CHAPTER SEVEN DISCUSSION
7.4 COMBINING THE PUBLIC HEALTH AND COUNSELLING APPROACHES
between individual rights and responsibilities and social responsibilities. The data suggests that VCT struggles to achieve this balance partly because VCT has a dual identity – it needs to be both client-centred as well as operate as a public health intervention with a set of preferred outcomes.
7.4 COMBINING THE PUBLIC HEALTH AND COUNSELLING
centred to a more directive orientation. This is likely to be even more difficult given the calls to revert back to “test and treat”, and to lose some of the counselling components of VCT as evident in the routine testing approaches.
The results from this study reveal similar difficulties that the counsellor has with being open-ended and non-directive, in a context where a set of preferred outcomes is obvious to the practitioner. Chapter Six showed how counsellors struggle to adhere to the dictates of both orientations. The tagging of an open-ended question on to the end of a directive advice assessment might be a way for the counsellor to manage this tension, and rein in this directive side with a more open-ended question that attempts to move the conversation in a client-centred direction. Alternatively, it could be construed that tagging an open-ended question on to the end of the directive advice segment constructs the pressure to change as a negotiable option – or constructs the advice as something the client wants.
7.4.1. Considering advice-giving in public health and counselling contexts
A critical practical dilemma for counsellors required to implement these two approaches is most acutely felt in the management of advice in health interventions and in more traditional counselling interactions. In the former approach, the dispensing of advice to clients is considered a core part of the intervention that, if appropriately used, has more benefit than harm (Feltham, 1995). In counselling on the other hand, advice is considered to be anti-therapeutic in that counsellors should not be telling clients what to do under any circumstances (Stein & Brouard, 1994).
Chester (1987, in Silverman, 1997) describes advice as imparting authoritative information, explanation, guidance, and clarification of options regarding where to seek symptomatic treatment, and what to do about safer sex. In this study, most counsellors struggled with their advice-giving role. For example, in “struggling with preferred outcomes and the freedom to choose” strategy, this struggle awareness was most noticeable. The counsellor managed this by giving his advice, and then making it more open-ended by reminding the client that it was up to her to decide what to do.
In other cases, this struggle is more subtly expressed. It appears that counsellors have difficulty in distinguishing between advice, and suggestion or mere confirmation of an intended action that the client should take. The appeals strategy in Chapter Five illustrates this advice dilemma. It comes at the end of a session where the counsellor has worked hard to get the client to take up a particular behaviour. The client gets to this point, and says “I see. So you suggest maybe I start using it?” In response the counsellor gives a somewhat cautious, reply that distances her from the advice that she has worked so hard to get the client to take up. She replies with “It will be better for yourself if you start using the condom straight away”. From an interactional perspective it would have been appropriate to acknowledge firmly the client’s proposed behaviour change with a clear “Yes!”
Gibson, Swartz and Sandenbergh (2002) address the issue of whether advice should form part of counselling. They point to the operational difficulties in upholding this widely held mantra that counsellors should not give advice. In the context of helping, clients often ask counsellors what it is that they should do, and counsellors often feel that they should give clients some answers or advice. VCT combines two approaches, one that supports and the other that seems to reject the role of advice-giving in the
interaction. As a dual-identified encounter, the role of advice in the context of HIV/AIDS counselling needs to be clarified.
In particular, greater clarity is required on the different types of advice and the circumstances under which advice may be advisable or not in HIV/AIDS counselling.
For example, Feltham (1995) suggests counsellors need to be able to distinguish when it would be unwise, incorrect or unethical to give advice (when you deprive the client of using their own decision-making resources) and when it would be useful to give crucial advice and information (when the client is not likely to know certain things or arrive at important conclusions without assistance). Gibson et al. (2002) advocate that in some instances it may be helpful to give a client firm suggestions, including laying down all the constructive alternatives before the client. Finally, Feltham (1995) observes that sometimes people need a sense that there is an authority who knows what needs to be done. In fact, many clients coming in for HIV/AIDS counselling may not be operating from this Western, client-centred perspective that counsellors do not tell you what to do. Mkhize (1994) argues that this approach to advice may not be a universal expectation since “people from many other cultures value and expect advice and even authoritative commands and are confused by the non-directive assumptions of Western psychology” (p. 10).
Central to this process is an acknowledgement that, whether as counsellor or health adviser, persuasion and influence are central features of counselling (Stokes, 2003).
Feltham (1995) advocates for a realistic and beneficial acceptance on the part of counsellors that they exert influence and would be wise to be aware of when and how to utilise their power on their clients’ behalf. Stokes (2003) highlights an important consideration for HIV/AIDS counselling policy makers and practitioners. He suggests
that there is a need to reflect upon and explore the notions of power and advice-giving in more non-directive counselling orientations, and whether these can comfortably co- exist in both theory and practice.
7.5 VOLUNTARY COUNSELLING AND TESTING WORKS AS A