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
ones 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, NGOs 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 patients 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

As model
FRAMES
Transtheoretical model (Stages of change)
Motivational interviewing
Problem-solving
BATHE*

APPROACHES TO COUNSELLING
IN THE PRIMARY CARE SETTING
Counseling
approach

Problem type

Patient characteristics

Five As

Health risk behaviour

Highly responsive to medical

authority; benefits from
education alone with concrete
plan

FRAMES

Health risk behaviour

Requires objective evidence

to consider change; benefits
from
emotional support and
recognition of personal
strength

Stages of
change
(transtheoreti
cal model

Specific behaviour
(positive or negative)

May be at various stages with

respect to readiness for
change; needs to consider
pros and cons of changing

APPROACHES TO COUNSELLING IN THE PRIMARY CARE SETTING

Counseling
approach

Problem type

Patient characteristics

Motivational
interviewing

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

Highly ambivalent, at best, about

change; core values and
behaviour 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; not
overwhelmed by emotional
expression; able to process
information sequentially and
brainstorm

BATHE*

Any type of
psychosocial
problem

Reasonable verbal skills; able to

meaningfully respond to
questions; benefits from emotional
support

BATHE =
five As = ask,
background,
advise, assess,
affect, troubles, assist, arrange
handling,
empathy

FRAMES = feedback about

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

FIVE AS: A BRIEF INTERVENTION FOR ADDRESSING

HEALTH RISK BEHAVIOUR

Five As

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 support
may help. Develop a clearly stated action plan; write it down
and make a copy for the patient and for the patients chart.

Arrange

Id like to see you again in two weeks. A nurse will call

you next week to see how the plan is going.

FRAMES PROTOCOL FOR ADDRESSING HEALTH RISK BEHAVIOR

Component

Physician intervention

Feedback about
personal risk

Describe the relationship between heath risk behaviour and objective

indicators, including CAGE questionnaire score, laboratory test
findings, and documented recurrent illness

Responsibility
of 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 youll
continue to smoke/drink?

Advice to
change

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 of
strategies

Offer the patient a range of options to assist in making the change,

such as pharmacotherapies, avoiding
high-risk situations, alternate behaviours, changing environmental
antecedents, and enlisting social support

Empathetic
style

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 few
days without a cigarette can be.

Promote selfefficacy

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

STAGES OF CHANGE (TRANSTHEORETICAL MODEL) TO

FACILITATE COUNSELING IN PRIMARY CARE
Stage

Physician intervention

Precontemplation

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 youll 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 didnt
expect? Any lapses? (If yes) What did you learn from that experience?
How did you get back on track?
Praise and support the patients 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 the
problem behaviour.
Are there any other situations that you didnt 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 patient
autonomy

Exploration
Patients desire

Are you interested in better controlling

your blood pressure?

Assesses value of
changing

Would you be able to walk for 30

minutes each day?
You mentioned that youre now more
open to taking medication for depression.
What makes you open to it now?
How important is it that you quit
smoking?

Assesses patient
self-efficacy
Assesses current
sources of
motivation
Assesses degree of
motivation

Drinking alcohol while pregnant has

been found to increase the
likelihood of physical and developmental
problems in infants.
Not drinking alcohol is one of the best
things you can do for
your baby. There are several options
available to help you quit.

Conveys hope;
relates risk
behavior to
long-term health
outcomes;
indicates
that there are
treatment options

Patients ability
Patients
reasons
Patients need
Providing
information

MOTIVATIONAL INTERVIEWING TO FACILITATE COUNSELLING IN

PRIMARY CARE CONT.
Component

Examples of physician statements

Rationale

Listening and
summarizing

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 patients
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 reevaluated 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
alternative
solutions

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 the
patient to generate options.

Decision making

Evaluate possible
solutions; predict
possible
consequences of the
selected solutions

Which of the options that weve

talked about seem
better to you? Of those, which one
seems best?

Solution
Restate the behaviour
verification and plan; review any
implementation 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

Whats 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 words
seem to fit how youre 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.

BATHE
This 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 patients
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 patients
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 patients responsibility.
However, the patients attempted solutions often cause more upheaval than the
problem itselfa point that the physician may reflect back to the patient. By
focusing and labelling key dimensions, the physicians questions facilitate the
patients 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 Downs syndrome.
Chronic disease conditions such as Hypertension,
Diabetes Mellitus, and Neurosis.
Child development and adolescent health
HIV/AIDS testing

HIV/AIDS COUNSELLING
This has been separated into preand 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 physicians 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 patients 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.

THANK YOU FOR LISTENING