Konseling Pasien dalam Kedokteran Keluarga

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
What is counselling?
• 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?
• 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
Kenapa perlu memahami konseling?
• 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
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
2. Therapeutic goal setting and
impelemantation
• Doctor and patient : establish a therapeutic
contract
• Doctor involves the patient in exploring new
ways of thinking and behaving  to attain the
therapeutic goals
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
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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
Barriers to good listening
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•
•
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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
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
The BATHE technique in counselling
• 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”
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?”
SOAP
• 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”
Dealing with the difficult patient
The difficult patient
A difficult patient : one whom doctor has trouble
forming an effective working relationship
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Frequent attendance with trivial illness
Multiple symptomatology
Non-compliant
Hostile or angry
Attending multiple therapist
Manipulative
Taciturn and uncommunicative
All knowing
Dealing with the difficult patient
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•
•
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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
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
How to deal with the angry patient?
• 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