Counselling – AFP2009

1 In patients with mental health concerns, explore the role of counselling in treating their problems. (Intervention is not just about medication use.)

1) Problem-solving therapy: helpful for MDE, med nonadherence

• Problem definition: Obtain factual, concrete information; clarify nature of the problem; describe the problem objectively and succinctly
  • “What part of this situation is most distressing for you?”
• Generating alternative solutions: Encourage the patient to brainstorm and generate several possible solutions2) the BATHE technique.
  • “What options have you considered?”
• Decision making: Evaluate possible solutions; predict possible consequences of the selected solutions
  • “Of those, which one seems best?”
• Solution verification and implementation: Restate the behavior plan; review any obstacles and develop a plan for each
  • “Is there anything that could get in the way?”

2) BATHE: helpful for patients exhibiting psychiatric syndromes or a broad range of psychosocial problems

• Background: “What’s going on in your life?”, “What has happened since I last saw you?”
• Affect: “How do you feel about (a situation that has happened to the patient)?”
• Troubles: “What bothers/troubles you most about the situation?”
• Handling: “How are you coping with/handling the situation?”
• Empathy: “It sounds very frightening/frustrating/sad.”

3) Five A’s: Health risk behavior

•  ask, advise, assess, assist, arrange (see smoking cessation post)

Although brief primary care counseling has been effective, patients who do not fully respond to the initial intervention should receive multimodal therapy or be referred to a mental health professional

2 When making the decision about whether to offer or refer a patient for counselling:

• a) Allow adequate time to assess the patient.
• b) Identify the patient’s context and understanding of her or his problem/situation.
• c) Evaluate your own skills. (Does the problem exceed the limits of your abilities?)
• d) Recognize when your beliefs may interfere with counselling.

3 When counselling a patient, allow adequate time.

4 When counselling a patient, recognize when you are approaching or exceeding boundaries (e.g., transference, counter-transference) or limits (the problem is more complex than you originally thought), as this should prompt you to re-evaluate your role.

Transference

• unconscious redirection of feelings, thoughts, wishes associated with an individual from the pt’s past to the clinician
• Unconscious re-creation of a past relationship in the present
• depends on the pt’s past and the clinician’s characteristics

Counter-transference

• conscious and unconscious redirection of a therapist’s feelings and thoughts towards a client
• The clinician’s feelings and thoughts about someone from a previous relationship that are displaced onto the pt
• Feelings and thoughts induced in the clinician by the pt’s behavior

References:

• http://www.aafp.org/afp/2009/0215/p277.html
• UpToDate.