COACH FEEDBACK: It sounds like Judith is not high risk for suicide, as she does have some protective factors in her life. Still, she does have some suicidal thoughts and she definitely needs a referral to a therapist.
DR. RODGERS: It sounds like your pain is preventing you from doing much, which is making you feel down. Unfortunately, both can both make your physical pain feel even worse. So it can become kind of like a cycle. Does that make sense?
JUDITH: It makes sense, yes.
DR. RODGERS: How important is it to you to do something to break this cycle?
JUDITH: Well, I’d like to feel better and get out of the house more. Maybe get back to doing some of the things I was doing before the pain got worse.
COACH FEEDBACK: Good job. Connecting Judith’s pain with her mood—and asking about her motivations for change--moved the conversation toward successful referral.
DR. RODGERS: I have a colleague – a psychotherapist – who I think you should talk to about your mood.
JUDITH: Oh, I don’t think I want to talk to a therapist. I just want to get rid of this wrist pain and these headaches. Then I could get back on my feet. That’s all I need.
COACH FEEDBACK: First, address Judith’s primary complaint. Then she will be more receptive to discussing treatment options for her depression. Let’s go back and choose a different option.
DR. RODGERS: So for your headaches let’s try something called propranolol. And for your arthritis, I think physical therapy is worth another try. Physical therapy is hard work, especially because you have to go for awhile before you see the pay off. If you take the ibuprofen before you go and use ice and then heat when you get home, it would probably really help with the pain. How does that sound?
JUDITH: Okay. I’ll try again and see....
DR. RODGERS: And how would you feel about talking to a colleague of mine—a therapist—to discuss your mood and maybe come up with some ways to help you feel better?
JUDITH: A therapist? I don’t know… I’ve never done that before…
JUDITH THOUGHT: Maybe I shouldn’t have opened up so much…
DR. RODGERS: This is really important, Judith. If you want to feel better, talking to someone about how you’ve been feeling is going to help.
JUDITH: Ugh, just thinking about it makes me exhausted.
COACH FEEDBACK: By directly disagreeing with Judith, you made her more resistant to listening to you. Try a different approach.
DR. RODGERS: It sounds like you have some concerns about talking to a therapist. What concerns do you have?
JUDITH: It’s just… it seems like so much work, getting out of the house for all those appointments.… Just to get here today was hard enough. And now, with the physical therapy, too… And I don’t even know if my insurance would cover it. It just seems like a lot of work to make it all happen.
COACH FEEDBACK: Great job! By asking Judith what her reservations are about meeting with a therapist, we now have two concrete concerns that we can address: the difficulty of getting to the appointment and her uncertainty about insurance coverage.
DR. RODGERS: I know it’s been hard for you to get out of the house, but you just have to push yourself to do it. You said yourself, this is important to you.
JUDITH: I know I said that, but this is just too much. Please let’s not talk about this any more.
COACH FEEDBACK: Pushing your agenda on Judith does not encourage her to listen to you. In fact, it does the opposite, making her feel like you’re in an argument, instead of working together to find a solution. Let’s go back and try a different way to approach the situation.
DR. RODGERS: In terms of the insurance, I can have Nurse Lee give my colleague a call and see if she accepts your plan. If not, I have some other people in mind that you could talk to. How does that sound?
JUDITH: Okay. I just don’t want to have to make so many phone calls on my own to make this happen. Dealing with insurance… it’s too much…
DR. RODGERS: I understand. These are very legitimate concerns – being in pain makes it difficult to control how we’re feeling, and I understand that getting out of the house is tough. Something we could explore with my colleague is doing a face-to-face introduction and then maybe some phone sessions instead of going into her office. Would that be something you’d be interested in exploring?
JUDITH: So she would just call me up and we’d do our appointments over the phone?
DR. RODGERS: Exactly. Lots of people work that way or even on the computer with video-conferencing.
JUDITH: Well, that doesn’t sound too hard…
DR. RODGERS: So we talked about trying propranolol for your headaches. I’m going to prescribe a low dose to start, and I don’t expect you to have any problems, but if you have any concerns at all call the office. Nurse Lee is going to help you set up some more physical therapy sessions. And we also talked about seeing a psychotherapist. You said you’d prefer doing phone sessions if that’s a possibility, and you’d like us to check on the insurance for you so you know you’ll be covered no matter who you talk to. How does all that sound?
JUDITH: Sounds good.
COACH FEEDBACK: Great! At the end of a conversation like this, it’s good to summarize the treatments you discussed to make sure you and the patient are on the same page.
DR. RODGERS: In addition to seeing the therapist, I know you also said you’d like to start getting out of the house more and doing some of the things you were doing before your pain got worse.
JUDITH: Makes sense, yes.
DR. RODGERS: And, Judith, if those thoughts of hurting yourself ever come back and you start to think about them more seriously, I’d like you to call me immediately. Would you do that?
JUDITH: Oh, I don’t want to bother you.
DR. RODGERS: It’s definitely no bother. And if for some reason you don’t want to talk to me, you can also call the National Suicide Prevention Lifeline. The people that work at the Lifeline are really good listeners and they’re available 24/7. So, even if it’s 3:00 am and you’re having a tough time, there’s still someone you can talk to. How does this sound to you? Are you willing to call me or the Lifeline if the thoughts get more intense?
JUDITH: It sounds fine. Yeah, I can do that.
DR. RODGERS: Great. I’ll write all this down for you, including the Lifeline number.
COACH FEEDBACK: Good. In case Judith doesn’t get help from a mental health professional, at least she has a way to reach out if her suicidal thoughts return. Also, Dr Rodger’s offer to be available reinforces his concern for her well-being.
DR. RODGERS: How confident are you that you can do these treatments we’ve talked about?
JUDITH: I want to feel better. I guess 80% confident.
DR. RODGERS: So why 80% confident vs., say, 50% or 30%?
JUDITH: I mean, even though it was tough, I got here today, so I guess I can get to physical therapy. And, if I can talk to a therapist on the phone, then it’s really just a matter of making the call. If we can find someone that’s definitely covered by my insurance, then I guess I’m more like 90% confident.
DR. RODGERS: Great. Nurse Lee will help you set up your therapy appointments, and I’d also like to see you for a follow-up in two weeks.
JUDITH: Okay. Thank you.
DR. EBER: Good job. You were able to talk to Judith about her depression and collaboratively decide on treatment options with her. It took more than seven minutes but in real life, you should be able to have this conversation in approximately seven minutes, depending on the patient’s readiness to accept a mental health referral. The more often you address these types of issues, the easier and faster these conversations will become.
DR. RODGERS: I considered prescribing Judith antidepressants; however, as she doesn’t have a history of prior depressive episodes, and it seems that her symptoms were tied to the loss of her husband and daughter, and because she wants to feel better, we decided that at this point therapy is the best choice.
DR. EBER: I agree. If Judith had experienced depression before, or if there was not a clear external cause for the change in her mood and behaviors, then antidepressants might have been the best course of treatment. In this case, therapy is the best option for helping Judith to process her loss and learn new ways of coping with her grief.