COUNSELLING SKILLS

The Counselling Process

The medical consultation is a helping process.
The relationship established is specific and
purposeful as it aims at dealing with the
problem that is presented.
In this sense, it is a special relationship.
STAGES of COUNSELLING
1. Relationship Building
2. Exploration and Understanding
3. Rational Discussion
Relationship Building
Goal: Pay attention to the counsellee, and as
such develop a supportive relationship with
him/her
The counsellor must be ready and willing to
ATTEND to the counsellee.
No attempt to dealing with the problem as
yet..
Exploration and
Understanding
Goal: Enabling the counsellee to gain a better
understanding of himself, his situation and
the problem he is presenting.
Explore the counsellee's world.
Counsellee is helped to deal with himself and
be motivated to engage in rational discussion
for problem-solving.
Rational Discussion
Goal: helping the counsellee cope with the
problem in a healthy and rational way
1. Problem definition and assessment
2. Therapeutic goal setting and
implementation
3. Termination and evaluation.
LISTENING
When we listen, people begin to feel at ease
and feel that someone cares.
How to Be A Good Listener
Should be accepting, patient, caring,
sympathetic, concerned, discreet,
understanding, respectful, knowledgeable,
encouraging, tolerant, warm, kind, and
trustworthy.
Just say : "I am with you, tell me...
Sensitive to the feelings of others
Several Barriers to be A Good
Listener
Impatience
Forming premature opinions, criticisms, lack of
understanding and jumping to conclusions that
the person is in the wrong
Giving the impression that one is not taking th
Being passive, thus appearing to say "I'm bored"
or "I'm not interested.
Inability to concentrate on person's problem
seriously
Making noise, such as telephone ringing.
The busy physician can help many patients by
applying BATHE (background, affect, trouble,
handling empathy) method.
Background : Ask about likely areas of psychological
problems
Affect : Ask about common areas generating strong
feelings
Troubling: Ask how much the patients problems bother
him or her
Handling: ask how he or she tries to solve the problem
Empathy: Express understanding of the patients distress,
like say I can understand that you would feel angry

Using Soap to Bathe
Support
Normalise problems as common dilemmas: Help
the patient focus on strengths.
Objectivity
Encourage patients to ask themselves how
realistic their thoughts and feelings are. Whats
the worse thing that could happen? How likely is
that?
Acceptance
Be as non-judgmental and accepting as possible
Encourage patients to feel better about themselves,
their parents, and other family members
Coach patients to think differently about themselves
more realistically, if they are overly self-critical
Urge patients to develop more of a sense of humor
about their issues
Acknowledge the patients values and priorities
Acknowledge the patients readiness for changes
Acknowledge the difficulty of making changes
Present Focus
Encourage focusing more on the present, less on the past
and future. Help patients identify, explore and evaluate
different attitudinal and behavioral options (including
doing nothing):
Express guarded optimism that the patients can and will do
better. Try to set up a positive self-fulfilling prophecy for the
immediate future:
Suggest a homework assignment for the patient to carry
out; for example:
a. Practice sending I messages:
b. Practice asking for what you want, rather than just
hoping for it:
c. Practice telling others how you are responding to their
behavior:
PROBLEMS OF LIVING

Problems of living are life situations that affect the functioning of a person.
When the limit tolerance is reached, the person may seek medical help.
Relevance to Family Medicine
As a front-line doctor, the family doctor is likely to encounter patients with
problems of living.
Not all presentations will be explicit.
The depressed, the lonely or the hard-pressed often report tiredness, lack of
energy, sleeplessness, abdominal pain or headache rather than reveal the
origin of their difficulties.
The patient presents his/her problem of living as a hidden agenda because
he/she perceives as not a legitimate problem to trouble the doctor, the
conversion to somatic symptoms make the problem "medical"and therefore
legitimate.
The attending doctor is therefore not likely to resolve the problem that the
patient brings along, unless he explores beyond the somatic symptoms.
Recognising Problems of Living (Signature Cues or Signal Behaviour)
The following are a dozen of signature cues that help us recognise problems of living:
Attendances for a symptom that has been present for a long time before and until
now fairly quiescent. The cue is to ask the questions: "why
again?" and "why now?"
Attendances for a chronic disease that does not appear to have changed e.g.,
osteoarthritis of the knee. The cue is again to ask the questions: "why again?"and
"why now?"
Incongruity between the patient's distress and the comparatively minor nature of
the symptoms.
Symptoms that have no physiological or pathological basis. Symptoms of this kind are
also known as conversion symptoms.
An adult patient with an accompanying relative.
Failure of reassurance to satisfy the patient for more than a short period.
Frequent attendances with minor illnesses.
Frequent attendance with the same symptoms or with new symptoms
Difficult Patient
A 'difficult patient' may be defined as one with
whom the physician has trouble forming an
effective working relationship
Some characteristics of problematic patients,
from the doctor's perspective, include: frequent
attenders with trivial illness, multiple
symptomatology, non-compliant, hostile or
angry, attending multiple therapists,
manipulative, taciturn and uncommunicative, all
knowing
Biasanya problem psikis
Dont!: allow feelings of hostility to affect our
communication with the difficult patient.
Management:
'feeling understoodincludes a full history of symptoms,
exploration of psychosocial cues and health beliefs, and a
brief focused physical examination
'broadening the agenda', the basic aim is to involve
discussion of both emotional and physical aspects during
the consultation
'making the link', simple patient education methods are
used to explain the causation of somatic symptoms such as
the way in which stress, anxiety or depression cafi
exaggerate symptoms.
THE ANGRY PATIENT
What is Anger?
Anger is a person's emotionat response to
provocation or to a threat to his or her equilibrium
Angry abusive behaviour may be a veiled
expression of frustration, fear, self-rejection or
even guilt.
Basically anger may be a communication of fear
and insecurity

Source Anger
There are many source of anger e.g. they may have
feelings of frustration and anger because they are not
getting better, disappointment at unmet expectations,
crisis situations, including grief, any illness, especially
an unexpected one, the development of a fatal illness,
iatrogenic illness, chronic illness, such as asthma,
financial transactions, such as high cost for services,
etc.

.
The Correct Strategy
Remain calm, keep still and establish eye contact; ask the patient to sit
down and try to 139 adopt a similar position (the mirroring strategy)
without any aggressive pose.
Address the patient or relative with appropriate name, be it Mr or Mrs
Tan or a first name.
Be interested and concerned about the patient and the problem.
Use clear, firm, non-emotive language.
Listen intently.
Allow patients to ventilate their feelings and help to relieve their
burdens
Allow patients to 'be themselves.
Give appropriate reassurance (do not go over-board to appease the
patient)
Allow time (at least 20 minutes).
Guidelines for Handling the Angry Patient
Do: Listen, be calm, be comfortable, show interest
and concern, be conciliatory, give time, arrange
follow-up, allay any guilt.
Do not: meet anger with anger, touch the patient,
Reject the patient, evade the situation, talk too
much, be judgmental, and be patronizing.
Changing Behaviour
Prochaska and DiClemente help by indentifying four stages
in the process of making health behaviour change:
1) Precontemplation (when people are not interested and
are not thinking about change)
2) Contemplation (when serious consideration is given to
making a behavioural change);
3) Action (the 6-month period after an overt effort tochange
has been made); and
4) Maintenance (the period from 6 months after a behaviour
change has been made and the behavioural problem been
ameliorated).
TERIMA KASIH
Farah Ekawati Mulyadi C 111 08 009
Andi Rahmayanti C 111 08 256
Andi Irhamnia Sakinah C 111 08 263
Ilma Khaerina Amaliyah C 111 08 274
Desi Dwi RNS C 111 08 275
Annisa Trie Anna C 111 08 280
Yunialthy Dwia Pertiwi C 111 08 303