(introduction...)

Counselling is one of the approaches most frequently used in health education to help individuals and families.

During counselling, a person with a need and a person who provides support and encouragement (the counsellor) meet and discuss in such a way that the person with a need gains confidence in his or her ability to find solutions to the problems. Counselling relies heavily on communication and relationship skills.

Opportunities for counselling arise whenever we work with individuals and families: with patients at the health centre, with pupils at school, or during a home visit, to name a few. Counselling should be part of the treatment and care given to a sick or troubled person. It is also an important aspect of disease prevention and health promotion because it helps people to understand what they can do, through their own efforts, to avoid illness and to improve their lives.

This chapter describes:

- The purpose of counselling
- The rules to follow when acting as a counsellor
- The different types of counselling
- Ways to facilitate decisions and follow-through
- A sample counselling session
- Suggestions for practice in counselling

The purpose of counselling

Through counselling, individuals are encouraged to think about their problems and thus come to a greater understanding of the causes. As a result of this understanding people will, it is hoped, commit themselves to taking action that will solve the problems. The kind of action taken will be a person's own decision, although it may be guided, if necessary by the counsellor.

Counselling means choice, not force, not advice. A health worker may think that his or her advice seems reasonable, but it may not be appropriate to the particular circumstances of the person receiving the advice. With counselling, it is the person concerned who takes the decisions so that the solutions adopted are more likely to be appropriate. An appropriate solution will be one that the person can follow with successful results.

Here is an example of the problems that arise when a person is advised and forced:

During a home visit one health worker saw a mother with three-week-old twins. The babies were so small that the health worker worried that they might not live. She scolded the mother for not coming to the clinic.

The health worker advised the mother to come to the hospital with the twins immediately and stay there with them until they became bigger and stronger. The mother nodded her head in agreement. While she was packing her things, she began to cry.

A brother of the woman's husband came to see what she was crying about. The health worker explained, but the man became angry. He said there were many good reasons why the woman was crying. She was worried because, if she stayed in hospital, there would be no one to care for her other two children. She had recently moved to another town with her husband. She felt that there would be no one whom her children knew and trusted enough to stay with. Also the mother was crying for fear that the health worker might refuse to help her in the future, if she did not agree to go to hospital now.

Rules for counselling

The health worker in this example had obviously not learned the techniques of counselling, otherwise she would have followed the simple rules below.

Relationships

Counsellors show concern and a caring attitude. They pay attention to building a good relationship from the beginning with the person they are trying to help. People are more likely to talk about their problems with someone they trust.

Identifying needs

Counsellors seek to understand a problem as the person with the problem sees it. People must identify their own problems.

Counsellors do not name the problems for them. The use of questions that lead to open comments will help here. A counsellor's task is to listen carefully.

Feelings

Counsellors develop empathy (understanding and acceptance) for a person's feelings, not sympathy (sorrow or pity). A counsellor would never say 'You should not worry so much about that.' It is natural for people to have worries and fears about their problems. A good counsellor helps people to become aware of their feelings and to cope with them.

Participation

Counsellors never try to persuade people to accept their advice. If the advice turns out to be wrong, the person will be angry and no longer trust the counsellor. If the advice is right, the person may become dependent on the counsellor for solving all problems.

Counsellors help people to think about all the factors involved in their problems, and encourage people to choose the solutions that are best in their particular situation.

Secrecy

Counsellors will be told about many personal and possibly embarrassing problems. The information must be kept secret from all other people, even from the client's relatives. If a person you are counselling discovers that you have told other people about the counselling session, that person will no longer trust you and will avoid you. A client may even get into trouble because of what a counsellor has told others. Counsellors always respect the privacy of the people they are helping. They never reveal information without specific permission.

Information and resources

Although counsellors do not give advice, they should share information and ideas on resources which the client needs in order to make a sound decision. For example, many people do not realize the connection between their behavior and their health. Counsellors do not lecture, but should provide simple facts during discussion to help people have a clearer view of their problems.

All health or community workers can practice a counselling approach in their work. Parents and friends can be counsellors too. The important thing is that the nurse, teacher, father, or friend is willing to listen carefully and encourage the person to take as much responsibility as possible for solving his or her own problem.

Now that you have read about the rules for counselling, think again about the case of the mother with twins. How could the health worker have made a better beginning with this home visit? What comments and questions could have been used to find out more about the mother's problems? How could the other relatives in the house have been involved? Can you think of possible alternative solutions to the problem?

Different types of counselling

Counselling with families

People may need the help of their families to solve a problem. Counselling skills are useful whether the counsellor is working with one person or with a whole family.

Sometimes it is necessary to involve the whole family in solving a health problem. Remember that each member of the family has different responsibilities in the home and therefore can help, in different ways, to find solutions.

When working with a family, we are dealing with more than one person, therefore there may be more than one problem, more than one need, and probably more than one solution. Also, be aware that in families different people have different responsibilities and powers. The father, for example, may have the major say on how money is spent by the family. The mother may make most of the decisions about the types of food eaten. Grandparents influence the degree to which families follow traditional customs. Find and talk to the right person for each problem. Also, show respect to the recognized head of the household.

Counselling with children

In a clinic, a school, or the community, you will find children with health, emotional, or other problems. Counselling can be provided for them if they are old enough to talk.

It is better to talk to the child alone. Background information can be obtained from the parents first, then they can be politely asked to wait outside. Sometimes parents want to answer all the questions; they do not give the child a chance to speak. The child may also be afraid of saying certain things in front of parents. The counsellor should explain to the parents that the child may speak more freely without others around.

This health worker is holding a child. This inspires confidence and trust. Now the child is willing to talk to the health worker about his problems.

Begin by talking about happy things. Ask the child about his or her favourite games, for example. Once the child is relaxed, begin talking about the problem. Let the child know that everything said will be kept secret. In this way the child will trust you and speak freely. Always keep your promise of secrecy. If parents, teachers, or others find out what has been said, the child will be afraid, and never let the counsellor help again.

Follow the counselling rules with a child as you would with an adult. The child will be able to learn much about health from a good counsellor.

Home visits

Counselling can be done in the clinic or at school, but home visits are also helpful. Health workers should visit all homes in their communities regularly. If a village is small, with 10-25 houses, visits can be made at least once a fortnight. In larger villages or neighborhoods, visits can be made monthly. Here are some reasons for home visits:

- Keeping a good relationship with people and families.
- Encouraging the prevention of common diseases.
- Detecting and improving troublesome situations early, before they become big problems.
- Checking on the progress of a sick person, or on progress towards solving other problems.
- Educating the family on how to help a sick person.
- Informing people about important community events in which their participation is needed.

Much can be learned from home visits. We can see how the environment and the family situation might affect a person's behavior. Does the family have resources such as a well? Which relatives stay in the house? Do they help or hinder the person's progress?

When people are in their own homes, they usually feel happier and more secure. You may find that people are more willing to talk in their own homes than when they are at the clinic. At the clinic they may fear that other people will see them or overhear the discussion. They may tell more at home, because they feel safer there.

Children are often afraid when they are sick. Before a health worker can treat and counsel a child, he or she must gain the child's trust and make the child feel comfortable.

Nutrition demonstrations, for example, may be more useful if done in a person's home. There the health worker will be able to use the exact materials and facilities that the person must use. This will make the demonstration more realistic and make learning easier. In Chapter 5 we will examine the organization of such demonstrations.

If you approach people with understanding, they will welcome you into their homes. There you will find many opportunities for health education.

When was the last time you made a home visit? What was the reason? Did the people welcome you? If people seemed afraid, what can you do next time to improve the relationship?

Did you use counselling in that home? How did the people respond? How can you make a better home visit next time?

During a home visit, a health worker can check on the progress of a sick person, meet other family members who can help care for the patient, observe new problems, and encourage preventive action.

Educational methods used in counselling

There are various educational methods that can be used to help individuals and families solve their problems. Some help people understand the cause of their problem. Some help them see possible solutions, while other methods help them reach decisions for action.

We have seen in Chapters I and 3 how important it is for us to place ourselves in the position of other people and understand why they behave as they do. But the people themselves also need to see why there is a problem. Our role therefore is first to understand the problem, and then to help the people understand it themselves. Next we need to work together with them to find solutions that are appropriate to their situations.

Sometimes people may be reluctant to take the action necessary to solve their problems. They may not feel that it is worth the time and effort. Encourage them to examine their values in order to take some decision about the importance they place on their health and welfare.

Another way to help people decide to act is the use of self-reward. People should decide on a reward that they will give themselves if they follow through with the necessary action.

It is important to help people choose solutions that will fit in with their ways of doing things, and with their beliefs. Try to help them avoid solutions that are uncomfortable. Find workable alternatives.

It may also be helpful to link a person with someone who has successfully coped with a similar problem as in the following example.

Mrs Angelino has recently learned that she has diabetes. She is worried about how she will manage the changes in her diet and activities and how she will test her urine and take her drugs. The health worker decided it would be helpful to introduce Mrs Angelino to Mrs Pedro who has been on diabetes treatment for five years. Mrs Pedro can provide support and encouragement based on her own personal experience.

Always remember that counselling calls essentially for a personal approach and for skills in listening, in providing information, and in helping people themselves determine what is best for them.

Demonstrating and displaying real objects are educational methods that can be used to counsel an individual.

Facilitating decisions and follow-through

What are the things we value most?

As we said in Chapter 1, values are standards and beliefs that are very important to us and that therefore affect our behavior. Some of the things people value include progress, happiness, friendship, security, and comfort. If asked, most people would say that they value health, but too often they do not think about their health until they have lost it.

Although people feel strongly about their values, they do not always seem to behave in ways that match them. People often do not even realize that the way they are behaving is not consistent with their values. The examples below show this clearly.

People value their children very highly. They consider it an honour to be a parent. Caring for children is a special duty not to be taken lightly. But sometimes you see a family spending their extra money on new clothing, cigarettes, or alcohol, even though the children are underweight and sickly. It may be that the family wants new clothing so that they can all feel proud when they attend a relative's marriage. Maybe they drink alcohol because their friends do or because it seems a way to help them mix easily with other people. Maybe they believe cigarettes will help them concentrate better at their work. Perhaps the family does not know that children need to eat certain foods to be healthy. You can probably think of other reasons for this family's behavior. It is unlikely that the mother and father want to hurt their children. They probably do not realize that their behavior is out of line with the value they place on their children.

Look now at the example of a schoolboy who has an infected toe. He complains a lot about the pain. He says he values his health. The health worker tells him to come to the clinic for injections for five days. After the second day, the boy does not come again. There are many possible reasons for this. Maybe the pain has been relieved and he thinks two injections are enough. Maybe it is a long way to the clinic. Maybe the boy has important work or ah examination at school. He may be afraid of the health worker or the injections. Whatever the reason, the boy probably does not see that his behavior is working against his stated value of health.

Clarify your own values. You may have to think hard. What are the five things you value most in life? Now look at one of them. Think back over the past week. Have you always behaved in a way that is in line with the value selected? If not, for what reasons? Why is it difficult for people always to behave according to their values? What can you do to bring your own behavior more in line with your values?

Adjusting behavior to values

It is our role to help people see clearly how their values may not be matched by their behavior. Then perhaps, they will try to change. If they are to do so, we need to help them find out what matters most in their lives. This is best done with individuals, although it can also be done in small groups. Values are very personal. People are unlikely to talk in front of others about their values and the contradictions in their behavior.

The discussions of this topic would usually be part of an individual counselling session. You would already have found out some of the problems the client is facing, and some of the reasons for these problems. Begin by asking what the client sees as the most important things in lifewhat is valued most. Ask what the client does to live up to these values. If health is valued, what does the client do to keep healthy? If children are valued, what does the client do to make sure children grow up to be strong and successful?

Once people are clear about the things they value most in life, ask them if they always act in ways that are in harmony with their values. If they say 'No', ask them why. Find out what makes it difficult for them to live always according to their values. Also if you have noticed any differences in the values a person holds and the person's actions, gently point them out. The realization of such differences is a very important step towards the decision to change one's behavior. But once a person has decided to modify certain habits, that decision has to be kept to day after day, until the changes in behavior have become part of a way of life. This is often very difficult. We will see now how people can be strengthened in their decision to adopt healthy practices.

Using self-rewards

If people receive a benefit for an action, they will be encouraged or motivated to repeat that action. Rewards can encourage good health behavior. But they must be used with caution. First, they should be used only when a form of behavior is very difficult to change (for example, cigarette-smoking).

Secondly, a health worker should be aware that it is quite possible to mislead someone by using rewards and thus cause many problems. To avoid this, always make sure, first, that people choose the kind of healthy behavior that they want to achieve and, second, that they choose their own rewards. Otherwise a problem like the following may result.

Mr Tem has hypertension. He is supposed to come to the clinic once a month to have his blood pressure checked and his supply of medicaments renewed. Unfortunately, Mr Tem comes to the clinic only when he is feeling unwell.

The physician on duty is worried about Mr Tem. He tells him that he will give him the money for his transport if he comes every month. Mr Tem agrees and begins coming to the clinic regularly.

Several months later the physician is transferred to another hospital. When Mr Tem meets the new physician, he asks for his transport money. The physician is surprised and says that he cannot afford to give patients money every month. Mr Tem is angry at this. Since that day he has not returned to the clinic. When he feels unwell, he buys drugs from a local drug-seller.

In the above example, the first physician failed to help Mr Tem, because the physician made all the choices. In health education, people must choose to change their own behavior and choose the rewards they will give themselves if they are successful. It is also important to try other methods first. If Mr Tem was having money problems, a better method would have been to link him with a social welfare agency.

Here is an example of how a health worker encouraged her client to participate in choosing self-rewards.

Mr Solo had been coughing for some years. The health worker helped Mr Solo understand that cigarettes made him cough more. When he understood this, he said he wanted to stop smoking. He tried to cut down, but by the next week he was smoking as much as before. He came back to the health worker for help.

The health worker listened to Mr Solo. She agreed that he was having a difficult time. She asked Mr Solo to tell her some of the things he liked to do in his free time. He said he really enjoyed playing draughts with his neighbor. She asked if he had any favourite foods. He said that chicken was his favourite, but that he could not afford to have it very often. His wife prepared chicken only once or twice a month.

The health worker then explained the idea of rewards to Mr Solo. She said that he could reward himself with something he liked, if he stopped smoking. Mr Solo thought about this. Then he said he would talk to his wife and his neighbor. On days when he did not smoke a cigarette, he would play draughts with the neighbor; if he smoked, he would stay at home and not play. He liked draughts very much, so playing would be a reward. While playing, the neighbor could help to remind Mr Solo not to smoke. (Support from friends and relatives is another important factor in health education.) Also, he would put aside the money saved by not smoking and give it to his wife so that she would make him a chicken dinner as a reward.

Finally, rewards should be something that is good for the person. A child may say 'I want candy if I clean my teeth every day.' Eating candy every day is not very healthy for a child. Maybe a small amount of candy at the end of the week would be possible. Better still, find another reward.

Compare the examples of Mr Tem and Mr Solo. In which case was the health worker correct in using rewards? Can you think of better ways to encourage Mr Tem to attend the clinic without using rewards? Do you think Mr Solo will keep his promise to stop smoking? What other approaches might be wed to help Mr Solo and Mr Tem?

A sample counselling session

Here is an example of a problem that requires counselling: A teacher has asked a community health worker to talk to one of his students. The teacher tells the community health worker several things about the student. He is seventeen years old. He is intelligent, but lately has missed a lot of time from school. He always seems tired. This is the student's final year, and the teacher is worried that he may not pass his exams.

The discussion that follows shows what the community health worker might do in this situation. Pay careful attention to what he says. Note that he asks general questions to start the boy talking freely. He greets the boy and tries to build up a good relationship. He listens carefully to all that the boy says. No advice is given until the community health worker has heard the whole story behind the boy's problem.

Also the community health worker encourages the boy to think carefully about the problem so that he can understand the cause better and come up with some possible solutions for himself. Remember that people are more committed to solving their problems if they participate in developing the solutions.

If you are with other people, you can use this counselling session as a short play. Ask everyone to read the discussion once. Get two volunteers. One will read aloud the part of the community health worker, the other will read aloud what the boy says. This will be a good way to practice counselling.

Sample counselling session
Health worker:	Good morning. I hope everything is going well with you and your parents.
Boy:	Thank you. Everyone is all right except that Mother has some back trouble.
Health worker:	I believe that this is your last year at school. How are your studies coming along?
Boy:	Well, I usually do fine at school, but you know the last year is always difficult.
Health worker:	Have you been healthy so far this year?
Boy:	Actually, I've been feeling a bit weak and get these headaches. I thought it was probably malaria, but I am not sure.
Health worker:	Malaria is bad at this time of year. Did you take any medicine for it?
Boy:	I've taken the full course of chloroquine tablets about three times so far, but I never seem to get completely well.
Health worker:	The tablets are necessary, but medicine alone cannot solve all our problems. Are you eating well?
Boy:	I think so.
Health worker:	Tell me, what have you been taking for your meals the past few days?
Boy:	My mother always tells us to have a good breakfast, so I make big bowls of cereal for myself and my brothers. Then, too, I always try to buy fruit.
Health worker:	You are saying that you do some cooking and shopping?
Boy:	These jobs are necessary. A few years ago my mother hurt her back. Now it is giving her a lot of trouble. The doctor says she is getting older and there is not much more that can be done. They give her pain-relievers, but the doctor told all of us children to try to help our mother in any way possible. Since I am the oldest, most of the responsibility falls on me.
Health worker:	What other chores do you have?
Boy:	I help prepare the evening meal too. I get the smaller children to clean the house, but I have to watch them to see that they do it well.
Health worker:	With all this work, when do you find time to study?
Boy:	That is a problem. It is really hard to do any serious studying until the chores are done and the younger children have settled down for the night. Then I read for as many hours as possible, or until I just fall asleep at the table.
Health worker:	Where do you actualIy study?
Boy:	As you know, we only have two rooms to live in. One is my parents' bedroom. The other is used for sitting and eating in, and as the children's bedroom. That's why I can't concentrate on my studies until the younger ones are asleep. I even try not to turn the lamp up too bright so they won't wake and disturb me.
Health worker:	I can see that things are difficult for you just now. From what you have said, you are under a lot of stress. I realize that you have duties you must carry out for your family, but I think all this extra work and reading late at night in a poor light have contributed to your feeling of weakness and your headaches. Does this sound reasonable to you?
Boy:	I guess I never thought about it like that before, but it does make sense. I am worried, however. As you said, I do have to do my chores at home. How can I deal with this problem?
Health worker:	First, what do you really want to achieve?
Boy:	I want to pass my exams this year, so I probably need to study more.
Health worker:	And to be able to study more you have to be strong and rested.
Boy:	That's true, so I also have to figure out how to get more rest.
Health worker:	Let us think about when you might find more time to study. You say you prepare the evening meal and do some shopping. What do you do between the time you leave school and the time you start preparing the meal?
Boy:	Usually after school I walk to the market to pick up the few things I may need for the evening meal. There I meet some friends and we talk and play games for a while. Then when I see the sun is going down, I go home to start the meal.
Health worker:	Play is necessary to keep your body fit, but do you think it might be possible to spare some time after school a couple of days a week to do a little reading? Reading in daylight would be better on your eyes than reading by a dim lamp at night.
Boy:	hat makes sense. I really like playing with my friends, though.
Health worker:	I am not saying that you should stop playing, because playing helps keep you fit. But you do have to think about what is most important to you. You do seem worried about your school work. You must decide for yourself what sacrifice you are ready to make for the sake of your studies. Right now you are sacrificing your health.
Boy:	I never thought of it that way, but you are right, I do value my studies and, if I am not in good health, I cannot do well in school. I am sure I could stay after school an extra hour and read at my desk there. No one would disturb me then, and even the teachers might still be around. They could help me with any questions I had. My friends would not miss me for only one hour, so I could join them later. I hope they will not make fun of me for wanting to remain at school.
Health worker:	Do your friends understand the problems you have at home?
Boy:	Of course, they always stop by the house at the weekend to say "hello" to my mother and ask how she is. I guess they would understand and not make fun of me.
Health worker:	Now about weekends. Can you arrange time to study then?
Boy:	Saturday morning is usually taken up with chores. And after that the house is never quiet. The younger children are always running in and out and then there are visitors.
Health worker:	Do you have to stay at home to study?
Boy:	Maybe I could see if some of the classrooms at the school are open, or I could even go out to my father's farm. It is always quiet there. I could take some snacks and sit under those big shady trees.
Health worker:	It's good that you are able to think of so many solutions to this problem. The teacher was right. You are a bright boy. Now I'm interested to know about your younger brothers. How old are they?
Boy:	The next younger is thirteen, and then there are the twins aged nine.
Health worker:	The one who is thirteen -is he also doing well at school?
Boy:	He tries very hard. His grades have been almost as good as mine. He could probably do better.
Health worker:	How old were you when your mother's back trouble began?
Boy:	About fourteen.
Health worker:	And you had to start doing all those chores from that age?
Boy:	Yes.
Health worker:	I was just thinking that if your brother is also a bright boy, and since he is nearly fourteen, maybe he could also start taking on more responsibility in the home. What do you think about this?
Boy:	I have always thought of him as being very young, but, if I could handle the chores at his age, I am sure he could manage too. Maybe we could take turns with the cooking and other jobs. That would be another way for me to get more rest and more time for study.
Health worker:	With all the ideas you have mentioned, I am sure you will have no more trouble with your studies, but please feel free to come to me again if you or any other member of your family has problems. Now, before you leave, please remind me of the things you are going to do to solve your problems. It will help us to make sure that we have forgotten nothing and that we are satisfied with what we have decided.
Boy:	First I need to get more rest and find better times for study. I will stay after school for about an hour so I can read in the daylight. Then at weekends I will go to the farm to read. At home I will get my younger brother to take turns with me in doing the cooking and other chores.
Health worker:	Thank you. That's very good. Now give my regards to your parents.
Boy:	I will. Thank you for your help. Good bye.

In this example the health worker never assumed that he understood the boy's problem until he had enough information. He never forced the boy to take advice. He always encouraged the boy to think about his problem and make his own decisions.

He asked questions that helped the boy to think carefully and seriously about the cause of the problem.

When the health worker discovered that the boy was reluctant to give up his play time, he asked the boy to examine his values. The health worker helped the boy realize what things were really important to him and guided the boy in making choices. A compromise was then reached so that the boy could study more, but not give up playing with his friends.

More practice in counselling

Like any skill, counselling improves with practice. Gather some other health or community workers and do a role-play. One of you will be a counsellor. The other will be a mother whose child has an infected ear. The remaining people will be the audience. They have an important job: they should watch the role-play carefully and at the end they can give the players suggestions for improving their counselling skills.

Suggestions for the person who plays the role of the mother

You should behave just like a normal mother in your community. What might a mother believe is the cause of the illness? What local treatments might she have been using before coming to the clinic? The counsellor may be interested in the mother's family, living conditions, and occupation. Make up a story about yourself, so you can give realistic answers to the counsellor. You have watched mothers come to the clinic many times. Sometimes they are worried and afraid. Behave just like the mothers you have seen. That will make the role-play better.

Suggestions for the counsellor

Remember the simple counselling steps. Think of what educational tools you can use. Can you demonstrate a skill that needs to be learned by the mother? Could you use posters or pictures? You may not have these with you, but in a role-play you can pretend that you have them. Can you make up a story, proverb, or fable? Will you need to help the mother get support from family members?

Do not rush the counselling

It is natural for the session to go slowly at first. After you have had a lot of practice and real sessions, your skills will increase. You will be able to understand problems more quickly and select educational methods more easily.

For further practice, use the case of the mother with twins (see page 90) as the basis for a role-play. People could take the roles of health worker, mother, brother-in-law, and possibly other relatives. Also you should make up your own role-plays based on actual problem situations you have seen in the clinic, school, and community. Always have a few other people watch the plays so that they can suggest improvements.

Whatever the situation may be, remember that counselling implies the following four steps:

1. Helping the client identify what is the problem.
2. Helping the client discover why it is a problem.
3. Encouraging the client to look at many possible solutions to the problem.
4. Having the client choose the most appropriate solution.