Services on Demand
On-line version ISSN 1518-8345
Rev. Latino-Am. Enfermagem vol.15 no.1 Ribeirão Preto Jan./Feb. 2007
HIV/AIDS counseling: analysis based on Paulo Freire1
Karla Corrêa Lima MirandaI; Maria Grasiela Teixeira BarrosoII
The study aimed to investigate the strategies health professionals use in HIV/AIDS counseling. This study is a qualitative research, based on Paulo Freire's theory and practice. Bardin's content analysis was used as the analysis technique. For the studied group, the counseling is focused on cognition, although new concepts permeating this subject are emerging. The main difficulties in counseling are related to the clients and the institution. The main facility is related to the team, which according to the group has a good relationship. Counseling represents a moment of distress, especially because it brings up existential questions to the counselor. It can be inferred that counseling is a special moment, but it does not constitute an educational moment yet. To obtain this goal, a counseling methodology is proposed, based on Paulo Freire's principles and concepts.
Descriptors: counseling; AIDS serodiagnosis; education
Counseling emerged as a strategy elaborated by the Brazilian Health Ministry team to work with HIV/AIDS. It is a preventive strategy that aims to act in the individual sphere, that is, it works with the identification of the risk per se and stimulates a reflection about viable preventive measures for individuals who intend to undergo AIDS serodiagnosis(1).
Several epidemiological studies, performed in the United States and England, question the efficacy of counseling, because they only take into account condom use and adherence to subsequent appointments. On the other hand, more recent studies evidence the importance and efficacy of counseling as a preventive mechanism, because it helps to reduce Sexually Transmitted Diseases(2-4).
We perceive that studies in counseling attempt to quantitatively verify the efficacy of counseling, motives, user's difficulties or the profile of clients using the test services. However, these studies consider efficacy as condom use, decrease in Sexually Transmitted Diseases, or yet adherence and attendance to previously scheduled appointments. While these data are relevant and can contribute to reduce diseases, they do not appraise counseling as an educational activity in the perspective of persons' change.
Every educational activity should take into account the subject's situation. In this sense, the counselor has to establish a dialogue in order to learn about the existential reality of the counselee. It is the counselor's role to enable the transformation from a naïve conscience into a critical one, where the human being is critically inserted in history, assuming a position as a subject who has the possibility to transform the world(5-6).
Considering counseling as a moment in which the client and the professional interact, exchange ideas and share knowledge and affection, this study is justified by the fact that this is a moment when the professional can work in health education, that is, perceiving existential questions, discussing educational points which lead to reflection, to the hope of a better quality of life for the person who seeks support when taking the test. Thus, we seek to inquire how we, nurses, social workers and psychologists are counseling people who want to submit to AIDS serodiagnosis and how we perceive this moment at a specialized care service in HIV/AIDS.
Is the counseling we are performing characterized as a dialogue, an educational moment that stimulates reflection and the individual's critical sense?
In our opinion, discovering this process will be fundamental for a constructive critical evaluation of the counseling team, and especially for professionals to ponder about this health education moment, improving the quality of their performance, making this counseling more reflective, minimizing several kinds of oppression present in the lives of these individuals who seek test centers and serodiagnosis counseling (CSC).
We considered the qualitative approach to reach the proposed study objectives, because it permits to "incorporate the question of meaning and intentionality"(7).
The research was developed in Fortaleza, capital of Ceará, in the Northeast of Brazil, at a Specialized Outpatient Care Service in HIV/AIDS (SAC) of the São José Infectious Disease Hospital.
Subjects included nurses, social workers and psychologists active in pre- and post-test counseling at a specialized HIV/AIDS service, totaling ten participants.
In view of the obtained study material, data analysis consisted of three stages:
The first stage was characterized by reading, choice and organization of the material for analysis. The composition of the corpus was defined in ten interviews, which corresponded to the total number of participants. We moved from a more superficial up to a deeper reading, in order to capture the contents and context of statements. In the second stage, the corpus was disassembled and the recording units were surveyed. The recording units found in the statements, by means of phrases, were grouped according to similarities and meanings. Then, their thematic categories were identified. We created fifteen subcategories, aggregated in three large categories(8). In the third phase, we organized the categories and interpreted them according to Paulo Freire's theoretical reference framework.
This study was permanently guided by the recommendations of Resolution 196, issued by the 59th Ordinary Meeting of the National Health Council, on October 10, 1996, which approved the regulatory guidelines and standards for research involving human beings on Brazilian territory(9). The research project was presented to and approved by the Ethics Committee of São José Hospital.
DISCUSSION AND DATA ANALYSIS
The study group consisted of ten health professionals: five nurses, two social workers and three psychologists. In terms of education degree, one was a PhD, one had a master's degree, six were specialists and two had a bachelor's degree. Time of professional activity ranged from five to 23 years, and specific activities in counseling varies from one to 13 years. The majority reported 30 minutes on average to do the counseling, although two interviewees affirmed taking 10 minutes, while another needed one hour. The majority also reported three to four counseling sessions per shift/activity, while one affirmed eight sessions per shift.
During the analysis process of the discursive material, we identified three categories. The first was related to the meaning of counseling for the study group and was called "Thinking the counseling". The other category, "Doing the counseling", referred to the counselor's experience of practice. The third category, characterized by feelings connected to counseling practice, was called "Feeling the counseling."
Thinking the counseling
We believe in counseling as an educational activity. Therefore, we need to think about how this activity is contemplated by the group who performs it. What are the features of this practice?
For the interviewed group, counseling is mainly perceived as a moment of information and orientation. They report.
If you give information to a person, specific orientations about a certain subject of a preventive nature […] It is a moment between the client and the professional, when doubts are clarified and patients are informed about AIDS.
The word orientation appeared in all reports by the interviewed group, showing that, for them, counseling significantly focuses on information. As we perceive from the reproduced statements, counseling at this service is predominantly informative. We know the relevance of information and knowledge about disease transmission forms, prevention and natural history of the etiologic agent. However, information per se would not be enough for counseling to constitute a transforming educational activity.
The educator's role is not only to transmit contents. Educators teach not only content through their practice; they also teach how to think critically. "If we are progressivists, then teaching, for us, is not to deliver content parcels into the empty conscience of our learners(10).
It is necessary to think about education as a practice beyond information, which stimulates creativity, curiosity and contemplation. It is a moment of taking risks, of interfering in the world in order to transform it. Education must be something moving, not static but in evolving and, hence, dialogical. It must defend the oppressed, which is why it is "in favor of", or against something; which is why it is political. Education according to Freire is not merely instruction or information, awareness is its first aim(11).
Although information is centered on the interviewees' discourse, support emerges in a relevant form. Support means being close to patients, welcoming them, having empathy, being willing to listen to their story.
In line with Freire, education, politics and power are interlaced, because we can only work in favor of the learners if we know who they are, if we learn about their dreams, desires, frustrations and joys(12). Other fundamental values are affection, multiculturalism, the context in which the person is inserted, in short, how the person arrives and what he/she brings in his/her cognitive and experienced background. These issues are fundamental to counseling in an educational perspective, valuing support to the counselee(13).
Other ideas brought by a smaller part of the study group were interaction, communication and reflection. They believe that, in counseling, these issues are important because they help the patient to reveal his/her history. Based on this revelation, the counselor can intervene and advise the person in a more secure way.
Education is meaningful only if understood as a moment when reality intervenes, during which the interpretation of problems incites an action-producing attitude. Consequently, information is not the only resource to do education, consequently, whether deposited in an authoritarian way or gently transmitted.
Doing the counseling
For the study group, having counseling experience is ambivalent. There are both difficulting and facilitating factors. According to one report, the main difficulty, situated quite significantly, is:
... what makes it difficult is the basics (laughs). It is opening and closing that door, I think that it cuts completely […] you cut it and can no longer return, especially when you are working the issue of feeling. It is really cutting.
We can say that the institution's role is to grant minimal work conditions, such as to provide the professional with a private environment, where there are no interruptions. Counseling is differentiated from other health professional activities because this moment is permeated by deep issues related to sexuality, sexual orientation, histories of suffering, abuse and pain. Therefore, in order to dialogue about these problems, the professional needs an adequate space where he/she can work without interruptions.
In planning the building of this unit, professionals were not even consulted about their individual work needs. This fact impairs the group's counseling activity which, because of its differentiated characteristics and specificities, requires an appropriate physical structure. Even management aspects, which can be solved through dialogue, such as not interrupting the professional for instance, are not respected. It is the institution's role to provide minimal security conditions, access to training access, emotional support, in short, to offer these professionals the means to perform their activity with a minimum of dignity.
Another difficulty reported by the interviewed group is related to the counselees. It mainly derives from this individual's degree of cognition, fear, taboos, prejudices that person introspects when (s)he is confronted with the possibility of being infected with HIV. These interferences affect the dialogue, jeopardizing the establishment of a trust relationship between counselor and counselee, in view of the intimate issues that can be addressed. Thus:
[…] what I notice a lot in the client's case is that, when he/she is a person who does not have the slightest idea, illiterate, does not have, does not understand what we are saying, arrives very sick already, it is difficult for him/her to learn, to assimilate anything.
As perceived in the interviewees' reports, they mention the counselee's cognitive level, his/her concentration and interest in what is being informed and the existence of diseases that compromise mental balance as factors that turn counseling more difficult. According to the interviewees, these issues are obstacles to an effective orientation. Therefore, we can infer once more the importance professionals attributed to information in counseling.
One interviewee's perception should be highlighted here. She believed that the individual comes to counseling completely needy of everything. But the fact the counselee did not have access to formal education does not mean that this person does not have any contribution to give. It is fundamental for the counselor to break with preconceptions, such as supposing that the individual cannot offer anything and that it is the counselor who will provide knowledge. One of Freire's most important legacies is to reorganize the relationship between educator and learner, showing that both learn mutually in this relationship. The educator will guide the learner to find his/her question.
Regarding facilities to do the counseling, integration with the multidisciplinary team was emphasized as the main facilitator, since the group's unity to help colleagues is very important for the group in counseling practice. Their discourse says:
The team, I particularly feel very good agreement in terms of referral, or when we need something, because you do not attend the need of that patient by yourself, you count on your co-workers a lot.
According to the professionals, integration is one of the main facilitators. Being in a team where there is communication, relationship, listening and dialogue is fundamental for the creation of openness and the possibility of a multidisciplinary posture, because the person is a relationship being and exists in and with the world.
An ethical, interdisciplinary posture for professionals needs to be defended, emphasizing coherence between theory and practice. The educators' role is to defend methodological options in favor of more comprehensive projects, guided by their pedagogical practice(14).
Feeling the counseling
In counseling, the counselor feels discomfort when facing the subject's existential situation, which often refers to histories of suffering, expropriation, abuse, subservience. All these problems heard by the counselor arouse several feelings. Two types of feelings excited in the professional by counseling practice can be distinguished: positive and negative.
Positive feelings occurred due to the fact that the counselor can be an instrument of support and help to the person seeking this service, minimizing the suffering caused by the possibility of being infected by HIV or having AIDS.
All participants mentioned negative feelings in a more intensive and significant way, due to the fact that this activity implies many emotions, hard demands, death, abandon. All these problems become complicated for the professionals because they do not find adequate support in public policies. These professionals feel insecure and abandoned, as shown in the following report.
They are very complex feelings. On the one hand, well, being able to support a person in a difficult moment, but on the other hand, I suffer a lot. In terms of feeling, because we start to feel limited. The support you give at that moment to that person, but I keep thinking, damn! She is going to leave here and what is she going to do? […] Because today we deliver more positive results, before, when we attended spontaneous demands, we delivered negative results, a lot. As, now, the clientele is concentrated, our tendency is to deliver more positive results. You are dealing with pre- and post-tests with positive or sick people. So I suffer […] They are very needy people with very difficult histories, and then we feel […] I suffer. In that sense, it is painful.
To avoid getting ill, the group uses strategies to cope with the situation, described as: hard, painful and causing suffering, mostly experienced negatively by professionals, due to the fact that counseling is intensively related to feelings and emotions. The professional develops, then, mechanisms to cope with these problems without getting sick and without compromising his/her routine.
All participants used some strategy to cope with the suffering caused by counseling practice. These strategies include reading, leisure, spiritual and even therapeutic search. This search, however, is solitary, because the institution is not ready to provide a continued activity that is part of the professional's hour load in order to minimize the "collateral effects" of counseling, that is, the density and sorrow caused by histories of so distressed lives.
AIDS is still a serious problem in public health policies and practice and has originated complex issues, suffering and losses. Counseling emerges as a theoretical and methodological strategy to help health professionals in order to work with the issues this raises and to give emotional and educational support and orientation in the prevention of this disease. We perceive, though, that this strategy was largely centered on information and disease.
In this sense, according to what we exposed above and our observations, counseling is not configured yet as an educational moment in the Freirean perspective, because it is not dialogical and neither stimulates critical conscience to interfere in reality, nor the subject's autonomy. However, we identified that part of these team members are willing and want to turn this activity into a reflexive and educational moment.
Thus, we present the possibility to realize HIV/AIDS counseling based on Paulo Freire, based on the premise of education as an act of knowledge and intervention in reality, and not as the accumulation of information. We confirm that we did not intend to formulate a counseling guide or recipe. We are interested in presenting our collaboration to such a significant moment in Health Education praxis.
Thus, there is an urgent need to reorganize counseling practice. The counselor should defend counseling as a political act as well and engage in the creation of an educational counseling project in which, through a caring dialogue, counselor and counselee together can construct an education for freedom, exposing ties and announcing a project for the person's autonomy. Counseling as an educational action should no longer be reproduction. Instead, it should be methodologically grounded as an educational activity with the perspective - as emphasized above - of transforming and guiding the person towards autonomy. As a result, through epistemological curiosity, the counselor can pass from a naïve to a critical conscience, stimulating the reading of reality and the possibility of autonomy.
Thus, it is fundamental for the counselor to develop some abilities, which we call virtues, to favor interaction and to gain the counselee's trust. Counseling should be mediated by a caring and problematizing dialogue, with a view to constructing the other person's narrative. It is through dialogue that the subject is strengthened to construct his/her own question and seek his/her answer. It is by generosity that the counselor is open to others, without judgment. It is also by exercising critical thinking that others are encouraged to sharpen their curiosity to discover the world, in order to interpret, intervene, transform it and transform themselves. It is through interdisciplinarity that we can see reality with other eyes, making it richer and more interesting. We cannot let ourselves get numb by the conformism and determinism predominant in public institutions, which complicate renovation and change projects. It is only by joy and hope that we can break with the inertia of public institutions' policies and fight for the dream that is possible.
For counseling to become an educational moment, moreover, a permanent dialogue is needed between Health Secretary, Family Health Program, home care services, continuing education, non-governmental organizations, schools and neighborhoods. Together, they can join efforts in order to turn counseling into a moment beyond information, a really educational circumstance for the subject's interpretation, intervention and transformation.
However, all of this will only be possible if regulatory institutions in the counseling area understand it from the Freirean educational perspective, in which the professional has enough time and conditions to perform this activity. Governmental institutions should value education in order to value counseling, avoiding it from becoming a "chat" without any obligation, conducted according to the counselor's will.
We insist on the idea that it is only through struggle, jointly with all other institutions and in a network, that we can build this possible dream. It is fundamental to think in terms of theory and practice with "features of beauty", beyond cognition, action and affect, in which anthropological, political, epistemological, ethical and esthetical principles are articulated. This can bring us closer to an educational action towards the subjects' freedom and autonomy.
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Recebido em: 18.8.2005
Aprovado em: 13.9.2006
1 Study extracted from Doctoral Dissertation, FUNCAP funded