Just before we switched on the tape machine this counselor and Nicolas were talking about using video recordings of sesions to capture the body language and nonverbal communication that goes on in a session as a way to train counselors. This got us into a discussion of how we prioritize what we can cover in a short amount of time.
C: Right. One way would be/ we don't have any two way mirrors her but if you had a situation like that, you could have the client looking here and the camera could only be on the counselor and you'd have the back of the client you know so it wouldn't be identifiable.
N: Absolutely.
C: So that that way you could capture a lot of that. What's so good about using a real client is no matter how authentic you're still gonna be Nicolas, you know, even if you're playing another character, and let's say you're playing it very believably, uh, there's just something that goes on when you're working with a real client that doesn't [ ]. I mean that's better than nothing but it would be a good.
N: In terms of the way the counselor acts or the way that the client gets into their role?
C: The way the counselor acts. Cause so much of communication is nonverbal.
N: Right.
C: And I think particularly in something like HIV testing if such a short period of time people walk in the door, I mean this is the ultimate in brief intervention, so you have to [ ] non verbal, the counselor's nonverbal, as well as the client's nonverbal, is so important in something that's completely non discussed in training.
N: Absolutely.
C: And I'm talking, it's subtle things, I mean it's things that nonverbal stuff really needs to be systematically studied you know, I mean I 'm not talking about the gross kind of you know, don't sit here with your legs all up in your face or you know, something that's really distrating but the whole thing about space, you know, how do you use the space or lighting, like the funny one where we have, it's completely dark, you know if you just had the lamp, the table lamp light on it's completely dark, you know,
N: Shine it in the client's face. HHHH
C: Right.HHH. So tell me, we have our ways. HHHH I know you're not being safe. And it's interesting about I think one of the things that could help is to say for ourselves how can, I think we need to learn how to differentiate clients once you see them sophisticatedly and to have techniques to work with different kinds of clients, I think our training in developing lots of standards and stuff tends to homogenize and you have an approach that has a checklist of 97 things to cover, all the different issues and there's this sense of if I don't get all the statistics down, if I don't get all the cover everything then it hasn't been a good session and learning when am I spending time where I don't need to be spending it
N: Right
C: And where do I really need to be spending it, and what is the trick is, doing this instant assessment on a client and trying to figure out how can I be most helpful particularly when so many of our clients, I'd be interested in what the percentages are, are retesters you know.
N: Well I can give you some figures on that later.
C: So, you know you have, you have two very different populations, the training is geared toward first time tester, so you spend a lot of time explaining antibodies and window period and possibly even how the virus works, although I see that less and less because you have to have a pretty big baseline of information before you even get tested, you know most people don't come in and say uh, you know, I thought you get HIV through coughing, you know.
N: It's a 1988 kind of model of the kind of education and questions that people bring to the counseling session.
C: Uh hm. And there are people that still have, aren't well informed about things, I mean you know, I'm sure I could go back to my home town and find people who think you can get HIV by sharing a glass of water, but those people don' t come into testing, they certainly don't come in here, uh, with the population we have, a lot of these are CAL graduates, you know, they're so,they come in and they're pretty sophisticated and so if you have twenty minutes or thirty minutes with a client or even fourty minutes with a client you can easily burn up twenty just going over what they already know and some things are, repetition is the key to learning, so repetition is very good but knowing when to do that and having more things and what I've observed in counselors and what I've tried to change in myself is having too, having the form set the structure for the whole intervention.
N: Hm.
C: That the form becomes the nucleus and anything else has to be tangent on that when I think most of the things that people are really dealing with aren't germs and viruses and RNA replication but things people are struggling with are intimacy, love, acceptance, self awareness, you know, I mean the tough cases, the toughest clients I see, I'm thinking of two particular cases, both of these men were young, you know 18, 20, uh, one was in a sex, was doing the work at the sex club and the other one was in a clinic and these are guys that come in who are very aware, they're gay, they're very aware of HIV, uhm, but they get into these situations where, cause a lot of I think their own shame issues and power issues and all this, they come in and they don't have the ability to set boundaries with their partners, so
N: And particularly if they have a history of abuse too.
C: Oh, probably, but the presenting behavioral problem is a guy wants to fuck him without a condom and I can't stop him, you know, and here I am a counselor, you know this is a worse case scenario, sex club, you know, half not, I'm not [anti sex club
N: [ ] sex club here at this point doing the counseling.
C: Yeah yeah, but here's a guy in a sex club and I'm not anti sex club but you know, there's probably gonna be the highest prevalence of HIV in those environments, uhm, it's gonna be the concentration, so here he is, he's having receptive anal intercourse and it makes him completely crazed with anxiety and uhm, you know they're just mortified that that fear is not able to change any behavior because what they're struggling with is not a lack of awareness and not HIV but how to interact with men, how to get the pleasure but also be empowered you know, and that so much of the pleasure is associated with being disempowered because it's a sense of leting go, if you try to control your life all the time, uhm, there's a lot of anxiety associated with that control and that sense of you know, I got to keep it in line, and then you go to this place where there are no controls, in fact it's the opposite, it's anarchy, and that is a part of the excitement.
N: So much about our cultural sense of what being a man is is boundaries and paticularly if you've grown up in a strong heterosexual macho thing, so it is attractive then to let those boundaries down when you're in a situation.
C: Uh hm. And I find when you try to probe a client like that, so here's, the point is here's somebody who'se well educated, so your fourty five minutes doesn't need to be go over, I mean, I think it's important to say well this puts you at high risk for HIV but they say I know, I know I know I was really stupid, it was stupid, it was stupid, it was stupid, I'm stupid, I'm [ ] HHH you know, and you want to say ok time out, why do you think it's stupid? Well I knew dadada. Well that's not stupidity, stupidity is about ignorance. You know, and you're not ignorant, you're totally informed, you're completely articulating everything to me right now, so that's not stupidity. Because the solution to stupidity would be education but you're already educated, and uhm, so then that's kind of opening up to go to the deeper level to what the, the don't chatstize me, don't give me a lecture cause I already know I've sinned and fallen short of the glory of God and should burn in ever and deserve to die of AIDS or whatever, it's like OK, let's, we got to change the frame here guys, and that was one of my objections to this Gallagher article in the, well first of all it was horrifically written and the facts didn't correlate with the point they were trying to make, that
N: The Gallagher article was referring to an article in Advocate that talks about proteas inhibitors encouraging men to take more risks.
C: Right. right. The thesis of the thing was, now that HIV is kind of being looked at as maybe a chronic disease, then a way to deal with the anxiety is not to worry about it and to view protease inhibitors as a morning after pill, but in the article HHH somebody from UCSF or you know, people from the, said, uh, well actually it's thirty pills every morning for the rest of your life, you know.
N: That'll make you throw up.
C: HHH Right, it has all these side effects. But see the whole tone of the article was fear, don't be so stupid as to think this, and the premise, the assumption is that the reason why people are doing that is that they really believe that proteas inhibitors take all the down side out of HIV, and that may be going on subconsciously, but I think there's an intervention aimed at that, that's not the root cause.
N: Right.
C: You know, no matter where it's going, there's something else underlying that.
N: Or that we found another thing that's causing people to sero convert, it's like, we can ignore everything else that's been known for fifteen years.
C: And the purpose of the article was to increase your anxiety, was to increase your anxiety, to say proteases are good but uh, AIDS is horrific and it's still horrific and it's gonna be, and you know it is, and so don't ever let your vigilence down for a moment.
N: What does fear produce, not behavior change.
C: That's right.
N: It produces denial.
This counselor illustrates his ability to prioritize by telling a story about how he dealt with two high risk gay male clients: Coping with the Unstoppable Force
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