Judith: I adopted her from a shelter and she was all alone. We're the only family we have.
Austin: What else keeps you from acting on those thoughts when they pop into your head?
Austin: I guess I think about my daughter and how disappointed she'd be in me. If she were here she'd say, "Come on, Mom. Snap out of it." And I couldn't do that to her. She didn't want to die and she didn't have a choice. And here I'd be, choosing to die? That's not right.
Judith’s thought: She'd never forgive me if I killed myself.
Coach: 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 Austin should definitely discuss referral to a therapist with her primary care provider.
Austin: So, I know we need to talk about your arthritis and headaches. I'd also like to talk about ways to improve your mood and how you've been feeling. Would that be okay?
Judith: Sure. 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: Austin did a good job. Asking Judith's permission to talk about treatment options moved the conversation toward successful referral.
Austin: So, Dr. Singh is recommending something called propranolol for your headaches. And for your arthritis, we 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.
Austin: And how would you feel about talking to 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’s thought: Maybe I shouldn't have opened up so much.
Austin: 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: Austin did a great job here! By asking Judith what her reservations are about meeting with a therapist, he now has two concrete concerns that he can address: the difficulty of getting to the appointment and her uncertainty about insurance coverage.
Austin: 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 is doing a face-to-face introduction with the therapist 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?
Austin: Exactly. Lots of people work that way or even on the computer with video-conferencing.
Judith: Well, that doesn't sound too hard.
Austin: In terms of the insurance, I can call and see if she accepts your plan. If not, there are other equally good therapists that I can check with. 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.
Austin: I understand.
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.
Austin: 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 our office immediately. Would you do that?
Judith: Oh, I don't want to bother you.
Austin: It's definitely no bother. And if for some reason you don't want to talk to one of us, 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.
Austin: 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 us or the lifeline if the thoughts get more intense?
Judith: It sounds fine. Yeah, I can do that.
Austin: Great. I'll write all this down for you, including the Lifeline number.
Coach: This was 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, Austin’s offer to be available reinforces his concern for her well-being.
Austin: How confident are you that you can do these treatments we've talked about?
Judith: I'm, I want to feel better. I guess 80 percent confident.
Austin: So, why 80 percent confident versus say 50 percent or 30 percent?
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. And if we can find someone that's covered by my insurance, then I guess I'm more like 90 percent confident.
Austin: Great. I'll help you set up your therapy appointments, and Dr. Singh would like to see you for a follow-up in two weeks.
Judith: Okay. Thank you.
Pic 1: The screen changes to a close-up of Dr. Eber at the table. A text box appears next to her titled “Nice Job!” Below the title are three items on a list, each with a check next to them.
Dr. Eber: Nice job! You were able to talk to Judith about her depression and, as a team, collaboratively decide on treatment options with her. You accomplished this in under seven minutes, not counting time you spent making menu selections.
Pic 2: The camera changes to a close-up of Austin.
Austin: Dr. Singh considered prescribing Judith anti-depressants. However, as she doesn’t have a history of prior depressive episodes, and it seems that her manifestations were tied to the loss of her husband and daughter, and because she wants to feel better, it was decided that at this point therapy is the best choice.
Pic 3: The camera returns to a close-up of Dr. Eber.
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 anti-depressants 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.