Issues in counselling

Key Points
  • The pyschological morbidity of a diagnosis often far outweighs physical symptoms.
  • Providing accurate up-to-date information in a non-judgmental way is key to assisting a person to understand and come to terms with herpes.

Genital herpes is a common and, medically speaking, usually a relatively minor condition in people who are sexually active. However, conditioning and social values contribute to individuals having a range of emotional responses when given a diagnosis of genital herpes.108-111

Emotions related to the diagnosis of Genital Herpes
  • Grief (includes anger, guilt, fear, shock and denial, sense of injustice).
  • Stigma (includes confusion, dirtiness, embarrassment, sense of isolation, loss of assertiveness, unworthiness.

Good therapeutic management acknowledges these emotional responses and addresses the patient's feelings and concerns. The patient who presents with genital herpes for the first time is very vulnerable. Acknowledge how difficult it must have been for the patient to present for treatment.112

Often the diagnosis is unexpected. Never be dismissive of the patient’s emotional responses to the infection. For some patients a diagnosis of genital herpes may be the most challenging health disruption they have ever experienced, given the stigma associated with sexually transmitted infections. Empathise with the patient and allow the patient to talk. Initiate questions and information about topics that may be difficult for patients to raise, but are common concerns, such as the impact of the diagnosis on sexual relationships.113,114 Aim for unhurried counselling at the patient's pace. The diagnosing clinician addresses the acute issues at the first presentation, even if the patient is referred elsewhere for counselling.26 Not all patients will take up the offer of initial counselling and support. It is very important to advise all patients of resources as these are often accessed at a later date; for example, when establishing a new relationship or wanting to conceive.

It is important that counselling and education about genital herpes take place in the appropriate setting. Incorporate the following points:

  • Comfortable setting
  • Patient dressed
  • Minimal interruptions
  • Confidentiality assured
  • Adequate time
  • Attentive listening
  • Avoidance of pejorative and prejudicial terms
  • Empathic attitude
  • Written information to take away and read
  • Encouragement to return with list of questions

Education may include answering questions about the natural history of the infection, including likely triggers for reactivation. Few solid data exist, but patient experience suggests that stress appears to be associated with recurrences in some patients.115Carefully advise about how to manage stress and lead a healthy lifestyle (exercise, good diet and complementary medicines). An emphasis on lifestyle may be stressful for the patient, heightening feelings of guilt and beliefs that recurrent symptoms are self-inflicted.

Correct management of genital herpes is time-intensive. The assessment of the likely impact of the diagnosis on the patient’s wellbeing depends in part on the following: whether a grief reaction is triggered, the person’s coping strategies, level of social support and underlying beliefs about sexuality and sexual health. Psychological issues and concerns should start to be addressed at the first session. Patients may have numerous worries: about the acquisition of HIV or other STIs, that they are seen as promiscuous and that the doctor has a low opinion of them.116 In all cases (whether primary, non-primary or first symptomatic reactivation), the emotional consequences and perceived social stigma of the infection need to be addressed. No matter the time since diagnosis, do not assume that another clinician has spoken with the person about genital herpes.113,117 The diagnosis of genital herpes will provoke a grief reaction in many patients and cause feelings such as guilt, anger, confusion and a sense of isolation. Patients with genital herpes are usually very concerned about the diagnosis, and its potential impact on their relationships and reputation amongst family and friends. Common concerns of patients relate to social stigma, transmission, fear of rejection upon telling potential sexual partners, and how herpes will affect their sex life and social activities.110,118

The above section on counselling is based on internationally accepted standards of practice. Grade C

Patients’ concerns are predominantly about relational issues
  • Fear of discovery
  • Intimate relationships and sex life affected
  • Social activities and lifestyle altered
  • Social stigma of STI
  • Condition is 'incurable'
  • Fear of transmission or contagion
  • Fear of disclosure and subsequent rejection
  • Inaccurate online material may exacerbate above points

Reassure patients that they are not alone in having genital herpes. The clinician or counsellor is encouraged to offer information about local herpes support groups and/or the NZ Herpes Foundation (tollfree number 0508 11 12 13) or refer for specialist counselling to the local sexual health clinic. Advise about reputable Internet resources and stress that the online ‘cure’ claims are not scientifically supported.

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