HIV Testing and Counseling: The Role Therapists Play

contemplative man in waiting room“You need counseling.” This is the most oft-cited refrain heard when self-testing for HIV is brought up. It reflects a deeply ingrained rhetoric, but is it really the case? The answer to this question can take many forms, and it is worth the time to look at these more deeply if therapists are to better serve clients and the community in supporting the eradication of HIV/AIDS.

If the reason for counseling people who take an HIV test is to promote behavior change, the data do not support that this is effective. A recent study out of Boston University showed that the current counseling/testing model does not alter risk behavior. Given the limited funding for testing, the researchers encourage innovations in testing paradigms to better use funds. In my experience, even if a person benefits from the counseling component that may come with testing, this does not mean he or she needs to go through this process each time tested. Duplicative counseling is not necessarily fiscally sound practice.

This does not mean counseling is not important for people at risk for or living with HIV and who are not aware (basically, the targeted groups for testing). Here, however, we have to recognize that people acquiring HIV have high rates of abuse, trauma, and addictions. They do not make up the majority of people with HIV, but they do make up 30% to 47% of cases. The trauma can be anything from physical or sexual abuse to the cultural abuse inflicted by anti-gay messages and economic poverty. The point is that, for many people with living with HIV, this is not the sole issue.

The current HIV testing model in public health settings is not designed to accommodate this reality. HIV testers typically receive a three- to five-day training on the counseling component. As many of us in the counseling/therapy profession know, this is not enough to deal with the complex issues involved here. In fact, the process of walking into a public health clinic, being asked a series of intrusive questions about sex and drug history, and then spending 20 minutes with a stranger can trigger and magnify trauma, fear, and shame.

This is why I am so passionate that counseling/therapy professionals know about self-testing. On one hand, I don’t think everyone needs counseling to go with testing. On the other, where counseling is probably needed, the highly trained counseling profession is best equipped to do this, not the public health setting. The HIV testing system in public health arenas is not fully equipped to deal with shame, trauma, fear, stigma, depression, and many of the other co-morbid factors connected to HIV. If therapists have a client population that has experienced trauma, shame, and/or addictions, and is sexually active, they have a role to play.

Over the coming months, I will explore two specific clinical areas and implications with regard to HIV to help therapists fulfill that role: trauma and shame/vulnerability.

© Copyright 2013 All rights reserved. Permission to publish granted by Bradley Ogilvie, MS, LPC, LMFT, HIV / AIDS Topic Expert Contributor

The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

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  • Willie

    December 27th, 2013 at 4:10 AM

    WHILE i am an advocate for people being able to have a say so in their own health I just as strongly feel that there are certain things that sohuld not be done alone and I think that HIV testing is one of them. And while there are wonderful counselors who work in public health type settings are they really going to be able to deal with the flood of emotions that come with finding out that you are HIV positive? I don’t think so, so there has to be another way to get people tested but to also get them to do it with the support of someone who is well trained and able to handle all of the emotions that they will feel if they get a positive test result.

  • Danny

    December 27th, 2013 at 7:46 AM

    Then what’s the answer? Obviously getting counseling every single time you walk in and need a test isn’t necessarily the most cost effective metod, especially since we see that this isn’t changing the at risk behavior in those who need it the most. So what do we do? Stop providing the testing? That only increases the chances that people will unknowingly pass the disease to others. So the answer has to be to change the behavior and stop the spread of the disease but it doesn’t seem that there is an easy way to do that in a community that so desperately needs this to happen.

  • laura

    December 28th, 2013 at 6:12 AM

    Don’t you think that the clinicians working in facilities such as these with a population that comes in like a revolving door needs more training in how to deal with their individual and unique situations? I mean, these are not people who made one mistake, these ate people who are exhibiting a lifetime of poor choices and behvior and need serious help in rehabilitating how they live their life. Don’t you think that there should be some funding for that so that they can be better trained for dealing with those who walk in like that every day?

  • Jackson

    December 29th, 2013 at 1:43 AM

    If there is not some feeling that there is a need for change then why do you think that certain patients keep coming back in time and again for testing?

    Surely they know that this means that somewhere inside they know they need to change their behavior and this is a cry for a help?

    And aren’t we then obligated to then address that cry?

  • Grace

    December 30th, 2013 at 10:29 AM

    You are going to have so many different things needing to be addressed in those looking for testing in these types of settings. You have past family histories that are horrible, drug and alcohol addiction and abuse, and various other issues that have just grown and manifested into irresponsible sexual behavior. In most cases it’s just such a mess that one counseling session won’t even begin to touch what’s going on. This is something that only intensive therapy could help resolve.

  • Brad

    December 30th, 2013 at 3:38 PM

    Thanks, all, for the comments. Here are a few thoughts/reactions:
    1. I think it is important that we as counselors check our assumptions, and recognize them as just that, holding them with a healthy dose of doubt so other truths can emerge. For example, Willie states that he feels certain things should not be done alone. This may not be an absolute truth, so instead perhaps we should be exploring pros/cons of the options available, and process them with clients.
    2. Danny – to me it’s not “so what’s the answer”, it depends on what the question is. For me, it’s how do we support people in being healthy and, in this particular instance, knowing their HIV status as part of a public health service. There really is no easy answer; instead, I think what we can do is to recognize the challenges and embrace them as opportunities. More testing, but with more options is the way to go.
    3. Laura – the revolving door in social services is a huge problem driven more by meeting numbers, spending dollars and raising dollars. I do think it is important, though, in your statement, to not make the assumption you make about “one mistake.” I used to work with a woman who did everything by the book – married, monogamous – but her husband cheated on her and gave her HIV. She was ridiculed by her pastor and was viewed skeptically by other professionals. We need to do better. Doesn’t matter whether it was once, twice, a hundred times, our job as counselors is to create the non-judgmental safe space so the person can work through his/her trauma and tell his/her own story.
    4. Grace – I would echo the same thing about making assumptions, esp. using judgmental language such as “horrible”, “irresponsible” and “mess”. Many people living with HIV have had these sentiments thrown at them prior to having HIV, such as religious messages condemning gay men. We have to walk the fine line between not perpetuating the victim/blame paradigm, but working with clients to find a space where we learn to live with integrity. It’s ultimately about drawing a fine line between the past and the future.
    5. Finally, Jackson, as many of us know, the desire for change is far easier than bringing about change. As I’ve stated above, when it comes to HIV-testing, in the counseling setting, our attitude matters. Having said that, you are right, many people come to test routinely, but not necessarily because they want to change. We cannot simply tell people “don’t have sex”, but we can talk about risks, and ways to minimize risk of both getting and spreading HIV. Routine testing is one such tool to do that.

    So, again, thanks for these comments. It’s a lively conversation.

  • June

    January 2nd, 2014 at 4:10 AM

    I think that it is just great that there would be any little bit of counseling available to anyone taking this kind of test. I had never really thought about the need for that, just thought about having the test and then getting the results. I guess I had never really thought beyond that because I have never worried that I could be HIV positive but then again that’ what I like about reading some stuff here, that it kind of forces me to think beyond what happens in my own experience and think a little more about what could possibly happen in the lives of others, things that I wouldn’t have considered before.

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