Counseling

• Counseling


  Various techniques & methods by which people can be helped to understand themselves & to be more effective
• Counseling


  Describes everything from skilled befriending to psychotherapy
• Task in counseling


  1. Clarify the problem

  2. Aid the patient in finding their own solution
• Implicit in counseling is the recognition by the patient that they will be required to modify their behavior
• Effective counseling provides comfort to the patient and can result in demonstrable improvement in physical and mental well-being and health
• Counseling


  More than just giving advice but falls short of psychotherapy
• Counseling should be incorporated into everyday practice
• Fundamental aim of counseling

  Assist a patient to identify and implement their own unique solution to a particular problem
• How the doctor becomes a good counselor

  1. Listens

  2. Is aware of the patient's feelings

  3. Helps the patient explore their difficulties and work with them using their own resources
• Only helping the patient to help themselves is likely to be effective
• A growing literature demonstrates the effectiveness of physician counseling of patients about lifestyle-related illness
• Communication skills & Evidence Based Medicine


  Important in counseling
• Clinicians must understand the nature of effective health communications and practice counseling skills to ultimately facilitate lifestyle changes for patients
• To be successful in helping patients change their health behaviors, you should know the epidemiology of medical problems and be aware of the scientific evidence that supports the intervention chosen
• Education and counseling help patients make behavioral changes
• Health behaviors


  • Add behavior
  • Eliminate non-addicting behavior
  • Eliminate addicting behavior
• Steps to maximize patient education for behavioral change

  1. Understand the power of physicians' expertise as a motivator toward behavior change

  2. Be patient-centered and patient responsive

  3. Choose one or at most two behavioral goals for changing at any one time

  4. Be specific in giving advice

  5. Obtain a firm commitment from patient to change

  6. Use positive reinforcement and short-term rewards

  7. Use multiple educational modalities when possible

  8. Use social support when possible

  9. Assure appropriate follow up

  10. Be realistic
• Brief Counseling Interventions (BCI)


  BCI of one to three visits can substantially help patients change problem behaviors, particularly in the areas of smoking cessation, hazardous alcohol use and exercise
• Elements of an effective brief intervention that help trigger patient motivation to change (FRAMES)


  • Giving feedback based upon a thorough assessment
  • Helping the patient take responsibility of changing
  • Giving clear advice on what behavior must change
  • Offering a menu of options for making the changes
  • Expressing Empathy for the ambivalence and difficulty in making changes
  • Evoking self-efficacy to foster commitment and confidence
• Only 20% of patients are ready to take action to change during an office encounter, the other 80% are in different stages and need something other than clinician advice
• Stages of Change


  • Precontemplation
  • Contemplation
  • Determination
  • Action
  • Maintenance
  • Relapse
  • Termination
• Precontemplation


  Person is not yet considering the possibility for changes
• Contemplation


  Once aware of the problem the person experiences ambivalence about the possibility of change
• Determination


  Patients in determination are apt to say "I must do something about this, I think this is trouble, what will I do?"
• Action


  Action requires little from the clinician since the patient does the work to change
• Maintenance


  The patient enters maintenance stage when measures to sustain the new behavior become routine
• Relapse


  During relapse the patient experiences a loss of control and a lapse into the old behavior
• Termination


  Occurs when individuals have made a permanent change, they no longer struggle to maintain the behavior nor are they tempted to relapse
• The counseling interview


  1. Data gathering

  2. Relationship building

  3. Patient education and counseling
• Tell a clear message
• Putting Preventive Services into practice


  • Office staff involvement
  • Reminders system
  • Patient education information
  • Develop a network of role models
  • Put prevention counseling notes in the medical record
  • Develop a referral network
  • Arrange adequate follow-up
• Barriers to offering preventive services

  • By definition preventive services are offered to patients who are currently well and therefore may have less motivation to change behavior
  • Physicians have no control over the intervention, only the patient can make the change
  • Patient may experience psychological or physiological withdrawal symptoms when they give up some behavior
  • Adding new behavior such as exercise may cause some initial pain and even injury
• Reasons for physician frustration

  • Lack of time
  • Lack of physician education
  • Patients often fail to follow advice
• Examples of Counseling


  • Counseling to prevent Tobacco use
  • Counseling to promote physical activity
  • Counseling to promote a healthy Diet
  • Counseling to prevent Motor-Vehicle injuries
  • Counseling to prevent low back pain
  • Counseling to prevent Dental and Periodental diseases
  • Counseling to prevent cancers
  • Counseling to prevent SIDS
  • Counseling to prevent STD, AIDS
  • Counseling to promote breast feeding
  • Counseling for stress
  • Counseling for sleep disturbance