The Fifteen Minute Hour Practical Therapeutic Interventions in Family Practice

1. The Fifteen Minute HourPractical Therapeutic Interventions in Family Practice Marian R. Stuart, Ph.D. Joseph A. Lieberman, III, M.D., M.P.H..

3. The sorrow which has no vent in tears may make other organs weep. Henry Maudsley, M.D..

4. PREVALENCE OF MENTAL ILLNESSIN GENERAL HEALTH CARE Current Mental Disorder 24 % Sub-threshold 9% Well 36% Symptomatic 31%

5. National Health Expenditures $1.2 Trillion Influence Health Status Access to Care Access to Care 10% Access to Care Environment Access to Care 20% 88% Genetics 20% Genetics Health Behaviors 50% Health Behaviors Other Heath Behaviors 8% Other 4% Health Behaviors Sources: Centers for Disease Control and Prevention, University of California at San Francisco Institute for the Future.

6. Soma Psyche Fibromyalgia Irritable Bowel Syndrome Coronary Artery Disease Circumstances

7. Stress • A syndrome that results from having to adapt to demands from the external and internal environments.

8. Stress • People have persistent behaviors. • Under stress people cope differently. • Overwhelmed people regress functionally. • Poor adaptation causes ill health. George Vaillant, Adaptation to Life, 1977

9. As Stress Levels As Social Support Sense of Control Subjective Stress Stress and Social Support

10. Social Support Provides Positive Information • About the person • About the relationship • About handling the problem

11. Two Basic Human Needs... • To feel competent • To feel connected Andrus Angyal

12. Types of Social Power • Reward Power • Coercive Power • Expert Power • Referent Power • Legitimate Power French and Raven, 1966

13. Crisis Intervention • Crisis: Time of greatest (potential) change • Overwhelming stress changes functioning ability • May trigger visit to physician • Victim very open to suggestion

14. Goals of 15 Minute Therapy • Preventing dire consequences • Re-establishing premorbid level of functioning • Expanding behavioral repertoire • Enhancing patient’s self esteem

15. The BATHE Technique Background Affect/Feeling Trouble Handling Empathy

16. Background Affect/Feeling Trouble Handling Empathy “What is going on in your life?” “How are you feeling about that?” “What troubles you the most?” “How are you handling that?” “That must be very difficult.” How to B.A.T.H.E. your patients as you S.O.A.P. them:

17. The BATHE Technique • Background: “What’s going on in your life?”

18. The BATHE Technique • Background: “What is going on in your life?” • Affect: “How do you feel about that?”

19. The BATHE TECHNIQUE • Background: “What is going on in your life? • Affect: “How do you feel about that?” • Trouble: “What about that troubles you ( most)?”

20. The BATHE TECHNIQUE • Background: “What is going in your life? • Affect: “How do you feel about that?” • Trouble: “What about that troubles you ( most)?” • Handling: “How are you handling that?”

21. The BATHE TECHNIQUE • Background: “What is going on in your life? • Affect: “How do you feel about that?” • Trouble: “What about that troubles • you (most)?” • Handling: “How are you handling that?” • Empathy: “That must be very difficult.”

22. Therapeutic Skills Using a New Paradigm • We constantly tell ourselves, as well as others, stories. • These stories create our reality and affect our experience.

23. Understanding the Impact of Our Stories • The stories reflect our view of who we are. • These stories determine what we are capable of doing.

24. Psychotherapy Means Editing the Story • First: The story must be heard. • Second: The story must be reflected back with empathy. • Third: Limits must be challenged.

25. Challenging Absolutes • Always • Never • Everyone • No-one

26. Challenging Imposed Limits • Can’t • Must • Should • It’s impossible

27. The Amazing Power of the Word “YET” • YET implies it is possible. • YET implies impending change. • YET empowers people to contemplate changes.

28. Expected Outcome • When the patient uses the word YET the story is being edited. • Behavioral change will follow.

29. Strategies for Helping Patients • Focusing on options. • Looking at consequences. • Applying tincture of time • Choosing not to choose

30. Four Options in a Bad Situation • Leave it • Change it • Accept it • Reframe it

31. Three-Step Problem Solving for Bad Situations 1.What is the patient feeling? 2. What does the patient want? 3. What can the patient do about it?

32. Putting the Patient in Control • Focusing on strengths • Delineating responsibility for behavior • Aiming for small wins • Initiating the new scoring system

33. Focusing the Patient in the Present • The past is gone • The future is not here yet. • We can only act/feel in the here and now.

34. Difficult Patients • The hypochondriacal patient • The chronic complainer • The substance abuser • The depressed patient • The grieving patient

35. PLISSIT • P Permission • LI Limited Information • SSSpecific Suggestions • IT Intensive Therapy

36. “The art of medicine is to keep the patient amused until nature effects a cure” Voltaire