Counseling Skills

Prof. Datuk Dr. D.M.Thuraiappah

MAHSA University College

http://www.patient.co.uk/improveddoctor/Counselling-in-Primary-Care.htm

Counseling

Consent

Agreement

Management plan

Confidentiality

Agreement to follow up

Family

Employers

Consent

Assumed consent

Virtual consent

Oral/Verbal consent

Limited consent

Written consent

Court order

Third party/proxy consent

Types of counselling

Problem-solving counselling

Interpersonal counselling

Psychodynamic counselling

Problem-solving counselling

This is a structured and systematic approach to resolving problems that are due to stressful circumstances.

First listen to the patient and analyze the problem with the patient step by step. Usually the problem is solved by the patient

If the patient cannot see the solution, then offer different solutions for the patient to identify the best fit.

This method has been shown to be useful in treating mild mood disorders.

Steps in Problem Solving

1.Problem Orientation

2. Identify the root cause

3.Select & Define

4.Generate Solutions

5.Decision Making

6.SMARTAction

7.Review Progress

Interpersonal Relationship Counselling

This is to problem-solving with the focus on breakdown of relationships in the home, work and in social

network

Problems like loss, interpersonal disputes, role transitions and interpersonal deficits.

A problem-solving approach is suggested to encourage the patient to try out different ways of coping.

This has been effectively used for patients with minor mood disorders

Psychodynamic counselling

In this technique emphasises on past experience and unconscious processes as the mainspring of current behaviour.

The patient's emotional reactions to the counsellor and situation are an

indicator of the nature of problems in other relationships.

This approach has not been as thoroughly evaluated as those above.

FRAMES• The principles underlying most approaches to brief interventions were

systemized by Hester and Miller in what is called the FRAMES model:[1]• Feedback: Give feedback on the risks and negative consequences of

substance use. Seek the client's reaction and listen.• Responsibility: Emphasize that the individual is responsible for making

his or her own decision about his/her drug use.• Advice: Give straightforward advice on modifying drug use.• Menu of options: Give menus of options to choose from, fostering the

client’s involvement in decision-making.• Empathy: Be empathic, respectful, and non-judgmental.• Self-efficacy: Express optimism that the individual can modify his or her

substance use if they choose. Self-efficacy is one's ability to produce a desired result or effect.

CLINICAL RECOMMENDATIONEVIDENCE RATING REF: COMMENTS

Primary care counselling leads to short-term benefits for psychiatric symptoms.

B 45, 46 Most studies involved a mental health counsellor in a primary care practice; heterogeneous counselling models were used.

Brief alcohol intervention is associated with reduced alcohol use over time.

B 47, 48 Systematic review and meta-analysis; benefit may be more enduring for men; counselling methods included the FRAMES technique.

The five A’s technique is effective for smoking cessation.

B 12, 13 Most studies in the systematic review evaluated pregnant women.

Stages of change (transtheoretical model), using individualized patient feedback, is associated with improved adherence to a hypertensive regimen at 12 and 18 months.

B 24 Study relied solely on patient self-report of adherence behaviour.

Brief motivational interviewing provided by non-specialists for substance abuse reduces alcohol and marijuana use.

B 32 Follow-up periods were variable; there was a limited number of marijuana studies.

SORT: KEY RECOMMENDATIONS FOR PRACTICEFive 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.A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

Developed Specifically for Family Physicians Approaches to Counselling in the Primary Care Setting

• 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.

Specific uses of counselling

Counselling to relieve acute distress

Counselling for late effects of trauma

Counselling for relationship problems

Risk counselling

Grief counselling

Mild-to-moderate depression

Chronic or terminal disease

Counseling to relieve acute distress

There is emphasis on emotional release and ways of coping with the

immediate problem.

Where the method is nondirective, unstructured and involves the recall of

distressing events, direct counselling may be inappropriate for those surviving traumatic

experience and may lead to worse outcomes than where the patient receives no counselling.

Well-timed Cognitive methods recommended

Counselling for late effects of trauma

Cognitive and psychodynamic approaches may be more useful.

Counselling for relationship problems

It May be helpful for a counsellor to encourage couples to talk

constructively about their relationship so that they come to appreciate their thoughts and feelings for each other

Risk counselling

• to discuss with a counsellor the nature of the risks and

• the possible responses to the various outcomes.

1.Risk of developing

an hereditary

disease 2.Acquiring a sexually

transmitted disease

Mild-to-moderate depression

The National Institute for Health and Clinical Excellence (NICE) questions the efficacy of this

compared with other therapies and has downgraded it to

second-line therapy in its latest guidance

Mild to moderate DepressionGeneral Anxiety and panic disorder

Obsessive-compulsive disorder

Psychosomatic conditions - chronic pain, chronic fatigue, gastrointestinal disorders such as irritable

bowel[5] and some gynaecological syndromes such as premenstrual syndrome and chronic pelvic pain.

Health promotion

Counselling can also play an important role in health promotion for some patients, including smoking

cessation.

Chronic or terminal disease

Counselling may help some patients to come to terms with chronic or terminal

disease. One study advocated the use of group

psychotherapy for this indication.[6]

Techniques of Counselling Nondirective counselling

Problem-solving therapy

Cognitive techniques

Behavioural therapy:

Cognitive behavioural therapy

Interpersonal therapy

Psychodynamic counselling:

Nondirective counselling:

Encourages the patient to share his or her problems with the counselor.

Through listening, the counselor affirms the patient's worth and allows him or her to take

the time to express his or her thoughts.

Problem-solving therapy:

Systematically teaches generic skills in active problem-solving,

helping individuals to clarify and formulate their life difficulties and apply principles of problem-solving to reduce stress and enhance self-

efficacy.

Cognitive techniques

Such as challenging negative automatic thoughts) and

behavioural techniques (such as activity scheduling and behavioural experiments): Are used to relieve

symptoms by changing maladaptive thoughts and beliefs.

Behavioural therapy:

Seeks to solve problems and relieve symptoms by changing behaviour and the

environmental factors which control behaviour.

Graded exposure to feared situations is one of the most common behavioural treatment

methods and is used in a range of anxiety disorders.

Cognitive behavioural therapy: Is a combination of the two techniques of cognitive and behavioural therapy.

It looks at how a person's self-perception can influence his or her behaviour.

It addresses some of the underlying issues and how these can give rise to destructive or damaging behaviour.

Can be useful in treating depression, anxiety and substance abuse. One study found it was beneficial in the management of elderly patients with depressive disorder.[7]

Access has always been the issue in primary care but one study found that online real time therapy delivered by a counselor over the internet was effective.[8]

NICE has reviewed the use of and access to cognitive behavioural therapy in general practice and has recommended:[9]

Beating the Blues - an internet-based cognitive behavioural therapy programme for the treatment of mild-to-moderate depression.[10]

Fear Fighter - a similar programme available for the treatment of panic and phobic anxiety.[11]

Interpersonal therapy

Structured, supportive therapy linking recent interpersonal events to mood or other problems, paying

systematic attention to current personal relationships, life

transitions, role conflicts and losses.

Psychodynamic counselling:

Based on the view that past and unresolved conflicts and events result in current emotional distress, a variety of

methods is used to help the client make sense of repressed or forgotten

experiences, allowing the client to move forward and resolve the conflict or

troubling behaviour.

Benefits of counselors in primary care

Effect is confusing

In some studies it has been shown that primary care counseling is more beneficial that psychiatric counseling

On-directive and CBT are the most useful

Is beneficial in mild-to-moderate MH problems in the short term(< 6 months)

In depression, anti-depressives act faster than generic counseling. Counselng should not exceed 12 weeks

Grief counseling

Counseling in this situation focuses on:

a. the normal stages of grieving,b. working through the normal stages of

grief and c. giving advice on coping without the

deceased

Grief in Bereavement

• What is bereavement?• Stages of bereavement• The importance of mourning• Coping with grief• How to tell if grief has become

depression• What is bereavement counseling?• Further help

What is bereavement?

Period of confusion after a sudden emotional and physical loss

Neurochemical changes-autonomic + endocrine

Manifests in physical signs and symptoms - fatigue

Non acceptance-denial syndrome

Period of irrational self-blame

Depression/anxiety

Stages of bereavement

• Not everyone experiences the same stages of bereavement at the same time or in the same order,

• accepting that your loss really happened• experiencing the pain that comes with grief• trying to adjust to life without the person who

died• putting less emotional energy into your grief and

finding a new place to put it i.e. moving on.

Accepting that your loss really happened

• Nothing prepares for the loss of a loved one. • Even when a person is ill & their death coming

for a long time.• When it comes there is disbelief,• Expect to see the person appear in a crowd,• Feeling of loss of appendage,• No grief

Experiencing the pain that comes with grief

• Grief is complex• sorrow• longing (to see them again)• guilt• numbness• anger• hopelessness• loneliness• despair.

Trying to adjust to life without them

• Adjustment to a new life. • Coping will depend on relationship with loss,• Change to life are bigger if contact is low• Feel like you are in a different dimension,

unreal.• Realise that everyday life has to go on,• With time of adjustment to life without them.

Moving on

• Life begins to take you on a new route,• Memory of loss is there,• Grieving is continuous,• Find alternate resources

The importance of mourning

• Mourning is an important part of bereavement. • Mourning involves rituals like funerals,

solicitations, and anniversary celebrations,• Mourning allows us to say goodbye. • Seeing the body, watching the burial, or scattering

the ashes or ways of where the remains are is a way of affirming what has happened.

• See evidence that a person really has died before we can truly enter into the grieving process.

What is bereavement counseling?

• Offer an understanding of the mourning process

• Explore areas that could potentially prevent you from moving on

• Help resolve areas of conflict still remaining• Help you to adjust to a new sense of self• Address possible issues of depression or

suicidal thoughts.

Assignment

• Name three techniques of counseling and discuss issues relating to such techniques.

• Total of 500 words• 1 ½ line spacing• Word format• Send to datukmahendran@mahsa.edu.my

Thank you for your attention