The 15-Minute Hour: Practical Psychotherapy for Primary Care Chapter 23 The 15-Minute Hour: Practical Psychotherapy for Primary Care

The 15-Minute Hour Accurately identifying the stressors Encouraging coping strategies Enhancing clinical outcome Increasing professional satisfaction Actualizing the Circle of Caring

The 15-Minute Hour (cont’d) Treatment approach needs to include the uniqueness of the individual and the psychosocial factors that may affect his or her disease Evidence ties emotional events to biochemical expression in the body Disease approach versus Engel’s 1980 model

Epidemiology Psychological expressed as physical symptoms Medical problems precipitated by psychological problems Goal is to accurately identify and treat

Epidemiology World Health Organization (WHO) 1,500 patients at 15 world sites One-third of patients presenting with medical complaints classifiable as having a psychiatric problem Present with a somatic complaint Treatable psychological problem not diagnosed

Ubiquity of Stress Stress Distress Physical and mental response Demands from external and internal Distress Resources overwhelmed Feel out of control

Ubiquity of Stress (cont’d) Valliant (1979) Overwhelmed regress functionally Poor adaptation associated with ill health; risk of disease increases in those with anxiety, depression, and inadequate stress management Offering support under stress may help the return to adaptive function and health

Ubiquity of Stress (cont’d) Health promotion and disease prevention Screen for stressors Teach constructive ways of coping with stress Provide support

Support An individual’s level of stress decreases as the level of social support increases Key element in stress management Provide positive information Suggest possible strategies

The Importance of Feeling Competent and Connected Basic human need Competent = autonomy Connected = valued by others Stressed Inadequate Isolated

The Importance of Feeling Competent and Connected (cont’d) Social support reestablishes sense of competence and connection See Table 23.1: Advanced Practice Nursing Intervention Can you think of any situations where you have assisted patients with social supports?

Commonalities Among Psychotherapeutic Techniques Talking with patients about their concerns often has a therapeutic effect Patient feels better after and often can figure out the problem This is a form of psychotherapy

Commonalities Among Psychotherapeutic Techniques (cont’d) Goldfried and Padawer (1982) Five common elements in all schools of psychotherapy Expectation of receiving help Participation in relationship Obtaining external perspective Encouraging corrective experience Opportunity for patient to test reality repeatedly

Commonalities Among Psychotherapeutic Techniques (cont’d) Role of APRN Expectation of help: The patient believes you will help him or her. Hope increases. Participation in therapeutic relationship: Expression of caring and concern is the therapeutic intervention. Obtaining external perspective: The patient feels overwhelmed; you listen and provide external perspective. Patient feels empowered.

Commonalities Among Psychotherapeutic Techniques (cont’d) Role of APRN (cont’d) Encouraging corrective experience: The patient feels overwhelmed; you listen respectfully and provide an external perspective. Encouraging corrective experience: Instigate effective patterns of behavior. Repeated reality testing: Notice small changes at follow-up appointments to change expectations.

The 15-Minute Hour: Goals Limited time Solve here-and-now problems Empower patient

The 15-Minute Hour: Goals (cont’d) Four specific therapeutic goals Reestablish premorbid level of functioning Prevent dire consequences Expand behavioral repertoire Enhance self-esteem

The 15-Minute Hour: Technique BATHEing the patient Technique used as quick screen test and intervention for psychological problems Questions focus on Background (What’s going on?), Affect, Trouble, Handling (How dealing with problem?) and Empathy (through reflective responses) Use after chief complaint and history of present illness Standard technique for primary care and complements medical documentation utilizing subjective and objective data, assessment, and planning (SOAP)

The 15-Minute Hour: Technique (cont’d) BATHEing Reestablish premorbid level of functioning Prevent dire consequences Expand behavioral repertoire Enhance patient’s self-esteem See Focus on History 23.1

The 15-Minute Hour: Technique (cont’d) Satisfies all five elements of psychotherapy Must have discipline not to explore issues in depth Screening tool Patient feels competent, connected, heard; also helps patient clarify the situation

The 15-Minute Hour: Technique (cont’d) Ownership BATHE helps practitioner assess patient Crucial that practitioner does not “own” patient’s problem; develop a better understanding of situation and effect on patient Patient “owns” problem Therapeutic relationship: patient is confident that you are supportive and able to help

The New “Positive BATHE” Emergence of positive psychology Focus on virtues, character strengths, and benefits of happiness and personal growth Literature links positive affect with health and longevity Bolsters immune system Research findings: gratitude letters and journals

The New “Positive BATHE” (cont’d) Focuses on Autonomy Personal accomplishment Thankfulness General positive affect

The New “Positive BATHE” (cont’d) Use Second form of intervention Chronically ill See Focus on History 23.2

The New “Positive BATHE” (cont’d) Best Account Thankfulness Happen Empowerment

Motivational Interviewing Developed by Robert Miller, PhD Supported by large volume of research Used to address substance abuse, weight loss, lifestyle change, health promotion, domestic violence, and many other clinical concerns

Motivational Interviewing (cont’d) Principles of MI Ambivalence is a normal part of any change process NPs address this ambivalence by exploring internal motivation, values, and goals

Motivational Interviewing (cont’d) Involves respect for patient autonomy and a belief that the patient is the expert on his or her own behavior Involves empathic listening and establishing a nonjudgmental, nonconfrontational approach

Motivational Interviewing (cont’d) RULE: Resist the righting reflex Understand your patient’s motivation Listen to your patient Empower your patient

Motivational Interviewing (cont’d) OARS: Open-ended responses Affirming patient Reflective listening Summarizing for patient

Case Vignette A 34-year-old woman presents for an appointment. Her weight has increased 6 pounds since her last visit and labs indicate an increase in fasting glucose. Your most recent progress note indicates that you spent clinical time stressing the importance of dietary management. Today the patient states, “I know I’m gaining. My pants are too tight. I try and eat healthy, you know, salads and fruit. But my family! You should see what my daughter brings home: boxes of doughnuts, chips, soda. I can’t say no to that stuff when it’s right in front of me!”

Motivational Interviewing (cont’d) Open-ended responses “Tell me about your experiences in trying to lose weight.” Affirming patient “You must have been frustrated trying to maintain a diet when your family continued to eat unhealthy foods.”

Motivational Interviewing (cont’d) Reflective listening “So you want to lose weight and are willing to make changes, but you feel that it is impossible to do when you are surrounded by junk food.” Summarizing for patient “You want a diet that is realistic for you given your family’s eating habits.”

Motivational Interviewing (cont’d) ASK permission “Would you like to brainstorm about ways to manage your diet given your family’s eating habits?”

Summary Psychological and physical health are related Intervention: BATHEing patients Intervention: Motivational Interviewing Primary-care visits are critical in addressing patients’ psychological well-being and assisting patients with desired lifestyle changes