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Brief counselling for the busy GP

How can busy GPs possibly support their patients properly in

just seven-and-a-half minutes? Counselling psychologist Terri Spy offers advice

Given that on average GPs have about seven-and-a-half minutes in which to decide, treat and assess their patients, how then can a GP provide brief, effective counselling support to their patients? After all, 'Time begins When time begins', according to an African proverb, so GPs have to make every minute of patient contact count.

For starters, it is important to avoid opening an appointment with 'How are we today?'. In this form of greeting, the information conveyed is clearly one of 'Don't tell me the truth, just say fine'. When you ask 'How are you feeling today?' be prepared to be told, be it good, bad or indifferent.

Questions come in two main forms – open and closed. Closed questions involve gaining information and the usual response will be either Yes or No, for example, to the question 'Are you coping?'.

Open questions can involve the following – which, who, when, how, where, what? 'Why' should only be used providing the patient will not see it as a threat or accusation. Open questions do involve feelings, so GPs need to be aware they can cope with feeling responses.

For example 'Do you feel suicidal?' (open question) can trigger all kinds of responses from the patient as it will entail reactions from the GP should the answer be 'Yes I do' (see right for box of useful open and closed questions to ask a patient during brief counselling).

American psychologist Carl Rogers (1902-1987) created person-centered counselling, based on the concept that the patient already has answers to the problems and the job of the counsellor is to listen without making any judgments, without giving advice, and simply help the patient feel accepted and understand their own feelings.

However, he believed unless the following core conditions were present during counselling – unconditional positive regard, genuineness, congruence and empathy – this approach would be unlikely to get an accurate response from the patient.

If and when the patient realises that his or her GP has these core conditions and is being listened to, valued for who they are and accepted for how they are at present, it is likely that they will feel held and be able to wait for their professional counselling appointment.

Probing statements are a good way to encourage people to talk: 'Can you tell me more about that?' or 'I am not sure I understand what you are feeling/saying'. These in themselves can appear closed yet try the above out on a peer or colleague and notice the response they give to you.

Another way in which to use these basic communication skills can be through either reflecting or paraphrasing what the patient is saying to you. Reflection – saying the patient's words back to them, which in turn, lets the patient know you have been listening.

Paraphrasing – conveying the essence of what the patient has said back to them. Both are techniques in which to convey active listening.

Using these techniques that convey the core conditions does enable the patient to feel helped and valued. Enabling the patient, through reflection, to hear some of their own words back again can help them clarify their own thoughts and feelings. While through the use of paraphrasing it is useful to preface a phrase with 'It sounds as if' or 'It seems as if what you are saying is.....'.

This of course gives the patient the opportunity in a non-threatening manner to correct you if you are wrong or if they disagree with what you are saying. It can also enable the patient to know just how they really are.

At this point the GP may feel a shift of power balance, either positive or negative, which in itself is good. The aim after all is to enable the patient to feel valued and listened to.

Listening is not an easy skill to attain. It is assumed that we can all listen – but do we? Each of us comes from our own past, which in turn gets carried into the present. From there your patients often can present with a variety of difficulties. How they are responded to is what counts now. Every GP has to put their personal issues aside in order to be very present for their patients.

Saying things like 'You will be all right' or 'It could be worse' or 'I got through that' does not help and should not be said. Do not ask feeling questions if you do not want to get a feeling response. Remember most of us are likely to be thinkers or feelers. So also are your patients.

The important aspect of brief counselling is for the patient to feel listened to, regarded, respected and contained. If brief counselling is not your skill then do not embark on it – both you and your patient will get hurt.

Meeting a patient infrequently yet in a genuine manner – be it for seven-and-a-half minutes – providing it is real, empathic and enabling will help people hold on until their appointments for counselling come through. It is the being available that counts and enables the patient to come through.

Terri Spy is a counselling psychologist

Useful questions to ask a patient

during brief counselling

lWhen was the last time you felt happy/well?

closed question

lIf you were to rate your mood on a scale of one to 10 – 10 being OK – how would you rate your mood today?

closed question

lIs this an example of how you generally feel?

closed question

lWhat would need to change for you to feel happy/well?

closed or open question

lIf you could change one thing to make things better, what would that be?

closed or open question

lTell me of a time when you felt well?

open question

lWhat would it be like for you to set goals for yourself?

closed or open question

lTell me more about that?

open question

lGiven you have to wait for your appointment, I would suggest you set yourself one goal per day to achieve and

tell me what you felt like after you had done so when we next meet.

encouragement

lHow do you feel about that?

closed or open

Useful organisations

•British Association for Counselling and Psychotherapy

Telephone 0870 443 5252

E-mail bacp@bacp.co.uk. www.counselling.co.uk

•British Psychological Society www.bps.org.uk

•The Association for Humanistic Psychology, Britain

Telephone 0845 7078506

E-mail ahp@saqnet.co.uk

•British Association for the Person-Centred Approach

Telephone 01989 770948

www.users.powernet.co.uk/bapca

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