Counselling and communication skills for patients with genital herpes

While good communication and counselling skills play an important part in the management of all kinds of patient difficulties, for the patient with genital herpes, or any sexually transmissible infection, they are particularly important.

The need for good counselling and communications skills

While good communication and counselling skills play an important part in the management of all kinds of patient difficulties, for the patient with genital herpes, or any sexually transmissible infection, they are particularly important.

A number of studies have established the importance of the patient/doctor relationship when managing the psychological impact of genital herpes1.

“Management at first presentation is critical to the patient’s subsequent recovery and adjustment to the disease. Good management will help the patient to cope well with the diagnosis whereas poor management may lead to subsequent stigmatisation.2”

This guideline focuses on the role of counselling and good communication in optimal management of a patient with genital herpes. An AHMF guideline for the medical management of the patient is available separately. (See the More Information section below.)

The patient’s perspective

Not surprisingly, there is a very high level of psychological morbidity associated with genital herpes, which needs to be addressed equally when managing the medical aspects of the disease3.

For many people, a diagnosis of genital herpes is the worst news they have ever received. While responses vary, patients commonly experience shock, anger, embarrassment, guilt and fear.

Of paramount concern is the potential impact the disease will have on their lives — how they will tell their friends, family and sexual partners, how they will be viewed by them, whether they will be rejected, fear of infecting others, and fear of ever being able to live a “normal” life, form lasting relationships and have a family.

Many people even fear consulting with a doctor, concerned that they will be judged as dirty or promiscuous.

The goals of counselling

Counselling is an integral part of the successful management of patients with herpes and has a number of clear goals. The broad goal is to have the patient accept that herpes is not a “punishment” but a relatively common medical condition, which can be managed successfully to minimise its negative impact on their lives.

Aims of counselling

Specifically, the aims of counselling should be4:

• To establish rapport with the patient so that history taking, compliance with treatment, and day to day management can be enhanced;
• To provide information and education about herpes, e.g. prevalence, transmission, recurrences, preventing infection of others, treatment options and support networks;
• To minimise psychological sequela, which commonly results from this chronic condition, including diminished libido, loss of self esteem, fear and anxiety about transmission, possible relationship breakdown, depression and extreme guilt;
• To assist with the process of informing the patient’s partner(s).
• To know when to refer patients on for more intensive psychological therapy; and
• Clarify issues surrounding transmission that may be affecting current sexual relationships, e.g. asymptomatic shedding

The Golden Rules of counselling the genital herpes patient

Having the right environment

A number of environmental factors can contribute to successful counselling:

• Ensure it is a comfortable, non-confrontational setting (e.g. comfortable chairs at right angles or side by side at the desk, rather than across the desk);
• Rather than engaging in detailed discussion during the examination, it is preferable to defer it to when the patient is fully dressed;
• The likelihood of interruptions should be minimised;
• The clinician should avoid taking notes (wait until later); and
• Allow adequate time for the patient to communicate their reactions in an unrushed manner.

Having the right attitude

The clinician should show a caring attitude, ask the patient open, non-judgemental questions and aim to develop the patient’s trust. Trying to imagine yourself in the patient’s place can help to establish empathy. Consider the consultation as an opportunity to openly explore all the relevant issues—both medical and psychological—so that the patient has the best possible opportunity to be involved in the ultimate management decisions.

It is important to have a balance between the need to obtain facts and give advice and the need to develop an open and trusting relationship. Adequate time should be allowed to cover key relevant points at the initial consultation (e.g. dealing with the shock of receiving the diagnosis or managing physical symptoms) with other facts and issues being covered at subsequent consultations.

Providing the right information

A major aspect of counselling the genital herpes patient revolves around dispelling myths and providing clear and accurate information about the nature and management of the disease. This should be provided both verbally and, ideally, in a written form, which the patient can take away and refer to over time for reassurance. There are several resources currently available.

Information covered should include:

• Clinical nature and natural history of the disease (e.g. infection, establishment of latency, symptoms, diagnosis, frequency and severity of recurrences, prodromes, transmission, asymptomatic shedding, chronic nature of disease etc);
• Treatment options (including different approaches to antiviral therapy);
• Likely triggers and their avoidance;
• Lifestyle management advice (diet, exercise, stress management etc)
• Safe sex practices and avoidance of transmission;
• Prevalence of the disease (they are not alone);
• Herpes and pregnancy;
• Strategies for informing partners; and
• Options for specialist/ongoing counselling, herpes support groups, further information etc.

Saying and doing the right things

Following are some general guidelines and useful tips for counselling the patient with genital herpes:

• Reassure the patient of the absolute confidentiality of the consultation/relationship and how the consultation is structured (i.e. the way notes are handled);
• Always express care and concern (acknowledge the difficulty for the patient in even being there and receiving the diagnosis) and use open questions which will encourage the person to talk (e.g. “Do you want to start by telling me how you are feeling about this so we can plan how to manage things from here?”);
• Listen to what the patient says. Remember, it is highly likely that you will be the only person with whom the patient is able to discuss the infection;
• Use correct but simple names and terms and check with the patient that they understand their meaning;
• Avoid pejorative or judgemental terms, e.g. using the term “herpes outbreaks”, instead of “herpes attacks”;
• Be aware of your own body language and how it may be interpreted;
• Always seek the patient’s own understandings and perceptions about things;
• Nod, affirm, acknowledge their concerns and the psychological impact of diagnosis;
• Encourage the patient to ask questions—at the time or at subsequent visits;
• Proceed at the patient’s pace; don’t rush (allow sufficient time or schedule subsequent consultations);
• Provide the patient with as much information as they need about the disease and its management in order for them to make informed decisions;
• Summarise and check decisions with the patient; and
• Conclude on a positive note.

Watch out!

People sometimes fail to “take in” large amounts of information at the time of initial diagnosis due to their distress. Sometimes it is better to reschedule when the person has had some time to let the diagnosis sink in.

Your own views and possible prejudices might negatively impact on the optimal management of the patient. Even if you say the right thing your body language can contradict and undermine your message. If you do not have the time to counsel the patient consider referring the patient to another doctor or the nearest sexual health clinic.

When clarifying information or advice, try to avoid undermining positive statements with the use of “but”. “And” has much the same function but none of the negative impact.

1. 1. Green J and Kocsis A: Psychological factors in recurrent genital herpes; Genitourinary Medicine 1997; 73: 253 -258
2. 2. Kroon S, IHMF management strategies workshop: limiting the continued spread of genital herpes; PPS Europe Ltd. and the University of Alabama School of Medicine, University of Alabama, Birmingham, 1994
3. 3. Mindel A and Marks C: Psychological symptoms associated with genital herpes virus infections: epidemiology and approaches to management. CNS Drugs (in press).
4. 4. Ross M and Channon-Little l: Discussing Sexuality -A guide for health practitioners. 1991 Sydney. Maclennan and Petty Pty Ltd (adapted from p67-68).