A problemsolving approach

Defining the problem (what the matter really is) is the most important step in the process of patient care. The following outline is one approach to counselling that is applicable to a general practice context. 1

1. Listen to the problem of first presentation: this involves listening not only to issues, events and experiences, but also to the patient's feelings and distress. The emphasis here is more on the communication skills of facilitation, silence, clarification, reflection, paraphrasing, confrontation and summary, than on questioning. In many cases this phase of the counselling constitutes the major part of the therapy; e.g. in grief or bereavement counselling, where the doctor supports the patient through a natural but distressing process.

2. Define a problem, if possible in behavioural terms:

Beneath the feeling is the experience, beneath the experience is the event, the event is related to a problem. 3

3. Establish a contract for counselling, with an agreed number of visits initially, e.g. weekly half hour or hour appointments for 4 to 6 weeks.

4. Define short-term and long-term goals for action.

5. Decide on one option—'experimental action'.

6. Build an action program with the patient— negotiate 'homework' for the patient between visits.

7. Evaluate progress.

8. Continue action or select another option.

9. Evaluate progress. 10. Terminate or refer.

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