Counselling in Health Care

I was recently at an international midwifery conference in Prague, where almost 4000 midwives from all over the world joined to discuss many issues related to women’s health worldwide. The issues that affect women across the world vary significantly, particularly when we look towards developing countries. Regardless of the issue at hand, however, two common threads weaved through all of the issues: education and counselling. The role of counselling in health care was something that I continued to think about after the conference, because it occurred to me that like it or not, and whether I’m wearing my midwife hat, or my ND hat, my words have power and influence over my patients. What I say matters. And beyond that, my ability to listen matters.

Of course, like any other area of medicine, there are experts who specialize in providing counselling and therapy to people who seek it out, but some aspect of counselling is inherent in our care, so it’s important for us to try and hone those skills.

Whether we’re sharing test results, discussing treatment options, or simply obtaining a history, it is possible for us to do so in a manner that makes our patient trust us, feel safe in our care, and thus be more open to being honest with us, to listen to our recommendations, and to receive good or bad news in a safe place. Creating this type of trusting relationship between patient and provider will improve our ability to provide competent care, and will improve our outcomes.

One example of the impact of utilizing basic counselling skills came to me in the form of a study from England on strategies for eliciting information on physical and sexual abuse in pregnant women. These are clearly issues that impact safety for not only our primary patient, the woman, but also her unborn baby. They are also issues that carry a lot of stigma with them, and can be really difficult to talk about. This study explored the most impactful time and method of asking about a history of abuse, as well as the frequency of it. It makes sense that women are less likely to answer honestly in your first appointment with them, or if their husband or another support person is present, but it was surprising to me that in some cases they found that the questions needed to be asked 6-7 times before eliciting an honest response.

Another issue that this study discussed, was the impact of asking these questions honestly, and directly without being dismissive. It’s not going to be effective to say, “well, we have to ask everyone this…do you have a history of abuse?”, anymore than it will be effective to ask, “I’m sure you’re fine in your monogamous relationship, but we have to ask everyone about sexually transmitted infections” because guess what? You cannot tell just by looking at someone, or even by knowing someone, what their history is or what their risk is, and they won’t share information that could at the very least impact their health, and at the very most save their life, unless they feel safe.

These are, of course, dramatic issues but they illustrate the importance of our role as counsellor in providing care. Even when discussing something as simple as dietary changes, or the recommendation of a new supplement or medication, utilizing active, open listening skills, and participating in the discussion at whatever level your patient is at, will increase their responsiveness to what you’re bringing to the table, and also will help to establish the type of relationship that will enable honest discussions in the future.

Counselling is a challenge for many of us. Most health care providers don’t get a lot of training in counselling, and even when they do, the training doesn’t really prepare you for practice. My naturopathic program included several courses in psychological assessment, counselling, addiction disorders, etc., but 90% of what I now know about counselling has come from practice. And I’m not done. I think all of us health care providers have a responsibility to learn, practice, and utilize these skills, even though we have such constraints on our time. Even starting with something as basic as making eye contact, being present, and having a few minutes of active discussion with our patients will improve their experience, but most importantly, will improve our care.

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