Behavioral Health Minute

February 2009 - Three steps in brief office counseling

The short summary

Counseling conversations can consider goals, approaches and next steps.

The modestly longer reflection

I often find myself thinking of three questions that organize my conversations with patients.

1. Where do you want to go?
2. How are you going to get there?
3. What is a next step?

These three questions presume that you have listened to people carefully enough that they feel respected and understood.

Where do you want to go?  It helps to define with people what their goal is in seeing us.  We need clear and controllable goals from patients in order to direct what we are doing and work collaboratively.  Goals that are not clear (“not be depressed”) or not controllable (“not have pain,” “not have COPD,” “not have these crazy thoughts in my head all the time”) are not cool.  Goals that are clear (“get out with other people more”) and controllable (“cope better with pain,” “cope better with COPD,” “put more time and energy into being a good dad”) are much better.  See the Behavioral Health minute from last October for more examples.

I find that when I am stuck with people or when I find myself pushing them to do something that they are not particularly interested in doing, the problem very often is that we are operating with different goals.

How are you going to get there?  This step involves a combination of wisdom from patients and wisdom from you.  You have some data-based evidence and some accumulated experience about how people in general cope with cancer and stop smoking and manage their diabetes.  We may say:

• ·         The data are that…
• ·         A lot of people I have seen who are dealing with this have told me…

Patients also have their own wisdom about how they can best be handling things.  We may ask:

• ·         How have you handled things like this before?
• ·         When are the times when you feel like you are handling things a little better?
• ·         What is your sense about what you can be focusing on as you go along that can help you handling this?

What is a next step?  Growing out of their conversations with you, how do patients think they could do that could do something concrete that would potentially move them forward?  See last month’s Behavioral Minute for more ideas about helping patients to Do something different.

Follow up

Try it out:  What’s the goal here… how do you think you’re going to be getting there… what specifically do you think you can be doing to follow up on what we have been talking about?

Fred Craigie, PhD