The fifteen minute hour therapeutic talk in primary care PDF
Preview The fifteen minute hour therapeutic talk in primary care
The Fifteen Minute Hour: Therapeutic Talk in Primary Care The Fifteen Minute Hour: Therapeutic Talk in Primary Care MARIAN R. STUART PhD Professor Emeritus of Family Medicine University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School and JOSEPH A. LIEBERMAN III MD, MPH Professor of Family Medicine Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA Foreword by ROBERT E. RAKEL MD Professor, Department of Family and Community Medicine Baylor College of Medicine, Houston, TX Radcliffe Publishing Oxford (cid:129) New York Radcliffe Publishing Ltd 18 Marcham Road Abingdon Oxon OX14 1AA United Kingdom www.radcliffe-oxford.com Electronic catalogue and worldwide online ordering facility. © 2008 Marian R. Stuart and Joseph A. Lieberman III Marian R Stuart and Joseph A Lieberman III have asserted their right under the Copyright, Designs and Patents Act 1998 to be identifi ed as the authors of this work. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the copyright owner. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library. ISBN-13: 978 184619 288 3 Typeset by Pindar New Zealand, Auckland, New Zealand Printed and bound by TJI Digital, Padstow, Cornwall, UK Contents Foreword by Robert E. Rakel MD vi Preface viii About the Authors xiii Acknowledgments xv 1 The Body-Mind and the Role of the Primary Care Practitioner 1 2 Patients, Stress, and the Offi ce Visit 23 3 Cognitive Behavioral Therapy and Other Practical Therapeutic Interventions 41 4 Starting with the BATHE Technique 61 5 Rationale and Techniques for Fifteen-Minute Therapy 79 6 Agenda for the Fifteen-Minute Counseling Session 101 7 Therapeutic Interventions for Diffi cult Patient Situations 125 8 Accenting the Positive: Putting an Affi rmative Spin on the BATHE Technique 147 9 Handling Special Situations, Staff, and Assuring Self-Preservation 157 10 Wrapping Up – Integrating Treatments, Modifying Lifestyles, Getting Results 171 Appendix A: Twelve Good Questions and Three Good Answers for All Seasons 185 Appendix B: Recommended Books for Patients 186 Index 189 Foreword The fact that this book has progressed to a fourth edition confi rms the usefulness of these techniques to those of us in primary care. Although the basic concepts presented are similar to earlier editions, much new material has been added to make these principles and techniques more useful to the primary care health professional. Today, perhaps more than ever before, stress plays a role in everyone’s life. It affects daily activities, infl uences the way symptoms are perceived, and detracts from quality of life. It is a component of every illness and must be addressed no matter what the presenting symptoms or how “organic” the illness may be. In fact, the person with a specifi c organic illness may need more help addressing the emotions related to that illness than someone with a purely “functional” disease. Our responsibility as primary care professionals is to help our patients manage this stress and recognize when it calls for specifi c therapeutic measures. The reader will notice the frequent reference to caring and compassion, which are essential to providing good primary care. Caring implies empathy, which is the ability to participate in the feelings of another. Compassion is the wish for the other to be free of their suffering and is associated with a sense of commitment, responsibility, and respect. Of the three attributes of prevention, curing, and caring, caring is the most important. An insightful medical student said, “I hope that someday my words will be as healing as my technical knowledge.” Too often our caring is supplanted by managing, and the art of listening is taken over by technological procedures. Listening is essential to caring, but it is not passive. Bernard Lown, in The Lost Art of Healing 1 says that “One must be an active listener to hear an unspoken problem.” Effective communication depends much more on our ability to be a good listener than on what we say to the patient. Truly listening is a form of respect and is essential to developing trust. A primary care practitioner who is locked into the biologic model is much less effective than one who appropriately incorporates the psychological and social aspects of health care. The mind-body approach to medicine is not a dichotomy but a dualism that promotes improved patient care and views the vi FOREWORD relationship with the patient as a complex interaction involving emotional, relational, and belief systems. We can treat a malfunctioning organ system but true healing occurs when we give relief to a distressed human being. The biopsychosocial approach presented here, although an accurate term, may be a turn-off because of its complexity. However, it is the essence of looking at the whole patient and recognizing the myriad of factors that can affect one’s mental and physical well being. Our preoccupation with biomedical medicine has not only diminished the attention given to the biopsychosocial but, as some believe, it may have denigrated it as irrelevant. The BATHE technique described in Chapter 4 allows the professional to incorporate the principal features of psychosocial medicine into the patient interview and achieve a better outcome than those who are stuck in the disease- oriented mode. Patients seen in primary care often present with vague, undifferentiated symptoms. The identifi cation of potentially serious problems in their early, undifferentiated stage is one of the most diffi cult and challenging tasks in medicine. This book is a valuable resource for primary care physicians and all health professionals involved in providing primary care to patients. It contains many simple and practical techniques that are useful in practice. Robert E. Rakel MD Professor Department of Family and Community Medicine Baylor College of Medicine Houston, TX July 2008 Reference 1. Lown B. The Lost Art of Healing: practicing compassion in medicine. New York: Ballantine Books; 1999. vii Preface The publication of this fourth edition of The Fifteen Minute Hour by Radcliffe Publishing is a source of great satisfaction to us. Our purpose in writing this book, which has not changed since our fi rst edition in 1986, is to convince you that by routinely incorporating therapeutic talk into your practice, you can solve and often prevent many problems. During the years since publication of the fi rst edition, many things have changed. In earlier editions we speculated about a number of mind-body connections that have since been substantiated by re- search. The increase in terrorism around the world has compromised people’s basic sense of safety. Evidence-based medicine, electronic communications, the plethora of information on the internet, cost control, cultural diversity, and other societal trends have affected the delivery of medical care. In spite of all these changes, the importance of the practitioner-patient relationship remains a constant. The approaches described in this text are designed not only to enhance the therapeutic relationship, but also to make your practice more productive and pleasurable. The book has grown out of our combined 70+ years of clinical practice and experience in teaching doctors training in the specialty of Family Medicine, practicing physicians, nurse practitioners, and other primary care providers in the art of therapeutic talk. In the 22 years since the publication of the fi rst edition of The Fifteen Minute Hour, we have heard from many enthusiastic practitioners in the United States, Australia, Brazil, Canada, Denmark, Israel, Malta, the United Kingdom, and elsewhere who have assimilated our techniques into their practices. We were delighted when the second edition was translated into Japanese, and the third edition was translated into Korean, because this attested to the multicultural relevance of our techniques. The overwhelming consensus is that the strategies work: patients respond, practitioners save time, provider-patient relationships become richer, and everyone feels a little less stressed out. Although our techniques will certainly increase your ability to recognize and treat emotional problems, this is not a psychiatry text. It is also not a text on providing in-depth psychotherapy or long-term counseling although it will viii PREFACE enhance your ability to recognize and manage common emotional conditions resulting from the stress of living in the 21st century. You will be able to address patients’ concerns often at an early and manageable state. Incorporating useful knowledge from psychology and psychotherapy into your medical practice will help you become more effective in dealing with the emotional component of problems patients bring to the primary care practitioner and leave you feeling more satisfi ed. When The Fifteen Minute Hour was fi rst published, addressing psychological issues related to the patient’s health status was not seen as critical. Max Planck has been quoted as explaining that “a new scientifi c truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.” We have been preaching this “gospel” for over 22 years. You are our new generation. We hope that you will master our simple techniques to deal effectively with the psychological dimensions of patient care. If you already focus on patients’ psychosocial problems or would like to do so more effi ciently, this book will provide you with background material to help you apply universal principles. We will point out what actually works in practice to improve patients’ functioning. Furthermore, we will provide specifi c suggestions, approaches to therapeutic interventions, and particular phrases that we have developed, prac- ticed, taught, and tested for over 30 years. We now have evidence to document that our techniques increase patient satisfaction1,2 and improve practitioner- patient relationships3 without adding signifi cantly to the length of the visit.4 Our way is not necessarily the only true, good, or beautiful way to make therapeutic interventions, but it is a pragmatic and fl exible approach that is easily learned, and it works! Also, it is designed to fi t into a regular offi ce visit of 15 minutes or less without requiring lengthy therapy sessions. We strongly recommend that you read this book from beginning to end. Early chapters provide the theoretical background and rationale, and subsequent chapters focus on putting this knowledge into action. In essence, this is a how- to book. We aim to help you develop skills that will benefi t both you and your patient. We provide some effective tools for use in your practice, and we explain exactly how to use them. These tools require less investment of time and energy than you might imagine. There are many schools of therapy. We are not preaching a dogma, nor do we have the need to establish a true religion in this area. We are quite comfortable with practical eclecticism because it works, and primary care practitioners desperately need techniques that work. We invite you to apply our techniques and empirically confi rm their usefulness for yourself. In essence, we are saying, “Try it, you’ll like it.” John Godfrey Saxe, a Vermont lawyer and humorist, wrote “The Blind Men and the Elephant” 5 over 100 years ago. This poem was based on an Indian tale thought to date back thousands of years. It still seems most applicable. ix
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