Let’s summarize where we have been and where this chapter is going. From Chapters 1 and 2, you learned that mental disorders often occur in patients presenting with the physical symptoms of chronic medical disorders and/or chronic medically unexplained symptoms (MUS). This means that, in any patient with severe, disabling physical symptoms, we must also actively inquire about the associated psychological symptoms that can lead us to a diagnosis of a comorbid mental disorder.
In this chapter, before presenting the specific mental disorders and their treatment, we introduce the Mental Health Care Model (MHCM), an overarching model for the treatment of the mental disorders we will consider. The MHCM identifies aspects of treatment that are common across all mental disorders. As we progress to later chapters, we will show how pharmacologic and other treatments of specific mental disorders are integrated into the MHCM. (While the MHCM actually applies to all health care interactions, we label it “mental” because these problems are far more complex and require this overarching framework.)
THE MENTAL HEALTH CARE MODEL
The MHCM has 5 dimensions addressing a wide range of often overlooked needs in treating patients with mental health disorders:
Establish communication and an effective clinician-patient relationship
Educate the patient
Obtain the patient’s commitment to treatment
Determine the patient’s goals
Negotiate a specific treatment plan
The pharmacologic and other treatments specific to each mental disorder that we present in Chapters 4, 5, 6 are integrated into the last dimension—negotiating a treatment plan. Treating mental disorders, however, is far more complex than simply prescribing medications. Rather, it also requires the other 4 measures we now discuss in detail.
The MHCM has a wide-ranging conceptual background in self-determination theory,1,2 shared decision making,3-7 motivational interviewing,8-10 social cognitive theory,11,12 and the chronic care model.7,13,14 The overarching theoretical backdrop is the general systems-based biopsychosocial (BPS) model,15,16 and the patient-centered approaches required to operationalize it.17-19 The BPS model contrasts with the current biomedical/biotechnical model and its isolated focus on diseases. It integrates the patient’s psychological and social life to complement the biological or disease aspects of the biomedical model. Instead of describing the patient just in disease terms, the BPS model describes them from disease (biological), psychological, and social perspectives. One elicits this multifactorial database, using PCI rather than the isolated physician-centered interview used when focusing only on diseases.20
The MHCM values patient autonomy21,22 and emphasizes that while the clinician is the expert on disease and treatment, the patient is the expert on their life experience, needs, limitations, and priorities.22,23 With the MHCM focus on self-management,7 fostering patients’ self-efficacy (confidence) is paramount.11,12 Finally, the MHCM emphasizes a negotiated (rather than prescribed) approach with a focus on the partnership with the patient,24 thus emphasizing the centrality of the clinician-patient relationship.3,25 Applicable to all mental health disorders, the specific way in which the MHCM is applied depends on the types and numbers of mental disorders and on the specific, unique problems they present.
Figure 3-1 graphically depicts the MHCM. Its centerpiece is the patient-centered interaction (PCI), and the following 4 principles are integrated with it: Educating the patient, obtaining a Commitment to treatment, establishing Goals for treatment, and Negotiating a specific treatment plan. The mnemonic ECGN is useful in recalling them. Now let’s discuss these 5 principles in more detail and how you can incorporate them into your practice.
Patient-centered skills are the single most critical aspect of treatment in mental disorders. In the various mental disorders we’ll consider in the chapters that follow, PCI are always at the center of treatment.3,25 Here, we describe exactly how to conduct them.26 PCI skills emphasize how to be empathic, the key variable in all interactions.27 PCI skills also maximize communication and the clinician-patient relationship.28 We know from an extensive literature in both medicine and psychiatry that PCI is associated with improved health outcomes as well as increased patient satisfaction and medication adherence and with decreased doctor-shopping and malpractice suits.26,29,30 Indeed, data demonstrate a greater treatment effect from the relationship with the clinician than from pharmacotherapy for mental disorders.31
We present a PCI model that is unique in having 4 controlled research studies that demonstrate it is evidence-based.32-36 The PCI model is summarized in Table 3-1 and presented in detail in Smith’s Patient-Centered Interviewing—An Evidence-Based Method26; several demonstration videotapes of the PCI accompany the book and are easily viewed from McGraw-Hill’s Access Medicine website (www.accessmedicine.com/SmithsPCI).
PATIENT-CENTERED INTERVIEWING METHOD
STEP 1—Setting the Stage for the Interview
STEP 2—Chief Concern/Agenda Setting
STEP 3—Opening the History of Present Illness (HPI)
STEP 4—Continuing the Patient-Centered History of Present Illness (HPI)
STEP 5—Transition to the Clinician-Centered History of Present Illness (HPI)
Each interaction with a new or follow-up mental health patient begins with the PCI, summarized here:
Steps 1 and 2, respectively, set the stage and develop the agenda for an interaction. They prepare for the patient-centered parts to follow in steps 3 and 4. See Table 3-1 for the specific substep items to address in steps 1 and 2. In step 2, it is especially important to elicit the full agenda, often asking, “What else?” or “Anything else? I want to be sure we cover all you want to address today.” After completing the agenda, the clinician transitions to steps 3 and 4 by saying, “Tell me more about (the chief complaint, such as chest pain or worry).” In the mental health patient with many complaints, especially when first seen, carefully setting the agenda will almost always prevent the frustrating occurrence of new items arising at the end of the interaction.
Steps 3 and 4 generate the patient’s story comprising26:
The physical symptom story reflects chronic MUS and/or comorbid disease and is applicable in patients with only a disease as well as those with MUS or mental disorders. The clinician repeatedly uses open-ended skills (eg, “expand on the chest pain”) for a minute or so to develop the physical symptom story in the patient’s own words. This is where you first learn about mental health patients’ chronic physical symptoms. You may not get all of them here, and any unclear details are revisited later in the clinician-centered parts of the interaction.
The personal story reflects the psychological and social context of the physical symptom story. Repeatedly employing open-ended skills over the next 1 to 2 minutes, the clinician facilitates a focus on the personal dimensions that arose when the patient told the physical story (eg, “tell me more about losing your job because of the pain” or “you said your wife was upset”). During this part, you will hear the psychological symptoms and other dimensions of the patient’s mental health problem, again pinning down additional details later when clinician centered.
The emotional story reflects the emotions related to both physical and personal stories.26 Using a new set of skills, the emotion-seeking skills, the clinician inquires directly about emotions37; for example, “how did that feel emotionally when you lost your job?” If no emotion is elicited after 2 to 3 tries with this direct inquiry, the clinician probes indirectly, asking what impact the illness has had on them and/or on their family or asks what the patients thinks is causing the situation. The clinician even can suggest others might be “upset” in this situation as a way to encourage emotion; for example, “I think I’d be upset if that happened to me.” The idea here is to elicit emotion. Once an emotion is obtained, it is essential to have a good understanding of it, so a few open-ended questions are required to achieve this understanding.
Responding to the emotion: We now have the full biopsychosocial story, comprising the physical or disease story and the psychological and social stories, including the patient’s emotional reactions. What now? Have we tapped into your greatest fear, a patient expressing emotions? While teachers often told you to “be empathic,” they seldom indicated exactly how to do that. Yet many clinicians feel helpless or confused when their patients become emotional, for example, wondering with discomfort, “What do I do? He’s crying.” Consequently, we have devised an effective way to deal with this.
In our model, we identify four empathic skills, sometimes descriptively called emotion-handling skills,37 that help you respond to a patient’s emotions:
Name the emotion
Understand the emotion
Respect the emotion
Support the emotion
They are recalled by the mnemonic NURS.26 For example, the clinician might say,
“You were pretty angry (naming)
I can understand that (understanding) after all you have been through (respecting)
Thanks for sharing that (respecting)
This helps me to better meet your needs (supporting).”
Thus, a provider will “NURS the emotion” after they elicit and understand it. One does this repeatedly as new emotions arise or old ones resurface. You can see how the NURS skills are especially needed in tension-laden conversations, for example, around disagreements on using opioids or fear of taking antidepressants; alternatively, they’re equally helpful with someone who is depressed because they are dying of lung cancer. Usually taking no more than 3 to 5 minutes to get to this point, one then transitions to step 5.
Step 5 is very brief and signals to the patient that a change in style of questioning will occur, one where the clinician will ask many more questions designed to pin down necessary details of the story in the clinician-centered part of the interview. For example, starting with a NURS comment, the step 5 transition might be, “… you’ve had this back pain for 5 years and it’s worse, that’s been really difficult (respecting), so let’s see what we can do working together here (supporting). I’d like to switch gears now and ask some questions to get the details I need on the chest pain and the high blood pressure you mentioned. Is that okay?” Alternatively, if you have already heard about the patient’s mental health issues, such as depression, you include that in the summary, “…switch gears … details of your feeling depressed.”
Clinician-centered interview: Using closed-ended skills, one elicits significant details of, say, the pain, medications, suicidality, prior depression treatment, and other important data needed to complete the HPI for both mental and physical disorders. As you know, we also obtain a great deal of routine information, such as the patient’s past medical history and social history. It is also at this point that you pin down necessary details of the mental health story; for example, ask about depression if suspected but not yet mentioned, medications used, suicidal thoughts, prior hospitalizations, or abuse. In Chapters 4, 5, 6, you will hear the details of the information needed for mental health patients, and in Chapter 7 we present the format for the entire psychiatric interview, including both patient-centered and clinician-centered dimensions.
While the PCI to this point occurred at the start of the interview, we continue using its open-ended and empathic skills (NURS) periodically throughout the clinician-centered and treatment phases. It is at the conclusion of the interaction, when outlining treatment, that we implement the remainder of the MHCM, which we now describe.
See the Table 3-2 overview for the remaining parts of the MHCM.