Counseling Skills

Prof. Datuk Dr.

D.M.Thuraiappah
MAHSA University College
http://
www.patient.co.uk/improveddoctor/Counselling-in-Prima
ry-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

Problemsolving
counselling
Interpersonal
counselling
Psychodyna
mic
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.SMART
Action

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 clients 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.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Five As = 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.

CLINICAL
RECOMMENDATION

EVIDEN
CE
RATING REF: COMMENTS

Primary care counselling

leads to short-term
benefits for psychiatric
symptoms.

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.

47,
48

Systematic review and metaanalysis; benefit may be

more enduring for men;
counselling methods
included the FRAMES
technique.

The five As technique is

effective for smoking
cessation.

12,
13

Most studies in the

systematic review evaluated
pregnant women.

Stages of change

24

Study relied solely on patient

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

BATHE = background, affect,

troubles, handling, empathy;
Five As = 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
psychodyna
mic
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
1.Risk of
developing to discuss with a
an
counsellor the
hereditary
nature of the risks
disease
and
2.Acquirin

the possible
ga
responses to the
sexually
various outcomes.
transmitte
d 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 secondline therapy in its latest
guidance

Mild to moderate
Depression
General 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.

 Name three techniques of counseling

and discuss issues relating to such
techniques.

Total of 500 words

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Thank you for

your attention