CHAPTER 2 COUNSELLING

Strilctu re
2.0 Objectives
2.1 Introduction
2.2 Concept of Counselling
2.3 Phys~calSettings for Counselling
2.4 Steps in Counsell~ng
2.5 Skills in Counselling
2.6 Teach Yourself Better Counselling
2.7 Meeting Counselling Challenges
2.8 Check Your Counselling Skills
2.9 Let Us Sum Up
2.10 Key Words
2.1 1 Answers to Check Your Progress
2.12 Further Reading

2.0 OBJECTIVES
After going through this chapter, you should be able to:

define what is counselling and the role of a counsellor;

discuss the importance of counselling in an older person; and
explain the process of counselling tl~usenabling you to counsel an elderly patient.

2.1 INTRODUCTION
You have learnt about the various morbidities that can be encountered in the elderly in the
theory units. You have also learnt the role of environment in hindering or facilitating the day
to day activities of elderly. Because of the multiple morbidities, disabilities and the various
psychosocial problems, the elderly are bound to come to you with their problems and need to
be counselled.
All of us have heard sometime or the other that a particular doctor is very good though the
same instructions are given by another doctor to the patient. This is due to the fact that the
former has developed a rapport and caters to the patient's needs and feelings to hidher
satisfaction.
Problems leading to an individual seeking counselling are not age specific. Therefore, the
problems of older persons are not unique. The primary counselling objective is to help maintain
and, where possible, to enhance the quality of life through changes in behaviour and practices.
While working with and for patients, it is very important to be concerned about their feeling
and needs. It is important to develop their confidence and the skill to help themselves. You
should listen to how people loolc at their own problems besides looking at it from medical
point of view.
In this chapter, you will be learning how to provide good counselling.

2.2 CONCEPT OF COUNSELLING

Counselling is a process through which one person helps another one by interaction in a
favourable atmosphere. The primary objective of counselling is to iilvolve individuals in a
process whereby they can be helped to reflect upon, and become aware of their current situation
Health Education and Counselling and complexity of their own needs. It seeks to allow them to express their own feelings about
their lives, without any attempt to impose their own ideas and views. Thereafter, it seeks to
enable them to initiate and develop new and appropriate responses to their situation.
Counselling establishes understanding relationship that helps the individual to change and
helps them make their own decisions. Each person knows his or her own situation and is the
best one to choose from various available options. Whenever, there is difficulty in deciding
what to do, the counsellor helps the person to make a decision. You as a counsellor should
never make a decision on behalf of the patient. You must however, steer the discussion in such
a way that the person or elderly is able to make a decision.

Counselling helps the client to solve his problems and may also help him in making decisions.
This sharing of facts and feelings are explained in the table below:

F Counsellor's role
Share facts
Give clear, accurate information that
the client wants and needs
Help client apply this information to
I
Share feelings
Care for the client by showing
understanding, respect and
honesty'
his or her own life

Client's role
conditions
Ask questions and make sure of
I
Describe personal situation and health a Express attitudes,preferences,
concerns, expectations and
wishes
understanding.

2.3 PHYSICAL SETTINGS FOR COUNSELLING

For a good counselling, you must ensure proper physical settings.
The physical setting should have the following criteria:
.i) Privacy: Counselling is most effective when it is done in a separate roomlchamber.
This will make the elderly feel free to bring up any personal matters related to family,
finance or other emotional issues. Physical privacy is ensured by restricting the entry to
others in the room, shutting doors, using curtains etc. Social privacy or confidentiality is
ensured by not sharing a client's experience with anyone else (not even the family unless
the client agrees), keeping records secret, and not talking so loudly in a clinic that everyone
outside can hear.
ii) Friendly and comfortable surroundings: The physical setting of the room should be
comfortable where the client can speak freely. Adequate sitting space should be available.
You may put posters that give useful health information. There may be brochures or
pamphlets for clients to look at.
Check Your Progress 1
Write true (T) or false (F).
a) In counselling, the doctor makes the decision for the client. (TF)
b) Counselling '~elpsthe client to made a decision. (TF)
c) The proble~l, of the elderly must be discussed with the family. (TF)
d) The elderly must be made comfortable while counselling him. (TE)

2.4 STEPS IN COUNSELLING

The process of counselling has the following steps. You may remember these steps by the
word GATHER:
G Greet your client in a friendly and respectful way and make him comfortable.
A Ask the elderly person his needs and direct the conversation to the problem by active
listening. The elderly people tend to bring in many extraneous factors or topics, which
may not be related to their problem for which they seek help.
 T Tell the elderly the various alternative choices they have for solving their problem. Counselling
Tailor the information to the elderly person's needs, which will help hiin to make a
decision. Ensure that the elderly has understood the choices.
H Help the elderly to decide for himself. Ask the elderly to consider factors like family
support, help, financial implications and other available supporting services, which he
may have access to. Help the client to decide which choice to make. Remember, you
will not choose for the elderly.
E Explain what the elderly can do to carry out his choice. Give any support in the form of
information, mediation etc.
R You may ask hiin for a return visit to clear his doubts or discuss any problems
encountered or any new choice he have come across which should be encouraged. The
elderly should feel that you are interested in helping him with any problems which he
inay encounter while carrying out the decision.

2.5 SKILLS IN COUNSELLING

Counselling is not just a matter of talking with another person, especially if that person is
distressed, anxious and preoccupied with personal problems. You need to learn the skills of
counselling. These are:

a) Setting a relaxed, non-threatening atmosphere

b) Active listening and non-verbal communication
C) Asking questions
d) Validating the client
e) Providing information
f) Facilitating decision making.

a) Setting a relaxed, non-threatening atmosphere

I As a counsellor, you should seek to be as warm, supportive and caring as possible. Comfortable
seating, discreet lighting, the absence of distracting noise, the avoidance of interruptions, and
a relaxing agent such as a cup of tea, can all be aids to a good counselling session.
It is your responsibility as a counsellor to move into the 'difficult' areas of feeling, and to do
so as gently as possible. As a counsellor you need to be as relaxed and natural as possible
because any sign of tension is easily transmitted and can create anxiety within the counselee.

I b) Active Listening and non-verbal communication

i Listening is the most important counselling skill. However, you mustsexpress your interest in
what the elderly is saying by use of non-verbal communication like nodding, occasional,
words like yes, go on etc. and positive body language. This makes the elderly feel that you are
I interested in him.
1I Tipsfor active listening are:
i) Listen to what the elderly say and the way helshe says it. Pay attention to her tone of
voice, choice of words and facial expression.
I
ii) Maintain eye contact.
iii) Lean forward when listening and nod your head.
iv) Make comments such as ' uh huh', 'mmm', go oil, yes, I see etc.
v) Try to feel empathy for the patients.
vi) Stop talking from time to time. Allow time for the patients to talk and ask questions.

I vii) Listen carefully to the patient instead of thinking about what you are to say next.

c) Interpreting the context and feelings of the elderly

For identifying and reflecting feelings, listen to what the elderly says and communicate the
Education and Counselling same feelings back to herihim. This empathetic response to what the elderly says, tells the
elderly that the counsellor has heard and understood what helshe is feeling and herhis situation.
Identifying and reflecting feelings tend to open communication. For example, we can use the
following phrases.
'I suppose that must make you rather anxious.'
'If that happened to me I'd be rather upset.'
In reflecting the underlying feelings, delicacy is required in order not to over expose the
elderly or press himher to admit to more than helshe would like to reveal.
d) Asking Questions
The counsellor asks questions to find out the basic social and medical information about the
elderly, to find out more about them or about a particular matter, need or problem and to
clarify what the elderly is saying. Questions can be open or closed and they can be used to
elicit either factual information or feelings from the elderly. Questions may fall into two
categories:
i) Closed versus open questions
ii) Informations versus emotionallfeeling questions
Let us discuss these two categories one by one. .
i) Closed versus Open Questions
Examples are:
Closed questions which are used to elicit facts:
- How old are you?
- How many children do you have?
- When did your problem start?
Closed questions which require a specific answer, often just yes or no. They cut off discussion.
Many are having questions. Some examples are:
- Have you been to a doctor before?
- Have you been told by your doctor that you have high BP?
- Are you a diabetic? _
Open questi.ons are those which usually seek thoughts, feelings and explanations. They invite
the client to give full, honest answers. Some examples are:
- What do you know about high BP?
- Can you tell me what drugs ire you taking?
ii) Information versu~motionaUFeelingQuestions
Informational questions are those which generally seek information without asking for the
client's feelings. The examples are:
- How old are you?
- How many children do you have?
- Who all are staying with you?
Emotional
These questions assess the emotions andLthoughtsof a person. They are usually open questions
and are preferred since they lead to more and more exposure of the speaker without letting
him or her know how the listener is receiving and evaluating the communications.
e) Validating the Client :
When elderly are expressing feelings that are common to a specific situation, it is helpful for
them to be told that. It is important for them to know that what they are feeling is not exceptional.
 ) Providing information Counselling

The counsellor needs to find out from the elderly what shehe already knows or has heard.
Then the counsellor must gently counter wrong information and provide additional new
information clearly using language which the elderly person can understand.
g) Facilitating decision making
Helping people make decisions about their lives is the ultimate goal of counselling. It is
! possible that new attitudes and determinations, innovative approaches, fresh behaviours and
i outlooks and novel challenges are quite possible in old age.
Counsellors can assist decision-making by considering the options that people feel that they
have in their situation, the advantages and disadvantages of choosing each option, and deciding
on the best option available to them. This then leads to a personal determination to self-action.
Check Your Progress 2
1) List the steps of counselling.

2 What are the tips for active listening?

..............................................................................................................................
3) What are open questions?
!

As a doctor, you ask the elderly to change their behaviour for better health. In the same way,
you want to change your own behaviour to be a better counsellor. Change is easiest one step
at a time. You can make a commitment to improve one counselling skill today and practice it
this week. Then next week you can make a commitment to another improvement. The various
methods by which you can teach yourself better counselling
. are:
I) Role Playing: Try role-playing with a colleague. One of you can play the role of
counsellor. The other person can pretend to be elderly. Imagine the elderly's character,
life situation, and the decision that he or she is facing. Then act out the counselling
session. Other colleagues can watch,
Afterwards, discuss what went well and what could be improved. Discuss other
approaches to the needs of this elderly. " Everyone's comments should be clear but
gentle."
Everyone can take turns playing different roles, both as elderly and as counsellor.
After some practice, one of you may pretend to be an elderly who poses a special
challenge e.g., an elderly who will hardly speak, an elderly who wants you to decide
for her or him, or an elderly who cries.
2) Observation: Ask a colleague to watch you counsel an elderly and then to make
comments. (Get the elderly's permission first.)
3) Supporting materials: Collect good pictureslposters to show elderly. Try out the
pictures with elderly and see what works best.
Health Education and Counselling
2.7 MEETING COUNSELLING CHALLENGES
Here are some challenges that counsellors often face. Also provided are suggestions about
meeting them.

i) The elderly is silent

If the elderly is silent at the start of the meeting, gently call attention to the silence.
You could say, "I can see that it is difficult to talk. It's often that way for new
clients. I wonder if you are feeling a little anxious?" Look at the client and use
body language that shows empathy and interest. Wait for the client to answer.
During discussion, silence can be normal. Sometimes, the client is thinking or
deciding how to express feelings or thoughts. Give the client time to think.

ii) The elderly cries

An elderly may cry for different reasons-to express sadness, to win sympathy, out
of stress or nervousness, or to stop further discussion. Do not assume why the
elderly is crying.
Wait for a while and, if crying continues, say that it is all right to cry-it is a natural
reaction. This permits the elderly to express the reasons for crying. It is okay to ask
the reasons gently.

iii) As a counsellor, you cannot see a solution to the elderly's problem.

Say honestly and openly that you do not know the answer but together you can find
out. Check with a supervisor, a knowledgeable co-worker, or reference materials,
and give the elderly an accurate answer.

iv) As a counsellor you make a mistake

Correct the mistake and say you are sorry. It is important to be accurate. It is not
important to look perfect. Admitting a mistake shows respect for the client.
Be honest. The more honestly you express your own feelings when appropriate
(without revealing your personal life), it is easier for the client to do the same.

v) If you know the elderly

Emphasize confidentiality and ensure privacy.
If the client wishes, arrange for another counsellor.

vi) The elderly asks a personal question

In general, try not to talk about yourself. It takes attention away from the elderly.
You do not have to answer personal questions. The relationship between elderly
and counsellor is a professional one, not a social one.
It can help to talk about your own family experience if you wish. Or you can describe
what happened to someone else, without using names or identifying them.
Sometimes, the elderly asks if the counsellor,has the same problem. It is best not to
say yes or no. Instead, you can say something such as, "I am familiar with that kind
of situation. Please tell me more."

viii) The elderly wants the counsellor to make the decision

This patient may actually be asking for help. You can ask questions such as these:
"You seem to be having trouble reaching a decision. Perhaps you are not quite
ready? Would you like to discuss this further? Do you need more information?
More time to think? Would you like to talk this over with someone else, perhaps
your spouse or your children?"
You can say, "I can answer your questions and help you think about your choices,
but you know your own life best. The best decisions will be the decisions you make
yourself."
 Counselling
2.8 CHECK YOUR COUNSELLING SKILLS
Given below is a checklist to assess your counselling skills.

GREET-Did you:
- Welcome each elderly, on arrival?
- Meet in a comfortable, private place?
- Were yourself relaxed?
- Assure the client of confidentiality?
- Express caring, interest, and acceptance by words and gestures throughout the
meeting?
- Explain what to expect?

ASK-Did you:
- '
Ask the elderly's reason for visit?
- Encourge the elderly to do most of the talking?
- Ask mostly open questions?
- Pay attention to what the elderly said and how it was said, and follow up with
more questions?
- Put yourself in the elderly's shoes-understand without expressing criticism or
judgement?
- Ask about feelings?
- Ask the elderly's preferences for solution to his problems?
TELL-Did you:
- Start discussion with the elderly's preferences?
- Tailor and personalize information?
- Give information important to the elderly's decision?
- Avoid "information overload"?
- Use words familiar to the elderly?
HELP-Did you:
- Let the elderly know that the decision is hers (or his)?
- Help the elderly identify the full range of possible choices?
- Help the elderly discuss the various choices that are possible to himher?
- Advise without controlling?
- Let the elderly decide?
- Ask the elderly to state her or his behaviour?
- Repeat the elderly's decision to confirm it?
- Make sure that the elderly's choice is based on accurate understanding?
EXPLAIN-Did you:
- Provide what the elderly wants, if possible like medication etc.?
- Explain and show how to use the methodltake medicines if required?
- Check the elderly's understanding?
- Ask for any questions?
Health Education and Counselling - Provide supplies?
- Explain any printed instructions and give them to the elderly?
RETURN-Did you:
- Plan the next visit, if needed?
- Invite the elderly to come back any time, for any reason?
- Refer the elderly for any care you cannot give?
- Thank the elderly for coming?
Check Your Progress 3

1) What methods can be adopted for teaching yourself counselling?

2) Write true (T) or false (F):

a) If the elderly becomes silent you must stop counselling. (TF)
b) If the elderly cries, gently try to find the reasons. (TF)
c) If you do not know the solution to a problem, try to find it. (TF)
d) If you make a mistake, do not let the elderly know. (TF)
e) If the elderly wants the counsellor to make a decision for
him, he should do so. (TF)

2.9 LET US SUM UP

Counselling is a face to face interaction in which the counsellor helps the client to make a
decision. For this process to be effective, the counsellor must be well equipped with counselling
skills which are summarized as:
Setting in a relaxed non-threatening atmosphere.
Active listening and non-verbal communication.
Interpreting the content and feeling of elderly.
Asking questions.
Validating the client.
Providing information.
Facilitating decision making.
You must make a conscious effort to teach yourself the counselling skills. This you can do
through role playing, observation or through supporting materials. You may cross check your j1
counselling skills by using the questionnaire provided in Section 1.8.
I

2.10 KEY WORDS 1

Counselling : A process through which one person helps another by
one to one interaction in a favourable atmosphere.
Non-verbal communication :, Expressing through means other than speaking like
nodding one's head, frowning, smiling, grimacing etc.
Role playing Doing a small play in which the actors behave like
identified personalities or people.
2.11 ANSWERS TO CHECK YOUR PROGRESS
Check Your Progress 1
1) a) False
b) True
c) False
d) True
Check Your Progress 2

1) The steps of Counselling are:

G-Greet
A-Ask
T-Tell
H-Help
E-Explain
R-Return

2) Tips for active listening are:

Listen carefully
Maintain eye contact
Lean forward and nod your head
Make positive comments
Show empathy
Do not interrupt frequently
Follow what the client says.

3) Open questions try to assess the thoughts, emotions and feelings of an individual.
They are indirect questions and help the counsellor and client to understand the problems
better.

Check Your Progress 3

1) The methods which can be adopted for teaching oneself counselling are role playing,
observations and supporting material.
2) a) False
b) True
c) True
d) False
e) False

2.12 FURTHER READING

Brockle Hurst 's Text Book of Geriatric Medicine and Gerontology, Chapter 99, pages 1399-
1408.
CHAPTER HEALTH EDUCA'TION
Structure
3.0 Objectives
3.1 Introduction
3.2 Organizing and Conducting Health Education Activities for Elderly
3.2.1 Group Discussion
3.2.2 Imparting Health Education
3.2.3 Place of Imparting Education
3.3 Let Us Sum Up
3.4 Key Words
3.5 Answers to Check Your Progress
3.6 Further Readings

3.0 OBJECTIVES
After going through this chapter, you should be able to:

assess the educational needs of the elderly, and prioritise them;

develop health education messagess; and
organize and conduct health education activities in any one 'health problem you commonly
see in clinic/community.

3.1 INTRODUCTION
You have already learned the concept and principles of health education, different
approaches to health education as also communication process in MME-004, Block 2,
Unit 3. In this chapter you will get an opportunity to orgemize and conduct the health
education activities in your own set-up or in districttsub-dis'trict or tertiary level hospital.
Since the health education involves change in behaviour and practices, it becomes
imperative to interact and learn the existing knowledge, belief, attitudes and practices of
elderly (in the community or other settings). Through riipid method of surveys and
interaction you will be able to assess the priority education r heeds of the elderly as also the
attitudes of family and community towards elderly. This will1 also help you to identify the
available resources, support systems that could enable the c:lderly to help themselves and
act upon the available information. Through the varied experiences of elderly people you
would be able to assess the success or failure of the method of education. Efforts on
education have to be sustained on a continuous basis and o n e time activity or effort may
be quite inadequate. In most of the settings you will not find any organized system for
health education of elderly; however you will be guided b y the counsellor of programme
study centre as to how to plan, organize and conduct health education activities on selected
problems encountered in a situation. These needs are to b e developed through trials and
errors. Since the national policy on elderly has been adopted, the educational activities for
the elderly people have to become the integral part of the primary, secondary and tertiary
health care system. It will take some time to have actual idan of implementation on the
ground, till such time we have to try our own model or whatever you can innovate with
the help and support of your counsellor.
In this chapter, you will learn how to organize and conduct t~ealtheducation activities for
the elderly.