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Counseling patients

Last updated: January 6, 2021


  • Patient counseling: Process of providing information, advice, and assistance to patients to improve their health, treatment adherence, and quality of life
  • Patient-centered approach
    • Focuses on open communication between the patient and the provider, shared decision-making, and a shared goal of alleviating discomfort for the patient.
    • Takes into account patients’ individual preferences, concerns, and emotions
  • Transtheoretical model of behavioral change: a biopsychosocial model that focuses on intentional behavior change of the individual
    • Assesses an individual's readiness to modify a certain behavior
    • Provides strategies to guide the individual, e.g. in overcoming substance addiction, managing weight, adhering to medication
    • Stages of behavioral change in a patient:
      1. Precontemplation: denial or no awareness of the problem
        • At this stage, physicians should ask open, probing, and nonjudgmental questions that explore the patient's perception of the situation.
      2. Contemplation: awareness of the problem but no willingness to change it
      3. Preparation: preparing to make a change
      4. Action: change in behavior
      5. Maintenance: behavioral changes are maintained
      6. Relapse (not obligatory): behavioral changes are reversed

Counseling on substance abuse

  • Counseling on smoking cessation
    • Five major steps to intervention: "5 As" approach ("Ask, Advise, Assess, Assist, Arrange")
      • The clinician should:
        • Inquire about and document use of tobacco ("Ask")
        • Urge quitting with clear and personalized language ("Advise")
        • Assess patient willingness to quit ("Assess")
        • Provide resources to aid quitting ("Assist")
        • Schedule regular follow-ups ("Arrange")

Smoking is the single greatest preventable cause of death worldwide, regardless of age at quitting or the number of previous pack years.

  • Counseling on alcohol abuse
    • A set of strategies to encourage patients to reduce alcohol consumption:
    • Assess the patient's readiness to change (transtheoretical model) and schedule regular follow-ups.
  • Counseling on illicit drugs
    • A set of strategies to encourage patients to stop using illicit/recreational drugs:
      • Assess the patient's readiness to change (transtheoretical model) and schedule regular follow-ups.
      • Engage the patient in a conversation using reflective or motivational listening (a technique in which the topic is broached by repeating or rephrasing the patient's own words, and using open-ended questions).
      • Provide feedback regarding the patient's drug consumption.
  • Counseling on the use of prescription opioids
    • A set of strategies to counsel patients on the risks of opioid therapy:
      • Inform about the possibility of overdose, addiction, and adverse effects.
      • Stress that patients should not use someone else's opioids.
      • Establish specific "SMART" goals (Specific, Measurable, Attainable, Relevant, Time-limited) for opioid therapy.

Counseling on sexual health and contraception

  • Counseling on safe sex practices
  • Counseling on contraception options

Counseling on lifestyle modifications

  • Counseling on support options for weight and diet changes
    • A set of strategies for supporting patients interested in losing weight, which includes:
      • Enhancing social support by including family members or friends
      • Encouraging patients to increase physical activity
      • Encouraging regular weighing
      • Encouraging patients to monitor what they eat
      • Engaging in stimulus control (e.g., buying fewer calorie-rich foods)
      • Providing nutritional education
      • Setting realistic goals
  • Counseling on support options for regular exercise
    • A set of strategies to counsel patients on physical activity:
      • Patients should have 150 minutes of moderate aerobic activity or 75 minutes of vigorous aerobic activity/week.
      • The specific activity or sport should be tailored to patient preferences to increase the likelihood of adherence.
  • Counseling on sleep hygiene
    • A set of strategies to encourage healthier sleeping habits, which includes:
      • Getting 7–8 hours of sleep per night
      • Maintaining a regular sleep schedule
      • Avoiding stimulants (e.g., caffeine, nicotine) in the evening
      • Limiting exposure to electronic screens before bedtime
      • Avoiding naps
      • Exercising regularly
  • Counseling on lifestyle modifications to improve mood
    • A set of strategies for supporting patients undergoing treatment for mood disorders, which includes:
      • Relaxation techniques
      • Exercise
      • Mindfulness
      • Meditation

Counseling on support options for domestic violence

  • A set of strategies to support patients that may be victims of intimate partner violence (IPV):
    • Express empathy, validation, acknowledgment, and nonjudgmental support after a disclosure of IPV.
    • Assess the patient's willingness to take action and evaluate whether the patient is presently safe.
    • The patient should be referred to a social worker or domestic violence advocate/hotline to receive advice about preparing a safety plan.

Clinicians should not encourage the patient to leave their relationship but should support them if they come to that decision on their own.

Counseling for patients with memory loss and/or cognitive impairment

  • Evaluate emotional stability (e.g., suicidality), safety risks, adequacy of supervision, and whether there is evidence of neglect.
  • Clinicians should have contact information for the patient's caretaker or next of kin, who should be advised to determine whether the patient is adequately handling finances, medications, and other responsibilities.

Counseling for patients with chronic diseases

  • A set of strategies for reducing feelings of isolation, frustration, and hopelessness that can be present in patients with chronic diseases:
    • Emphasize that the patient is not alone and offer referral to support groups.
    • Listen to the patient's frustrations and challenges and empathize with them. Do not dismiss their concerns.
    • Avoid platitudes such as “everything will be OK” or “I'm sure you'll feel better soon.”
    • Discuss why treatment adherence is important for slowing/reversing disease progression.
    • Counsel on lifestyle modifications that may improve mood.

Counseling for patients following disfiguring injuries or surgeries

  • Following disfiguring injuries or surgeries (e.g., amputations, facial injuries), patients frequently experience psychiatric distress and are at an increased risk for psychiatric disorders (e.g., major depressive disorder, posttraumatic stress disorder, social phobia).
  • If the patient feels “ugly”
    • Explore the patient's reaction to their condition with an open question.
    • Do not give false reassurance (e.g., telling the patient they are “still beautiful”).

Counseling on avoidance of contact sports in suspected mononucleosis

  • Counsel patients with mononucleosis to avoid:
    • Strenuous physical activities for at least 21 days after initial symptoms develop
    • High-contact sports (e.g., football, wrestling) for at least 4 weeks because of the risk of splenic rupture.

Counseling on sudden infant death syndrome

  • A set of strategies for reducing the risk of sudden infant death syndrome while the baby is < 1 year of age:
    • Counsel patients to always place babies on their backs on a firm surface for sleep.
    • There should be no pillows, loose bedding, or blankets in the crib.
    • The baby should sleep in the same room as the parents but not in the same bed.
    • Encourage mothers to breastfeed as long as possible and to avoid exposing the baby to cigarette smoke.
    • Use of a pacifier can also reduce the risk of SIDS.

Communication with patients of nonbinary gender identity

Best practice according to National LGBT health education center:

  • Use gender-neutral language until a setting can be established to ask the patient what name and pronoun they prefer.
  • Routinely ask for name and pronoun preference, as they may change.
  • Provide all-gender restrooms if possible.
  • Share the patient's gender identity with other members of the team so that everyone can address the patient respectfully.
  • Be honest about mistakes made in gendered language, showing the willingness to learn and improve.
  • Offer open communication about gender identity, and do not assume gender binarity.
  • Ask the patient what language they prefer to use to talk about their body.
  • Provide information, resources, and contacts of specialists in transgender care if the patient expresses interest.