COUNSELLING

BY

DR. J.I. NWAPI

INTRODUCTION Family physician counselling is an

efficient and cost-effective initial intervention in a stepped-care approach.

As a first-line therapy, brief counselling is:

effective for many problems is acceptable to most patients reduces the need for more time-intensive, costly

treatment and referral for specialty care.

INTRODUCTION Counselling is a process to influence the

individuals knowledge about their health and healthcare with a purpose to not only inform but also to change behaviour.

It involves rendering assistance to people to overcome obstacles in their personal growth and in their interpersonal relationships.

It helps clear away such obstacles so that one’s personal potential can be developed and realistic life goals achieved.

AIM OF COUNSELLING The goal is to improve adherence to a set objective and achieve control over health issues.

This objective can vary from a therapeutic regimen or a necessary screening test to a new lifestyle.

COUNSELLING TIPS

Effective counselling requires the following:

Warmth and genuineness, or congruence (being the same inside as outside, giving the same message verbally and nonverbally);

Unconditional regard for patients Accurate empathy Therapeutic optimism Good listening skills Patient empowerment Confidentiality

EDUCATIONAL PRINCIPLES OF COUNSELLING Feedback - the patient is informed about

progress towards goals and objectives. Reinforcement - encouragement Individualization - specific needs for

patient problems Facilitation - materials, cues or training

of skills Relevance - appropriate for patients

circumstance Use of multiple educational channels -

verbal, pictorial, written, team.

THE PROCESS OF BEHAVIOUR CHANGE

The process of behaviour change or taking a major decision has been analyzed as a six-stage model.

Pre-contemplations Contemplation Preparation Action Maintenance Termination

The first three stages involve motivation and readiness and may span over a considerable time e.g. 6months.

Once the action has been taken there is need to work to prevent a relapse and increase confidence.

This may last 6months to 5years. When the individual is 100% confident that he will not relapse the process has terminated.

COUNSELLING PROCESS AND PATIENT EDUCATION

Exploring patients perceptions Fully inform patient of the purpose and expected

effects of interventions and when to expect these effects.

Explore the perceived benefits of change Suggest small changes rather than large ones Be specific in recommending new behaviours Get explicit commitment from the patient Use a combination of strategies Involve other staff e.g. nurses, counselors, family

members Refer to community agencies, NGO’s and even other

patients with similar circumstances Monitor progress

COUNSELLING PROCESS AND PATIENT EDUCATION

Other considerations are; There must be an atmosphere of acceptance not

necessarily approval i.e. the physician must have a non-judgemental stance when enquiring about experiences, beliefs and behaviour.

Physician should understand the patient’s perspective even if they do not agree.

There should be specificity and clarity of language. The physician should continually ‘check the patients’

understanding of what is being discussed. The process of counseling can occur continuously

throughout the consultation and examination period or intermittently at different consultations sessions. 

APPROACHES TO COUNSELLING IN THE PRIMARY CARE SETTING Counselling approaches that address

health risk behaviours or adherence problems, ambivalence to change, and broader psychosocial issues include:Five A’s modelFRAMES Transtheoretical model (Stages of change)Motivational interviewingProblem-solving BATHE*

APPROACHES TO COUNSELLING IN THE PRIMARY CARE SETTING

Counseling approach

Problem type Patient characteristics

Five A’s Health risk behaviour

Highly responsive to medical authority; benefits fromeducation alone with concrete plan

FRAMES Health risk behaviour

Requires objective evidence to consider change; benefits fromemotional support and recognition of personal strength

Stages of change(transtheoretical model

Specific behaviour (positive or negative)

May be at various stages with respect to readiness forchange; needs to consider pros and cons of changing

APPROACHES TO COUNSELLING IN THE PRIMARY CARE SETTING

Counseling approach

Problem type Patient characteristics

Motivationalinterviewing

Applies to specific behaviour; however, range of behaviour is broad

Highly ambivalent, at best, about change; core values andbehaviour often are inconsistent; responds to empathy

Problem-solving therapy

Anything that can be formulated as a“problem”

Able to view life issues from an intellectual perspective; notoverwhelmed by emotional expression; able to processinformation sequentially and brainstorm

BATHE* Any type of psychosocial problem

Reasonable verbal skills; able to meaningfully respond toquestions; benefits from emotional support

BATHE = background, affect, troubles, handling, empathy

five A’s = ask, advise, assess, assist, arrange

FRAMES = feedback about personal risk, responsibility of patient, advice to change, menu of strategies, empathetic style, promote self-efficacy

FIVE A’S: A BRIEF INTERVENTION FOR ADDRESSINGHEALTH RISK BEHAVIOUR

Five A’s Physician intervention

Ask “How often do you drink alcohol?”“How much do you smoke?”“How often do you exercise?”Administer self-report questionnaire

Advise “As your doctor, I strongly recommend that you quit smoking/quit drinking/initiate regular exercise. It is one of the most important things you can do for your health.”Briefly describe patient-relevant risks of continuing the behaviour and the benefits of changing.Provide written educational material to reinforce your message. Do not admonish the patient.

Assess “Are you ready to quit drinking/quit smoking/initiate exercise in the next 30 days? I can help you with this change.”

Assist “Quitting smoking/drinking can be a real challenge.Pharmacotherapy/community resources/spousal supportmay help.” Develop a clearly stated action plan; write it down and make a copy for the patient and for the patient’s chart.

Arrange

“I’d like to see you again in two weeks. A nurse will callyou next week to see how the plan is going.”

FRAMES PROTOCOL FOR ADDRESSING HEALTH RISK BEHAVIOR

Component Physician intervention

Feedback aboutpersonal risk

Describe the relationship between heath risk behaviour and objective indicators, including CAGE questionnaire score, laboratory test findings, and documented recurrent illness

Responsibilityof patient

“The decision to quit smoking/drinking/adhere to a treatment plan is a choice that only you can make.” “How long do you think you’ll continue to smoke/drink?”

Advice tochange

“For your health, I strongly recommend that you quit smoking/reduce alcohol use.” For patients who appear ambivalent about change: “Are you interested in this discussion, do you want to continue?”For patients who are not yet ready to change: “Do you mind if I ask about this again at your next visit?”

Menu ofstrategies

Offer the patient a range of options to assist in making the change, such as pharmacotherapies, avoidinghigh-risk situations, alternate behaviours, changing environmental antecedents, and enlisting social support

Empatheticstyle

“Staying on this diet is a real challenge.”“Quitting smoking after all these years will be hard. It sounds like you appreciate how tough those first fewdays without a cigarette can be.”

Promote self-efficacy

“Your plan sounds like you have thought through some of the most difficult situations you’ll face. You seem very determined to make this important change in your life.”

STAGES OF CHANGE (TRANSTHEORETICAL MODEL) TOFACILITATE COUNSELING IN PRIMARY CARE

Stage Physician interventionPrecontemplation

Provide a factual statement about the health effects of the behaviour (e.g., smoking, alcohol abuse, non-adherence), then ask the patient what he or she thinks about it. “What do you like about smoking/drinking?” “How long do you think you’ll smoke/drink? “Have you tried to quit before?” (If yes) “What happened?” “What would tell you that it might be time to quit?”

Contemplation “What are the advantages of changing?” “What are the disadvantages of changing?” “What could get in the way of changing?” If advice is offered, state it as a generalization:“Many patients find it helpful to…”

Preparation Discuss a specific date for change with the patient. If the patient has chosen a date, ask: “How did you choose that particular day?” “What specific strategies are you planning to use?” “Do you foresee any situations where you might be tempted to overeat/smoke/drink?”

Action “How is the plan working?” “Has anything come up that you didn’t expect?” “Any lapses?” (If yes) “What did you learn from that experience?” “How did you get back on track?”Praise and support the patient’s efforts.

Maintenance Continue to praise and support the patient.Remind the patient that lapses and relapses are common but can be useful for learning about unexpected situations that may trigger theproblem behaviour.“Are there any other situations that you didn’t anticipate?” (If yes) “What was it about the situation that was a trigger for you?”

MOTIVATIONAL INTERVIEWING TO FACILITATE COUNSELLING IN PRIMARY CARE

Component Examples of physician statements Rationale

Agenda Setting “Would you mind if I talked with you about managing your diabetes?”

Asking permission emphasizes patientautonomy

Exploration Patient’s desire Patient’s ability

Patient’s reasons

Patient’s need

“Are you interested in better controlling your blood pressure?”

“Would you be able to walk for 30 minutes each day?”You mentioned that you’re now more open to taking medication for depression. What makes you open to it now?”“How important is it that you quit smoking?”

Assesses value of changing

Assesses patient self-efficacyAssesses current sources of motivationAssesses degree of motivation

Providinginformation

“Drinking alcohol while pregnant has been found to increase thelikelihood of physical and developmental problems in infants.Not drinking alcohol is one of the best things you can do foryour baby. There are several options available to help you quit.”

Conveys hope; relates risk behavior tolong-term health outcomes; indicatesthat there are treatment options

MOTIVATIONAL INTERVIEWING TO FACILITATE COUNSELLING IN PRIMARY CARE CONT.

Component Examples of physician statements

Rationale

Listening andsummarizing

“What do you think about that idea?”“It sounds like you are interested in seeing a therapist for depression but are worried about finding the right one.”

Elicits patient’s views of personal health risk and acceptable interventions; identifies sources of patient ambivalence

Generating options and contracting

“It sounds like you have several good ideas about how to reduce your fat intake. Which one do you think would work best? I look forward to hearing about it at our next appointment.”

Patient selects specific plan, which will be re-evaluated in a specific time frame

PRINCIPLES OF PROBLEM-SOLVING THERAPY

Component Description Examples of physician statements

Problem definition

Obtain factual, concrete information; clarify nature of the problem; describe the problem objectively and succinctly

“What part of this situation is most distressing for you?”“It sounds like the key difficulty is…”

Generating alternativesolutions

Encourage the patient to brainstorm and generate several possible solutions

“What options have you considered?” Any others?”If the patient cannot provide options, the physician may suggest several possibilities and then encourage thepatient to generate options.

Decision making

Evaluate possible solutions; predict possibleconsequences of the selected solutions

“Which of the options that we’ve talked about seembetter to you?” “Of those, which one seems best?”

Solution verification and implementation

Restate the behaviour plan; review any obstacles and develop a plan for each

“At this point, your plan is…”“Is there anything that could get in the way?” “What could you do about that specific challenge?”

BATHE TECHNIQUE FOR ADDRESSING PSYCHOSOCIAL PROBLEMS

Component Examples of physician statements

Background “What’s going on in your life?”“What has happened since I last saw you?”

Affect “How do you feel about (a situation that has happened to the patient)?”“Many people in that situation report feeling…”Suggest descriptors, then ask: “Do any of those wordsseem to fit how you’re feeling?”

Troubles “What bothers/troubles you most about the situation?”

Handling “How are you coping with/handling the situation?”

Empathy “It sounds very frightening/frustrating/sad.”

BATHEThis technique, developed specifically for family physicians, is helpful for patients exhibiting psychiatric syndromes or a broad range of psychosocial problems. The questions are almost always asked in the specific order listed above. The initial open-ended background question is a reminder to listen to the patient’s presenting narrative. Physicians are often concerned that initial open-ended questions will lead to overly long descriptions. However, most patients complete their answers in less than one minute, with 90 percent completing their answer in less than two minutes. If the patient takes longer than a few minutes, keep the interview moving by politely interrupting and asking how the patient feels about his or her concerns. Although the physician may briefly summarize the patient’s answer to the background question, the physician should quickly proceed to the “affect” question. Some patients have difficulty articulating feelings and continue to describe the problem, or they are simply unaware of their emotions. In response, the physician may repeat the question or suggest descriptors. The “troubles” question provides a useful focus, particularly when the problem seems overwhelming. Although the physician may believe that he or she knows what is most upsetting, the assumption may be incorrect. It may be tempting to recommend solutions, but handling the problem is the patient’s responsibility. However, the patient’s attempted solutions often cause more upheaval than the problem itself—a point that the physician may reflect back to the patient. By focusing and labelling key dimensions, the physician’s questions facilitate the patient’s ability to generate realistic coping strategies. Communicating empathy creates a physician-patient partnership and indicates that the physician is actively listening to the patient. If the visit is a follow-up, the opening question should target events in the time interval from the last visit. Most BATHE interviews can be conducted in less than five minutes.

PRACTISING COUNSELLING Circumstances that require

counseling include:Genetic counseling especially Sickle cell

disease and Down’s syndrome.Chronic disease conditions such as

Hypertension, Diabetes Mellitus, and Neurosis.

Child development and adolescent healthHIV/AIDS testing

HIV/AIDS COUNSELLING This has been separated into pre- and post-tests counselling.

The highlights are information, support; respect and confidentiality.

PRE-TEST COUNSELLING GUIDELINES

The patients should be in a position to make an informed decision about whether or not to have the test.

The patient should be provided with all the information about the test.

The physician should prepare the patient for a positive or negative result.

The patient should be informed of his or her legal rights and the physician’s ethical obligations.

The patient should be told the advantage of having the test.

A relationship between the physician and the patient should be established based on trust, confidentiality and continuing care.

Give the patient the opportunity to ask questions. 

POST-TEST COUNSELING GUIDELINES

 Check that the patient understands the results.

Allow expression of feelings. Identify patient’s immediate concerns. Educate the patients on the implications of

disclosure. Assess any risk of bodily harm. Identify source of support other than physician Discuss possible future difficulties Encourage patient to ask questions Encourage healthy lifestyle Infection control Follow up

COUNSELLING IN CRISES SITUATIONS

A crisis in this context is defined as a situation or event where the person feels overwhelmed or unable to cope. 

A typical crisis may include a death in the family, being let go at a job, or a rough ending to a relationship. 

People are emotional beings, and crisis counselling may help one deal with feelings such as being frightened, anxious, or depressed.

CRISIS COUNSELLING Crisis counseling:

The physician works to provide support and guidance to the patient. 

This care works to reduce emotional pain, provide a safety net, and develop a plan to increase mental health. 

It helps patients develop skills that may help them anticipate and cope with a crisis, with the benefit of improving the quality of life affected persons.

STEPS OF CRISIS COUNSELLING

1.  Assess the situation• Ask the patient questions to better understand what each

he/she needs.  • Then, provide the client with emotional and mental health

support while ensuring the emotional and physical safety of the client.

2.  Educating the client• Provide information of the condition during the crisis.• Spell out necessary steps to be taken. • Assist the patient to understand that their situation is

common, and that, through work, they will return to their normal functionality.

3.  Offering support• Stabilize the mental health of the patient through emotional

support and the offering of resources. • It is important in this step to listen actively to the client and

provide non-judgmental, encouraging support.• Hopefully, a dependency between the physician and client

will develop, strengthening the emotional and mental health of the client.

4.  Development of coping skills• Developing skills to deal with coping is of utmost

importance. • Such skills may include exploring and listing different

solutions to problems, stress lowering techniques, and techniques for positive thinking.

CONCLUSION If therapists can believe that people are inherently good

and have a natural tendency to grow, and if patients feel safe and accepted as they are, change for the better can occur.

A growth-based or love-based approach to life works better than a fear-based one.

It is widely believed that optimists usually have good lives.

Pessimism is a self-fulfilling prophecy. Helping people see their illnesses and events in their

lives as meaningful, particularly as learning events, and the planet as a schoolhouse and crisis as opportunity moves them to a new level of growth and optimism.

It is advocated that Physicians should try to help their patients find a sense of coherence in their lives.

Doctors must assist patients and family members as they suffer from illnesses, as well as help them handle their emotions during various life crises.

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