Stages Of Counselling The stages Stage I: Stage II: Stage III: of counselling can be described as a process consisting of three

stages: Relationship Building Exploration and Understanding Rational Discussion

Stage I: Relationship building

The first stage of counselling is relationship building. It is necessary that time be spent in building this relationship. To make this possible the counsellor must be ready and willing to ATTEND to the counsellee. This involves listening very carefully to him and attempting to understand the feelings and thoughts conveyed. Structuring, paraphrasing reflecting of feelings and summarising are the skills to use at this stage. There is no attempt to deal with the problem as yet. The goal is to pay attention to the counsellee, and as such develop a supportive relationship with him.

Stage II: Exploration and understanding

In this phase, the counsellor enters further into the counsellee's world. To do this, the counsellor must attempt to gain better understanding of the person he is dealing with. This is achieved by applying the skills of probing, information giving and clarification to ascertain the meaning of messages and feelings that the counsellee is conveying. The aim in this phase is to enable the counsellee to gain a better understanding of himself, his situation and the problem he is presenting. In so doing, he is helped to deal with himself and be motivated to engage in rational discussion for problem-solving.

Stage III : Rational discussion

The purpose of the rational discussion stage is to help the counsellee cope with the problem in a healthy and rational way. It can be divided broadly into three phases, namely (a) problem definition and assessment; (b) therapeutic goal setting and implementation, and (c) termination and evaluation. (a) Problem definition and assessment Defining a treatable problem is often not easy, as family practice patients present with a wide and complex variety of complaints. Examples of defined problems are coping with a chronic illness, grieving the death of a loved one, dealing with an alcoholic parent, and overcoming psychological aspects of depression while also taking antidepressants. Therapeutic goal setting and implementation Therapy involves eliciting as clearly and specifically as possible the patient's expectations for improvement but often flounders on the nonobjectifiable goal of "feeling better". Therefore it is well worth the clinician's time to define target symptoms for improvement or specific outcomes the patient expects (hopes) to achieve. This definition allows physician-patient negotiation to modify unrealistic expectations and to lead to mutually agreeable goals.

(b)

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Once the goal of therapy is clarified, the next step is to establish a therapeutic contract. Once again, being as explicit as possible at the beginning of counseling/ therapy yields a much greater probability of success and clarifies for the patient the frequently nebulous experience of being in a counseling situation. During this phase, the counsellor involves the patient in exploring new ways of thinking and behaving in order to attain the therapeutic goals that have been set. 'My physician is supportive, encouraging, or confrontative depending on what s/he perceives the patient needs. The patient frequently makes substantial changes during this phase. (c) Termination and evaluation During this phase there is a mixture of consolidation of change achieved as well as recognition of the need to do further work or to accept unchanging/ unchangeable situations. Each step leads to the other in sequence though it is not a matter of rigid application that is intended. A measure of flexibility is needed. Although this is a happy guide, it may not always be necessary to go through the sequence in helping the counsellee. Listening

The need to listen

The first and most important step in counselling is to listen. One hears ever so often that people do not listen to each other often enough. There are those who say that if someone would listen to them, they would not find life and problems so difficult to cope with. When we listen, people begin to feel at ease and feel that someone cares. On the need to listen, Taylor Caldwell has said, "Man's real need, his most terrible need, is for someone to listen to him - not as a 'patient' but as a human soul. He needs to tell someone of what he thinks, of the bewilderment he encounters when he tried to discover why he was born, how he must live, and where his destiny lies."

Usefulness of listening
When a person is allowed to talk freely to a good listener, the following happens: there is a release of tension. draining off of anger, aggression, frustration (like having an infection opened up so that poison can be drained off and purified). clarifying thinking - as the counsellee is talking, he may see the problem more clearly. The listener can repeat what has been said, paraphrase it, mirror it and reflect it back without introducing any new thoughts. the counsellee is helped through a better and more realistic understanding of himself and his situation. sharing the burden : 'A sorrow shared is a sorrow halved'. establishing a relationship so that loneliness is broken; the person is giving a feeling of being worth someone's time and attention.

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Qualities of a good listener

a good listener has many positive qualities: accepting, patient, caring, sympathetic, concerned, discreet, understanding, respectful, knowledgeable, encouraging, tolerant, warm, kind, and trustworthy. A good listener will try to 'be with' the person. The message : "I am with you; tell me..." is continuously conveyed. A good listener is sensitive to the feelings of others. He tries to understand the dynamics of the other person, and to get an idea of 'what makes him tick'. There is a need to sense the feelings behind the spoken words. In many cultures, people are taught 'to put on a brave front', 'not to wear your heart on your sleeve'. It is considered right to hide feelings. Thus words often obscure the real feelings of a person. The good listener is one to whom the speaker can find show his true feelings and even verbalise such statements as "You are the first person who has really listened to me" or "You make me feel I am of some value... you seem to hear everything I say". You know that you have been a good listener.

Barriers to good listening

Several barriers to good listening have been identified: Impatience. Forming premature opinions of what the person is like and how the problem can be solved. Making comments, implying judgement, criticisms, lack of understanding and insight; jumping to conclusions that the person is in the wrong, disagreeing, arguing, or interrupting. Giving advice which implies one knows the answer to the particular problem. (A worried person will reject a glib solution given in a few minutes without the due process of listening. He will surmise "It is ridiculous to think he knows all about it in a few minutes he is of no help at all"). Giving the impression that one is not taking the problem seriously. ("Is that all that's worrying you?", That's not much of a problem"). Trying to change the subject or to get the client's mind off it is also not a solution. Wanting to talk - perhaps being reminded by something that is said of one's own experiences and talking about them instead of listening. Being passive, thus appearing to say "I'm bored" or "I'm not interested" or "I'm nearly asleep". Inability to concentrate on person's problem or story because of pre-occupation with one's own affairs or taking one's attention away from the person. Interruptions - other people around are making noise. A quiet atmosphere free of telephone rings and distractions is necessary for good listening to take place. Lack of time or being too time conscious is a barrier. The speaker feels constrained and is unable to express himself properly.

THE BATHE TECHNIQUE IN COUNSELLING

The busy physician can help many patients by applying Stuart and Liebermans 15-minute hour method of primary care counseling. The technique provides a structure for counselling patients in primary care. It helps draw out the quiet patient and provides a structure of when to move on in a talkative patient. The acronym BATHE (background, affect, trouble, handling empathy) summarizes the methods as follows:
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B Background assessing whats the background situation Ask about likely areas of psychological problems: How are things at home? At work? Whats different in your life between now and before? A Affect the patients affect Ask about common areas generating strong feelings: How do you feel about your home life? How do you feel about your work/school? How do you feel about your life in general? T Troubling the problem that is most troubling for the patient Ask how much the patients problems bother him or her: What most worries you about your life? How stressed are you by this problem? What do you think this problem means to you? H Handling the manner in which the patient has been handling the problem Problems are often mishandled life difficulties: How are you handling the problems in your life? What have you tried to solve the difficulty? How much support are you getting at home/work? Who gives you support for dealing with problems? E Empathy response that conveys empathy Express understanding of the patients distress: I can understand that you would feel angry That must have been difficult This is a tough situation to be in Using Soap to Bathe Physicians can further help patients with emotional and psychological problems by talking in therapeutic ways, summarized by the acronym SOAP (support, objectivity, acceptance, present focus):

S Support
Normalise problems as common dilemmas: Lots of people struggle with similar problems. Help the patient focus on strengths: What resources could you use to deal with this?

O Objectivity
Encourage patients to ask themselves how realistic their thoughts and feelings are (reality tests). Whats the worse thing that could happen? How likely is that?
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A Acceptance
Be as non-judgmental and accepting as possible: Thats an understandable way to feel. Encourage patients to feel better about themselves, their parents, and other family members: I think youve done real well considering all the stress. Sounds like your parents did the best they could under tough circumstances that were hard for them to survive. Coach patients to think differently about themselves more realistically, if they are overly self-critical: I wonder if you are being too hard on yourself. How much time and energy are you putting into worrying about this? What else could you do with all that time and energy? Urge patients to develop more of a sense of humor about their issues: I wonder if you could see the humor in this sometimes. Acknowledge the patients values and priorities: It sounds like family is more important than work to you. Acknowledge the patients readiness for changes: Sounds like you are not quite ready to change. Acknowledge the difficulty of making changes: Changes is real hard, and usually pretty scary.

P 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): How could you cope better? (reframe problem) What could you do different? (leave or change the situation) What are the likely consequences of A versus B? Express guarded optimism that the patients can and will do better. Try to set up a positive self-fulfilling prophecy for the immediate future: My guess is that if you set your mind to it now, you can do much better and feel a lot better, and I think you might just do that. Suggest a homework assignment for the patient to carry out; for example: a. Practice sending I messages: I think our vacation plans are too hectic. b. Practice asking for what you want, rather than just hoping for it: I would like more help with the children. c. Practice telling others how you are responding to their behavior: I feel very angry when you go on trips by yourself so often.
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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. Satisfactory resolution of problems of living requires the ability to recognise it based on the signature cues that are presented time to be devoted; although small in number compared to the total number of patients seen: they take up a lot of time and effort in the helping process some basic counselling skills, and appropriate use of teamwork & community resources. Family doctors are urged to take up the challenge of helping the patient deal with problems of living as part of their scope of care. 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, e.g., dyspepsia, headache. 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

THE DIFFICULT PATIENT

Definition A 'difficult patient' may be defined as one with whom the physician has trouble forming an effective working relationship. However it is more appropriate to refer to difficult
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problems rather than difficult patients, it is the patients who have the problems while doctors have the difficulties. Characteristics of Problematic Patients 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 Such patients are often referred to as the 'heart-sink' patients, referring to that certain sinking feeling on seeing them in the waiting room. They can provoke negative feelings in us and we have to discipline ourselves to be patient, responsible and professional. Pitfalls to Avoid An inevitiably poor consultation will follow if we allow feelings of hostility to affect our communication with the difficult patient. The solution is to get above these feelings. We also need to consider the possibilities of the following disorders which may be masked: anxiety depression obsessive compulsive disorder bipolar disorder (manic depression) drug dependency alcohol abuse schizophrenia It is therefore appropriate to maintain traditional standards of care by continually updating the data-base of the patient, integrating psychosocial aspects, carefully evaluating new symptoms, conducting an appropriate physical examination and being discriminating with investigations. A 'Heart-Sink' Survival Kit This is a model for the management of patients with somatic symptoms of emotional distress. The first part of the three-part model, which is called 'feeling understood', includes a full history of symptoms, exploration of psychosocial cues and health beliefs, and a brief focused physical examination. In the second stage, termed 'broadening the agenda', the basic aim is to involve discussion of both emotional and physical aspects during the consultation. It includes

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reframing the patient's symptoms and complaints to provide insight into the link between physical, psychological and life events. In the third stage, '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. It also includes projection or identification techniques using other sufferers as examples.

THE ANGRY PATIENT

Anger in patients and their relatives is a common reaction in the emotive area of sickness and healing. The anger, which may be concealed or overt, might be a communication of fear and insecurity. It is important to bear in mind that many apparently calm patients may be harbouring controlled anger. Sources of Anger 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, referral to colleagues, which is often perceived as failure, poor service, such as long waits for an appointment, and problems with medical certificates, inappropriate doctor behaviour, e.g. brusqueness, sarcasm, moralistic comments, aloofness, superiority. The patient's anger may manifest as a direct confrontation with the doctor or perhaps with the receptionist, with litigation or with public condemnation. What is Anger? Anger is a person's emotionat response to provocation or to a threat to his or her equilibrium. If inappropriate, it is almost always the manifestation of a deeper fear and of hidden insecurity. Angry abusive behaviour may be a veiled expression of frustration, fear, self-rejection or even guilt. On the other hand, its expression may be a defence against the threat of feeling too close to the doctor, who could have an over familiar, patronising or overly friendly attitude towards the patient. Some patients cannot handle this threatening feeling. Basically anger may be a communication of fear and insecurity. Consulting Strategies When one feels attacked unfairly, the response is to react. This response should however be avoided since it will damage the doctor-patient relationship further and aggravate the problem. The Correct Strategy Remain calm, keep still and establish eye contact; ask the patient to sit down and try to
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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).

Question to Uncover the True Source of Anger The following represent some typical questions or responses that could be used during the interview.

Rapport building
'I can appreciate how you feel,' 'It concerns me that you feel so strongly about this.' 'Tell me how I can make it easier for you.'

Confrontation
'You seem very angry.' 'It's unlike you to be like this.' 'I get the feeling that you are upset with .' 'What is it that's upsetting you?' 'What really makes you feel this way?'

Facilitation, clarification
'I find It puzzling that you are angry with me. , 'So you feel that, . . , 'You seem to be telling me. . .' 'If I understand you correctly . . .' Tell me more about this . , : 'I would like you to enlarge on this point, it seems important.' 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. Completing the Consultation A skilful consultation should provide both doctor and patient with insight into the cause of the anger and result in a contract in which both parties to work in a therapeutic relationship. The objective should be to come to amicable terms which, of course, may not be possible, depending on the nature of the patient's grievance.
References Mcculloch J, Ramesar S, And Peterson H. Psychotherapy In Primary Care: The Bathe Technique. American Family Physician May 1, 1998

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Servan-Schreiber D, Tabas G, And Kolb Nr. Somatizing Patients: Part Ii. Practical Management. American Family Physician March 1, 2000 (Http://www.Aafp.Org/Afp/20000301/1423.Html) Murtagh J. Difficult, Demanding And Angry Patients. In: General Practice. Mcgraw Hill:Sydney, 1998

CHAPTER 4

CHANGING BEHAVIOUR

Outline Changing behaviour Stages of Behaviour Change Smoking Cessation The Prochaska-DiClementi Model And He 5As Of Smoking Cessation Patient Health Education On Excercise

CHANGING BEHAVIOUR
If we are to find ways to extend the benefits of good health to the most vulnerable and promote responsible behaviour and the adopotion of lifestyles that are conducive to good health, we in the health profession must find the most effective means of extending the benefits of good health for all. 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 to change has been made); and (4) maintenance (the period from 6 months after a behaviour change has been made and the behavioural problem been ameliorated). This stages of change model is particularly useful when designing health promotion interventions for specific target populations. It forces the practitioner to use the most effective strategies for eliciting and sustaining behaviour change depending on which stage of change people are in. According to Prochaska, the majority of health promotion/disease prevention programs are designed for the small minority of people who are in the action stage. He estimates that among those people who were smokers in 1985, nearly 70% were not ready to take action. Their 1986 stages were as follows: (1) precontemplation stage-35%; (2) contemplation stage-34%; (3a) ready for action stage-15%; (3b) taking action stage12%; (4) maintenance stage-4%. In planning, implementing, and evaluating health promotion programs, the practitioner should know something about the stages of adoption and the diffusion curve.) It is generally acceptedc that there are six types of individuals/groups when considering the adoption of an innovation. These individuals range from innovators to laggards at Opposite ends of the bell curve, with early adopters, early majority, late majority, and late adopters falling between the two tails of the bell curve.

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