SUPERVISORY SKILLS

DAY ONE
Inaugural
Roles that a clinician plays daily
Prioritizing the roles
Matching roles with skills
Counseling skills
Active Listening
Providing information care
Breaking bad news

Supervisory Skills

RATIONALE
The quality of any training program rests on a number of factors out
of which the quality of supervisors and that of assessment are essential
ingredients. In any discipline, especially in the health sciences, experts
are not trained during their medical school phase in a number of skills
that they will be called to rely upon during their post graduate days.
These skills are not directly related to the field of expertise of the
supervisor and hence may make him / her feel as if learning them is
superfluous. However, for successful supervision of training, a trainer
must be adept at the myriad of roles that need to be performed on a
daily basis.
This workshop is geared towards providing basic insight and practice
in the essentials of juggling the hats that have to be worn from one
moment to another.
The perceived skills that are required are:

Communicating effectively with patients (for the benefit of patients

and as a role model for learners)
Teaching effectively (delivering lectures, small group discussions,
conducting teaching in all clinical settings)
Providing feedback
Managing angry people
Conflict management
Stress management
Time management
Supervising research work
Dealing with legal and ethical issues
Delegating tasks

Supervisory Skills

ISSUES:

A workshop is a setting in which the learners get hands-on practice so

that they are able to transfer the skills in their own settings. Since all
the topics listed earlier can not be dealt with in detail in the limited
time frame available, therefore, issues need to be prioritized. If an
attempt is made to include all the issues, then the workshop would
turn to a series of mini lectures which is against the practice of DME
and counter to the principles of adult learning. Hence, only the main
issues are being discussed in this workshop.
OBJECTIVES:

By the end of the workshop, participants will:

Enlist the responsibilities of a supervisor for FCPS training

Provide effective feedback to learners
Demonstrate ability to teach critical thinking/ problem solving
Demonstrate ability to improve learning in various settings
Manage stress, conflict and time related issues
Negotiate issues in order to resolve problems
Delegate tasks more effectively
Enlist the steps for effective implementation of FCPS training
program

Supervisory Skills

CLINICAL SUPERVISION
Definitions of Clinical Supervision
There are a number of definitions of clinical supervision and some of
the most common ones are set out below:
Butterworth (1995)

Hawkins and Shohet

(1992)

Wright (1989)
Proctor (1993)
and
Vision for the future
(1993)

UKCC (1996)

Clinical supervision is an exchange

between practicing professionals to
enable the development of professional
skill.
Our experience is that supervision can be
an important part of taking oneself,
staying open to new learning and an
indispensable part of the helpers on-going
self- development, self-awareness and
commitment to learning
Supervision is a meeting between two or
more people who have declared
interest in examining a piece of work.
A working alliance between supervisor
worker in which the worker can reflect on
her/himself and receive feedback and
where appropriate guidance.
A term used to describe a formal process
of professional support and learning which
enables individual practitioners to develop
knowledge and competence, assume
responsibility for their own practice and
enhance consumer protection and safety of
care in complex clinical situations. It is
central to the learning process of learning
and to the expansion of the scope of
practice and should be seen as a means of
encouraging self assessment and analytical
and reflective skills.
Clinical supervision brings practitioners
and skilled supervisors together to reflect
on practice. Supervision aims to identify
solutions to problems, improve practice
and increase understanding of professional
issues.

Supervisory Skills

WHAT IS CLINICAL SUPERVISION?

PROBLEMS OF DEFINITION:

Literature on clinical supervision has grown rapidly over the past few
years. However, despite the increase it remains poorly defined.
MISCONCEPTIONS:

There exists considerable confusion within the profession about its

exact nature and many misconceptions present include:

Supervision is often associated with formal management

relationships
Supervisees tending to think of their supervisors as authoritarian
Clinical supervision is hierarchical in nature
Supervision is simply as a provision of support
For a medical workforce suffering from stress, supervision is an
adhoc, unstructured activity

The idea that clinical supervision can be equated to an informal peer

support group is a clear misunderstanding of what clinical supervision
is about.
ORIGINS:

The term clinical supervision stems from the areas of psychotherapy,

counseling and social work. In this context, it is important to
remember that there is a distinction between counseling and
supervision. Counseling would place emphasis on addressing personal
problems and difficulties which might emanate from any aspect of an
individuals life.

Clinical supervision, on the other hand, should be exclusively

work-centered.

It is however acknowledged that personal and private matters play a

significant part in a practitioners ability to deliver quality care to
patients, but these should be work-focused during supervision.

Supervisory Skills

SOURCE MATERIALS:

Several important documents have addressed clinical supervision in

nursing. These include:

UKCC Code of Conduct (1986)

UKCC Scope of Professional Practice (1992)
NHS/MEA Vision for the future (1993) Faugier and Butterworths
Position paper on Clinical Supervision (1994)
DOH Working in partnership (1994)
DOH Making a Difference (1999)

THE UKCC (1996)

SUPERVISION

POSITION

PAPER

ON

CLINICAL

Some of the misconceptions of clinical supervision emphasize that

clinical supervision is NOT:

a managerial control system

the exercise of overt managerial responsibility or managerial
supervision
a system of individual performance review
hierarchical in nature

It was recognised, however, that links between clinical

supervision and management are important. Development and
establishment of clinical supervision should, therefore, involve
managers and practitioners with the emphasis on light touch
management influence which may be agreed in local policy or ground
rules.
What has emerged is the need for individuals to work on a
version of clinical supervision which best suits them within
their own working environment.

Supervisory Skills

WHAT SKILLS DO I NEED TO ACT AS

CLINICAL SUPERVISOR?
Developing as a supervisor means being competent in a wide range of
qualities, skills and activities.
Some of these skills will be discussed in this section and will be divided into:
Organizational

Assertiveness and self confidence

Negotiation and arbitration

Information giving and sharing

Ability to appropriately self disclose

Task delegation

Resource Management

To find and create an environment that promotes, dignity and

personal space

To creatively use existing resources

Administration of resources

Administration

Written communication skills

Evaluation and reviewing

Time Keeping

Time management and diary keeping

Ability to begin and end sessions on time

Supervisors judicious use of time within sessions

Supervisory Skills

Boundary-Keeping

Awareness of personal and other boundaries

Ability to maintain limits appropriately
Communication of boundaries to supervisee
Administration of boundaries-e.g. record keeping

Action planning

Indentification of supervisory issues

Problem identification and solving
Analytic and synthetic

SELF AWARENESS SKILLS:

How we see ourselves, our own self-concept, develops as a result of our

life experiences and also by receiving feedback from other people. It
affects how individuals see themselves body image and the way
they feel about themselves self-esteem. Therefore we have the
concept of what constitutes self and this concept is usually referred to
as self awareness.
In clinical supervision, every supervisor and supervisee should be
given the opportunity to go through a self awareness process. They
ought to be aware of what their bodies are saying and be capable of
seeing themselves as having an impact on the lives of others.
Keegan et al (1985) related self awareness to the following:
Personal identity - Who am I?
Internal events

- Thoughts, feelings, attitude, behaviors

Self as agent

- Having control over things that happen to us

External events

- Behavior, speech

Being aware of yourself can give you a better understanding of where

you are coming from and what you hope to achieve in self .
It may help you understand your strengths and weaknesses and can
facilitate your own personal growth and development. There are many
exercises to help you become more self aware.

Supervisory Skills

INTERPERSONAL SKILLS:

In a supervisory relationship, the supervisor may need to:

create a context for curiosity for the supervisee

generate multiple perspectives on a situation
invite supervisee to arrive at their own solutions
give positive feedback
confirm persons ability
create new perspectives on doctor - patient relationships

The supervisors role might be described as being there to generate

ideas and possible solutions. The climate of a successful supervisory
relationship is characterized by the development of certain personal
qualities and use of effective interpersonal skills.
REFLECTIVE SKILLS:

Reflection has been defined by Boud, Keough and Walker (1985): Boud
D, Keogh R & Walter D (1985) Reflection: Turning experience into
learning, Kogan Page. London.
Reflection is an important human activity in which people recapture
their experience, think about it, mull it over and evaluate it. It is this
working with experience that is important in learning. The capacity to
reflect may characterise those who learn effectively from reflection.
Reflection is more than just carrying out our actions it is a process of:

seeking reasons on which to base our actions

becoming aware of our experiences and critiquing them
using a number of mental activities and turning them into learning.

In clinical supervision access to experience can be obtained through

what Schon (1983) described as:
Reflection-On-Action

Reflection-on-action can be described as reflecting on an incident after

the event. Supervisees may bring their reflections to the supervisory
session by using reflective diaries, note keeping or maybe critical
incident analysis.

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Supervisory Skills

Reflection-In-Action

Reflection-In-action, on the other hand, is reflecting on an incident as

it occurs. The supervisees thinking, shapes what they are doing whilst
they are doing it. As supervisees become more experienced they are
more likely to use reflection-in-action, perhaps bringing their reasons,
justifications or changes in practice to the supervision session.

Supervisory Skills

APPROACHES TO CLINICAL SUPERVISION

Approaches to clinical supervision are simply the way youre going to
organise the implementation.
APPROACHES:
Individual

meeting one to one with a more

experienced clinician acting as supervisor

Peer

meeting one to one with an equally

experienced clinician sharing supervision
tasks equally

Triad

meeting two to one, two peers sharing

supervisor

Group

meeting as a group with more experienced

clinician acting as supervisor

Peer Group

meeting as a group of similar level

experience with no designated supervisor
or group leader; aim is to share
supervisory tasks equally among group

Team

meeting as multi-disciplinary clinical team

to address clinical issues of team, either
with or without designated supervisor

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Supervisory Skills

COSTS/BENEFITS OF DIFFERENT APPROACHES:

Approach

Individual

Benefit
exclusive time
easier to build
trust
confidentiality /
privacy
no competition
with peers
able to negotiate
personal needs
can choose own
model
more accessible

Peer

Triad

could build on
existing good
relationship
stronger ownership
of supervision
cost effective
learning from peer
mutual support
peer may have
more clinical
credibility/
understanding
less intense and
intimate
as above plus
opportunity to
learn from group
process

Cost (limitations)
resource expensive
lack of suitably
qualified
supervisors
can intensify any
supervisory
relationship
problem

intimacy may be
too intense
may encourage
dependency
may be difficult to
organise
could deteriorate
into chat
could be more
collusive and
become stuck
boundaries more
difficult to keep
deficits in
knowledge
competition to get
needs met, blurred
supervisory,
management/tasks
sharing time
competition with
peer
reduced privacy
and confidentiality
peers may collude
against supervisor
as above plus
group dynamics
may interfere or
become destructive

Supervisory Skills

Approach
Group

Peer Group

Team

Benefit
increases range of
supervisory
techniques
available
all as above plus
may enhance peer
relations

as with group plus

may enhance team
relations

Cost (limitations)
supervisor needs
ability to manage
group and
understand
dynamics
all as above, but in
absence of named
supervisor, group
dynamics may
more easily become
unmanageable
with particular
rivalry for
leadership
as with group but
can only address
limited clinical
issues due to multiprofessional
backgrounds of
group

MOVING FORWARD:

Clinical supervision is not something that will stay the same, it should
evolve as your practice moves on. One of the ways you can ensure that
this happens is to review your activity on a regular basis with your
supervisee(s). There are three stages to this process:
A. Reflection

You should start by reflecting upon your own recent experience of

supervision. This will help you to make sense of, and learn from your
experience. You will need to think about your experiences of
supervision as both a supervisor and your superisee(s). You might like
to think about:

What involvement have you had in clinical supervision?

How have you felt about the supervision session?

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Supervisory Skills

What do you think you have achieved?

What aspects of the supervision do you feel are working well?
Is there anything you would like to change?

B. Review

If you are going to improve your clinical supervision, you will need to
share your reflections with your colleagues in supervision on a regular
basis. This is the process of review. You may want to think about the
following questions and use them as a basis to review your supervision
at the next supervision session:

Is there anything you want to change about the model(s) of clinical

supervision you have used?
What approaches to supervision have you used, i.e. one to one, group etc.?
What has worked well with this approach?
Is there anything you need to change?
Is there anything you want to alter in your supervision?
Are there any issues about the organisation of your clinical
supervision you need to discuss with your manager?

C. Evaluation

Many organisations have invested in supporting clinical supervision

and want to evaluate its effectiveness. Evaluation is an important part
of professional practice and you will already be familiar with various
types of audit. Your employer may have a mechanism for measuring
the success of clinical supervision.
There have been some attempts to evaluate the benefits of clinical
supervision. They have shown positive effects at a qualitative level, but
with little firm quantitative evidence so far. There is concern that if
clinical supervision cannot be seen to have demonstrable outcomes,
then it may not be supported. If however, clinical supervision is to be a
way of achieving some of the goals of clinical governance, then the
measurement of its benefits may be within the frameworks of clinical
governance.

Supervisory Skills

SUPERVISORY SKILLS WORKSHOP

ROLES OF A SUPERVISOR
Instructions: In the column titled How often, please write
approximate percentage of the time that you spend doing that activity
in a work week.
Please Tick () the appropriate box regarding each role you play
according to follwoing key:
1. Very Uncomfortable
2. Uncomfortable
3. Neutral

4. Comfortable

5. Very Comfortable
Section A:
Administration

Roles

Maintaining discipline
Roster making
Advisor

Coordinator arrange meetings

(organizer)

Planning for department

(future planning, annual development
plans for hospital/word)
Warden (parenting)
Budget making

Training people & (conducting exams)

Research

Accountability for funds

Developing a team spirit (as a leader)

Being a role model

How often

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Supervisory Skills

Roles

Counseling people

Conflict management

Dealing with angry relatives

Career guidance

Entertainer, stress reliever

Mobilize finances, (manager)

Coordinator, communicating effectively

Public relations
Section B:

Any other role(s):

Section C:

Prioritize five roles you play most

with the level of comfort:
1.
2.
3.
4.
5.

How often

Supervisory Skills

COUNSELING
AN OVERVIEW
Counseling is a technique designed to help people help
themselves by the development of a special relationship which
leads a client into a greater depth of self-understanding,
clarifies the identity of problems and conflicts and mobilizes
personal coping abilities.

The counseling conversation is not an ordinary, every day

conversation. It has special features of every day conversation and to
emphasize others which may normally be present. It is a limited,
supportive activity aimed at developing a persons understanding to
and placing him or her in a position where it is possible to decide upon
and initiate constructive change. The counselor is active in creating
the special relationship and atmosphere of the sessions, but his or her
input is subtle, drawing the client towards greater personal insight.

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Supervisory Skills

TARGETS IN COUNSELING

Researchers have summarized a number of important purposes of

facilitative conditions, including the following :a.
b.
c.

d.

1.
2.
3.
4.

The use of facilitative conditions establishes a relationship of

mutual trust and caring in which patients feel secure and able to
express themselves in any way or form necessary.

The facilitative conditions help to define the counselor or therapist

role; counselors utilize effective therapeutic behaviors and try to
avoid ineffective skills and behaviors.
The use of facilitative conditions helps patients to obtain a more
complete and concrete self-image, allowing them to see or
understand things that formerly may have been hidden or only
partly understood.
Facilitative responding is a concrete way to show patients they
have your full attention without personal or environmental
distractions.

COMMON MISCONCEPTIONS ABOUT

COUNSELING

Counseling is directly concerned with making people less

emotional or even stemming emotion.
Counseling involves giving direct advice to clients or attempting
to solve their problems for them.
Counseling involves challenging a client's feelings and
perceptions in order to impose one's own values and perceptions these having the feel of being more realistic or accurate.
Counseling is an activity which may be investigated in order to
satisfy our need to make people feel and function better (this a felt
misconception rather than one which is consciously thought).

Supervisory Skills

WHAT IS COUNSELING?

We are all counselors. Anyone who works with people who are
distressed in any way, whether psychologically, physically or
practically, offers counselling help. In this sense, counseling is
something that is familiar to everyone. There needs to be no mystique
about it. Nor should it be something that is reserved for particular
group of professional who call themselves counselors.

The process of counselling may be defined as the means by which one

person helps another to clarify their life situation and to decide upon
further lines of action. Lack of clarity often brings anxiety. Such fear
and lack of clarity often leads, in turn, to inaction. This is often true in
the healthcare setting.
Counseling, then involves empathic listening, helping and befriending.
In these respects, it is the central feature of the work of all health
professionals in whatever branch. Examples of the application of
counseling skills and principles are numerous and few examples of
such applications are identified below. The examples of health
professions and applications are not claimed to be exhaustive of either.
1.

Medicine:
a. Helping clients who experience emotional, social and
relationship problems.
b. Facing family crises and difficulties.

2.

c.

Clarifying diagnoses.

Nursing:
a. Coping with dying and bereaved people.
b. Assisting relatives and colleagues.
c.

3.

Handling other people's emotional release.

Occupational Therapy:
a. Talking through personal issues with clients individually and
in groups.
b. Discussing coping skills.
c.

Enabling clients to regain their ability to live independently.

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Supervisory Skills

4.

5.

Physiotherapy:
a. Helping clients to adapt to long-term disability.

b. Helping people to regain motivation in the rehabilitation

process.
Teaching:
a. Talking through academic problems.
b. Vocational guidance.
c.

6.

Interpersonal problems.

Voluntary Work:
a. Listening to clients, problems in living.
b. Supporting other health professionals.

7.

Social Work:
a. Enabling the client and family group to clarify problems and
identify goals.
b. Enabling client advocacy.

8.

Speech Therapy:
a. Discussing problems with clients.

b. Talking to parents and other relatives.

Clearly, many of these aspects of professionals roles overlap with each
other and interrelate between professional roles. It is, however, also
clear that counseling forms an integral part of the daily work of all
health professionals. The skills described and discussed in this guide
will enable all such professionals to enhance their daily practice,
whatever their particular focus.

Supervisory Skills

WHAT IS INVOLVED
1.

Support:
a. This acts as a sounding board for the client's ideas, plans or
suggestions.

b. The primary skills required are listening with concern and

empathic understanding i.e. how the world seems to be viewed
by the client. The counselor offers support on a professional
basis with sincere commitment to the process.
2.

Providing Information:
a. All professionals by nature of their training and education
acquire a body of specialized knoweldge.

b. The basic skills required include simplifying information

according to context of the client and arrange it in order of
priority.
3.

Providing Reassurance:
a. It involves helping the client face upto a situation, by
discouraging denial on one hand and enclosing proper
expression of emotions on the other.
b. The basic skill required is to control the often natural tendency
to move in too quickly with your own solutions.

4.

Helping Aquire Coping Skills:

a. It involves helping the person learn to break up the problem in
manageable 'doses' .
b. The basic skill required is teaching of problem solving approach and active use of social networks of family, friends
societies etc.

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Supervisory Skills

COUNSELING TECHNIQUES
These counseling techniques may be subdivided into directive (the first
three) and facilitative (the second three), interventions. The directive
counselor plays an authoritative role in the relationship. The
facilitative counselor plays a less directive role and enables the client
to take more control over the relationship. The skilled counselor is one
who can use a balance of two types of interventions appropriately and
skilfully in a wide range of counseling situations. Following are
examples of these types of therapeutic intervention.
1. Prescriptive Interventions
Prescriptive interventions are those in which the counselor's intention
is to suggest or recommend a particular line of action. Thus, if the
counselor says, I recommend you talk this over with your family; he
is making a prescriptive intervention.
2. Informative Interventions
Informative interventions are those in which the counselor informs or
instructs the client in some situation for example, the health
professional says, you will probably find that you will have some
discomfort in your leg for about three weeks or a nurse who instructs
a patient to complete a course of antibiotics is offering informative
counseling. It should be limited to concrete and practical issues.
Otherwise, it is easy to take over a patient's life and create dependence
through offering too much information.
3. Cathartic Intervention
These are interventions that enable the client to release tension
through the expression of pent-up emotion. The counselor may give the
client permission to cry by saying you seem to be near to tears it's
alright with me if you cry. There are many situations in health care
when effective use of cathartic skills is valuable. A short list would
include, at least, the following:
a. supporting the recently bereaved person.

b. helping the person who is adjusting to new, yet profound

disability.

c.

assisting people to cope with shock after trauma.

Supervisory Skills

d. helping the person to express their feelings after assault, rape

or accident.
e. enabling the depressed person to release pent-up feelings of
anger or self-doubt.

4. Catalytic Interventions
Catalytic interventions are those that draw the client out and
encourage him or her to discuss issues further. Thus, any sort of
questions are examples of catalytic interventions. If used
inappropriately, questions can appear interrogative and intrusive.
They need to be well timed and sensitively phrased. The person skilled
in catalytic counseling can discretely and tactfully help the person to
express his own wants and needs. Thus, catalytic counseling can
become an integral part of healthcare assessment.
5. Supportive Intervention
These are interventions that support, validate or encourage the client
in some way. Thus, when the counselor tells the client 'I appreciate
what you are doing', they are offering a supportive intervention. Used
badly, supportive interventions can degenerate into patronage, this
attitude should be avoided.
6. Confronting Interventions
Interventions of this sort are those that challenge the client in some
way or draw their attention to a particular type of repetitive behavior.
An example of a confronting intervention may be 'I notice that you
frequently complain about the way your wife talks to you'. If
confrontation is used too frequently in the counseling situation, it may
be perceived by the client as an aggressive approach. Clearly,
confrontation needs to be used appropriately and sensitively.

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Supervisory Skills

NECESSARY PERSONAL QUALITIES OF

THE EFFECTIVE COUNSELOR
There are certain personal qualities of an effective counselor, which
have to be identified for positive therapeutic change via the counseling
relationship.
1. Unconditional positive regard
Unconditional positive regard involves a deep and positive feeling for
the patient working with them, not judging them, trusting them, and
placing the expectation on them that they will do whatever is
necessary to handle their problems in living more effectively.
2. Empathic understanding
Empathy is the ability to perceive accurately the feelings of another
person and to communicate this understanding to him. Empathy is
clearly different to sympathy. Sympathy suggests feeling sorry for the
other person or identifying with how they feel. The process of
developing empathy involves a willingness to listen to both what is
said and what is implied in, what is being said. An interactive ability
is just as important in empathy as is technical skill.
3. Warmth and genuineness
Warmth and genuineness in the counseling relationship refers to an
attitude of a counselor towards the patient, which includes the
following aspects:

Do not overemphasize your professional role and avoid stereotyped

role behaviors.

Be spontaneous but not uncontrolled or haphazard in your

relationship.
Remain open and non-defensive even when you feel threatened.

Be consistent and avoid discrepancies between your values and

behavior, and between your thought and your words in interactions
with patients while remaining respectful and reasonably tactful.
Be willing to share yourself and your experiences with clients if it
seems helpful.

Supervisory Skills

4. Clarity
The counseling relationship should remain clear and unmysterious to
the patient. As a counselor, you are required to be clear and explicit in
your dealing with the patient and should help the client to express
himself clearly and to put into words those things or issues that are
only being
hinted. This is essential if communication between the
two parties is to be successful.
5. Here and Now
Generally the distressed patient tends to talk excessively about the
past. As a counselor, our task is to help to identify present thoughts
and feelings, to enhance problem-solving attitude to the present-day
issues. Because the patient who talks excessively about how things
were, avoids the reality of the present.

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DON'TS IN THE COUNSELING

RELATIONSHIP
Having identified some of the qualities and characteristics that make
an effective counseling relationship, it is time to turn to some issue
that do not enhance it. As a general rule, the following issues run
contrary to the qualities identified above and are best avoided.
1. Don't ask 'why' questions:
For example, when the counselor asks the patient why he is depressed,
he is inviting him to offer a theory about why he feels that way, which
is not going to help the patient to develop problem solving approach.
Further, the word why suggests interrogation, probing and a sense of
disapproval.
2. Dont use should and ought:
Moralizing rarely helps. Don't impose your own values and frame of
reference on the patient, because the issues under discussion are
usually the patient's problems in living. Possible exceptions to this rule
are those situations in which concrete facts are under discussion. For
example, a doctor may suggest that a patient should finish a course of
medicine.
3. Dont blame the patient:
Counselor's blaming attitude is not constructive. In a sense, it doesn't
matter who is to blame in any particular situation. The point is that a
situation has occurred and the client is trying to find ways of dealing
with it.
4.

Dont automatically compare the patient's experience with

your own experience:
The counseling relationship belongs to the client, it is his time to
explore his problems. It is likely that if the counselor expresses such
similarity of experience to the client, the latter will resent it, for how
can it be that both have similar problems and get one to sort out the
other to help solve those problems? Such a contradiction can confuse
and irritate the client and spoil the counseling relationship.

Supervisory Skills

5. Dont invalidate the patients feelings:

For example, saying you just think you are is sort of judgement that
suggests either the client is not telling truth or the counselor is better
able to judge the client's feelings than the client himself. Such
interventions are by no means rare. But, rarely are they therapeutic.
A more appropriate approach may be to explore the expressed feelings
in order to understand more fully the way in which the client is using
words to describe feelings.

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SUMMARY OF PRINCIPLES OF
COUNSELING
Basic principles of counseling may be summarized as follows:

1.
2.
3.
4.
5.
6.
7.

The client knows what is best for him - help him to decide upon his
own course of actions.
Interpretation by the counselor is likely to be inaccurate and best
avoided. Help him to clarify and offer a framework on which he
may make future decisions.
Advice is rarely helpful - help to enable the client to formulate his
own advice rather than you supplying it (except in case of concrete
medical advice).
The client occupies a different personal world from that of the
counselor and vice versa - counseling is a two way process. You can
also learn and grow through this relationship.
Listening is the basis of the counseling relationship - develop
listening attitude.
Techniques should not be overused - quality of relationship is more
important than techniques.
Counseling can be learned through experience, practice and
training.

Supervisory Skills

PROCESS OF COUNSELING

A three stage model of the counseling

STAGE ONE: Identifying and clarifying problem situations.

In stage one, the counselor helps the client to tell his story to explore
his present life situation as he sees it now. Out of that story emerges
the specific problems of living that could not have been identified. prior
to this exploratory process. This stage is also useful for exploring "blind
spots" -aspects of the-client's life that he had not considered. This stage
is also crucial for the 'establishment of "therapeutic relationship" and
"an empathic understanding".
STAGE TWO: Goal-setting --- development and choosing
preferred scenarios.

In stage two, the client is helped to imagine a possible future situation

that would be preferable to the present one. Initially, this often means
imagining a variety of: possible future scenarios, out of which the client
slowly homes in on / one. Once this realistic scenario has been
discussed, the client and counselor can identify goals that can help in
the achievement of the proposed future state.
STAGE THREE: Action --- moving towards the preferred
scenario.

In stage three, the client and counselor devise ways in which the
proposed future scenario is achieved. In the first instance, this can be
aided by the process of brainstorming. All possible methods of
achieving the desired outcome are identified and then, gradually, a
particular approach is chosen out of all the possibilities. Then, an
action plan is drawn up in order to aid the achievement of the desired
scenario further.
The final substage of stage three is action on the part of the client --the time when the client makes concrete decisions and puts the plan
into action, supported by the counselor. This three-stage model can
serve as a useful and practical map in counseling and a means of
bringing structure to the process of counseling. The three stages,
although interrelated, can be dealt with as separate aspects of
counseling. Keeping the three stages in mind can help counselor to
assess where the relationship is going and how it is developing.

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Obviously, no time limit can be put on how long each of the stages may
take to work through with any given person but using them can ensure
that the relationship remains dynamic and forward - moving.

Example of Three-Stage Model In Practice

Aslam is a counselor working with a group of young patients in a

hospital. He is approached by one patient, Nawaz, a young man of 22
years of age, recently discharged from hospital where he was treated
for depression. Nawaz says that he wants to talk but is unclear about
what his problems are.
Aslam uses three - stage model and allows Nawaz to describe
everything that is happening to him at present time. Thus, a picture of
Nawaz's life emerges. Out of this picture, Nawaz identified two
problem areas: his over dependent relationship with his father and his
lack of confidence. Aslam asks him to clarify how he would like the
future to be. Nawaz talks of greater independence from his father and
an enhanced ability to socialize and mix more easily.
Out of their discussion, Aslam and Nawaz draw up a list of practical,
manageable tasks for the immediate future, including:
1.
2.
3.
4.

Nawaz to set aside time to talk to his father

Nawaz to consider the practicality of finding an independent job
near his home.
Nawaz and Aslam to work out a social-skills-training program for
Nawaz to follow with a group of other clients.
Nawaz to attend social gatherings such as marriages etc., and to
start participating in team games in his locality.

Supervisory Skills

COUNSELING SKILLS TECHNIQUES

LISTENING AND ATTENDING

Listening and attending are by far the most important aspects of the
counseling process. Often the best counseling is that which involves
the counselor only listening to the other person. Unfortunately, most of
us feel that we are obliged to talk! It is over talking by the counselor
that is least productive. If we can train ourselves to give our full
attention to the other person and really listen, we can do much to help
them. First, we need to discriminate between the two processes attending and listening.

Attending:

Attending is the act of truly focusing on the other person. It involves

consciously making ourselves aware of what the other person is saying
and of what they are trying to communicate to us. The counselor
through practicing the process of focusing attention between visits and
by taking a few minutes in his office to disassociate from the client
he / she has just seen, he can develop the skill of giving full attention
to the next person he sees.

Listening:

Listening is the process of hearing the other person. This involves not
only noting what they say but also a whole range of other aspects of
communication. Three aspects of listening are given below:
Linguistic aspect: of speech refers to the actual words, phrases etc.
that the patient uses to convey how they are feeling.

Paralinguistic: refers to all those aspects of speech: that are not

words themselves such as timing, volume, pitch, accent, fluency and
'ums and errs' etc. They can offer us indicators and clues as to how the
person is feeling beyond the words that they use.

Nonverbal / body language: aspect of communication refers to the

way the client expresses himself through the use of his body such as
facial expression; proximity to the counselor, touch in relation to the
counselor, use of gestures body position and movements and eye contact etc. All these aspects indicate and give clues about the client's
internal status beyond words he uses and can be understood by the
attentive counselor.

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Body language interpretation is dependent to a large degree on a wide

number of variables --- the context in which it occurs, the nature of
relationship, the individual's personal style and preference, the
personality of the person using the body language and so on. So, it is
safer to treat it as a clue and clarify with the client what he means by
this use of it. For example, the counselor may note and say to the
client: "I notice that you have your arms folded and that you're
frowning. What are your feelings at the moment". It is preferable, to
merely bring to the client's attention the way he is sitting, or his facial
expression, rather than to offer an interpretation of it.

Do's For Better Listening:

1.

2.
3.
4.
5.
6.

Use of minimal prompts: Whilst the counselor is listening to the

client, it is important that he shows that he is listening. To convey
this, he uses 'minimal prompts' -the use of head nods, yess, mm's
and so on. All these indicate that 'I am with you'. On the other hand,
overuse of them can be irritating to the client. So, the counselor
should be consciously aware of his use of minimal prompts and try
to vary his repertoire according to the client's needs.
Sit squarely in relation to the client.
Open body position in relation to the client.
Lean slightly towards the client.
Eye contact with the client should be reasonably maintained.
Relax while listening.

Dont's For Better Listening:

1.
2.
3.
4.
5.

The counselor's own problems.

Counselor's stress and anxiety.
Awkward / uncomfortable seating.
Lack of attention to the behavioral aspects of listening.
Value judgments and interpretations on the part of the counselor.

Supervisory Skills

Example: Listening in practice

Dr. Waseem is a GP in a busy city-centre practice. He gets repeated

visits from a young woman, Sarah, whose husband has recently been
killed in a road accident. She often makes allusion to the problems of
adjusting to her bereavement but presents with fairly minor physical
ailments. Dr. Waseem gently suggests to her that it may be helpful, if
they talked about her loss in more detail and offers her an appointment
at more convenient time. At first she is reluctant to accept this but
later phones to make such an appointment. During the next few weeks,
Dr. Waseem meets Sarah on regular basis and listens to her. During
these appointments, he has had to make very few verbal interventions.
Sarah is able to describe and ventilate her feelings very easily once she
is offered the opportunity. She works through stages of anger, extreme
sorrow and meaninglessness and finally to some acceptance. During
these stages, Dr. Waseem has had to 'do' very little. His supportive
attention and ability to listen, without making too many suggestions or
offering too much advice has been therapeutic itself. He realizes,
however, that he has had to learn to listen. Previously in his career, he
tended to finish a sentence for other people and has slowly learnt to
focus attention upon the other person and really listen to him.

Summary

The attending and listening aspects of counseling are essential skills

that can be used in every professional's job. The skills are clearly not
limited only to use within the counseling relationship but can' be
applied in other interpersonal exchanges. An advantage of paying
attention to the development of these particular skills is that becoming
an effective listener not only makes for better counseling practice but
interpersonal effectiveness and self-awareness are also enhanced.

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VERBAL TECHNIQUES

In this section verbal interventions that compliment listening and

attending will be dealt with. Again, such interventions, the things that
the counselor says in the counseling relationship can be used both
inside and outside the counseling relationship and can do much to
improve every professional's performance.
Certain basic skills may be identified, although, it is the overall
relationship that is more important in the counseling relationship.
Skills exercised in isolation amount to little: the warmth, genuineness
and positive regard must also be present. On the other hand, if basic
skills are not considered, then the counseling process will be shapeless.
The skill of standing back and allowing the client to find his own way
is a difficult one to learn. The following skills may help in the process.
Each skill can be learned. In order for that to happen, each must be
tried and practiced.

1.

Questions

Two main sorts of questions may be identified in approach:

Closed questions:
A closed question is one that elicits a yes, a no or a similar response.
Too many closed questions can make the counseling relationship seem
like an interrogation. On the other hand, the closed question is useful
in clarifying certain specific issues. Examples of closed questions are as
follow: what is your name? How many children do you have?

Open questions:
Open questions are those that do not elicit a particular answer. Open
questions are the one that encourage the clients to say more, to expand
on their story or to go deeper. Open questions are generally preferable,
in counseling, to closed ones. They encourage longer, more expansive
answers and are rather more free of value judgments and
interpretations than are closed questions. As with all counseling
interventions, the timing of the use of questions is vital.

Supervisory Skills

When to use questions?

Questions can be used in counseling relationships for a variety of

purposes. The main ones include:
1.
2.
3.
4.

Exploration: What else happened? How did you feel then?

For further information: What sort of work were you doing before
you retired? How many children have you got?
To clarify: Im sorry, did you say you are going to move or did you
say you're not sure? What did you say then?
Encouraging client - talk: Can you say more about that? What are
your feelings about that?

Questions to be avoided

There are some questions to be, avoided! Examples of such questions

include:
1. Leading questions: These are questions that contain an
assumption that places the client in an untenable position.
Examples are as follow:
Have you stopped beating your wife? Are your family upset by your
behavior? Is your depression the thing that's making your work so
difficult?
2.

Value - laden questions: Does your homosexuality make you feel

guilty?

This kind of questions not only possess a moral question but

guarantees that the client feels difficulty answering it.
3.

'Why' questions: In the counseling relationship they should be

used very sparingly, if at all.

4.

Confronting questions: Confrontation in counseling is quite

appropriate once the relationship has fully developed but needs to
be used skillfully and appropriately. It is easy for apparent
confrontation to degenerate into moralizing.

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2.

Funneling

Funneling refers to the use of questions to guide the conversation from

broad, opening questions slowly to more specific questions to focus
the discussion. It could be done either by following or leading. In
following, the counselor takes the lead from the client and explore the
avenues that he wants to explore. The counselor may take a more
active role and pursuing certain issues that he feels are important
(Leading).

Example of Funneling in Practice:

Azam is a medical counselor at NIH. A young man of 18 comes in to ask
about the symptoms of AIDS and for general information about the
condition. Azam, in return, asks some open questions of the young.
man in order to establish a counseling relationship. As the
conversation progresses, Azam gradually asks more specific questions
and helps the young man to express more particular, personal
anxieties about his own sexuality and his fear that he may be
homosexual. Azam, through using the funneling approach of
questioning, is able to help the person through a difficult personal
crisis that continues to be worked through in subsequent counseling
sessions.

3.

Reflection:

Reflection is the process of reflecting back, or a paraphrasing of the

last few word, that the client has used in order to encourage him to say
more. It serves as a prompt, used skillfully and with good timing,
reflection can be an important method of helping the client On the
other hand, if it is overused or used clumsily, it can appear stilted and
is very noticeable. For example:
Client: We had lived in Lahore for number of years. Then we moved
and I suppose that when things started to go wrong.
Counselor: Things started to go wrong.

4.

Selective Reflection:

It refers to the method of repeating back to the client a past of

something they said that was emphasized in some way or which
seemed to be emotionally charged. Thus, selective reflection draws
from the middle of the client's utterance and not from the end. An
example of the use of selective reflection is as follows:

Supervisory Skills

Client: We had just got married. I was very young and I thought things
would work out. We started buying our own house. My wife hated the
place! It was important though we had to start somewhere.
Counselor: Your wife hated the house.

5.

Empathy- Building:

This refers to the counselor making statements to the client that

indicate that he has understood the feelings that the client is
experiencing. A certain intuitive ability is needed here, because the
empathy-building statements are ones that read between the lines. If
used skillfully, they help the client to disclose further and indicate to
the client that they are understood. An example of such statements is
as follows:
Client: People at work are the same. They're all tied up with their own
friends and families they don't have a time for me though they're
friendly enough.
Counselor: You sound angry with them.

6.

Checking For Understanding:

Checking for understanding involves either (a) Asking the client if you
have understood them correctly or (b) Occasionally summarizing the
conversation in order to clarify what has been said. The first type of
checking is useful when the client quickly covers a lot of topics and
seems to be thinking aloud. It can be used to focus the conversation
further or as a means of ensuring that the counselor really stays with
what the client is saying. The second type of checking should be used
sparingly or the counseling conversation can seem to get rather
mechanical and studied.

Example In Practice:

Dr. Imtiaz is asked by his client a young widow mother about her
young daughter's inability to sleep. Dr. Imtiaz draws out the details
surrounding the family situation. In allowing the young mother to talk
through her financial and emotional worries, he allows, some of the
pressure on the mother to be dispelled. He follows this up with some
practical suggestions about how to help the daughter to sleep,
including the suggestions of a regular bed time, a planned routine

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during the evening and a 'winding - down period before going to bed.
The combination of allowing the mother to talk out her own anxieties
and offering practical suggestions enable both mother and daughter to
live more comfortably.

Summary:

Whilst the discussion, in this chapter, has focused on the use of

client - centred intervention skills that encourage self - direction on the
part of client and can be learned and used by all the professionals
easily They form the basis of all good counseling and can be returned
to as a primary way of working with the client in counseling
relationship. The range of skills involved is clearly useful in a wide
range of health contexts. Workers in the primary health - care level
may use them as part of their assessment programme whilst
professionals in longer - term care can use them as supportive
measures and as a means of evaluating the effectiveness of care. In
nursing, they may be used to draw up care plans and to implement,
effectively, the use of models -particularly self - care models.

Supervisory Skills

HELPING WITH FEELINGS

In this section, we will consider the effects of suppression of feelings or
emotions and identify some practical ways of helping people to identify
and explore their feelings. The skills involved in managing feelings can
be seen to augment the skills discussed in the previous chapter.
A considerable part of the process of helping people in counseling is
concerned with the emotional or 'feeling' side of the persons. In our
culture, a great premium is placed on the emotional expressions as
embodied in our every day impressions.

Types of Emotions:

There are at least four types of emotions that are commonly

suppressed or bottled up anger, fear, grief and embarrassment. The
emotions that are suppressed are rarely of one sort only, very often,
bottled-up emotion is a mixture of anger, fear, embarrassment and
grief. Often, too, the causes of such blocked emotions are unclear and
lost in the history of the person. What is perhaps more important is
that the expression of pent-up emotion is often helpful in that it seems
to allow the person to be more clearer in his thinking. It is notable that
the suppression of feelings can lead to certain problems.

The Effects of Bottling up Emotion:

1.
2.
3.

4.
5.
6.

Physical discomfort and muscular pain.

Difficulty in decision - making.
Faulty self - image:- If we have hung onto unexpressed grief, we
turn that grief in ourselves and experience ourselves as less than
we are. When old resentments are! expressed, the person begins to
feel better about himself.
Setting unrealistic goals.
Faulty beliefs.
The 'Last straw' Syndrome:- Sometimes, in case of long term
bottled - up emotions, a valve blows and the person explodes out either literally or verbally e.g. displacement of anger on some
other object or someone else.

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Supervisory Skills

METHODS OF HELPING OTHERS TO EXPLORE

FEELINGS

These are practical methods that can be used in the counseling

relationship to help the patient in identifying, in examining and, if
required, releasing emotion. Most of them will be more effective if the
counselor has first tried them on himself or with a colleague or friend.
All of the following activities should be used gently and thoughtfully
and timed to fit in with the client's requirements. There should never
be any sense of pushing the client to explore feelings because of a
misplaced belief that 'a good cry will do him good!'
1. Giving permission:
The client may hang on to strong feelings and not express them due to
the cultural norm that suggests that holding in is often better than
letting go. Thus, a primary method for helping someone to explore his
emotions is for the counselor to 'give permission' for the expression of
feeling. This can be done simply through acknowledging and
reassuring the client that 'It's alright with me if you feel you are going
to cry'.
2. Literal description or Active Imagery:
The client is invited to go back in his mind and describe in literal terms
a place that was the scene of an emotional experience, it can often
bring
that emotion back. The client is asked to identify and
understand the new meanings of the feeling that emerges from that
description and imagination. It is important that the client should be
asked to describe the 'scene in present tense.
3. Locating and developing a feeling physically:
Often feelings are accompanied by a physical sensation .It is often
helpful to identify that physical experience and to invite the client to
exaggerate it, to allow the feeling to expand in order to explore it
further. In this regard such questions are quite helpful: How are you
feeling at the moment? Where, in terms of your body, do you feel the
tension? Can you increase that feeling in your stomach or (any other,
mentioned part)? What is happening now? Etc.

Supervisory Skills

4.

The Empty Chair:

In this method the client is invited to imagine the feeling that they are

experiencing as sitting in a chair next to and then to have them

address the feeling. The empty chair can be used in a variety of ways
to set up a dialogue between either the client and his feelings or

between the client and a person that the client talks about. It offers a
very direct way of exploring relationships and feelings and deals
directly with the issue of "projection"; the tendency we have to see

qualities in others that are, in fact, our own. It can bring to light those
projections and allow the client to see them for what they are.
Following example shows one of its applications:

Counselor: How are you feeling about the people you work with? You

said you found it quite difficult to get on with them.

Client: Yes, it's still difficult, especially my boss.

Counselor: Imagine your boss is sitting in that chair over there, How

does that feel?

Client: Uncomfortable! He's angry with me.

Counselor: What would you like to say to him?
Client: Why do I always feel scared of you? Why do you make me feel

uncomfortable.

Counselor: And what does he say?

Client: I don't! It's you that feels uncomfortable, not me. you make

yourself uncomfortable. (To the counselor) He's right! I do make myself

uncomfortable but use him as an excuse.

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5. Contradiction:
It is sometimes helpful if the client is asked to contradict a statement
that they make, especially when that statement contains some
ambiguity. An example of this approach is as follows:
Client: (looking at the floor) I have sorted everything now. Everything's
OK.
Counselor: Try contradicting what you've just said.
Client: Everything's not OK. Everything isn't sorted out (Laughs).
That's right, of course there's a lot more to sort out.
6. Mobilizing Body Energy:
Tension due to bottled-up emotions can be trapped within the body's
musculature, it is sometimes helpful for the counselor to suggest to the
client that he stretches different, body parts / muscles or takes some
very deep breaths. In the process, the client may become aware of
tensions that are trapped in his body and may begin to recognize and
identify those tensions. This, in turn, can lead to the client talking
about and expressing some of those tensions.
7. Exploring Fantasy:
We often set fairly arbitrary limits on what we think we can and
cannot do. When a client seems to be doing this, it is sometimes helpful
to explore what may happen if this limit was broken. The counselor
may facilitate the client to explore his fantasy world deliberately, after
this exploration, the client always reach towards new understanding
about his emotional world. In this way, the client may develop an
"emotional stability",
8. Rehearsal:
Sometimes the anticipation of a coming event or situation is anxiety
provoking such as interview, examination or encounter with boss etc.
The counselor can usefully help the client to explore a range of feelings
by rehearsing a future event with him both at behavioural level and in
imagination, through role-playing. Often, if the client can practice
effective behavior, then the appropriate thoughts and feelings can
accompany that behavior.

Supervisory Skills

Example of helping with feeling in Practice:

Seema is a student nurse on a busy medical ward. She develops a close

relationship with Ahmed Ali, an elderly man who has been treated for
heart failure. Suddenly and unexpectedly, Mr. Ahmed Ali dies, Seema
finds herself unable to come to terms with this and seeks the help of an
older tutor in the school of nursing. The tutor helps her to talk through
her feelings and she cries a great deal. Through the process of talking
and crying she comes to realize that Ahmed Ali reminded her of her
own father, who had also died suddenly and for whom she had been
unable to grieve. In grieving for Mr. Ahmed Ali, she was enabled to
work through some of her grief for her own father.

Summary

The methods of exploring feelings can be used alongside the

client-centred interventions described in the previous chapter. They
need to be practiced thoughtfully and confidently. Emotional counseling
can never be a mechanical process but is one that touches the lives of
both client and counselor.
The counseling interventions that deal with the expression of feelings
have a wider application than just the counseling relationship. There
are many occasions when the professional is called upon to help and
support the person who is in emotional distress. Sometimes, such
situations arise as something of an emergency or arise suddenly and
without warning. The professional who has considered the skills
involved in helping with the expression of emotions is likely to be
better equipped to deal with these emergencies when they arise.

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Supervisory Skills

ACTIVE LISTENING

Listen For Message Content

Listen For Feelings
Respond To Feelings
Note All Cues
Paraphrase, Reflect and Restate (Summarise)

Listen & Win Confidence of patients / significant others/

clients
Clear paraphrase / repeat message verify
Caring for feelings (Reflection)
Continuous exploring ask follow up questions. Focus-in questions
Probing.
Build rapport, ensure empathy, communicate positive regard
Respect: Clients / patients / students observe, note nonverbal and
verbal cues
Relate: Customize style to match clients / patients / students
Relax: Respect pauses and silences (Do , or always try to fill them up)
Practice art of questioning:

Symptoms of poor listening

Condemning the subject as uninteresting without a hearing.
Criticizing the speakers delivery or methods.
Selective listening.
Interruption.
Day dreaming.
Succumbing to external distractions.
Evading the difficult or technical.
Submitting to emotional words
Going to sleep.
Listening - the basics
Sabr
Self control, self mastery
Understanding self and others NLP

Supervisory Skills

Guidelines to effective listening

Listen for emotions.
Avoid jumping to conclusions.
Use door openers.
Remember the last three words.
Observe the congruence between the verbal and non verbal.
Practice listening.
Limit your own talking.
Be patient
Concentrate.
Show interest and use effective interjections.
Paraphrase.
Empathy
Empathy & Sympathy
Points of view
Putting yourself in the other persons place
Understanding where s/he is coming from
Why is the patients attendant angry
Guilt to anger displacement
Understanding to self control, self mastery

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INFORMATIONAL CARE (IC)

IC is providing information to the patients through the use of
principles of communications, regarding the 3Ds (Doctor/relevance of
specialty, disease, drugs/interventions) and filling the gap in their
knowledge in the patients language. It includes removal of myths and
misconception about the 3Ds. Done in an appropriate way IC
contributes positively to the process of
recovery.
The quantum of information provided, timing, language and setting in
a given informational care session however needs to be tailored to the
patients needs and stage of illness or recovery. Any premature
attempts at sounding conclusive and definitive when adequate data is
not evident may be counter therapeutic or even disastrous.
The essential questions (of the patient and the family) answered in an
IC session are:
What is wrong with me?
Is there a risk of the illness spreading to those around me or passing
it to my offsprings?
Is there an effective treatment for my problem?
Is the treatment safe / are there any serious side effects or dangerous
effects of the treatment (drugs, interventions, surgery etc) Khushki
(dryness), garm/sard hot/cold), effects on sex, appetite, sleep, weight
etc
How long will I take to recover?
Is there a Parhez(restriction)?

Supervisory Skills

BASIC STEPS IN INFORMATIONAL CARE

The physician must set aside a certain time within a consultation to

cater for an individuals informational needs. It is crucial to
maintain a reasonable level of information about the disease with
the patient and the family.
The patients knowledge and expectations must be assessed prior to
and after the communication of significant information to see what
and how much has been retained.
The task of giving information should be professionalised which
means giving data - based factual information without fear of
causing a negative reaction in the patient or the relatives. It must
however be done with passion, empathy and sensitivity. Vague
statements or building up false hopes must be avoided under all
circumstances e.g. it is important to refer to scientific studies on
survival rates when discussing prognosis of life threatening
situations in stead of saying dua karen, sab theek ho jai ga or
saying ab mareez ke bachne ka koi imkan nahin.
Factors which may weaken the process of an effective
informational care.

Inadequate comprehensibility:

The doctor undertakes the session without assessing the patients prior
knowledge of medical terminology, his level of intelligence and
language or vocabulary differences that may exist between the two.
The use of medical jargon is often made even in patients with no
medical background e.g. an ignorant doctor passing information on
the nature of the disease to a patient who is a farmer with no formal
education may say: You have consolidation of right pulmonary lobe
because of pneumococci Such a statement will obviously mean
nothing to the farmer, while the doctor believes that he has passed the
essential information.

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Unfavourable context:

At times the patients mental state and his social context are ignored
while providing data that could wait for another setting e.g. a patient
with an issueless marriage at the verge of a break-up who is anxiously
waiting for the report of his semen analysis may not entertain data on
the result of his routine stool examination that has shown ova of
ascaris lumbricoides.
Inappropriate form and quantity:

Too much information about the disease in a single session or

information overload, haphazard presentation of information and a
variable quality of information passed to the patient by various
members of the health team such as doctors, nurses, ward boys or the
receptionist of the laboratory can enhance confusion in the patients
mind and thus dilute the impact of the exercise.
Censored information:

Information is experienced as misleading if only positive aspects are

exchanged with the patient and his family. Such an exercise can shake
the confidence of the affected in the integrity and competence of the
physician for all times.

Supervisory Skills

DELIVERING BAD NEWS

What is considered bad news?

The vast majority of doctors will have to break bad news at some time
in their career. Breaking bad news involves imparting information to
patients that will have serious adverse consequences for them and
their families. Bad news can be defined in simple practical terms as
"any news that adversely and seriously affects an individual's view of
his or her future."
There are two important principles that can be derived from this
definition.

1. The gap between your patients' expectations and the reality of their
medical situations affects the "badness" of the bad news; in other
words, this gap determines the impact of the information on your
patient.
2. As the physician, you cannot know how your patients will react to
the news until you ascertain their perceptions of their clinical
situations; a useful rule is "before you tell, ask."
There are many clinical situations during which this news delivery
could occur:

Disclosing the diagnosis of cancer

Discussing cancer recurrence or failure of treatment to impact
disease progression
Disclosing meta-static disease
Discussing the presence of irreversible disease or serious treatment
toxicity
Disclosing positive results of genetic tests
Announcing the death to spouse

Why is breaking bad news so difficult?

Naturally, breaking bad news is unpleasant. None of us looks forward

to telling someone that his or her life is about to adversely change, nor
does anyone enjoy seeing another person cry or experience pain. It's
natural that we feel anxious about breaking bad news to our patients
and supporting them as they react and adjust to the news of the
medical situation. Breaking bad news is a difficult task.

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We may feel helpless breaking bad news, especially when there are no
active treatment options available to the patient. Perhaps we may feel
an unwanted need to confront your own feelings about death and the
dying process. A feeling of sadness for the patient, especially for those
with whom we have enjoyed a long - standing relationship, can also
add pressure to this difficult situation. It's not surprising that some
physicians may find themselves camouflaging the whole truth from the
patient in an effort to avoid either the patient's or their own emotional
reactions to the bad news.

Past and present truth telling

Fifty years ago, many physicians were able to avoid discomfort by

concealing the truth from patients, justifying this deceit with the claim
that it would be too distressing for the patient. But now, disclosing a
cancer diagnosis has become the norm, and we now have legal and
ethical obligations to tell our patients any detail about their illness, if
that is their wish.
While most of us will want full disclosure of their medical situation,
some would rather not hear it or couldn't cope with it. Therefore, it is
always worth asking the patient if he or she would prefer to be fully
informed, or if they would rather want that you talk with a family
member or friend about their medical situation. It is also important to
obtain the patient's permission to discuss his or her care with the
patient's family members or friends.
It has been said many times that the manner in which you tell the
truth may be even more important than the fine details of the
information. Insensitive truth telling may be just as harmful as
insensitive concealment. This is where having a strategy for breaking
bad news can help you.

The need for a strategy - the physicians'

perspective

1. Learning through senior physicians

2. Learning through professional experiences
3. Most patients expect full disclosure delivered with

Empathy

Kindness

Clarity

Supervisory Skills

Meeting patients' expectations

The manner in which bad news is imparted certainly impacts the

patients' lives, but it can also affect patient - physician relationships.
Most patients expect full disclosure delivered with empathy, kindness
and clarity. In fact, several studies show that how bad news is disclosed
can affect patient satisfaction with the care they receive and
subsequent psychological adjustment to bad news.

A strategy (How do we break bad news)

This strategy highlights the most important features of a bad news

interview, and suggests methods of assessing the situation as it evolves
and responding constructively to what happens.

Step 1 - Setting
A.

PRIVACY

B.

INVOLVE SIGNIFICANT OTHERS

Where the bad news is broken can have significant effects on the
outcome of the interview, especially if the setting is inappropriate for a
sensitive, private and potentially devastating discussion. Patients'
mistrust and antagonism may result simply from a poorly chosen
location. Hence, it is worth trying to find a private location, such as an
interview room, your office with the door closed, or curtains drawn
around a hospital bed. You and the patient must be able to focus on this
discussion for the interview to succeed. If you have just examined your
patient, allow him or her to dress before your discussion begins.

Some patients like to have family members or friends with them when
they receive bad news. If there are a number of people closely
supporting the patient, ask your patient who will act as the
spokesperson for the family during the discussion. This gives your
patient support while alleviating some of your stress of dealing with
multiple people during an emotionally charged interview.

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C.

SIT DOWN

D.

LOOK ATTENTIVE AND CALM

E.

LISTENING MODE

You must be seated during an interview involving bad news, but avoid
sitting behind physical barriers, such as a desk. If your patient is in a
hospital bed, pull up a chair, or if there isn't a chair, ask permission to
sit on the edge of the bed. As you sit, undo your jacket or lab coat and
put down any items that aren't critical to the discussion, so it gives the
impression that you have time to sit and talk with your patient. Being
seated lessens the intimidating visual impact of the doctor towering
over the patient, which can make the patient feel vulnerable; gives the
patient a feeling of some form of partnership in the discussion; and
also makes level eye contact easier to achieve.

Most of us feel anxious during a "bad news" interview, and it is worth

spending some effort to try to reduce or eliminate the body signals that
we tend to send when we are nervous. Maintaining eye contact will
also assure your patient of your attentiveness; although, if he or she
becomes tearful, it is a good idea to break eye contact momentarily. No
one likes to be seen crying because they feel particularly vulnerable. It
is very important to have a box of tissues available so you can
physically respond to the tears. You can also rest your hand on your
patient's shoulder, arm or hand if he or she is comfortable with this
gesture.

Silence and repetition are two communication skills that will send a
message to your patient that you are listening. Your silence, which
includes not interrupting or overlapping the patient when she or he is
talking, displays respect for what he or she is saying, and indicates
that you are in "listening mode." Repetition involves using the most
important word from the patient's last sentence in your first sentence.
For example, a patient might say, "I'm fed up with the treatment." You
might reply, "What aspect of it makes you most fed up?" Other basic
techniques that show you are listening include nodding, smiling, or
saying "Hmmm," as appropriate.

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F.

AVAILABILITY

If you have appointments to keep, give your patient a clear indication

of your time restraints. Make arrangements before your important
discussion so that phones are answered by other staff members or go
to voice mail, and staff does not physically interrupt the meeting.
If phone calls or other interruptions do occur, courteously address them
so that your patient doesn't feel less important than the interruption.
If your patient is hospitalized, it might be helpful to check with the
nurses working with your patient to ensure this is a good time for the
discussion. This courtesy also alerts the staff that bad news has been
or will be delivered. Once you leave, the staff can then offer support to
the patient, or give the patient time to deal with the news, as
appropriate.

Step 2 - Perception

This is a very important step; it's the center of the "before you tell, ask"
principle. Before you break bad news to your patient, you should glean
a pretty accurate picture of his of her perception of the medical
situation. You do this to find out if your patient has an idea of the
seriousness of his or her condition. How you find this out can vary with
your communication style, few of questions that can be used to
ascertain this information:

"What did you think was going on with you when you felt the lump?"
"What have you been told about all this so far?"
"Are you worried that this might be something serious?"

As your patient responds to your question, take note of the language

and vocabulary that he or she is using, and be sure you use the same
vocabulary in your responses. This alignment is so important because
it will help you assess the gap (often unexpectedly wide) between the
patient's expectations and the actual medical situation. It will also
help your patient understand what you are saying if you use the same
level of vocabulary, particularly in this possibly overwhelming time.

If a patient is in denial, it is often helpful not to confront the denial at

the first interview. Denial is an unconscious mechanism that may
facilitate coping, and should be treated gently over several interviews.
Confronting denial at this early time will most likely just raise the
patient's anxiety unnecessarily or, more likely, set up an adversarial
and antagonistic relationship.

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Step 3 - Invitation

Although most patients want to know all the details about their
medical situation, you can't assume that this is the case. Obtaining
overt permission respects the patient's right to know (or not to know).
Some examples of ways to address this are:

"Are you the kind of person who prefers to know all the details about
what is going on?"

"How much information would you like me to give you about your
diagnosis and treatment?"

Would you like me to give you details of what is going on or would

you prefer that I just tell you about treatments I am proposing?"

Offer to answer any immediate questions that your patient has, and
make sure he or she knows that additional questions can be answered
in subsequent interviews. If your patient prefers not to hear all the
details of the situation, ask if he or she wants you to talk to a family
member instead.

Step 4 - Knowledge

Before you break bad news, give your patient a warning that bad
news is coming. There's no need to drop a bombshell when you can ease
into a sensitive topic. This gives your patient a few seconds longer to
psychologically prepare for the bad news. Examples of warning
statements include: "Unfortunately I've got some bad news to tell you,
Mr. Khan," and "Mrs. Shams, I'm so sorry to have to tell you".
A.

B.

C.

When giving your patient bad news, use the same language your
patient uses. This technique of aligning is very important. For
example, if your patient uses the words "growth" and "spread,"
you should also try to use these words.

Avoid technical, scientific language. You want your patient to

clearly understand what you are saying and don't want the
information to be misconstrued. Even the most well - informed
patients find technical terms hard to comprehend and remember
during enormous emotional turmoil.
Give the information in small chunks and clarify that the
patient understands what you have said at the end of each
chunk, for example: "Do you see what I mean?," or "Is this
making sense so far?"

Supervisory Skills

D.

Tailor the rate at which you provide the information to your

patient. If the indication is that your patient understands
perfectly so far, move on to the next piece of information. If he or
she isn't clear, go over the information again.

E.

As emotions and reactions arise during this discussion,

acknowledge them and respond to them.

Step 5 - Empathy

For most physicians, responding to our patients' emotions is one of the

hardest parts of breaking bad news. In our effort to alleviate our own
discomfort and lighten some of our patients' burden, it is often
tempting to withhold some of the information, downplay the severity of
the situation or give a more hopeful prognosis than we should.
Although these "tactics" may reduce stress for you and your patients in
the short term, they are likely to result in long - term problems for the
both of you, and you may discredit yourself in the process.
It is much more useful - and more therapeutic - to acknowledge the
patient's emotions as they arise and to address them. The technique
that is most useful for this task is called the empathic response and it
comprises three relatively straightforward components:

listen for and identify the emotion (or mixture of emotions). If you
are not sure which emotion(s) the patient is experiencing, you can
use an exploratory response, such as "How does that make you
feel?," or "What do you make of what I've just told you?"

identify the cause or source of the emotion (most likely to be the bad
news that the patient has just heard)
show your patient that you have identified both the emotion and its
origin:

"Hearing the result of the bone scan is clearly a major shock to you."
"Obviously this piece of news is very upsetting."
"Clearly this is very distressing."
"That's not what you wanted to hear, I know."

Empathic responses help to validate your patient's feelings and relate

the response to you ("I wish the news were better"). You don't have to
experience the same feeling to provide an empathic response; it simply
displays your recognition of the patient's emotion. Let your patients
know that showing emotion is perfectly normal. This will minimize
their feelings of embarrassment and isolation.

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Combining empathic responses, exploratory responses (if needed),

then validating your patient's feelings (in that order), should show him
or her that you understand the human side of the medical issue and
you recognize that these feelings are normal. If you employ these kinds
of responses when delivering bad news, your patient will no doubt
consider you to be a sensitive news breaker. Your patient will
remember the words you say to him or her for a very long time, so it's
important to be as sensitive as possible to their feelings.

Step 6 -Summarize

One of the best ways to prepare a patient for participation in

treatment decisions is to ensure that he or she understands the
information you have provided. Check frequently to make sure you
and your patient are both on the same level.
Before the discussion ends, summarize the information in your
discussion, and give your patient an opportunity to voice any major
concerns or questions. If you don't have time to answer them right at
that moment, you can tell your patient that this issue can be discussed
in detail during your next interview.

Step 7 - Plan of action

You and your patient should go away from the interview with a clear
plan of the next steps that need to be taken, and the role you both play
in those steps.

Conclusion

Breaking bad news is quite frequently a tense and distressing

experience for both the patient and the physician. Messengers of bad
news often inadvertently identify themselves with the negative aspects
of the message. Your patients' emotional responses will be hard to
withstand unless you have a strategy with which to address them.
Without a plan for addressing emotional issues (including your own),
you may attempt to downplay the bad news by only revealing part of
the information to your patients. This could be disastrous. As a result,
patients may become reluctant to participate in decision-making, and
it could erode their trust in you as their physician.

Supervisory Skills

WHAT IS THE DOCTOR'S ROLE?

The principles to be followed are:

Plan in mind before starting.

The physician who has not thought through his management plan
before introducing the bad news begins to feel the pressure of having
to solve problems as well as attend to a distressed patient, as the
interview progress.
Be honest, acknowledge the limitations and uncertainties of your
knowledge.
Be warm and understanding.
Be aware of the religious and cultural values of the patient.
Use basic counseling skills such as sensitivity, active listening,
paraphrasing and summarizing.
Serve as a source of continuing support and encouragement as long
as is needed, letting it be known that grief, anger and despair are
normal and can he safely expressed in your presence.

As a person who will listen, encourage questions and encourage

legitimate hope that a full valuable life can still he lived.

Be prepared to spend time exploring alternatives with the patient,

even though the cure is not likely.

Be prepared to receive the patient's anger, pain and grief.

Be prepared to have his / her professional competence challenged
Be prepared not to have all the answers.

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PROVIDING FEEDBACK
SCENARIO

A candidate who has failed his term

examination has taken an appointment to see
you. You have 15 minutes.
How will you provide him feedback by using
principles of feedback and counseling?

Supervisory Skills

PROVIDING INFORMATION CARE

SCENARIO

You have diagnosed a 40 year old married

farmer from a village to be a case of Hepatitis
B. He has been receiving drips from a local
quack and goes to a community barber for his
shaves. You plan to offer him interferon
therapy.
How would you employ principles of couseling
in undertaking an information care session?

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BREAKING BAD NEWS

SCENARIO

A 42 year old lady has delivered a mongol child

after 17 years of issueless marriage. The child
is in the nursery and she does not know about
the disability of the child.
She is looking forward to receiving the baby
the next day..... on discharge.
Using principles of counseling, how will you
communicate the bad news?

Supervisory Skills

CHECKLIST FOR EVALUATING

A COUNSELING SESSION
INSTRUCTIONS: Please place a tick mark under the most
appropriate number.

KEY: 0 = not done; 1 = done, but not well; 2 = neutral / average,

3 = done well.
0
Exclusivity
Time setting
Effective communication:
a. Setting and seating
b. Active listening:
i. Clarification
ii. Paraphrasing
iii. Reflection
iv. Summarization
Ventilation
Empathy
Unconditional positive regard
Discussing pros & cons
Mobilizing personal coping capacity and
social support
Making informed decision

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