Patient counseling is the process of providing information, advice, and assistance to patients to improve their health, treatment adherence, and quality of life. A patient-centered approach facilitates and improves the patient-physician relationship and communication. This approach is based on open communication and shared decision-making. Health care decisions should be discussed using understandable terms and straightforward language. If there is a language barrier, medical interpretation services should be provided to the patient. For counseling and communication in specific circumstances, see the individual sections below.
General concepts of patient counseling
Key principles of communication and counseling 
- Patient counseling: the process of providing information, advice, and assistance to patients to improve their health, treatment adherence, and quality of life
Establishing the patient-physician relationship 
- Patients may feel vulnerable and have a fear of rejection/apathy from caregivers.
- A patient's first visit is critical to the patient-physician relationship (e.g., establishing trust).
- Empathy, interest, and continuity of care are valued by patients.
- Open communication between the patient and the provider, , and a shared goal of alleviating discomfort for the patient (see also “ ” in “Principles of medical law and ethics”)
- Takes into account the patient's individual preferences, concerns, and emotions
- Start with an introduction of all people present at the visit, address the patient by their preferred name, and sit at eye level.
- Identify the patient's concerns and set goals collaboratively.
- Listen actively: Use open-ended questions and allow the patient to speak freely.
- Express genuine interest, compassion, and empathy to legitimize the patient's point of view.
- Summarize information provided by the patient to ensure it has been understood correctly.
- Communicate that questions asked by the patient are valued, accepted, and valid at any time throughout the interview.
- Provide information on (working) diagnosis and treatment options.
- Provide reassurance to reduce and address fear or anxiety regarding a diagnosis or treatment.
- Ask for the patient's perspective on a proposed medication or procedure to ensure there have been no misunderstandings and to explore and support the patient's emotions.
- Definition: a psychosocial model that aims to help caregivers express empathy and support emotions in order to build a trusting relationship with patients
- Partnership: Reassure the patient of your commitment to the collaborative goals, offer resources.
- Empathy: Acknowledge and validate the patient's emotions.
- Apology: Take responsibility if appropriate (e.g., for a long waiting time).
- Respect: Commend constructive patient behavior (e.g., attending a doctor's appointment, remaining optimistic).
- Legitimization: Validate and acknowledge the patient's emotions (e.g., frustration, anger).
- Support: Offer and ensure support.
- Avoid judgmental or defensive language or behavior.
- Discuss health care decisions with patients in relatable terms (e.g., avoid medical jargon, tailor language to the patient).
- Ask the patient questions to assess language proficiency before starting an interview.
- If there is a language barrier between the patient and caregiver, establish the patient's preferred language and use a professionally trained medical interpreter.
- Spoken interpretation services are available in person, via video call, or telephone.
- Deaf patients or patients with hearing impairment should be offered a medical interpreter trained in American Sign Language. Other communication options include computer-assisted real-time transcription and assistive listening devices.
- Having a family member interpret should be avoided unless it is the patient's wish (in which case, this should be recorded in the patient's chart).
Interviewing techniques when an interpreter is present
- Introduce the interpreter to the patient.
Position of the interpreter
- Spoken language: slightly behind or next to the patient
- Sign language: behind the physician
- Address the patient, not the interpreter, and maintain eye contact.
- Avoid third-person statements; , keep phrases short, and ask one question at a time.
- Allow extra time for the interview.
- Definition: care related to the emotional and psychological well-being of the patient and their family members.
- Aims to reduce both psychological distress and physical symptoms by increasing quality of life and enhancing coping (e.g., identify and treat anxiety and depression)
- Based on good communication, assessment, and interactional skills (e.g., compassion, empathy) to build a rapport with the patient and their family.
- Encourages patients to express their feelings about the disease (e.g., consequences, relationships, self-esteem issues)
- Provides psychological and emotional well-being tools for patients and their caregivers
Enabling behavioral change
- Patients should be encouraged to participate in treatment and therapy decisions.
- enables patients to make informed choices.
can be a helpful tool to strengthen a patient's motivation to change behavior (e.g., substance use disorders, lifestyle changes).
- Aims to explore and resolve ambivalence about changing behaviors by eliciting the patient's reasons for change
- Helps to assess the barriers that make behavioral change difficult for the patient
Transtheoretical model of behavioral change
- Definition: a biopsychosocial model that focuses on an individual's intentional change of behavior
- To assess an individual's readiness to modify a certain behavior
- To provide strategies to guide the individual, e.g., in overcoming substance use disorder, managing weight, adhering to medication
|Stages of behavioral change|
|Patient behavior||Interviewing techniques|
|Precontemplation stage|| || |
|Contemplation stage|| || |
|Preparation stage|| || |
|Action stage|| || |
|Maintenance stage|| || |
|Relapse stage|| || |
5 As model of behavior change
- Definition: an evidence-based behavioral intervention strategy originally developed for smoking cessation that can be adapted for multiple behaviors and health conditions to help individuals with intentional behavior change 
- Assess the patient's behavior, beliefs, knowledge, and level of motivation.
- Advise the patient on personal health risks and the benefits of change.
- Agree on appropriate treatment goals and methods ( ).
- Assist the patient to identify personal barriers, create self-help strategies, access social or environmental support for behavioral change, and supplement with adjunctive medical treatments if appropriate.
- Arrange specific plans for follow-up support to provide ongoing support and adjust the treatment if necessary.
Screening for substance use disorder
- Should be routinely performed in a primary care setting
- Use initial screening questions.
- For alcohol use: “How many times in the past year have you had four or more drinks in a day?”
- For drug use: “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”
- If a patient screens positive in the initial screening question, assess the severity of misuse.
- SBIRT approach: screening, brief intervention, referral to treatment 
- Aims to enable early intervention for patients with, or at risk of developing, substance use disorders
- Used in primary care centers, emergency rooms, or trauma centers
- Brief intervention is used to increase insight and awareness regarding substance use and to motivate behavioral change.
- Referral to specialty care ensures more extensive treatment.
- Techniques for counseling on substance use disorder
- General principles of addiction counseling
Using the 5 As model of behavior change, the clinician should:
- Ask: Inquire about and document the use of tobacco.
- Advise: Urge quitting with clear and personalized language.
- Assess: Assess the patient's willingness to quit.
- Assist: Provide resources to help the patient quit.
- Arrange: Schedule regular follow-ups.
- Provide feedback to the patient regarding their level of alcohol consumption and 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).
- Inform the patient about psychosocial support groups (e.g., Alcoholics Anonymous).
- Inform the patient about pharmacological treatment options (e.g., naltrexone, disulfiram).
- Assess the patient's readiness to change by using the , and schedule regular follow-ups.
- Engage the patient in a conversation using reflective or .
- Provide feedback to the patient regarding their level of drug consumption.
- Assess the patient's readiness to change by using the and schedule regular follow-ups.
- Lifestyle modifications involve altering long-term habits, and adopting and maintaining healthier behaviors.
- Lifestyle modifications can be used to treat a wide range of conditions (e.g., cardiovascular diseases, obesity).
- Cardiovascular diseases are the leading cause of death in the US for both men and women.
- In one hour, approx. 83 people in the US die from heart disease and stroke.
- More than 25% of these deaths could have been prevented or delayed by lifestyle modifications that help control modifiable risk factors and promote healthier behaviors (e.g., smoking cessation, regular exercise).
- See “Etiology” and “Primary and secondary prevention of atherosclerosis” in “Atherosclerosis” for more information.
- Many people in the US are affected by sleep disorders (e.g., insomnia) or insufficient sleep. 
- The prevalence of obesity in the US is approx. 42% and has been increasing substantially in the past decades, and behavior modification is a cornerstone of therapy. 
Counseling on support options for regular exercise and diet changes
Counseling on regular exercise
- Patients should have 150 minutes of moderate aerobic activity or 75 minutes of vigorous aerobic activity per week. 
- The specific activity or sport should be tailored to patient preferences to increase the likelihood of adherence.
Counseling on weight and diet changes
- Suggest including family members or friends in diet and exercise plans to enhance social support.
- Encourage patients to increase physical activity.
- Encourage regular weighing.
- Encourage patients to monitor what they eat and develop stimulus control (e.g., buying fewer calorie-rich foods).
- Provide education on nutrition.
- Set realistic goals in collaboration with the patient.
Counseling on sleep hygiene and lifestyle modifications to improve mood
Counseling on sleep hygiene
- Recommended amount of sleep per night 
- Encourage patients to maintain a regular sleep schedule.
- Advise patients to avoid the following:
- Encourage regular exercise.
Counseling on lifestyle modifications to improve mood
- Educate patients on relaxation techniques.
- Encourage regular exercise.
- Educate patients on mindfulness and meditation.
- Inform patients about the possibility of Opioid intoxication and withdrawal”). , addiction, adverse effects, and (see “
- Educate patients on buying opioids only from licensed pharmacists and stores.
- Stress that patients should take opioids exactly as prescribed and that they should not use opioids prescribed for someone else.
- Patients should avoid mixing opioids with any other drugs, especially alcohol or sedatives (e.g., benzodiazepines).
- Establish specific opioid therapy. for
- Opioids should be stored in their original containers, out of sight/reach of children.
- Physicians should address suspected opioid misuse in a nonjudgmental, collaborative discussion with the patient that aims to understand the reasons for misuse.
Taking a sexual history
- Routinely incorporate sexual history into primary care.
- Adolescents > 12 years of age should be interviewed alone and confidentiality should be ensured.
- To take a baseline sexual history, the 5 Ps can be used to determine a patient’s sexual health needs. 
- Partners: Ask the patient about the number and gender(s) of sexual partners.
- Pregnancy: Ask the patient whether they want to avoid pregnancy or are planning a pregnancy.
- Practices: Ask which types of sex are practiced (e.g., oral, vaginal, anal).
- Protection against STIs: Ask about the protective measures against STIs currently used by the patient or their partner(s).
- Past history of STIs: Ask the patient if they have a previous history of STIs.
- See also “ ” below.
- Counseling on safe sex practices
Counseling on contraceptive options
- Discuss the patient's priorities regarding whether, when, and how to have children.
- If the patient wishes to know about contraceptive options, discuss their effectiveness and adverse effects.
- Hormonal contraceptive options (reversible)
- Nonhormonal contraceptive options
- For more information on contraceptive methods, see “ ” and “ .”
Screening for intimate partner violence (IPV)
- At initial visits or routinely
- If a patient mentions a new intimate relationship
- At prenatal and immediate postpartum visits
- If a patient presents with concerning trauma or symptoms consistent with IPV
- Screening should be conducted using standardized questioning tools (e.g., abuse assessment screen).
Counseling on IPV
- Encourage disclosure by asking direct questions and ensuring confidentiality.
- Express empathy, validation, acknowledgment, and nonjudgmental support following disclosure of IPV.
- Thoroughly document the details of abuse.
- Assess the patient's willingness to take action and evaluate whether the patient is currently safe.
- The patient should be referred to a social worker or domestic violence advocate/hotline for advice on preparing a safety plan.
- Do not encourage patients to leave the relationship.
- Counsel and evaluate for psychological comorbidities.
- For more information on IPV, see “ ” and “ ” in “ .”
Clinicians should not encourage patients to leave an abusive relationship but should support them if they come to that decision on their own.
- 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 caregiver or next of kin, who should be advised to determine whether the patient is adequately handling finances, medications, and other responsibilities.
- Use concrete, direct, and specific language.
- Provide a quiet, nondistracting space for the interview.
- Adjust questions to the patient's level of comprehension.
- Do not make assumptions about a patient's abilities (e.g., literacy).
- See “ ” below.
- Patients with chronic/terminal diseases can feel isolated, frustrated, and/or hopeless.
- These patients should be counseled on learning how to handle difficult emotions and develop an understanding of their disease.
Counseling for chronically/terminally ill patients
- 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 or reversing disease progression.
- Counsel the patient on lifestyle modifications to improve mood.
- Educate patients on mindfulness and meditation.
Spiritual counseling/care: Health care professionals should assess the spiritual needs of patients and provide support.
- Spirituality: an individual's experience, expression, or search for purpose, connection, meaning, and transcendence
- Can be expressed in various ways (e.g., as religious beliefs, art)
- Can be an important and effective coping mechanism, as it can reduce suffering and pain
- Spiritual care: interventions that facilitate the expression of spirituality
- An essential component of palliative care
- Has positive effects on the patient's quality of life
- The lack of spiritual support by health care providers is associated with dissatisfaction with care, less hospice utilization, more invasive treatments, increased costs, and poor quality of life.
- Benefits include positive mood changes, relaxation, perception of support, and facilitation of verbal and nonverbal communication./end/
- Spirituality: an individual's experience, expression, or search for purpose, connection, meaning, and transcendence
- See also “Psychosocial models” in “ ” and “Psychosocial counseling.”
End-of-life counseling for families
- Assess and support family caregivers during the prebereavement period and develop pathways for bereavement care.
- Ensure the family members are aware and informed of the changes in the condition of the dying relative.
- Assess preparedness for death.
- Ask what kind of support the family desires leading up to or after the death of the relative.
- Answer questions in detail and address the next steps (e.g., what to expect, deterioration, loss of abilities)
- Listen and offer support, while also remaining professional
- Encourage gathering information on the illness and offer resources about the illness, grief, and bereavement services.
- In some cases, follow up with caregivers to assess how they are coping and plan a follow-up appointment.
- See “ ”
- 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 a patient feels unattractive:
To prevent SIDS, physicians should educate parents on the following measures:
- Babies should be placed to sleep on their backs and on a firm surface.
- Encourage mothers to breastfeed for as long as possible.
- Avoid exposing the baby to cigarette smoke.
- There should be no pillows, loose bedding, or blankets in the crib where the baby sleeps.
- Avoid overheating the baby.
- The baby should sleep in the same room as the parents but not in the same bed.
- The use of a pacifier can also reduce the risk of SIDS.
The National LGBTQIA+ Health Education Center recommends the following when communicating with transgender and gender-diverse patients: 
- Use gender-neutral language until a setting can be established to ask the patient what name and pronoun they prefer.
- Try to ensure that registration systems allow for including information on preferred name and pronouns.
- Provide signage to indicate that restrooms are all gender.
- Be honest about mistakes made in gendered language and show a willingness to learn and improve.
- Offer open communication about gender identity and do not assume gender binarism.
- Provide information, resources, and contacts of specialists in transgender care if the patient expresses interest.
- Reassure patients of confidentiality.
- Only address gender identity if it is relevant to the patient's visit.
- Only discuss a patient's gender identity with team members or colleagues involved in the patient's care if it is relevant, i.e., the information is needed to address the patient respectfully.
Evaluation of grief
- Normal acute grief: various symptoms (e.g., depressed mood, somatic distress, simple hallucinations, thoughts of dying to join the lost one)
- Complicated grief
- Express sympathy and concern.
- Provide a space to discuss the patient's feelings.
- Discuss further treatment options if necessary.
- Use a normal tone of voice and talk directly to the patient.
- Caregivers accompanying the patient may provide additional information if necessary.
- Ask the patient if they need assistance, do not assume help is needed.
- When communicating with family members or caregivers, apply people-first language, e.g., “a person with a disability” instead of “the disabled (person).”
- Make eye contact.
- If a physical examination is necessary, do not miss out any relevant components.
- Only address the patient's disability if it is relevant to the visit.
- Communicating with patients who have hearing loss
Communicating with patients who have speech difficulties
- If you have difficulties understanding a patient, ask them to write down the information.
- Repeat information provided by the patient to ensure correct interpretation and/or understanding.
- Eliminate background noise and distractions.
Behavioral health screenings for patients with a history of trauma
- Substance use
- Social support
- Suicide risk
- Trauma-related symptoms interfering with social/occupational function
Interviewing techniques 
- Avoid asking the patient to repeat their trauma history. Review the patient's chart instead
- Emphasize confidentiality.
- Inform the patient about what to expect during the history taking and, if relevant, during a physical examination.
- If the patient requires a physical examination, inform them beforehand that they determine the pace and/or continuation of the examination and can signal at any time if there is emotional or physical discomfort.
- Ask the patient for permission before conducting each part of the physical examination.
- Let the patient know that they can have one or more friend or family member present in the room for support.
Culture as an aspect of health and medicine
- Culture is the set of ideas, social behaviors, and customs shared by a group of people as a defining factor of their social cohesion. Manifestations such as religion, ethnicity, language, and nationality can be regarded as elements of culture as well as cultures in their own right.
- Culture shapes people's perceptions of and views on health, disease, and medicine.
- Accordingly, culture also shapes the way people experience and manifest symptoms as well as how they express the experience of symptoms.
Cultural concepts of distress
- The interaction between health and medicine in a specific cultural context can give rise to , which refers to cultural idioms, explanations, or conditions that individuals from the corresponding culture use to describe and contextualize symptoms (see below for details).
- Such descriptions may have no correspondence to concepts of evidence-based medicine, making diagnosis and treatment difficult.
- To avoid misdiagnosis and provide the best possible care, physicians should be aware of the patient's cultural background. This is best done with the help of a .
Types of cultural concepts of distress
- Cultural explanations/perceived causes of distress: culture-specific etiological models for symptoms, illness, or distress. Such models may be founded on traditional medicine as well as cultural manifestations such as folklore, religion, and diet.
- Cultural idioms of distress: culture-specific expressions for symptoms or states of distress
- Cultural syndromes: clusters of psychiatric and/or somatic symptoms that occur exclusively in a specific culture or context and are generally recognized as medical conditions in the respective communities
Examples of cultural syndromes
Ataque de nervios (“attack of nerves”)
- An acute syndrome among individuals of Iberian origin or descended cultures (e.g., Hispanic, Caribbean) characterized by intense emotional distress (typically anxiety, anger, or grief) and a sense of losing control
- Symptoms include uncontrollable screaming and crying, trembling, verbally and/or physically aggressive behavior, palpitations, chest tightness, breathlessness, a sensation of heat rising up to the head, sweating, fainting, dissociative experiences (e.g., amnesia, depersonalization), and seizure-like episodes.
- Typically precipitated by stressful events in the family (e.g., death, divorce, accidents, conflict) or, less commonly, the accumulated experience of suffering
- Manifestations may resemble panic attacks, specific or unspecific dissociative disorders, and conversion disorder.
Khyal cap (“wind attack”)
- An acute syndrome among Cambodian individuals and those of Cambodian descent characterized by symptoms of panic attacks (e.g., palpitations, tachycardia, anxiety) and autonomic arousal (e.g., neck soreness, tinnitus)
- Attributed to disruptions of the flow of khyal (a form of inner “wind” comparable to air and pneuma in classical humoral theory) in the body.
- Often meets the criteria of panic attacks and may be associated with PTSD 
Taijin kyofusho (“disorder of fear of interpersonal relations”)
- A syndrome among Japanese individuals and those of Japanese descent characterized by social anxiety about and the avoidance of interpersonal relations due to a sense of inadequacy or feeling that one's actions or appearance may be offensive to others
- Social situations or their anticipation may trigger panic attacks.
- Manifestations may meet the criteria of social anxiety disorder, body dysmorphic disorder, and delusional disorder.
Dhat syndrome (“semen loss”)
- A broad range of symptoms seen in South Asian male individuals and those of South Asian descent characterized by fear attributed to the loss of “dhatu,” one of the seven essential bodily humors in Ayurvedic medicine (generally equated with semen).
- Common manifestations include fatigue, anxiety, erectile dysfunction, weight loss, and depressive mood in absence of any physiological dysfunction.
Cultural considerations in clinical care
- A patient's cultural background may influence their views on health and health care and affect their preferences and decisions regarding treatment.
- Such preferences and decisions may conflict with standard clinical practice and/or physician values. 
- Physicians should make an effort to understand and accommodate cultural differences with their patients' best health interests in mind.
- Physicians should not provide treatments that they believe are unethical or harmful, regardless of any cultural concerns.
A direct conversation with the patient about their cultural background can help to improve mutual understanding. 
- An interpreter should be involved if there is a language barrier; between a physician and a patient (see “General concepts of patient counseling” in “” for more information about the use of interpreters).
- If needed, social workers, chaplains, or team members with the same cultural background may be involved in the conversation.
- Physicians may not override a capable patient's wish to refuse treatment, even if the wish is motivated by cultural precepts that conflict with standard clinical practice. However, physicians may offer education to convince patients to reconsider refusing treatment, recommend against treatments they believe are ineffective, and refuse treatments that they believe are harmful or unethical.
Cultural formulation interview
- A set of questions asked during a mental health examination in order to assess a patient's perception and experience of psychiatric symptoms within their cultural context, including cultural factors that influence the way the patient perceives the manifestation and cause of the distress as well as the actions they take to resolve distress
- Promotes physician-patient communication, helps avoid linguistic and/or cultural misunderstandings, enhances the patient's cooperation during the mental health examination, increases the accuracy of diagnosis and therapeutic planning, and helps bridge any cultural differences between the physician and the patient that may hinder treatment