the fifteen minute hour practical therapeutic interventions in family practice marian r. stuart,...
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The Fifteen Minute HourPractical Therapeutic Interventions in
Family Practice
The Fifteen Minute HourPractical Therapeutic Interventions in
Family Practice
Marian R. Stuart, Ph.D.
Joseph A. Lieberman, III, M.D., M.P.H..
The sorrow which has no vent in tears may make other organs weep.
Henry Maudsley, M.D..
PREVALENCE OF MENTAL ILLNESSIN GENERAL HEALTH CARE
Current Mental Disorder
24 %
Well 36%
Symptomatic31%
Sub-threshold9%
T.B. Üstün + N. Satorius, 1995
Health Status
10%
20%
20%
50%
Access to Care
Genetics
Health
Behaviors
Access to Care
Other
Heath Behaviors
88%
8%4%
InfluenceNational
Health Expenditures$1.2 Trillion
Sources: Centers for Disease Control and Prevention, University of California at San Francisco Institute for the Future.
Access to Care
Genetics
HealthBehaviors
Environment
Access to Care
OtherHealth Behaviors
Fibromyalgia
Irritable Bowel Syndrome
Coronary ArteryDisease
Som
a
Psyche
Circumstances
Stress
• A syndrome that results from having to
adapt to demands from the external and
internal environments.
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
Stress and Social Support
As Stress Levels
As Social Support
Sense of Control
Subjective Stress
Social Support Provides Positive Information
• About the person
• About the relationship
• About handling the problem
Two Basic Human Needs...
• To feel competent
• To feel connected
Andrus Angyal
Types of Social Power
• Reward Power• Coercive Power• Expert Power• Referent Power• Legitimate Power
French and Raven, 1966
Crisis Intervention
• Crisis: Time of greatest (potential)
change
• Overwhelming stress changes functioning
ability
• May trigger visit to physician
• Victim very open to suggestion
Goals of 15 Minute Therapy
• Preventing dire consequences• Re-establishing premorbid level of
functioning
• Expanding behavioral repertoire
• Enhancing patient’s self esteem
The BATHE Technique
Background
Affect/Feeling
Trouble
Handling
Empathy
How to B.A.T.H.E. your patients as you S.O.A.P. them:
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.”
The BATHE Technique
• Background: “What’s going on in your
life?”
The BATHE Technique
• Background: “What is going on in your
life?”
• Affect: “How do you feel about
that?”
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)?”
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?”
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.”
Therapeutic Skills Using a New Paradigm
• We constantly tell ourselves, as well as others, stories.
• These stories create our reality and affect our experience.
Understanding the Impact of Our Stories
• The stories reflect our view of who we are.
• These stories determine what we are capable of doing.
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.
Challenging Absolutes
• Always
• Never
• Everyone
• No-one
Challenging Imposed Limits
• Can’t
• Must
• Should
• It’s impossible
The Amazing Power of the Word “YET”
• YET implies it is possible.
• YET implies impending change.
• YET empowers people to contemplate changes.
Expected Outcome
• When the patient uses the word YET the story is being edited.
• Behavioral change will follow.
Strategies for Helping Patients
• Focusing on options.
• Looking at consequences.
• Applying tincture of time
• Choosing not to choose
Four Options in a Bad Situation
• Leave it
• Change it
• Accept it
• Reframe it
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?
Putting the Patient in Control
• Focusing on strengths
• Delineating responsibility for behavior
• Aiming for small wins
• Initiating the new scoring system
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.
Difficult Patients
• The hypochondriacal patient
• The chronic complainer
• The substance abuser
• The depressed patient
• The grieving patient
PLISSIT
• P Permission
• LI Limited Information
• SS Specific Suggestions
• IT Intensive Therapy
“The art of medicine is to keep the patient amused until nature
effects a cure”
Voltaire