Counselling skills for GPs

Counselling is a difficult area for GPs. There is no agreement on which counselling methodologies should be adopted, how effective the various strategies are and how to find the time in the first place.

Counselling is defined as something that provides direction or advice about a decision or course of action. This simple description gives us some hope that most of our day-to-day work in the surgery could be described as counselling.

Any effective consultation contains large amounts of the first accepted counselling skill, active listening. This skill is enhanced by seeking out belief systems highlighted by the listening, then using the higher level skill of synthesising this information into a narrative that can be understood.

This information needs to be stored until the time comes in the consultation to respond to the problem or scenario your patient has presented.

Almost all significant problems brought to GPs require a professional response, with advice on possible courses of action that allows an element of informed choice.

Schools of thought

Professional counsellors will belong to one of three schools of thought – psychodynamic, humanistic, or behavioural and cognitive. The first is essentially Freudian and unless you are that way inclined, best avoided.

Humanistic counselling is commonly called Rogerian, although Maslow's hierarchy of needs is a central tenet. Freud lurks in the background and the skills include active listening but almost no advice giving.

The goal is the patient being enabled to see what they need to do by insight into their own condition from their own narrative, the aim being Maslow's pinnacle of human needs, self-actualisation. This type of counselling may suit some GPs, but it is time consuming, and requires training and constant support.

CBT, the most popular form of counselling over the past decade, is based on cognitive psychology and behaviourism. The theory is that how we think (cognition), feel (emotion) and act (behaviour) are related and interact together.

Using CBT

Its great attraction to most GPs is the lack of mysticism, combined with a logical approach and the relative absence of psychoanalytical theory.

In fact, it can be traced to Pavlov and his dogs and Skinner and his pigeons.

As ever, the evidence base for CBT can be argued over, but it appears to be the most scientifically supported method of talking therapy.

This is, however, not a routine tool for most surgeries. Depending on the problem and the patient, this form of counselling usually needs several sessions and requires expertise, time and regular practice.

The underlying CBT concept of patients being helped to help themselves by recognising and changing unhelpful thought patterns does lend itself to self-help programmes.

There are two for NHS patients: Fear Fighter for people with phobias or panic attacks and Beating the Blues for mild to moderate depression.

Perception of counselling

In the surgery, one of the main problems with the notion of 'counselling' is the perception induced by many sources, including the media, that it is a panacea for all traumas and a requirement for any form of shock and bereavement.

This is also an unregulated growth industry, with many substandard practitioners. A situation has arisen in recent years of GPs spending significant time counselling patients against counselling, or worse, handing them over to therapists whose beliefs are usually unknown, as a way of washing their hands of the problem.

Counselling strategies

• Make things easy. People are more likely to do things if there are fewer things to do, if they fit their lifestyle and if they have the resources.
• Think of the context. People are more likely to do things if they do them with other people, if they are reminded at the time to do them, if they know someone might check to see if they have done them and if the people with whom they live and work are willing to help them.
• Think of the patient's perceptions. People are more likely to do things that seem important, when they understand why and how they should do them. If they believe in your advice, they will follow it, and they are more likely to do things if their anxiety level is raised moderately, but not too high.
• Think of the relationship. People are more likely to do things if they have helped to decide it would be beneficial, if they have promised to do them and if they have faith in you as their doctor, especially if they think you like and respect them, and if they are rewarded for doing them.

• Dr Tate is a retired GP in Dorset and author of The Doctor's Communication Handbook. To order his latest educational DVD, Developing an Efficient Consulting Style, for £27.99, visit gponline.com/consulting