Konseling Pasien dalam Kedokteran Keluarga

dr. Nindya Aryanty, M. Med. Ed

Tujuan Pembelajaran

• Mahasiswa memahami definisi dan proses konseling

• Mahasiswa mengetahui teknik konseling

• Mahasiswa mengetahui ciri-ciri pasien sulit atau butuh pendekatan khusus

• Counselling is a relationship between a concerned person and a person with a need.

• This relationship is usually person-to-person, although sometimes it may involve more than two people.

What is counselling?

What is counselling?

• Counselling is a process by means of which the helper expresses care and concern towards the person with a problem, and facilitates that person's personal growth and brings about change through self-knowledge

What is councelling?

It is designed to help people to understand and clarify their views, and learn how to reach their self-determined goals through meaningful, well-informed choices, and through the resolution of emotional or interpersonal problems.

Kenapa perlu memahami konseling?

• Dokter bertemu dg pasien yg memiliki ‘masalah kehidupan’

• Keadaan depresi, kesepian, kesulitan uang keluhan lelah, lemah, sulit tidur, nyeri perut, sakit kepala

• Pasien tidak menceritakan masalah hidupnya menganggap tidak pantas dibicarakan kepada dokter

• Jika keluhan berupa masalah kesehatan pantas dibicarakan kepada dokter

• Dokter perlu memahami latar belakang ‘masalah kehidupan’ untuk dapat memberikan tata laksana yang tepat

• Konseling : membantu pasien menyelesaikan permasalahannya sebagai bagian dari pelayanan medis

Kenapa perlu memahami konseling?

• Pasien dengan keluhan dispepsia, sulit tidur, tekanan darah tinggi :

wanita, 50 th, ibu rumah tangga, suami telah meninggal dunia,

Jika dokter tidak paham ‘masalah kehidupan’pasien

hanya memberikan resep obat (captopril, ranitidine, ctm)

bgmn ?

Kenapa perlu memahami konseling?

• Jika dokter paham ‘masalah kehidupan’ pasien, apa yang dapat dilakukan dokter ???

• Pasien memiliki 1 org anak penderita schizophrene, tiga anak lainnya normal dan sudah bekerja

• Tanyakan apa yg mjd kekhawatiran pasien.

Biaya ? Sarankan solusi : – Terangkan kondisi pasien pd 3 anak yg normal, minta

membantu & perhatikan ibu

– Keluarga tak mampu jamkesda

Kenapa perlu memahami konseling?

Three Stages of Counselling

Relationship Building

Exploration and Understanding

Rational Discussion

A. Relationship Building

• Be ready and willing to attend to the patient

• Listening carefully to the patient

• Attempting to understand the feelings and thoughts conveyed

• Structuring, paraphrasing, reflecting of feeling and summarising the patient’s statements

Pay attention to the patient, develop a supportive relationship with him

B. Exploration and Understanding

• The doctor enters further into the patient’s world

• Doctor needs skills of probing, information giving, clarification to ascertain meaning of messages and feelings that the patient is conveying

The aim : to enable the patient to gain a better understanding of himself, his situation, and the problem he is presenting

He is helped to deal with himself and be motivated to engage in rational discussion for problem solving

C. Rational Discussion

• The aim : to help the patient cope with the problem in a healthy and rational way

• 3 phases :

1. Problem definition and assessment

2. Therapeutic goal setting and implementation

3. Termination and evaluation

1. Problem definition and assessment

• Define a treatable problem among a wide and complex variety of complaints

2. Therapeutic goal setting and impelemantation

• Eliciting as clearly and specifically as possible the patient’s expectation of improvement

• Doctor define a target symptom or specific outcome = the patient expect to achieve

negotiation to modify unrealistic expectation and to lead to mutually agreeable goals

• Doctor and patient : establish a therapeutic contract

• Doctor involves the patient in exploring new ways of thinking and behaving to attain the therapeutic goals

2. Therapeutic goal setting and impelemantation

3. Termination and evaluation

• Evaluate the change achieved recognize the need to do further work or to accept unchanging/unchangeable situations

The Need to Listen

“Man’s real needs, 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”

(Taylor Caldwell)

Usefulness of Listening

• Release of tension • Draining off of anger, aggression, frustration • Clarify thinking • The patients is helped through a better and more

realistic understanding of himself and his situation

• Sharing the burden • Establishing a relationship so that loneliness is

broken; the person is giving a feeling of being worth someone’s time and attention

Qualities of a good listener

• Accepting, patient, caring, sympathetic, concerned, discreet, understanding, respectful, knowledgeable, encouraging, tolerant, warm, kind, and trustworthy

• Try to “be with” the patient

• Is sensitive to the patient’s feeling

Barriers to good listening

• Impatience • Forming premature opinions of what the person

is lie and how the problem can be solved • Making comments, implying judgment, criticism,

lack of understanding and insight; jumping to conclusion that the patient is in the wrong, disagreeing, arguing, or interrupting

• Give a glib solution without the due process of listening

• Giving the impression that doctor not taking the problem seriously

• Talking instead of listening

• Being passive show bored, not interesting

• Inability to concentrate on patient’s problem

• Interruptions – other people around making noise

• Lack of time – the patient feels constrained and is unable to express himself properly

Barriers to good listening

How to conduct counselling ?

The BATHE technique in counselling

• Stuart and lieberman’s “15-minute hour” method of primary care counselling

• B ackground

• A ffect

• T rouble

• H anding

• E mpahty

• B Background

“how are things at home?” “At work?”

• A Affect

“how do u feel about your work?”

“how do u feel about u’r home life?”

• T Troubling

(ask how much the patient’s problem bother him)

“how stressed are u by this problem?”

The BATHE technique in counselling

• H Handling (the manner in which the patient has been

handling the problem) “what have u tried to solve the problem?” “who gives u support for dealing with the

problems?” • E Empathy (express understanding of the patient’s distress) “that must have been difficult” “I can understand that u would feel angry”

The BATHE technique in counselling

Using SOAP to BATHE

• Doctor can further help patients with emotional and psychological problems by talking in therapeutic way

• S Support

• O Objectivity

• A Acceptance

• P Present focus

SOAP

• S Support

Normalize problems as common dilemmas

“Lots of people struggle with similar problem”

Help patient focus on strength

“what resources could u use to deal with this?”

• O Objectivity

encourage patient to ask themselves how realistic their thoughts and feelings are

“what’s the worse thing that could happen?”

SOAP

• A Acceptance – Be as non-judgmental and accepting as possible

– Encourage patients to feel better about themselves, their parents, and other family members

– Coach patients to think differently about themselves more realistically

– Acknowledge the patient’s value and priorities

– Acknowledge the difficulty of making changes

“changes is really hard, and usually pretty scary”

SOAP

• P Present focus

– Encourage focusing more on the present, less on the pass and future

“what could u do different now?”

– Express guarded optimism that the patient can and will do better

“my guess is that if u set u’r mind to it now, u can do much better and feel a lot better, and I think u must just do that”

SOAP

Dealing with the difficult patient

The difficult patient

A difficult patient : one whom doctor has trouble forming an effective working relationship

• Frequent attendance with trivial illness • Multiple symptomatology • Non-compliant • Hostile or angry • Attending multiple therapist • Manipulative • Taciturn and uncommunicative • All knowing

Doctor need to consider the possibilities of the following disorders which may be masked:

• Anxiety

• Depression

• Obsessive compulsive disorder

• Drug dependency

• Alcohol abuse

• Schizophrenia

Dealing with the difficult patient

• Continually updating the data-base of the patient

• Integrating psychosocial aspects

• Carefully evaluating new symptoms

• Conducting an appropriate physical examination

• Being discriminating with investigation

• Give councelling when needed

Dealing with the difficult patient

The angry patient

• Anger in patient and their relatives :

because they are not getting better, disappointment at unmet expectation, crisis situation, the development of fatal illness, high cost services, long waits for an appointment, inappropriate doctor behavior

May manifest as a direct confrontation with the doctor

How to deal with the angry patient?

Do : • Remain calm, keep still and establish eye contact,

ask the patient to sit down and try to adopt similar position (the mirroring strategy) without any progressive pose

• Address the patient or relative with appropriate name : Mr. Andi, Mrs. Tan

• Be interested and concerned about the patient and the problem

• Use clear, firm, non-emotive language

• Listen intently

• Allow patient to ventilate their feelings and help to relieve their burden

• Allow patient to ‘be themselves’

• Give appropriate reassurance

• Allow time (at least 20 minutes)

How to deal with the angry patient?

Do Not :

• Meet anger with anger

• Touch the patient

• Reject the patient

• Evade the situation

• Talk too much

• Be judgmental

• Be patronizing

How to deal with the angry patient?