DR RODGERS: So Antoine, in addition to your back pain, we talked about how you’ve been having nightmares and trouble sleeping and some problems at home and at work. It sounds like, to manage these things, you’ve been taking the Percocet, drinking more than you used to, and spending more time alone—trying to create a quiet space for yourself. All this makes me wonder if maybe you… brought some of the war home with you.
ANTOINE: Well… yeah. How can you not? I saw some crazy shit over there... and I guess the beer and my time alone… it helps. And the Percocet does a good job with the pain. I mean, I feel guilty that I’m not spending more time with my family, but… I guess that’s the way it is.
DR. RODGERS: On a scale from zero to 10, where zero is “not at all willing” and 10 is “totally willing,” how willing would you be to try some new approaches to help you feel better?
ANTOINE: I don’t know… maybe five? I mean… You’re the doctor, but I don’t want to try a bunch of stuff that may not make me feel better. I want to feel better now.
COACH FEEDBACK: Great approach! By asking Antoine how willing he is to try different approaches, you’re making him an active partner in this conversation. You may want to follow up by asking him why he chose “5” instead of a lower number.
DR. RODGERS: Sometimes when there’s a lot going on, it’s helpful to address one problem at a time. I know you’ve had some difficult experiences in the war and I can see that you’re struggling. I think you should see someone to talk more about your drinking patterns and the nightmares and sleep issues you’re having.
ANTOINE: So you’re not going to give me any more Percocet? That’s why I came to see you, Doc! I need to get rid of this pain so that I can get back to work and keep my job.
COACH FEEDBACK: Antoine has made it clear that his back pain is a priority. Address treatment options for that first. Let’s go back in time and try a different choice.
DR. RODGERS: Sometimes when there’s a lot going on, it’s helpful to address one problem at a time. It sounds like getting your back better is a priority right now.
ANTOINE: Definitely.
DR. RODGERS: One of the best ways to do that is to have you see an orthopedist, someone who specializes in back pain and can better identify what the problem is so we can treat it correctly. In the meantime, I’m going to prescribe some physical therapy and an anti-inflammatory to help your back let go of some of the tension, which is where a lot of your pain seems to be coming from. What do you think about putting together a plan like that?
ANTOINE: So you’re not going to give me more Percocet? That’s why I came to see you. I need to get rid of this pain now… not a month from now after running around to a bunch of other appointments.
COACH FEEDBACK: Good job breaking down your discussion of treatment options. Although Antoine is upset upset that you’re not prescribing the Percocet, addressing his primary complaint first may make him more willing to discuss mental-health treatment, later.
DR. RODGERS: I actually have some concerns about how you’re using the Percocet to manage your pain. They can be addictive and I’m worried you may be addicted. I just don’t feel comfortable prescribing them—especially with the way you’ve been drinking, since they shouldn’t be taken with alcohol.
ANTOINE: I’m not addicted! A few beers and a few pain pills aren’t going to hurt anybody.
COACH FEEDBACK: Labeling Antoine as “addicted” made him defensive and decreased the likelihood that he’ll accept your referral. Try focusing on the facts, and avoiding negative labels. Let’s go back and try a different choice.
DR. RODGERS: I know the Percocet has been working for you, but unfortunately, Percocet isn’t a long-term solution. It’s not really fixing the cause of the pain, just covering it up… like a band-aid.
ANTOINE: Does it matter, if it takes away the pain?
DR. RODGERS: Well, over the long term it could matter because you don’t want to keep having these issues year after year. I feel pretty confident that the physical therapy and orthopedist can help you get to the root of the problem and fix it, and the anti-inflammatory will help with the pain in the meantime.
ANTOINE: (pauses to think) I see. I get what you’re saying.
DR. RODGERS: Now, let’s talk for a second about the sleep issues and nightmares you mentioned…
DR. RODGERS: I think you should see a therapist to help with some of the emotional stress you’ve been having that may be related to your combat experience.
ANTOINE: Honestly, Doc, I don’t think that’s going to help me. Just need to get my back pain squared away. So let’s just focus on that and then, if you still think I’m crazy, then maybe we can talk about a therapist.
COACH FEEDBACK: Telling Antoine he “should” see a therapist made him defensive. More effective tactics include bringing it up as a question (“Have you ever considered talking to a therapist?”) or asking permission (“Do you mind if I share some information about other approaches?”). Undo this decision and try a different tactic.
DR. RODGERS: What would you think about talking to someone to help work through some of the emotional stress you’ve been having--like your nightmares-- that may be related to your combat experience?
ANTOINE: What do you mean… you mean, like a therapist? I don’t think I need that. I’ve never done that.
DR. RODGERS: It sounds like talking to a mental health professional would be something new for you and you’re not certain you need it.
ANTOINE: Yeah. I mean, my problem is my back. If we can get that to go away, I’ll be fine.
DR. RODGERS: Whether or not you talk to a mental health professional is entirely your decision. Would it be okay with you if I explained why I think talking with someone might be helpful?
ANTOINE: Uh, sure.
DR. RODGERS: Well, it seems like you’re experiencing a lot of stress, and you feel some of that stress as muscle tension, which is likely making your back pain worse. A mental health professional could teach you techniques for releasing that tension, which should make your back feel better. Plus, it’s very common for people who’ve been at war to come home and have nightmares, prefer to spend time alone, or have trouble sleeping and adjusting to civilian life. And there are mental health professionals who have a lot of experience working with veterans. Meeting with someone like that, you could benefit from their experience and what they’ve seen help other veterans.
ANTOINE: I don’t know… I mean, I know my wife would be very happy about that. She’s always telling me I need to see somebody. You know, but I don’t know. It’s… I just don’t think it’s right for me. Maybe down the road, after my back is fixed…
COACH FEEDBACK: Good. Broaching the topic of counseling as a question (“Have you ever thought about…”) instead of as a suggestion (“You should…”) made Antoine more comfortable with the referral.
DR. RODGERS: What are some of the reasons you feel like talking to a therapist wouldn’t be right for you?
ANTOINE: I don’t know… I mean, I’m not a “crazy vet.” Not all veterans need to see a therapist. I have not been back that long and it’s just kind of normal to have a transition when you come home. Like, I know some of my buddies have gone to therapists, and sometimes it works, but for most of them, it doesn’t work. It’s just a waste of time.
COACH FEEDBACK: By asking open ended questions about Antoine’s resistance, you’ve uncovered that he’s afraid therapy will be a waste of time. Make sure you acknowledge his point of view before sharing any differing opinion.
DR. RODGERS: So you’re concerned that it may not work for you and you’d just be wasting your time.
ANTOINE: Yeah.
DR. RODGERS: Well, you’re absolutely right that some people don’t benefit as much from therapy as others. Often times, this is because there’s a mismatch between the therapist’s approach and the client’s goals or personality. If you decided to try this, it would be important to find a therapist who is a good match for you. I can recommend a colleague I know and trust completely. She’s helped a lot of other patients of mine.
ANTOINE: Well, tell you what… I’ll definitely take her number and I’ll think about it. I will. I’ll think about it real hard.
DR. RODGERS: Great. I’ll have Nurse Lee come in and she’ll get you all the information you need for your appointments and prescription. She’ll also give you a call in about a week to follow-up, okay?
ANTOINE: Sounds good.
DR. RODGERS: And, if you decide to talk to my colleague and it doesn’t feel like she’s a good fit for you, that’s okay; just call us and we can discuss other people who might be a better fit.
ANTOINE: Okay. Thanks.
DR. EBER: Great job! Talking with Antoine first about his motivations for change made him more of a partner in the conversation and led him to accept the eventual referral, rather than becoming defensive. You did a good job of outlining Antoine’s treatment options. Next time, though, try addressing the patient’s primary concern first—in Antoine’s case, his back pain. Once this primary concern is addressed, the patient should be more willing to have a discussion about their mental health. In real life, you should be able to have this conversation in approximately five 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.