anger, fear, and humiliation as well.
She may feel guilty, repulsive and defiled since her body has been violated. She
51
may feel impure and ashamed through no fault of hers. She may feel that she is not
worthy of her husband or that she has brought disagree to her family.

The victim’s pain or emotional scars should not be treated lightly. S/he should be
reassured that, with support and professional help, she can look forward to
recovery and resuming her life. The victim’s family, especially the husband (if
married), will also require lot of support and professional help to deal with this
crisis.

Incest: This is a sexual abuse where the perpetrator, who is most often a male, is
a close family relative of the victim (in most cases a female, though in some
cases the victim can be a male) or a member of the extended family. The abuse
generally involves sexual intercourse. Incest is more common than people like to
believe. It occurs with shocking frequency; and, yet, these cases are not reported.
The affected family can be from any race, religion, social, economic, or
educational background.

The incest victim, be it a male or a female, will suffer guilt, pain and intense fear
of continued abuse. In Indian homes, little support is given to the victim. The
closest relatives will find the news outrageous; and, therefore, will not believe
the victim. If they do believe the victim, they are likely to maintain silence and let
the victim suffer rather than make public the family scandal. Hence, the vulnerable
victim has no way out but to suffer in silence.

Incest is a crime: While legal help is very important, physically removing the
victim from the exploitative environment should be the first priority. The victim
should be provided with access to professional counselling to deal with the feelings
of guilt and fear, and to help him or her rebuild his or her life. There are self-help
groups for incest survivors where they could also be referred.

Child Sexual Abuse: Child sexual abuse occurs much more frequently than is
likely to be believed. The abuser may inappropriately kiss, fondle or touch bodily
parts associated with sex. In some
instances, the abuse could also
include sexual intercourse. Most
sexual contacts are with relatives
or friends. Studies show that the
abuser is often the father or a male
relative in case of females. In the
case of boys, the abuser is often an
older adolescent, a male
acquaintance, a relative (father,
uncle, and sibling), or a neighbour.
A small proportion of sexual
offences against children are
committed by people who are
strangers (men and in rare cases,
women) who habitually molest
children.

A child is almost always severely

scarred emotionally by the abuse,
especially if it has been extensive
and/or violence was involved. The child may withdraw, have eating, sleeping
and school problems, be depressed, be afraid of strangers and may have a number
of physical and psychological symptoms. Many also suffer long-range effects.
Their social, psychological, and sexual adjustment could be impaired well into
adulthood. The child, who has been deeply hurt, will need the concerted help of
his or her family and of a professional therapist to recover.

Child Rights Legislations

The Protection of Children from Sexual Offences Act (POCSO Act) 2012 was
formulated in order to effectively address sexual abuse and sexual exploitation
of children. The Protection of Children from Sexual Offences Act, 2012 received
the President’s assent on 19th June 2012 and was notified in the Gazette of India
on 20th June, 2012.

The Act defines a child as any person below eighteen years of age. It defines
different forms of sexual abuse, including penetrative and non-penetrative assault,
as well as sexual harassment and pornography. It deems a sexual assault to be
“aggravated” under certain circumstances, such as when the abused child is
mentally ill or when the abuse is committed by a person in a position of trust or
authority like a family member, police officer, teacher, or doctor. The Act also
casts the police in the role of child protectors during the investigative process.
Thus, the police personnel receiving a report of sexual abuse of a child are given
the responsibility of making urgent arrangements for the care and protection of
the child, such as obtaining emergency medical treatment for the child and placing
the child in a shelter home, and bringing the matter in front of the CWC, should
the need arise.

The Act further makes provisions for avoiding the re-victimisation of the child at
the hands of the judicial system. It provides for special courts that conduct the
trial in-camera and without revealing the identity of the child, in a manner that is
as child-friendly as possible. Hence, the child may have a parent or other trusted
person present at the time of testifying and can call for assistance from an
interpreter, special educator, or other professional while giving evidence. Above
all, the Act stipulates that a case of child sexual abuse must be disposed of within
one year from the date the offence is [Link] Act also provides for mandatory
reporting of sexual offences. This casts a legal duty upon a person who has
knowledge that a child has been sexually abused to report the offence; if he fails
to do so, he may be punished with six months’ imprisonment and/ or a fine.

3.6 SEXUAL PROBLEMS

It is not uncommon for clients to raise anxieties and fears about sexual functioning
during counselling. Counsellors, therefore, need to be aware of the common
sexual problems that clients face and where to refer them for appropriate help.

Sexual problems may be the result of medical, biological, relational, personal

and related concerns. They affect desire as well as satisfaction. Most adults with
sexual problems do not seek help. Some may consult their gynaecologists, family
physicians or psychiatrists while others approach quacks with disastrous
consequences. There are very few health professional in India who are trained in
sex therapy. Counsellors need to refer clients to professionals who are trained to
53
 handle these issues or who at least have the sensitivity and correct knowledge to
discuss these matters with clients. In most cases, such help in India is inadequate.

Problem in sexual desire: Sexual desire is a problem when the level of interest
is persistently low or absent. In this case, the person wants sexual relations so
rarely that it causes the partner considerable strain and dissatisfaction. Problems
in sexual desire could be a symptom of other difficulties. What appears as low
sexual desire may be hormonal dysfunction, or may be due to depression,
relationship conflicts, stress, or a combination of these. Still other underlying
concerns might include sexual inhibition, the inability to recognize or deal with
one’s own sexual arousal, or subtle but disabling negative sexual signals from
one’s partner. Couples need to see a counsellor or a physician for help.

Problems in arousal: Arousal problems manifest themselves in men quite

dramatically. Despite foreplay and sexual interest, the penis does not get erect or
seem firm enough for intercourse. At other times, the penis becomes erect but
does not stay hard long enough for intermission.

Difficulty in arousal is less obvious in women but is nevertheless critical. The

vagina does not expand and lubricate. Unlike the man with an erectile problem,
the women with an unlubricated vagina may still have intercourse if she wishes.
She may use a lubricant to enable the penis to be admitted and intercourse to take
place. Arousal problems are common in both sexes, although they may be temporary
or only occur once in a while. Such momentary difficulties are not likely to
necessitate treatment; but if arousal is persistently problematic, professional help
should be considered.

Orgasm and Ejaculation Problems

a) Delayed ejaculation: Orgasm/ejaculation problems in both sexes often centre
about time. A woman or a man may require a good bit of sexual stimulation,
perhaps an hour or so, before reaching a climax. The woman may then be
diagnosed as having delayed orgasm, and the man as exhibiting delayed (or
retarded) ejaculation.
b) Rapid (Premature) ejaculation/orgasm: Orgasm or seminal emission may
occur so rapidly that it frustrates one or both partners.

Genital pain: Most men and women occasionally feel some discomfort during
intercourse. Often, a pause in sexual activity (a little rest, talk, and tenderness) is
very helpful in such cases. But relaxing and starting foreplay again may not
correct the problem. Pain in the genital area, dyspareunia, could be serious and
persistent.

A related problem can occur in the vagina, which usually opens to facilitate
intercourse. The vagina may also close quite tightly. In vaginismus, the muscles
associated with the vagina go into spasm. They contract and close the organ so
effectively that even inserting a small-lubricated finger may be difficult or
uncomfortable. Typically, the vaginal spasm occurs as foreplay intensifies; but
it could also happen at any time. The vaginal spasm may be a reflex like
response to dyspareunia or emotional distress: the organ is guarding itself from
intercourse and pain.

54
Treatment of sexual problems generally consists of counselling, teaching of certain
sex techniques, behaviour therapy and in some cases medical treatment.

Check Your Progress III

Note: Use space given below for your answer.
1) According to section 375 of IPC, what are the six circumstances under
which a man is said to have committed a rape?
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3.7 LET US SUM UP

Human sexuality is a very important aspect of people’s lives and needs to be
well understood by the counsellor involved in HIV prevention and supportive
counselling. It refers not only to sexual intercourse but also to feelings, attitudes
and values. What is considered as normal by one person in one society may be
considered as abnormal by someone else in another social environment. It is
important for counsellors to be non-judgmental about client’s sexual preferences
and orientations. Some of the sexual behaviours that need special attention in
connection with STIs and HIV are: abstinence, masturbation, nocturnal emissions,
oral sex and homosexuality.

To obtain an understanding of the circumstances that led the client to place himself
or herself at risk of HIV infection, the counsellor must be able to obtain
information on such sensitive topics as sexual practices and drug injecting habits.
This can be done only through informed questioning. Questions must also be
used to ensure that all clients have the basic information on HIV infection and its
prevention. Clients must be given advice on healthy and safe sexual practices.
They should be made to understand that the only completely safe behaviour is
sexual abstinence or a monogamous long-lasting relationship. The latter is
particularly important in cultures in which advice on non-penetrative or safe
sexual practice is not well received. In discussing levels of risk, counsellors will
again have to talk to clients about sensitive topics, and will themselves need to
decide how ready they are to talk about them. The importance of not sharing
needles and syringes and other injection equipment should be emphasized and
the methods of sterilizing injecting equipment should be explained.

55
 3.8 SUGGESTED READINGS
TISS (1994), HIV/AIDS Prevention and Counselling: A Manual For Grassroots
Level Workers, Cell for AIDS Research Action and Training, Department
of Medical and Psychiatric Social Work, Tata Institute of Social Sciences.
WHO (1994), An Orientation to HIV/AIDS Counselling, A Guide for Trainers,
World Health Organisation, Regional Office for South-East Asia, New
Delhi.
NACO (1994), HIV/AIDS/STI Counselling Training Manual, National AIDS
Control Organisation (Ministry of Health and Family Welfare) Government
of India, New Delhi.
Thomas Gracious (1997), Prevention of AIDS: In search of Answers, Shipra
Publication, New Delhi.
Indian Penal Code (45 of 1860), Section 376A. Intercourse by a man with his
wife during separation.—Whoever has sexual intercourse with his own
wife, who is living separately from him under a decree of separation or
under any custom or usage without her consent shall be punished with
imprisonment of either description for a term which may extend to two
years and shall also be liable to fine
Indian Penal Code (45 of 1860), Section 376(1).
Ibid 14 Indian Penal Code (45 of 1860), Section 376A.
Indian Penal Code (45 of 1860), Exception to Section 375.
The Protection of Women from Domestic Violence Act, 2005, Section 3
Explanation 1 (ii)

56
 Counselling on Sexuality and
UNIT 4 EXISTING TRENDS IN Sensitive Issues

COUNSELLING SERVICES IN
INDIA

Contents
4.0 Objectives
4.1 Introduction
4.2 Who are Mental Health Professionals?
4.3 Training Facilities
4.4 Places of Work
4.5 Scope for Lay Counsellors
4.6 Scope for Social Work Counsellors
4.7 Let Us Sum Up
4.8 Suggested Readings

4.0 OBJECTIVES
This unit introduces you to the various professionals who cater to the emotional
(mental) health needs of the public. Descriptions are given of the qualifications
and areas of expertise of each of these professionals. Information is provided
about places at which these mental health workers (psychologists, psychiatrists
and social workers) are trained, as well as places at which they work. The scope
for lay counsellors is also discussed. This unit has a special emphasis on the
situation in India.
After studying this unit you should be able to:
 describe who the mental health professional are;
 explain the training facilities for such professionals, and be familiar with
the places where they work; and
 explain the scope for trained social workers and lay counsellors in the field
of HIV/AIDS in India.

4.1 INTRODUCTION
As of today, India has the largest number of HIV infected persons in the world.
All of them require social and emotional support. There are several target groups
who require this much-needed support in a special way. Since HIV has spread to
the general populace, including people living in rural areas, the need for and
scope of counselling services has increased. Some of these target groups are: the
youth, people at work places like hospitals and nursing homes, sex workers,
prison inmates, homosexuals, lesbians, blood donors, drug addicts and others
involved in risk behaviour. Today these services are limited in India as we have
very few professionally trained psychiatrists, psychoanalysts, psychologists, social

57
 workers, nursing personnel, lay counsellors, traditional faith healers, elders,
teachers, and other volunteers for this enormous task.

With the advent of HIV, there is an urgent need to provide in-service training for
the existing professionals as well as concentrating on induction of fresh trainers.
This unit tries to look at the availability of mental health professionals in the
country, including trained social workers who could provide the much needed
social and emotional support to HIV infected persons.

4.2 WHO ARE THE MENTAL HEALTH

PROFESSIONALS?
There are many professionals who, in various ways and to various extents, treat
or assist individuals with emotional and other problems related to mental health.
These professionals are:
 Psychiatrists
 Psychologists
 Psychoanalysts
 Social workers
 Nursing personnel
 Lay counsellors
 Traditional faith healers
 Elders, teachers, and other volunteers.

Each of these categories has its own sphere of competence, and its own role to
play. A brief discussion on each of them is provided below.

Psychiatrists: A psychiatrist is a mental health professional who holds an

allopathic medical degree. The basic qualification is an MBBS, and is followed
by post graduation in psychiatry (also known as psychological medicine in some
universities). The postgraduate degree may be a diploma (DPM), a master’s degree
(MD) or an equivalent of a master’s degree (MNAMS or DNB).

The psychiatrist is the most important of all the mental health professionals, and
is ideally the first person to be consulted by anyone with problems related to
mental health. This is because of the following reasons:

i) Many mental illnesses are fundamentally medical illnesses because they

are biological in origin, that is, they arise out of disturbances in the
functioning of the brain. For example, schizophrenia and endogenous
depression are disorders, which are associated with chemical,
electrophysiological, neuro-hormonal and even structural brain
abnormalities. Therefore, only a person with a valid medical degree is
qualified to diagnose and treat such disorders.

ii) Many mental illnesses maybe complications of primary medical illnesses.

For example, depression may arise from the hormonal changes that
58
 characterize hypothyroidism; or schizophrenia-like symptoms may develop
consequent upon a brain tumour. Therefore, only a person with a valid
medical degree is qualified to evaluate and manage such disorders.

iii) Many mental illnesses require medical treatments, such as drug therapy or
electroconvulsive therapy, as the primary line of management. Even disorders
for which counselling is appropriate may benefit from the use of psychotropic
drugs. Therefore, only a person with a valid medical degree is qualified to
determine the treatment of such disorders.

Once a psychiatrist has seen a patient and has defined the future plan of
management, other mental health professionals can validly be involved in the
treatment team.

Psychologist: A psychologist is a professional who studies behaviour. There are

many kinds of psychologists. These include industrial psychologists, social
psychologists, developmental psychologists etc. For the field of mental health,
the individual of importance is the clinical psychologist.

Psychologists complete their bachelor’s and master’s degree in arts with

psychology as the main subject. During the master’s course, a degree of
specialization is undertaken. Proper training in mental health discipline, however,
is provided during a Master of Philosophy course (M. Phil). The person who so
qualifies is known as a clinical psychologist. A subsequent doctorate is an
additional, optional qualification.

Clinical psychologists are uniquely trained to conduct psychological tests, and

to treat through psychotherapy. Psychological tests may be useful in certain kinds
of disorders, to determine the nature, extent and severity of the dysfunction.
Psychotherapy is an interpersonal process, which seeks to heal through
psychological means, within the framework of a defined psychological theory.

Psychiatrists and psychologists often work in teams, complementing each other’s

skills and areas of competence.
Psychoanalysts: A century ago, and up to the 1950’s or so, psychoanalysis was
a much respected field. Today, there are very few psychoanalysts left, and the
profession has a negligible role to play in the care of the mentally ill.
One tenet of psychoanalysis is that all behaviour develops from past experiences,
which lie in the conscious, subconscious or unconscious mind. Psychoanalysis
is an entirely theoretical field and cannot be subjected to experimental validation.
Nobody can become an analyst unless he or she undergoes analysis himself or
herself. Analysis takes years, and only some individuals are capable of doing
analysis. The process is time-consuming, expensive, and comes with no guarantee
of benefits. Obviously, it cannot help persons for whom medication is a primary
requisite.
Psychiatric Social Workers: A psychiatric social worker in an individual who
has completed a bachelor’s degree in arts, a master’s degree in social work, and
a master of philosophy degree ([Link].),PhD in psychiatric social work. His
primary area of competence lies in providing counselling, support, and
rehabilitation services to mentally ill persons and their caregivers. We will discuss
the role of professional social workers more elaborately later in this chapter.
Psychiatric Nurses: A psychiatric nurse is one who is specially trained in handling
the nursing needs of mentally ill persons who are admitted to hospitals. Such an
individual would have completed his or her bachelor’s degree in nursing, and a
master’s degree in psychiatric nursing. Since very few centres in the country
offer a postgraduate degree in psychiatric nursing, most of the professional
psychiatric nurses are those who have only a bachelor’s degree and practical
experience in the care of the mentally ill.

Lay Counsellors: Lay counsellors are fast becoming the backbone of mental
health services in the country. As will be indicated in a later section, the primary
trained professionals in the country, comprising psychiatrists and psychologists,
are too few in number to effectively handle the mental health needs of the
population. So, lay counsellors may be the first, and often the only personnel
available and accessible to persons in distress.

Lay counsellors are usually trained in non-governmental organisations by

motivated mental health professionals. A few professional organisations also
offer training programmes. These programmes are mostly certificate courses in
counselling, lasting from a couple of weeks to months. The training provided is
very basic, and covers the rudiments of recognition of psychiatric disorders and
their management through counselling.
Christian organisations provide counselling services of a somewhat different
nature. Individuals in religious orders are exposed to courses in counselling to
varying extents, depending on the nature and purpose of the course. These
individuals devote their lives to the service of the underprivileged and those in
distress. During the course of their services, they provide material and emotional
assistance. Although there may be moral overtones in their counselling, their
secularity, high motivation and deep commitment are beyond doubt.
In rural areas, most villages boast of traditional healers from indigenous religious
groups. These may heal through herbal and other means, but also often provide
counselling. A limitation of such individuals is that many are guided by erroneous
ideas governing mental health, ideas that are steeped in superstition. As a result,
many rely on black magic, exorcism and processes that may physically and
mentally cause actual harm to the patients. Even today, one comes across reports
of mentally ill patients being branded with fire, beaten or otherwise abused for
the crime of harbouring evil spirits, or for being practitioners of black magic.
Attempts are being made by mental health professionals who work in community
settings to educate such traditional faith healers to provide a more rational care,
and to recognize and refer patients with severe forms of mental illness to more
professional personnel.
Elders, Teachers, and Others Volunteers: Studies have shown that motivated
teachers and college professors are equally effective in counselling their wards
as trained psychologists and psychotherapists. This indicates that non-specific
factors operate during counselling. The most important criteria required in this
case are commonsense, experience, and concern.
To this extent, elders in the family or in the village, teachers, neighbours and
other well-wishers can often offer good counselling provided that they do not
have vested interests that bias their guidance. In India, such sources of guidance
are often much respected.
The Situation in India

The number of psychiatrists in the entire country are very limited. Most of these
psychiatrists are concentrated in cities, particularly Bangalore, Mumbai, Delhi,
Chennai and Kolkata. Kerala is the only state in which there are psychiatrists in
every district. The Kerala Government has appointed professionally trained social
workers in district hospitals for counselling HIV/AIDS/STI patients.

The implication of this situation is that the bulk of persons with mental health
problems are seen by medical professionals who are not psychiatrists, and who
are consequently ill-equipped to diagnose and treat the problems in the best
possible manner. Worse still, patients with mental health problems are seen by
non-medical mental health professionals, who may fail to recognise a primary
medical disorder, and who may attempt to treat such a disorder by counselling.
Either way, the patient suffers.

There is, therefore, a pressing need for the availability of primary resource
personnel who can identify persons with mental health problems, offer basic
services to resolve immediate crises, refer the patients to appropriate medical
professionals, and later undertake counselling if it is indicated. To this extent,
the availability of psychologists, psychiatric social workers, psychiatric nurses,
lay counsellors, and other professionals is invaluable.

A point may also be made that if the service of a medical professional, particularly
a psychiatrist, is unavailable, then, whatever other help is available is better than
nothing. This means that a lay counsellor has an important role to play even in
those psychiatric disorders, which are medical in origin, especially if no
psychiatrist is available. This is a sorry state of affairs; but that is a fact of life in
a developing country such as India.

Happily, the bulk of mental health problems is situational rather than biological
in origin, and relate to difficulties in adjustment. Thus, lay counsellors can
primarily manage marital discord, adolescent turmoil, and many forms of anxiety
and depression. There is therefore a great need for lay counselling services that
are voluntary or professional in nature, and for training programmes that produce
such counsellors.

Check Your Progress I

Note: Use space given below for your answer.
1) Who is a psychiatrist?
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 2) Who is a psychologist?
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3) Why are lay counsellors much needed in India?

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4.3 TRAINING FACILITIES

Postgraduate degrees in psychiatry are offered by most medical universities in
the country. A diploma course is of 2 years duration, while a master’s degree
course lasts 3 years. A central board offers the DNB degree for persons who
work in psychiatric facilities in recognized hospitals, but who have not received
admission to a university course. Several universities offer bachelor’s and master’s
degrees in psychology. Certain universities offer the further facility of a master
of philosophy degree ([Link].) in clinical psychology, and a doctorate (Ph.D) in
the discipline.

The National Institute of Mental Health and Neurosciences at Bangalore has one
of the most extensive training programmes in the country. It offers diploma and
master’s courses in psychiatry, master of philosophy courses ([Link]) in clinical
psychology and in psychiatric social work, Master of Science courses in
psychiatric nursing, and certificate courses of diverse natures.

Another institute is Central Institute of Psychiatry (CIP) Ranchi offering wide

range of courses in the field of Psychiatry.

Training programmes in lay counselling are available from various non-

governmental organisations all over the country. Almost all such organisations
are located at and function from urban settings.

The importance of formal training:

Formal training in mental health and in counselling is necessary for several

reasons:

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i) Without a sound understanding of the causes, symptoms and treatment
regimens of diverse mental illness, it is difficult to offer competent counselling
services.
ii) Without a sound understanding of the processes involved in counselling, it
is difficult to competently counsel a client.
iii) Without proper supervision of the course of counselling during their initial
cases, trainee counsellors are almost certain to run into difficulties due to
inexperience.

It is to be noted that by completing this course on “Communication and Counselling

in HIV” one does not become a qualified psychiatrist, psychologist, social worker,
or for that matter, a professional counsellor.

4.4 PLACES OF WORK

Mental health professionals work in the following locations:
 Government-run psychiatric hospitals or asylums
 Private psychiatric hospitals and nursing homes
 Departments of psychiatry in general hospitals
 Child guidance clinics
 Alcohol and de-addiction clinics
 Marital and family therapy clinics
 Mental retardation clinics
 Rehabilitation centres
 Day care centres
 Vocational training centres
 Half-way homes
 Long-stay centres for patients with chronic illnesses

Mental health professionals may also practice privately in clinics, or work in

schools, colleges, factories, and other organisations. Lay counsellors often work
as assistants in most of these locales.

4.5 SCOPE FOR LAY COUNSELLORS

The case load of psychiatrists is usually so heavy that few or none have the time
to counsel patients. This is unfortunate because persons with mental health
disturbances and their families as well are almost always in grievous need of
counselling. Thus, lay counsellors can fill a void.

Lay counsellors are invaluable in the management of the following situations:

i) Depression: To help the individuals adjust to the stresses in their lives, to

build up their confidence and self-esteem, to remove faulty ways of thinking
 that predispose to depression, to help them find their own niches in society,
to develop avenues for social support, to help them develop a life plan that
gives them reasons to live, etc.

ii) Anxiety: Besides coping with depression, they can also help the patients to
identify ways and means of relaxation.

iii) Alcoholism: To help the alcoholics recognize that they have drinking
problems, to motivate them to seek psychiatric help, to help them to persist
with the psychiatrist’s management programme, to help them resolve the
problems that drove them to drink, to help them to deal with the problems
that resulted from their drinking, to help them to reintegrate themselves
into their families and society, etc.

iv) Drug Addiction: Besides helping one to cope with alcoholism, they can
also to help the patient withstand peer pressure and other pressures that
compromise adjustment. Drug addiction is commonly a problem of youth,
while alcoholism is a problem of middle-aged persons.

v) Rehabilitation: Patients with a variety of psychiatric disorders require to be

reintegrated into their family and into society. Towards this goal, before
they are returned to their family, they may require social skills training,
training in self-help skills, vocational training, and day care or managed
care in a halfway home. While mental health professionals are needed to
oversee these services, lay counsellors can usefully assist in such situations.

vi) Other situations: Likewise, lay counsellors can assist in the management of
problems of childhood and adolescence, in dealing with marital discord,
and even with providing crisis support and round the clock help lines to
persons who are suicidal. Many cities have such facilities run entirely by
highly motivated lay counsellors.

Check Your Progress II

Note: Use space given below for your answer.
1) Briefly explain any one situation in which lay counsellors can provide
their services.
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4.6 SCOPE OF SOCIAL WORK COUNSELLORS
Role of a Medical Social Worker

The role of a medical social worker in a medical team is as important as that of

a physician. While the medical practitioner’s role is limited to treatment of a
patient, the social worker deals with the social, physical and psychological aspects
of the patient who is under treatment. In fact, it is primary task of the social
worker to supervise the arrangements for the treatment of the patient. To the
patient and his family, the social worker is a friend, philosopher and guide.

Social workers in health care are called upon to address a myriad issues that
challenge one’s mastery of the fundamental elements of professional practice. As
clinicians, social workers walk right into the heart of the pain as a primary focus,
unlike any other on the health care team. Social workers are challenged to work
in a setting where their presence is admittedly needed, often beyond what their
colleagues can understand and accept. Social workers have to advocate on many
fronts and with many outside agencies for entitlements and resources for their
patients: with community groups for education and with the health care institution
itself for sensitivity to the psycho-social perspective of the patient.

The role of social workers in the health care system in India has become all the
more important with the unabated spread of the killer disease AIDS and the
unchecked involvement of young people in substance abuse. This is one area,
which is very much neglected by the policy makers while formulating the health
care policies in our country.

It is high time for the medical experts, academicians, policy makers, social and
medical researchers and the NGOs to realize that providing help to HIV/AIDS
patients is not a one-man-business but a team effort that should include physicians,
nurses, para-medicals and social workers. Having about 1000 million people in
the country does not mean that some of them can be used as ‘guinea-pigs’ in the
medical laboratory.

Social work in a medical set up is based on the assumption of the individual’s

dignity. A patient in need of treatment is faced with several problems, which may
have direct or indirect impact upon the illness. These problems may be broadly
categorized under physical, psychological, economic, social and environmental
aspects of the patient.

Social and Physical Discomfort

The fact that a patient seeks medical care confirms the reality that he is facing
some sort of physical discomfort. Any physical discomfort has its own impact on
the mind of the individual who could become emotionally and psychologically
disturbed as a result. These mental disturbances can be more intense depending
upon the economic, social and environmental aspects of the patient. In our country,
where a substantial percentage of people live below the poverty line, the economic
hardships faced by patients are enormous. More often than not, most of our people
have to travel many miles before they can find a reasonably satisfying nursing
home or a hospital. The topdown approach of the policy makers has made it
more unaffordable for the majority of our population to get proper medical
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 care in a lopsided system where over 80 per cent of medical facilities are available
only in urban areas, catering to the needs of only about 25 per cent of our people.
That leaves just 20 per cent of the available medical facilities at the service of
the rural masses who form over 75 per cent of the population. Apart from this,
one has to also consider the socio-economic condition of most of our people who
do not have access to proper food, shelter and clothing.

Assistance to the Physician

An individual living in poverty, with disrupted social relations and a poor social
environment, is doubly vulnerable to many types of diseases. The social worker
is the right person who is professionally trained to understand all these aspects
of a patient who needs care and treatment. In the process of treatment, the social
worker studies the individual in relation to his family, social living conditions
and financial situation. This is an important component of the treatment process.
The social worker conveys these relevant bits of information to the medical
practitioner who takes into consideration all these aspects while treating the
patient.

Coordinating Medical Team

The social worker helps in coordinating the work of the entire medical team. He
prepares the patient to accept the treatment prescribed by the physician. In certain
instances, particularly in cases of patients with STI/HIV/AIDS, the social worker
explains to the client the need for undergoing laboratory tests. The very decision
to go for an AIDS test requires counselling by a social worker. In several cases,
the social worker may have to receive the result of the test and convey it to the
client. Given the present situation, when no cure is available for AIDS patients,
a positive test result is a death sentence. The client, his family and relatives need
to be psychologically prepared for receiving the test results. It is, in fact, a
stupendous task for a social worker in India to handle AIDS cases because of the
taboos attached to some of the routes of transmission, such as indulging in
promiscuous sex and drug use. Although HIV can be transmitted through other
means, like blood transfusions or the use of a contaminated needle used for
injecting an AIDS patient, the kind of mass awareness programmes resorted to
in our country have generally failed to provide accurate and complete information
to the public. The result is that most people believe that AIDS is spread only
through sex.

The existing social structure in our country offers hardly any other option than
one’s own family for the care and rehabilitation of an AIDS patient. However,
most of the HIV/AIDS carriers report that disclosing their HIV status brings
about only scorn and contempt from every quarter. In such a situation, it is only
a social worker from the health care team or an NGO who can come to the
rescue of the HIV/AIDS patients.

The HIV infected individuals need care and emotional support. A social worker,
with his or her professional background, is able to organize HIV/AIDS support
groups. Through the method of social group work, the social worker can enable
the HIV clients to share anxieties, find emotional support, and engage in
meaningful creative, educational and recreational activities.

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Social Work Methods

Social work activities are classified into six methods: (a) Social casework,
(b) Social group work, (c) Community organisation, (d) Social action, (e) Social
work research, and (f) Social welfare administration.

The first two categories, social casework and social group work are used largely
in providing assistance to meet the needs of the HIV/AIDS patients. These two
methods consist of programmes, which have direct contract with the individuals
faced with these problems. However, the other methods such as community
organisation, social action, social work research and social welfare administration
are used to establish, maintain and operate social agencies which provide social
casework and group work services.

Let us look at the definitions of these methods and briefly discuss how practical
they are in the process of preventing and controlling the spread of HIV/AIDS in
our country, and how best these methods can be used for helping individuals,
groups and communities faced with the problem of HIV/AIDS.

a) Case Work

Social case work may be defined as “the art of doing different things for and
with different people by cooperating with them to achieve at one and the
same time their own and society’s betterment” (Richmond). According to
Gordon Hamilton, “The objective of casework is to administer practical
services and offer counselling in such a way as to arouse and conserve the
psychological energies of the client – activity to involve him in the use of
the services toward the solution of his dilemma.” In the words of Friedlander,
“Social casework is a method which helps by counselling the individual
client to effect better social relationships and social adjustment that makes
it possible for him to lead a satisfying and useful life.”

A professionally trained social worker is able to go deep into the pain of an

HIV infected client and enable him to face up to the problem by using the
method of social casework counselling. This method of social work still
remains in its infancy as far as India is concerned. The number of clients
requiring social casework counselling is far too many and the number of
problems is exceedingly big. However, we have a very limited number of
trained social workers in the country, and most of them are employed in
non-medical sectors. In fact, every hospital with indoor patients should have
trained social workers. To be effective, there should be a social worker for
every ten-hospital bed. But the actual situation in the country is far from
this requirement. Even in the most prestigious medical institutes in the
country, one cannot find social workers in the various departments in
adequate numbers. One of the major reasons for this is the fact that the
curricula of medical colleges do not contain adequate input from behavioural
sciences. This is adversely affecting the medical service system in the country
where a good number of medical practitioners fail to show human concern,
a caring attitude and an understanding approach in rendering their service
to the patients.

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 b) Group Work

Trekkers defines group work as “a method through which individuals in

groups in social agency settings are helped by a worker who guides their
interaction in programme activities in accordance with their needs and
capacities to the end of individual, group and community development.”
Group work is an activity, “which helps people to participate in the activities
of a group for their intellectual, emotional and physical growth, and for the
attainment of desirable goals of the group” (Friedlander, 1982). Human
beings do not live alone. They need a reciprocal give-and-take relationship.
This is very much required especially in times of need. In the present context,
HIV infected individuals are much in need of group help. The HIV support
groups in Europe, USA and African countries are doing wonderful work in
sharing the anxieties of one another. In India, there are very few HIV support
groups.

In an HIV support group, group work focuses on the HIV infected individual
in the group. The group itself is a platform where the HIV/AIDS clients are
able to express themselves freely and share their problems to help one
another. The social worker, who is instrumental in organising the HIV
support group, guides the group work process. HIV support groups function
in the setting of a social agency, a hospital setting or in any other institutional
or informal group setting. Mutual acceptance is the basis of social group
work. It is easier to help an HIV infected person to change his attitude for
the rest of his life in a group setting than to change it through social casework
counselling. Social casework prepares an HIV infected client to join the
HIV support group for meaningful living with HIV in the given situation.

c) Community Organisation

Childred Barry says, “Community organisation in social work is the process

of creating and maintaining a progressively more effective adjustment
between community resources and community welfare needs. The

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 adjustment is achieved through the help of the professional social worker
and through the participation of individuals and groups in the community. It
involves the articulation of solutions and the foundation and conduct of a
plan of action”. According to Friedlander, “Community Organisation is the
process of planning and developing social services in order to meet the
health and welfare needs of a community or larger unit.” In order to organise
a community for any meaningful development effort, the first step should be
the psychological preparation of the community.

When we talk in terms of community organisation for HIV/AIDS and de-

addiction services, an essential component of the process should be to create
awareness among the people in the community about the impending disaster
that AIDS can bring upon their community. There is already a massive
programme of awareness campaign going on in the country. But, at the
same time, there is also a widespread feeling among people that HIV/AIDS
is not a disease that can affect them. The social worker, who is experienced
in dealing with the individuals and groups through the casework and group
work process, can very well bring together the people of a particular
community for necessary action to prevent and control the spread of AIDS.
The very programme of awareness campaign can be meaningfully executed
by a social worker who knows the language and pulse of the people in a
given community.

The community organiser guides the formation of action groups in the

community using the discontent generated among the people in the
community. The social worker is well aware of the religious beliefs, social
taboos, cultural ethos, negative family attitudes and lack of appropriate
communication tools within the community which are the principal obstacles
in rural settings to educating the people about AIDS. In order to overcome
these obstacles, AIDS education programmes must be specifically targeted
on a community-by-community basis. Recruiting “community leaders” from
among local residents is an important strategy in this respect, and can result
in the development of unique and innovative programmes. Social workers
are the best persons to successfully implement result-oriented awareness
campaigns in a given community.

d) Social Work Administration

Social welfare administration is the process of planning, organising, and

directing the activities of a social welfare agency. It is the process by which
we apply professional competence to achieve desired goals, and transform
social policy into social action. In providing services to the HIV/AIDS
patients, the social agencies have to shoulder a very major responsibility.
Since HIV/AIDS/STIs and substance abuse issues are very sensitive, the
social agencies handling any programme related to these areas should have
professionally trained social workers to man the service delivery system.

e) Social Work Research

Social work research is a systematic, critical and careful investigation of a

social problem with an effort to find relevant information around the issue.
The finding of social work research will enable the social worker, the agency
and the policy makers to plan effective programmes based on the needs of
 a particular community.

For the effective implementation of any HIV/AIDS related programme initiative,

the role of social work research is as important as any other scientific and medical
research. The issue surrounding HIV/AIDS are very sensitive to individuals,
groups and communities. A social worker is the ideal person to assess these
social issues, the type of people most affected or vulnerable, and suggest the
most appropriate action plans that would be effective and acceptable to the
community.

f) Social Action

Social action is an organised effort to solve mass social problems. It always

involves public pressure in one form or the other. It is a legally permitted
activity to mobilize public opinion and public pressure to bring about socially
acceptable change or modification in the social and economic institutions,
which do not function adequately and effectively. According to Helen
Witmer, “the term social action refers to organised and legally permitted
activities designed to mobilize public opinion, legislation and public
administration in favour of objectives believed to be socially desirable.”
Since HIV infection is transmitted mostly through behaviour patterns that
are intimate, the health authorities often find it difficult to make their services
reach such high-risk behaviour groups. This gap can be bridged if there are
effective working relations between Government and Non-Governmental
Organisations (NGOs) through their Professionally Trained Social Workers
(PTSWs).
With the unchecked and the steady growth of HIV-infection among people
from every walk of life, counselling and guidance regarding HIV have
become essential aspects of dealing with the problems associated with HIV/
AIDS. Unlike in the West, there is a taboo attached to the very idea of
seeking counselling and guidance among most people in our country. This
is again due to misinformation and a lack of proper knowledge. The very
idea of consulting a psychologist or psychiatrist are automatically linked in
many people’s minds with problems related to insanity or mental
deficiencies.
They say it is better late than never. Perhaps, we need to initiate a new
beginning in addressing issues pertaining to HIV/AIDS in our country, with
the involvement of professionally trained social workers in a big way.

Check Your Progress III

Note: Use space given below for your answer.
1) Define social case work.

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4.7 LET US SUM UP
There are several different categories of professionals who work with persons
with mental illness. Among them, the psychiatrist is the most important professional
because he has a medical degree, and can diagnose and treat disorders which
have a medical basis. The psychologist is next in importance as most disorders
require counselling in varying degrees. Other professionals, too, contribute in
varying degrees. The professional social workers can render the best of services
especially by providing social and emotional support to clients afflicted with
HIV/AIDS and their communities.

The professionals in this field are trained in universities, hospitals and non-
governmental organisations and work in clinics, nursing homes, hospitals, welfare
institutions, educational and professional institutions, and other private and
governmental setups.

Lay counsellors are much need in India because mental health professionals are
too few in number to cater to the needs of the population. Lay counsellors work
as the first line of defence for crisis management and referral, assist mental health
professionals in various settings, and function independently in the context of
disorders that call for counselling or rehabilitation as the primary response.

4.8 SUGGESTED READINGS

Gracious Thomas (1997), Prevention of AIDS: In Search of Answers, Shipra
Publications, New Delhi.

Pincus Allen and Anne Minne Minaham (1973), Social Work Practice: Model
and Method, Illinois: F.E Peacock Publishers Inc.

Walter A. Freidlander. (5th Edition. 1982), Introduction to Social Welfare,

Prentice Hall of India Private Limited, New Delhi.