In-Person and Online One-To-One Counselling

What is the Program?

The one-on-one counselling program at ACT (formerly the AIDS Committee of Toronto) offers counselling for people living with and affected by HIV. Counselling topics can be related to HIV, sexual health, mental health and substance use. Sessions are free and confidential. Counselling sessions are available in person and online (e.g., by phone or online teleconferencing) through the ACT office. Counselling services are also available in community-based locations, including bathhouses and community health clinics.

Why Was the Program Developed?

The one-on-one counselling program was developed to provide community supports to people affected by HIV. At its inception, ACT mainly provided counselling services to people diagnosed with HIV and grief counselling. Over time, the program has evolved to continue to meet the needs of communities affected by HIV by expanding its counselling services to include topics related to mental health and substance use more broadly (among other topics).

Initially the one-on-one counselling program was only offered in person through the ACT office with two or three counsellors. Service users helped to inform the evolution of the counselling services through the topics they raised in counselling sessions: counsellors who had the skill sets necessary to address these topics were hired, and the training provided to staff was modified to encompass the growing range of fields. The program has also been informed by a service user satisfaction survey, which is sent out to everyone who engages with ACT services, as well as to community partners, every one to two years. This survey has informed the expansion of counselling services to community-based locations and health clinics where HIV care is being provided.

Originally, the one-on-one counselling program was delivered only in person. In 2018, ACT identified online counselling as a way to potentially increase clients’ access to its services. A dedicated person was hired to review the approaches to, and the potential benefits of, online counselling. This work resulted in the Online Counselling: Community Report, which included a review of relevant research evidence. The report indicated that online counselling could offer benefits such as increased convenience, accessibility and anonymity for clients. It also identified challenges associated with online counselling including the loss of visual cues (in non-video forms of communication) and the need for access to a reliable online platform and Internet connection. ACT slowly began to introduce online counselling through counsellors who were comfortable and interested in engaging clients in this way. When the COVID-19 pandemic began in 2020, all of ACT’s services were moved online. The previous work that ACT had done to set up online counselling enabled the organization to pivot quickly to offer one-on-one counselling to clients via an online platform.

How Does the Program Work?

The program strives to make counselling free and accessible to people living with or affected by HIV. The topics covered in counselling sessions are varied, and they are tailored to what clients need. Sessions often include topics related to mental health issues (e.g., depression, anxiety), substance use (e.g., crystal meth use), being newly diagnosed with HIV (e.g., anxiety management), disclosure planning, health system navigation planning and relationships. Counselling topics can differ depending on the location of the counselling. For example, community-based counselling sessions in a bathhouse may cover substance use or anxiety related to high-risk sexual activities, while counselling sessions at a community health clinic may include topics related to HIV care. Counselling is mainly done one to one, but sessions can also include an additional person, such as couples counselling.

Services are offered both in person and online. In-person services are offered at the ACT office, in community locations (i.e., bathhouses) and in community health clinics. Online counselling is coordinated through the ACT office and offered via the Zoom platform.

All counsellors are psychotherapists, social workers or community counsellors. They are identified generally as “counsellors,” and placement of clients with a counsellor is not related to the counsellor’s professional designation. A women’s program coordinator and a youth program coordinator also provide peer-based support for the counselling program. The coordinators’ role is similar to that of a case manager in that they work one on one with clients to provide emotional support and assist clients with service navigation, but they do not provide clinical counselling services. Coordinators can help with letters of support for school, immigration documentation and referrals to physicians. Coordinators engage in active listening and refer clients to ACT counselling services when additional support is needed.

ACT’s “in-house” counselling, which include in-person counselling at the ACT office (on either a drop-in or a scheduled basis) and online counselling, is mainly advertised online and through word of mouth. The in-house counselling service predominantly serves gay, bisexual and queer guys, but services are also provided to women and queer youth. Counselling sessions are free of charge and generally an hour in length. In-person counselling at the ACT office happens from Monday to Friday, between 10 a.m. and 6 p.m., with sessions also available on one evening between 6 p.m. and 9 p.m. ACT ensures that there are multiple people present onsite for all evening counselling sessions to ensure the safety of staff and clients. Online counselling offers flexibility in terms of counselling times, with more evening sessions available. Counsellors and clients determine meeting times.

Community-based counselling is advertised directly through bathhouses and community health clinics. Community-based counselling is exclusively for gay, bisexual and queer guys. Counselling in community health clinics is for people receiving care at the clinic. The timing of community-based counselling depends on the operating hours of the host site. For example, counselling in a bathhouse might take place late at night or early Monday morning to enable counsellors to connect with people who were at the bathhouse over the weekend.

The intake process for ACT’s in-house counselling services is the same for both in person and online services:

Potential clients connect with ACT in person or via phone or email to discuss what counselling services are available (including options for online counselling and drop-in options) and to determine which service will work best for them.
An intake form is completed by the intake staff.
Internal documentation to track the enrolment of service users is completed.
A follow-up email summarizing the conversation is sent to clients.

Once intake is complete, clients are connected to a counsellor. Clients can either book an appointment by calling or emailing their counsellor directly. ACT also offers drop in counselling from Monday to Thursday, they can check in with the ACT office on any day to ask about drop-in availability that day. Intake for drop-in sessions follows the regular intake process. Drop-in counselling is offered on a first-come, first-served basis. ACT’s in-house counselling service does not limit the number of sessions that clients can receive.

Counsellors who are meeting their clients in person normally do so at the ACT office, although they can also meet clients in community locations (e.g., coffee shops) to increase accessibility and decrease the potential stigma associated with visiting the ACT office.

If counsellors are meeting their clients online, ACT currently offers four options for connecting:

Phone: requires a phone and access to a private space
Video (through Zoom for Telehealth): requires a smartphone or computer with a working camera/audio, headphones, a good Internet connection and access to a private space
Private conversations (through PrivacEmail, email style communication): requires a smartphone or computer and an Internet connection to sign in and to send content (content can be added without a connection)
Live chat (through PrivacEmail, instant messaging): requires a smartphone or computer, an Internet connection and ideally access to a private space

In community-based counselling, counsellors meet clients in three bathhouses and two community health clinics (the Maple Leaf Clinic and Church Wellesley Clinic) in Toronto. ACT has memoranda of understanding (MOUs) with each of these locations. Intake in the bathhouses happens when counsellors meet clients onsite and provide counselling on the spot (i.e., the intake session and counselling session are completed simultaneously). Counselling happens in bathhouses on an as-needed basis. Some clients may only be seen once, and others may visit with the same counsellor multiple times. In the community health clinics, doctors or nurse practitioners make referrals to counsellors using an online booking system. The health professional books an appointment with a counsellor directly and the counsellor completes intake with the client during their first onsite meeting. Because of waitlists for the community-based counselling services, clients are usually eligible for a maximum of eight to 15 sessions.

Referrals to other community services are an important component of all of the types of counselling services and can be provided by counsellors or peer support workers. Clients can receive a variety of referrals, such as the following:

They can be referred for confirmatory HIV testing after a reactive point-of-care HIV test.
They can be connected with physicians after receiving a positive HIV diagnosis. ACT has an MOU with an HIV care clinic in Toronto that allows ACT to make direct and timely referrals to the clinic for people diagnosed with HIV.
They can be referred to clinics offering pre-exposure prophylaxis (PrEP) for HIV prevention.
They can be connected with other social support services including employment programs and youth programs (e.g., services that help clients to navigate the school system).

All counselling services can end with referrals to other community support services (e.g., support groups), and clients are notified that they can return to one-on-one counselling services in the future if needed.

Special considerations related to online counselling

Online video counselling takes places via the Zoom platform. When a counsellor first meets with a client, they review the Zoom platform, including the available privacy safeguards, and clients complete an informed consent form. ACT completed a review of the Zoom platform and determined that Personal Information Protection and Electronic Documents Act (PIPEDA) and Personal Health Information Protection Act (PHIPA) requirements could be met.

ACT has developed several documents outlining best practices when using Zoom, including protocols for counselling sessions. These practices include locking Zoom meeting rooms, requiring participants to use a password to enter meetings and enabling a waiting room so that the meeting organizer can prescreen participants before they enter. ACT also offers a private room in their office, which can be booked by the hour, where clients can have a private online counselling session.

Required Resources

A program coordinator or intake staff person to staff the front desk (part-time)
Managers (one for the in-house counselling program and one for the community-based counselling program) to oversee the community counsellors and in-house counsellors and provide administrative support for the program (part-time)
Clinical supervisor (external) who is picked by each individual counsellor and with whom the counsellor can debrief for a few hours each month (this person is not involved in administering the program or managing the performance of counsellors)
Counsellors (i.e., psychotherapists, social workers, community counsellors)
Coordinators to provide peer and navigation support
Space for in-person counselling (e.g., counselling room, external meeting space)
Technology to complete remote counselling sessions (i.e., Zoom subscription and application, access to a telephone or computer, access to other online text-based services [e.g., PrivacEmail], access to the Internet)
A data management system to track how the service is being used

Challenges

Finding the right fit between a client and a counsellor can be a challenge for any counselling program. Establishing connections can take time. A counsellor can refer a client to another counsellor with the consent of the service user; referrals are usually done when another counsellor has a specific skill set or expertise in particular practice areas that would benefit the service user.
There can be high demand for free counselling services in the city of Toronto. ACT’s services have had 1- to 3-month waitlists at times, which can be difficult for clients.
Specific challenges with online counselling include calls getting dropped in the middle of sessions, safety related to discussing potentially sensitive topics in the participants’ home environments, finding a quiet and private space to have a counselling session and making the time to have a session with competing priorities at home.
When the idea of online counselling was first introduced some staff and clients were hesitant to engage with the technology. This meant that there was slow uptake of online counselling services to start.

Evaluation

From April 1, 2019, to March 31, 2020, ACT saw 579 unique clients for in-person counselling, both in-house at the ACT office or in community-based settings:

In-house counselling at the ACT office:
- 264 unique services users across 1,310 sessions
Community-based counselling:
- In bathhouses: 201 unique services users across 201 sessions
- In community health clinics: 114 unique service users across 644 sessions

During the COVID-19 pandemic five full-time counsellors saw approximately four service users per day online (i.e., 20 sessions collectively per week). An evaluation tool to evaluate online counselling is under development.

Lessons Learned

Let clients help to guide the type of counselling services provided. Listen to what clients need and hire staff according to the topics that clients want to discuss.
Internal capacity related to the use of online counselling increased as a result of needs that became a reality during the COVID-19 pandemic. Clients and staff have become more comfortable with the idea of online counselling and uptake of the services has increased.
People have different levels of comfort when it comes to online services, so this must be considered when implementing online approaches. Accessibility of computers and a reliable Internet connection needs to be considered, as do the safety concerns that service users may have about talking about sensitive issues within their home.
The more the online counsellor knows about the counselling platform and all its features, the better the service they can provide. It’s no longer just about counselling skills, modalities and practices; now, it’s also about information technology and software competencies. For example, if a service user is seeking counselling because of body image issues, the counsellor needs to know the different software features that will best support the service user experience (e.g., how to use a feature that will turn the service user’s webcam view off on their screen but retain the view on the counsellor’s screen).

Program Materials

Contact Information

Ryan Lisk, Director of Community Health Programs
AIDS Committee of Toronto (ACT)
543 Yonge Street, 4th Floor
Toronto, ON
M4Y 1Y5
rlisk@actoronto.org
416-340-2437 x 246

In-Person and Online One-To-One Counselling

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