Austin: Judith, a couple times isn't really giving the physical therapy a chance. You should try it again. It can really help with arthritis pain.
Judith: Oh, okay.
Coach: This sounded like criticism and shut Judith down. Austin knows she screened positive for depression. Her reasons for not going to physical therapy may be related. He should come back to the topic of physical therapy a little later on in the conversation.
Austin: Okay, Judith, before we talk more about your pain and headaches, I'd like to talk about the forms you filled out in the waiting room. You have indications of depression.
Judith: Depression? What about my wrist and headaches?
Coach: Austin should try to ease into this conversation. He should ask Judith about her chief concern and then about her mood before jumping into the results of the screening. Let’s look at a more effective response.
Austin: Tell me more about your pain. How are your arthritis and headaches affecting your ability to get around and do things?
Judith: It's not easy. I don't move around much.
Austin: Sometimes when people have this kind of pain and don't move around that much, it can make the pain worse, which can make it even harder to move around. It can become a cycle. So actually, if you start moving around more, it'll help with the pain.
Judith: Okay, that makes sense.
Judith’s thought: Who has the energy? There's only so much moving around I can do in my apartment.
Austin: How often are you getting out of the house?
Judith: Not often. This is the first time in a while, actually.
Austin: What about work, or seeing family or friends?
Judith: I retired last year and, I don't, I don't have any immediate family. I had a lot of friends at work, but I haven't really seen them since I retired. It's just really hard with my pain.
Judith’s thought: It's just me now, me and Rosie.
Austin: You should get out of the house more, call your friends, try to do some activities with them. It'll help you feel better.
Judith: Oh, no, no. No, it's too hard.
Coach: Clients rarely react well to unsolicited advice about sensitive topics. And "getting out of the house more" is much easier said than done for someone who has depression.
Austin: Is there anyone around who can help you with things when you're in pain?
Judith: No, it's just me and Rosie, my cat. My, my daughter and my husband are both gone.
Austin: Gone?
Judith: They died a while back.
Austin: Oh. I didn't know. I'm so sorry to hear that.
Judith: Thank you.
Coach: Death or illness of a loved one is a significant risk factor for developing a mental health disorder. Even if Judith had not already screened positive for depression, hearing this would clue Austin in that she might be suffering from emotional distress.
Austin: Judith, would it be alright to talk about the forms you filled out in the waiting room?
Judith: Sure.
Austin: You indicated that you've been feeling kind of down lately and that you've been having trouble sleeping, feeling tired, and there are some changes in your appetite. What's your mood been like?
Judith: Not great, I guess. I just wake up, feed my cat, Rosie, watch a little TV, take a nap. Just kind of go through the motions. I really don't feel good. And my arthritis and headaches just make me feel even worse.
Coach: This was a great approach. By asking Judith's permission to discuss the forms, Austin made her more of an equal in this conversation, which encouraged her to open up.
Austin: Sometimes when people lose loved ones, it's natural to feel extra tired, have trouble sleeping, eat far less or more than they normally do, in general, to feel down, maybe even for a long time, some of the things you indicated you were feeling on the forms you filled out in the waiting room.
When did you lose your husband and daughter?
Judith: It's been a while now. My husband died of cancer and then about a year later Lori, she died.
Austin: You know, I'd, I'd hate for anything bad to happen to you, Judith.
I mean, I hope you're doing alright.
Judith: (confused) Uh, thank you.
Austin: You wouldn't do anything drastic, I'm sure.
Judith: Drastic? I'm sorry, I don't really follow.
Coach: By phrasing the question about suicide in this way, Austin is presenting a very clear "right" and "wrong" answer to the client, which might prompt her to conceal her thinking. Instead, when asking about suicide, it's best to be direct, which shows the client that you're nonjudgmental and comfortable having this type of conversation.
Austin: Sometimes when people are in a lot of pain and coping with the loss of loved ones, they may think about hurting themselves or that they'd rather not still be here. I noticed on your form you said you've had thoughts like this from time to time. Can you tell me a little about that?
Judith: Oh. Well, I've thought about it here or there. I'm not working, I don't have a family to take care of, I'm not much use to anybody anymore. And I'd get to be with my daughter and my husband again. But, honestly, I'd never actually do anything.
Coach: Austin did a good job asking Judith about suicide. She seems to be low-risk for suicide, but he needs to ask a few more questions to better assess her risk level.
Austin: And, when you've had those thoughts, did you ever think about specific things you might do to end your life?
Judith: I don't know, a couple of things have crossed my mind, but I didn't dwell on them. Really, I wouldn't do anything like that. It's just something that pops into my head when I'm really down. But I wouldn't actually do anything.
Coach: Austin did a good job. If Judith had said she does think about suicide, Austin would have followed up by asking about specific plans: when would she do it? how would she do it? does she have the means to carry out her plan?
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: This was a great approach. Asking Judith's permission to talk about treatment options moved the conversation toward successful referral.
Austin: Dr. Singh has a colleague, a psychotherapist, who I think you should talk to about your mood.
Judith: Oh, I don't 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: First, Austin should address Judith's primary concern. Then she will be more receptive to discussing treatment options for her depression. Let’s look at a more effective response.