COUNSELING SKILLS I:

ACTIVE LISTENING SKILLS

KIM ADRIAN LOMPOT, MD

2ND YEAR FAMILY MEDICINE RESIDENT
SOUTHERN PHILIPPINES MEDICAL CENTER
 CLIENT CENTERED
•

COUNSELING
It is the client, or counselee, who sets the pace and the direction of the counseling

• The patient leads and counselor follows

• Once insight is achieved, the counselee will decide

what to do and how it will be done
•

•
ACTIVE LISTENING SKILLS
It allows the doctor-counselor to obtain psychosocial information that will allow
him to enter the inner emotional world of a patient, understand how the patient
sees the world and how he perceives the problematic reality for which he is
counseling

• Attending, bracketing, leading, reflecting content, reflecting feeling, reflecting

experience, focusing, and probing
 I. ATTENDING SKILLS
• we use our bodies to communicate nonverbal

• Gestures that communicate the message of openness and understating: Leaning

forward towards the patient as he speaks, tilting or nodding the head, raising
eyebrows and maintaining eye contact

• Gestures that communicate the message that one is not interested in what the patient is
saying: leaning backwards, looking away from the patient, crossing ones arm
 I. ATTENDING SKILLS
• Avoid certain habits of movement we may have which can distract a patient, or which
can detract the message of wanting to understand (habitually twirling pencils,
scratching our heads, or tapping our feet)

• Staying too close can be threatening, while staying too far can be interpreted as
unwillingness to get involved

• It is better if the patient is seated at a 45 degree angle from you as sitting in front of
the patient may be threatening
• A mental skill II. BRACKETING
• Setting aside the feelings, thoughts, and judgements temporarily

• Metamorphically, we are removing our tinted lenses for a while so we can put on
the lenses of our patient to see the world from his point of view
 III. LEADING
• INDIRECT leads- open invitations made by the doctor-counselor for the patient
to talk about anything what he wishes.
•

• “What would you like to talk about” or “What can I do for you?

• It can also take the form of words or phrases, such as “yes,” “Go on,” “And
then?”

• they do not even have to be words, such as “uh-hmm”

•
III. LEADING
DIRECT leads- the doctor-counselor make a judgement call as to where the
patient should go and asks him to go in that direction

• Focus on what the patient has already brought up and does not introduce any new
material or direction other that what the patient has already brought up
 LEADING (DIRECT)
Example: Patient: You
see, we have been married 5 years and we were okay most of the time. But since
several months ago, I noticed that she became less talkative. Lately she has been
very irritable and I’m having a hard time because she keeps cutting me off

Direct lead: Tell me more how she cut you off.

Alternative Direct lead: Cutting you off? (followed by and expectant pause, thus
allowing the patient to pursue this aspect of the problem
•
LEADING (DIRECT)
Wherever the feelings is greatest and most intense, that is where the doctor-
counselor should go

• A patient will mention many things but only as a prelude to the more important
issues which he saves for last
•
IV. REFLECTING SKILLS
To act as a mirror so that the patient can see himself and his situation more clearly

• Reflecting content, Reflecting Feeling, Reflecting experience

 IV. REFLECTING SKILLS

(45/M walks in the office, sits down, then stands up again

and looks out the door to where his wife is sitting. He
shuts the door and sits down again)

patient: a month ago, I had this sore throat, so I went to a

doctor and he gave me penicillin for it. So I took if for seven
days and it went away. But a week later, I had the sore throat
again

(patient shifts in his seat and looks down at

 REFLECTING CONTENT
• The doctor-counselor takes the verbal content of what the patient says, repackages
and rephrases it so that it becomes clearer, and gives it back to the patient.

• Paraphrasing
•

• The doctor-counselor listens to what the patient is saying and then, using fewer
but clear words, summarizes to the patient what the latter has just said.

• We help them to know themselves and their situation by helping them to

articulate their thoughts

• One must be careful not to add to the paraphrase anything which the patient has
not mentioned
Example:
REFLECTING CONTENT
Paraphrase: This is the third time you have had a sore throat within a month and
you can’t understand why it keeps coming back.

• Paraphrasing should be well constructed

•
REFLECTING
Perception checking
CONTENT
•

• It is used when the doctor- counselor is not certain if he understood the patient
correctly and would like confirmation from the patient.

• it is phrased in an interrogative form

 REFLECTING CONTENT
Example:

Perception check: This is the third time you have had a sore throat within a month
and you can’t understand why it keeps coming back. Is that it?

• Correction allows to reorient the doctor-counselor toward the right direction

•
 REFLECTING FEELING
• The doctor-counselor articulate the feelings for the patient

Example

Reflecting feeling: You seem to be quiet anxious about your sore throat.
 REFLECTING FEELING
• Helping the patient articulate his feelings serves several therapeutic purposes
•

• giving a name to his feeling, he becomes more aware of the emotion

• feelings that are not articulated and acknowledged have a way of taking
control of behavior

• when feelings are reflected back, rapport increases and the patient feels
encourage to tell the doctor more
 REFLECTING EXPERIENCE
• Reflecting back the nonverbals
•

Reflecting experience: I noticed that a while ago, you looked out at the door at
your wife the you shut it. Could you tell me what was behind that action?

Alternative: When you were talking about this third episode of sore throat, your
voice seemed to become softer and you shook your head. What does that mean?

• The doctor-counselor allows the patient to become aware of how he is behaving

•
•
REFLECTING EXPERIENCE
The most threatening reflecting skill for the patient because of some form of
embarrassment involved on the patient’s part

• Should not be used too early when rapport is not sufficient

 V. FOCUSING
Patient: My headaches have been increasing because I have been under a lot of
pressure lately. You see, I have been out of work for the past few months and my wife
has been nagging me about our financial problems and on top of this, our eldest
daughter is getting very rebellious and keeps answering me back. My son had an
accident and you can imagine the trauma I felt when I heard about it. I just have so
many problems right now.
• Usually there are just 1 or 2 problems that accounted for the emotional pain and
therefore worth focusing
 V. FOCUSING
• Ask the patient to do the choosing of what is important to him (client-centered)
Focusing: You have financial difficulties, your wife is nagging you, your daughter is
rebellious, and your son had a accident .That is quite a lot. But of these four, which
is the one that gives you the most pressure?
Focusing: So you feel afraid, angry, guilty and frustrated. But of these four, which is
the feeling that is giving you the most pain.
 VI: PROBING
• Probes are questions that are asked in order to elicit more information.

• They should not be answerable by yes or no, as well as “what” “where” and
“when” since these type of questions do not encourage much exploration on the
part of the patient.

• Much better are probes beginning with “how”, “could you explain” “could you tell
me more” and “could you give an example”
 VI: PROBING

Example: Probe:
How does that make you feel? Can you tell me more about that feeling?

• Probe where the emotional content is greatest.

• As in direct leading, the doctor-counselor probes only what the patient has already
presented
•
• In summary, active listening skills:
•

• allows us to develop better rapport with the patient

• allows us to see how the patient views his illness, its impact on his life, and the
aspect of the illness

• is a necessary preparation for the working phase process of primary care

counseling.
 COUNSELING SKILLS IN HEALTH
•

•
EDUCATION: THE C.E.A METHOD
•

• Patients consult for two reasons: either they have physical symptoms, and they
are anxious about the physical symptoms.

• Patients who are anxious have difficulty absorbing our attempts to educate them.

• Patient’s emotions have their root in the patient’s perceptions about the reality he
is experiencing

• using the active listening, physicians can accurately identify the misperceptions
that are most anxiety provoking (Emotionally Critical Misperceptions) through the
use of active listening.
 COUNSELING SKILLS IN HEALTH
CATHARSIS EDUCATION ACTION
EDUCATION: THE C.E.A METHOD
•

• Systematic way of dealing with the medical issues and how they are
perceived by the patient and family, an encourage the family to openly
discuss the illness and their emotional responses to it.
 CAHTARSIS
• Becoming aware of the hidden emotion, giving it a name, allowing the emotion to be
experienced fully, and coming to a realization of what is behind

• Steps to elicit the required information, and uncover the feeling and misperception
•

What came to your mind when you started feeling your symptoms?*

What feelings came out when these thoughts came to your mind?*

What consequences of your illness makes you feel this way the most?*
• EDUCATION
Goal is to correct the misperception first

• Identify the misperceptions of the patient that are most anxiety-provoking

(Emotionally Critical Misperceptions)
 EDUCATION
• A few pointers in educating patients
•

• the physician should speak in the language of the patient

• the power of analogy in explaining complicated concepts

• our patients generally do not speak the EBM language

• Misperceptions may only be marginally related to pathophysiology and

pharmacology
 ACTION
• The emotionally appropriate time to explain the proposed treatment is AFTER the
ECM has been addressed- NOT BEFORE. Otherwise, the patient will just keep
going back to the ECM and no forward movement can be accomplished.

• Patients may also have ECMs about the treatment. Use active listening skills to
elicit misperceptions and addressed it using CEA
• In summary:
•

• All patients who consult have two problems that need to be addressed- the
physical illness and the anxiety

• it is the anxiety that is usually the more powerful motivator for a patient to
consult.

• Active listening allows the physician to identify the misperceptions of the

patient regarding his illness

• Use CEA to address the misperceptions

THANK YOU