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

HealthBehaviors

Access to Care

OtherHeath 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

BackgroundAffect/FeelingTroubleHandlingEmpathy

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