Defining and Measuring Spirituality in South African Specialist Psychiatry.

To define the meaning of "spirituality" in a South African phenomenological, theory-generating qualitative inquiry, theory construction methodology was used. This refers to the tradition of nursing theory development, where a central core concept identified from the integrated data-in this case, interviews and the literature content-had to be defined. A major focus of the study was to distinguish spirituality from religion. The denotative and connotative meanings of "spirituality" were explored to establish the components for a definition. The attributes of this definition included that spirituality constitutes a "quality", a "journey", a "relationship" as well as a "capacity". While these items derived from this local definition of spirituality can be proposed for inclusion in a questionnaire for measuring spirituality in a South African context, the limits of the scope of the explorative qualitative inquiry from which it was derived must be considered.

The role of spirituality in specialist psychiatry: a review of the medical literature.

A review of the international medical literature was undertaken on the role of spirituality in the discipline of psychiatry, within the context that a perceived change is taking place in the health care environment in South Africa. Revitalized interest in spirituality was evident from the literature partly because Western societies have, through the migration of people, become more heterogeneous in recent years. The literature concurred that spirituality must be incorporated into the current approach to the practice and training of psychiatry, but within the professional scope of the discipline, while all faith traditions and belief systems should be regarded equally. Beyond South Africa, it is envisaged that the review has implications for the practice of psychiatry in Africa.

Student nurses' experience working with mentally challenged individuals in South Africa.

South African student nurses experience emotional discomfort that might influence their adjustment and coping while working with mentally challenged individuals. Adjustment and coping might impact on their mental health and support needed while working in this challenging context. Student nurses working with mentally challenged individuals experience emotional discomfort that may result in work-related stress. The experiences of student nurses working with mentally challenged individuals were explored and described as it may influence their adjustment, coping and result in work-related stress, impacting on their mental health. The study used a qualitative, explorative, descriptive, contextual research design with a case study as strategy. Thirteen student nurses from a specific higher educational institution in Gauteng, South Africa, participated in the focus group interviews. The researcher utilized reflective journals, a reflective letter, naïve sketches, drawings and field notes to collect data. Data analysis was done according to Tesch's descriptive method of open coding and theme analysis. A central storyline emerged where student nurses described working with mentally challenged individuals as a process of personal transformation that was initiated by an engagement on a deeper emotional level with these individuals. The process of personal transformation started a journey towards the discovery of meaning for the self, as student nurses. Student nurses working in challenging environments during their training may experience emotional discomfort and need additional support in coping and adjustment within this context. The nurse educator plays an important role in providing this support to manage work-related stress as well as in creating learning opportunities for the student nurses working in challenging contexts.

Experience and views of academic psychiatrists on the role of spirituality in South African specialist psychiatry / Experiência e visão de psiquiatras acadêmicos sobre o papel da espiritualidade na prática e no treinamento de especialistas em psiquiatria na África do Sul

BACKGROUND: The importance of having to consider the role of spirituality in health, mental health and psychiatry in South Africa has in particular been emphasized by recent legislation on African traditional health practice. OBJECTIVE: The purpose of this study was to explore the views and experience of local psychiatrists regarding the role of spirituality in South African specialist psychiatric practice and training. METHOD: This study is an explorative, descriptive, contextual, phenomenological and theory-generating, qualitative investigation. In-depth, semi-structured interviews with individual academic psychiatrists affiliated to a local university were conducted as primary data source. Measures to ensure trustworthiness included credibility, transferability, dependability and confirmability. RESULTS: Awareness of spirituality, "mindfulness" and an open-minded approach about spirituality should, according to participants, be facilitated in psychiatric practice and training. Six themes were identified through open coding. DISCUSSION: All participants, disregarding of their own views on spirituality and religion, agreed, that under certain conditions, spirituality must be incorporated into the current bio-psycho-social approach in the local practice and training of specialist in psychiatry.

CONTEXTO: A importância de ter de considerar o papel da espiritualidade na saúde, saúde mental e psiquiatria na África do Sul tem sido especialmente enfatizada pela recente legislação sobre práticas tradicionais de saúde na África. OBJETIVO: Explorar as opiniões e experiências de psiquiatras locais sobre o papel da espiritualidade na prática e no treinamento de especialistas em psiquiatria na África do Sul. MÉTODO: Este estudo é uma pesquisa qualitativa, exploratória, descritiva, contextual, fenomenológica e geradora de hipótese. A fonte principal de dados foram entrevistas semiestruturadas com psiquiatras filiados a uma universidade local. Para assegurar de que os dados fossem confiáveis, as seguintes medidas foram incluídas: credibilidade, transferibilidade, confiabilidade, e confirmabilidade. RESULTADOS: A consciência da espiritualidade, "mindfulness", e uma abordagem de mente aberta sobre a espiritualidade, segundo os participantes, devem ser facilitadas na prática e no treinamento psiquiátrico. Seis temas foram identificados por meio de códigos abertos. DISCUSSÃO: Todos os participantes, independentemente de suas próprias visões sobre espiritualidade e religião, concordaram que, sob certas condições, a espiritualidade deve ser incorporada na abordagem biopsicossocial atual na prática local e no treinamento de especialistas em psiquiatria.

Experiences of psychiatric nurses exposed to hostility from patients in a forensic ward.

BACKGROUND: Hostile behaviour is becoming a way of life in South Africa. Hostility prevails at all settings, including in the health sector. In a forensic ward psychiatric nurses are subjected to hostile behaviour by the patients. AIM: The aim of the present study was to explore and describe the psychiatric nurses' experiences of hostile behaviour by patients in a forensic ward and make recommendations for nurse managers to empower these psychiatric nurses to cope with the patients' aggression. METHOD: Qualitative, in-depth, phenomenological interviews were conducted with nine psychiatric nurses exposed to hostility from patients in a forensic ward. Recommendations were derived from the results from nurse managers to assist psychiatric nurses. RESULTS: It became apparent from the findings that psychiatric nurses in a forensic ward work in a stressful environment. Hostile behaviour in the forensic ward is consistently experienced by the psychiatric nurses as hindering therapeutic relationships. The psychiatric nurses experienced being disempowered. CONCLUSION: Psychiatric nurses experience hostile behaviour by patients in a forensic ward as disempowering. IMPLICATIONS FOR NURSE MANAGEMENT: Nurse managers can facilitate psychiatric nurses' empowerment by providing them access to: information, support, resources, opportunity and growth.

Registered nurses' experiences of interaction with patients with mental health challenges in medical wards in Johannesburg.

AIM: The aims of this research were to explore and describe registered nurses' experiences of interacting with patients with mental health challenges in the medical wards of a public hospital in Johannesburg. BACKGROUND: Nurses are the major providers of hospital care and have become an important resource in the delivery of mental health care to patients with mental health challenges. However, the attitude and ability of many nurses in providing this care have been shown to be poor. METHOD: In-depth phenomenological interviews were conducted with eight female registered nurses working in four medical wards where they interact with patients with mental health challenges. RESULTS: From the findings it is clear that registered nurses experienced frustration, unhappiness, fear and perception of danger when interacting with patients with mental health challenges in their wards. This could be attributed to a lack of knowledge and skills in mental health. CONCLUSION: Registered nurses have negative experiences with interaction with patients with mental health challenges in medical wards because of a lack of knowledge and skills in mental health. IMPLICATIONS FOR NURSING MANAGEMENT: Ward managers can facilitate the psychological empowerment of registered nurses.

Perceived basic needs and resources for the elderly in the peri-urban and rural communities in the Hhohho region in Swaziland.

The purpose of the study was to explore and describe the basic needs and resources for meeting the needs of the elderly in the peri-urban and rural communities in the Hhohho region in Swaziland. A qualitative, exploratory, descriptive and contextual research design was used. The study population consisted of the male and female elderly aged from 60 years old and above, and key informants (health motivator, community leaders and members from welfare organizations that serve as advocates for the elderly in Swaziland). Purposive sampling was utilized to select participants who met the inclusion criteria. Data were collected using focus groups and individual in-depth face-to-face interviews till data saturation was achieved as evidenced by repeating information. Tesch's method of qualitative data analysis was utilised to identify themes. A total of 30 elderly persons and eight key informants participated in this research. From the study findings the researcher identified the following themes: need for resources because of poverty; need for support because of the burden of caring for others; need for health care because of health challenges; need for company because of loneliness, and need for protection because of abuse of elderly persons. Recommendations were made for community nursing practice, nursing education, nursing research and the Ministry of Health and Social Welfare.

The Lived Experiences of Late-Adolescent Female Suicide Survivors: 'A Part of Me Died'

People's thoughts often focus on the suicide victim immediately after a completed suicide. Yet; the real victims of such an event are those individuals who are left behind to cope with the aftermath of the suicide. This phenomenological psychological study explored the lived experiences of lateadolescent suicide survivors; particularly those negative experiences that seemed to worsen in the weeks and months after a significant other's completed suicide. The research participants were five female late-adolescents (aged 17-22 years) who were recruited by means of purposive sampling at a South African tertiary institution and at youth camps. Data collection consisted of collagefacilitated; face-to-face phenomenological interviews. In addition; some participants provided documentary material in the form of personal diaries; letters and poems. The data analysis was conducted according to Giorgi's phenomenological method. The following salient experiences emerged during the data analysis: guilt; self-blame; blaming others or God; anger; loss or restriction of 'self'; depression; suboptimal behavioural coping patterns; changes in relationship dynamics; and suicidality. The results of this study can be used by mental health professionals and caregivers to support adolescent suicide survivors effectively; in the midst of their mourning

The lived experience by psychiatric nurses of aggression and violence from patients in a Gauteng psychiatric institution.

Caring for good people is difficult enough; to care for people who are either aggressive or violent is even more difficult. This is what psychiatric nurses working in the psychiatric institution in which research was done are exposed to on a daily basis. The aim of the research was to explore and describe the lived experience by psychiatric nurses of aggression and violence from patients in a Gauteng psychiatric institution. A qualitative, explorative, descriptive, and contextual study design was utilised. Data was collected by means of semi-structured interviews and naïve sketches. Tesch 's (Creswell, 2004: 256) method of open coding and an independent coder were utilised for data analysis. This study shed some light on the lived experience by psychiatric nurses of aggression and violence from patients in a Gauteng psychiatric institution. The findings show that the level of violence and aggression to which psychiatric nurses are exposed is overwhelming and the consequences are alarming. The contributing factors to this violence and aggression are: the mental status and the conditions in which patients are admitted; the staff shortage; the lack of support among the members of the multidisciplinary team (MDT); and the lack of structured and comprehensive orientation among newly appointed staff members. As a result, psychiatric nurses are emotionally, psychologically, and physically affected. They then respond with the following emotions and behaviour: fear, anger, frustration, despair, hopelessness and helplessness, substance abuse, absenteeism, retaliation and the development of an "I don't care" attitude.

Exploration of the views of traditional healers regarding the termination of pregnancy (TOP) law.

The North-West Province is predominantly a rural area, and traditional healers remain the most important and influential members of the rural communities. A qualitative, explorative, descriptive and contextual research design was used. In-depth, individual focused and interactive interviews were held with eight traditional healers from the rural areas of Mmabatho-Mafikeng. In addition, field notes and observations were utilised. The objective of this article is to explore the views of the traditional healers regarding termination of pregnancy (TOP) law. The results reflected the following themes: termination of pregnancy is killing; a child is a precious gift from God and the ancestors; there are alternatives to TOP; people who had any type of abortion should be cleansed with "dipitsa" or herbs; TOP may be allowed only in case of rape and incest, rape and incest offenders should be severely punished; and the traditional healers were not consulted during formulation of the TOP Law. It is therefore recommended that traditional should be involved in TOP workshops and educational programmes to enable them to provide counselling before and after abortion.

Life stories of depressed adult women in peri-urban Namibia.

The problems women in peri-urban Namibia are faced with are multi-dimensional. Like women in other communities they face the pressure of having a number of responsibilities, namely working, being a wife and mother, taking care of their families and perhaps caring for aging parents. Sometimes the pressure can be too overwhelming to manage. As a result, many women become depressed. Studies on depression among black African women in Namibia could not be traced. It was therefore considered to find out how women suffering from depression from this part of the world tell their life stories. The purpose of the study was two-fold: Firstly, to explore and describe the life stories of depressed adult women in peri-urban Namibia, and secondly to use the information obtained to describe guidelines for psychiatric nurses working with these patients at psychiatric outpatient clinics as well as in the community. A qualitative phenomenological research design of an explorative, descriptive and contextual nature was used. The researcher approached the subjects and their experiences with an open mind. Ten depressed adult women between 21-55 years were involved in the research. The researcher strived to adhere to the principles of trustworthiness. To ensure this Guba's model (in Krefting, 1991: 217) of trustworthiness was adopted. All the interviews were analysed following Tesch's method (Creswell, 1994: 154-55). The services of an independent coder were obtained. The results indicated that impaired interpersonal interactions and stressful life events have a negative influence on the daily life of women leading to the development of depressive symptoms. Guidelines to support psychiatric nurses working with depressed women were drawn up.

Women's experience of termination of a pregnancy.

In November 1996 the Act on the Termination of Pregnancies (no 92 of 1996) was promulgated. This Act enabled women from the age of twelve years old to decide to terminate their pregnancies before twelve weeks gestation without permission of anybody else. Since February 1997 almost 160 000 terminations of pregnancy have been carried out in South Africa. Little research has been conducted to explore and describe the effect of the termination of pregnancies on women Two aims were formulated for the research project described in this article: (1) the exploration and description of the women's experience of terminating a pregnancy, and (2) the description of counselling guidelines for caring professionals to assist these women. Participants were included in the sample through purposive sampling. Phenomenological interviews were conducted individually. Data were analysed by means of Tesch's descriptive approach. Counselling guidelines for educational psychologists and other caring professionals to empower the involved were being logically inferred from the results of the interviews. Measures to ensure trustworthiness have been applied in the research and ethical measures have been strictly adhered to during the research. One central theme was identified from the results of the interviews and naïve sketches, namely women's experiences of a negative relationship with themselves and other persons as well as their focus on their terminated pregnancies.

The lived experience of women subjected to domestic violence and abuse.

The number of incidents of domestic violence appears to be continually on the increase. Domestic violence and repeated victimisation and offending can even give rise to fatality. Evaluation of the quality of service delivery and understanding of domestic violence by community members and health care workers show poor results with some people still clinging to myths coming from cultural beliefs. The goal of this article is to explore and describe the lived experience of women subjected to domestic violence and abuse; and to make recommendations for nursing practice, nursing education and nursing research to support women who were subjected to domestic violence and abuse, in facilitating their mental health and optimising their ability to terminate the abusive situation. The framework of the Theory for Health Promotion in Nursing (Rand Afrikaans University, 2000) was used. A qualitative, explorative, descriptive and contextual research design and in-depth, semi-structured, qualitative research interviews were used. Guba's model of trustworthiness (Poggenpoel, 1998: 348-350) was applied. Guba's model for trustworthiness was used (Poggenpoel, 1998: 348-350) Data analysis was done according to Tesch's method (Poggenpoel, 1998: 343-352). The target population of this study was white women in Middelburg, Mpumalanga Province, that experienced abuse for at least the last year and were still married to or in the process of divorcing the abuser. The researcher used a sample of nine participants of which one was involved in the pilot study.

[The psychiatric health model for meaningful support by family members who must decide on the treatment of life support]. / 'N geestesgesondheidsmodel vir ondersteuning van gesinslede wat moet besluit oor die onttrekking van lewensondersteunende behandeling.

The aim of this research is to develop, describe, operationalize and evaluate a model as framework for meaningful support by the advanced psychiatric nurse, which will serve to support family members who are involved in the decision-making process regarding the withdrawal of life sustaining treatment, in order to promote their mental health. The paradigm of the Department of Nursing of the Rand Afrikaans University, which endorses the Theory for Health Improvement in Nursing (Randse Afrikaanse Universiteit: Departement Verpleegkunde, 200: 1-16) was accepted for the purpose of this research. A theory generating design which is qualitative, descriptive and contextual was used to develop the model as framework of reference for meaningful support. Step one identifies, classifies and defines the central concept "meaningful support", as well as the essential and relative concepts. Step two formulates the inter-relational views of the identified and defined concepts. In step three the guidelines of Chinn & Kramer (1995: 105-124) was utilised for the structural and process description of the model. The structure of the model's process, which comprises three phases, is cyclic. Step four consists of evaluation regarding the process description of the model, done according to the definition of the central concept "meaningful support". The evaluation criteria of Chinn & Kramer (1995: 125-135) were also used.

The experience of therapy by therapists and survivors after exposure to armed robbery.

In this article the results of research undertaken to explore the experience of therapy by respectively the survivor of armed robbery and the therapist of the survivor of armed robbery in the case where therapy is prematurely terminated by the survivor of armed robbery are discussed. A high percentage of therapy for the survivor of armed robbery is being terminated prematurely by the survivor. This might be the reason for failing to use all possible opportunities to recover within reasonable time. The research questions that arouse are: "How do survivors of armed robbery experience therapy after being exposed to armed robbery?" and "How do therapists experience therapy for the survivor of armed robbery?" A qualitative, exploratory, descriptive and contextual research design was utilised. Phenomenological, semi-structured interviews were conducted with survivors of armed robbery and therapists of survivors of armed robbery to explore and describe their experiences. It was found that therapy leads to the experience of anger, fear, sadness and peace. The following needs of the survivor of armed robbery in the course of therapy were identified: a need to be cared for, availability, empathy, listening, focus on the armed robbery, help with the handling of problems, a trustworthy relationship with the therapist, sensitivity by the therapist and caring by important others in the life or the survivor of armed robbery. These needs were identified by both groups of participants. When these needs are not met within therapy, therapy is terminated prematurely and experienced as unsuccessful. Three principles of therapy were identified, namely that therapy should start as soon as possible, the trend and technique should be explained and signs and symptoms should be explained.

A model of facilitative communication for support of general hospital nurses nursing mentally ill people. Part 2: model description and evaluation.

Part 1 of this article dealt with a full description of the research design and methods. This article aims at describing a model of facilitative communication to support general hospital nurses nursing the mentally-ill. In this article a model of facilitative communication applicable to any general hospital setting is proposed. Fundamental assumptions and relationship statements are highlighted and the structure and process of facilitative communication is described according to the three steps employed: 1) assisting the general hospital nurse learn the skill; 2) assisting the general hospital nurse practise the skill in order to develop confidence; and 3) using the skill in a work setting. The guidelines for operationalizing this model are dealt with in the next article. The evaluation of the model is also briefly described.

The life world of the adolescent with mental health problems.

Adolescents are currently being more and more exposed to the expectations of parents, educators, health-workers/helpers and policy makers to meet the demands of society and conform to it. The perception arises that adults are not able to let the adolescent take responsibility for the HOW of his own life story, despite all the expectations and demands. Under the influence of the post-modernistic approach to science and the narrative therapy it appears that each person is an expert of his own life and that each person is responsible for the how and the writing and rewriting of his own life story. This means that even the adolescent with mental health problems is busy with the writing and rewriting of his life story till even unpleasant incidents and experiences gain new meaning. This demands from the adolescent with mental health problems to be actively involved with his treatment program while the therapist is a participating observer of the therapeutic events. A one-sided approach, where the therapist's objectives and ideas make the difference in the treatment of adolescents with mental health problems, becomes redundant. An alternative approach is suggested where the adolescent with mental health problems becomes co-author of his own life story and his treatment program. In this research the researcher aimed to explore and describe the HOW of the life world of the adolescent with mental health problems. The utilization of the case-study format as research method enabled an in-depth, holistic description of the life world of the adolescent with mental health problems. The implementation of the strategies to ensure trustworthiness, as described by Guba was applied to ensure the validity and reliability of this study. Focus was specifically placed on the application of the strategy of cross validation. This implies that multiple data-collection sources, different experts, theories and respondents were utilized in the exploration of the life world of the adolescent with mental health problems before this life word was described in depth. The researcher makes a few conclusions and based on these make recommendations for application in practice, education and research.

A model of facilitative communication for the support of general hospital nurses nursing mentally ill people. Part I: background, problem statement and research methodology.

The impressive growth in the extent and range of psychiatric services provided by general hospitals in South Africa creates stress among nurses employed in these settings who are not psychiatric trained. This manifests itself in negative attitudes displayed towards mentally ill people. The aim of this paper is to discuss the process followed in the development of the model of facilitative communication. A theory generative design was used. The research methods were dealt with in four steps of theory generation as set out below. Step 1 entailed concept analysis. This step was dealt with in two phases, namely concept identification and concept definition. During concept identification, a qualitative research strategy that is explorative, descriptive and contextual was used. This was achieved through field research conducted in an urban general hospital. A sample of twelve professional nurses was selected from a population of 800 professional nurses employed in a general hospital using the purposive sampling technique. This sample size was determined by saturation of data in themes. Both semi-structured individual phenomenological interviews and observations were used as methods of data collection. Giorgi's method of descriptive data analysis (1985) was used. Four themes emerged from the results of the study. The main concepts of the model were identified and classified using a survey list of Dickoff et al. (1968). Step 2 dealt with the creation of interrelationship statements between concepts identified in Step 1, while Step 3 dealt with the description of the model using strategies proposed by Chinn and Kramer (1991). In Step 4, the description of guidelines for operationalizing in practice was ensured. To ensure valid results, a model for trustworthiness proposed by Guba (Lincoln & Guba, 1985) was used. The following criteria for trustworthiness were applied in all the steps of theory generation: truth value, applicability, consistency and neutrality.

Life stories of families with a terminally ill child.

Family units with a terminally ill child have a tendency to withdraw and this isolation may lead to problems in their mental health. A tendency with psychologists, clergy and helpers from other professions is to act as ideal experts on the lives of saddened people. From painful personal experience, this does not seem to enable acquiescence. Therefore, the aim of research on families with terminally ill children, was to explore and describe their lives and to develop an approach to facilitate their families to obtain acquiescence. In this article however, attention will be given to the life-world of families with terminally ill children. The research consists of two phases. In phase one the experiences of four families with terminally ill children are explored and described by means of phenomenological, unstructured, in-depth interviews. In phase two an acquiescence approach, which was designed for educational psychologists to facilitate families with terminally ill children to achieve acquiscence, is described. This approach is based on results from phase one. This article focuses on phase one. In this phase four families were interviewed individually, in the privacy of their homes. The interviews were audiotaped, and were transcribed for the purpose of data gathering. The data was analysed according to Tesch's method and a literature control was performed to verify the results. Guba's model for the validity of qualitative research was used. Five recurrent themes were identified: 1. Families are able to choose their reactions to the crises of having a terminally ill child. 2. When there is a terminally ill child in the family, the family's values change. 3. Acceptance of the circumstances with a terminally ill child, makes life easier. 4. As families with a terminally ill child learn to live every moment to the full, their quality of life improves. 5. As people learn to accept support, their quality of life with a terminally ill child improves. The research indicated that families with terminally ill children move through a lonely and painful process, which is characterised by growth at the end. This growth implies that the life skills mentioned above, were obtained after years of unimaginable suffering. In order to reduce this period of suffering, an acquiescence approach was designed for educational psychologists to facilitate discovery and acceptance regarding the above life skills with family units and thus allow them to achieve acquiescence.

The experience of HIV reactive patients in rural Malawi--Part I.

Malawi has a population of 9 million people with AIDS the leading cause of death in the 20-40 age group. The HIV positive prevalence rate, estimated at 23% in urban areas and 8% in rural areas, is one of the highest in the world (AIDSEC, 1994:1). Evaluation of counselling practices showed poor results with counsellors feeling ineffective and inadequate. Patients are mostly tested on medical indication but patients who do not see the benefit of knowing their HIV status increasingly refuse testing. The counselling practise as it is known in the Western world is a foreign concept for patients living in rural Malawi. The high stigma of AIDS complicates support of the patients. The goal of the research study was to describe a model of counselling that would meet the needs of an AIDS patient in rural community in Malawi. A qualitative research design that was explorative, descriptive and contextually specific to rural Malawi was used for the study. In order to describe a counselling model it was important to understand the illness experience of HIV reactive patients. The patients are seen in group context congruent with the African culture and therefore the experience of the primary care giver of AIDS patients is explored as the other major factor in the phenomenon examined. One phase of the research is described in this article namely exploring and describing the experience of the HIV reactive patient in rural Malawi. Results show that patients are in an advanced stage of AIDS when they are diagnosed and complain of weakness and an inability to do work, including an inability to do their daily chores. This causes a feeling of desperateness that is worsened by the perception that support systems are inadequate. Support systems are mostly identified as parents, partners and siblings to assist mainly with the physical care and financial support. Despite the fact that the family is very important to patients there is a reluctance to acknowledge their HIV status. Patients fear being rejected once it is known that they have AIDS--not only because AIDS is a sexually transmitted disease, but also because it is perceived that financial and other support will be withheld if it is known that patients have AIDS and will therefore die and not be able to return the support provided. Patients feel they have no future once a diagnosis of AIDS has been made which results in refusal of testing, as they do not see the benefit of knowing their HIV status. Assessing the coping ability of the patient within the household as part of an overall assessment is one proposed strategy that could be taken. Secondly the patient is encouraged to take a more active role in the counselling process, which could be achieved by narration. The family should be incorporated into the counselling process as early as possible.