EMPATHY

Empathy is a core component of the therapeutic alliance. When patients express negative or distressing feelings or experiences, we want to communicate acceptance and concern both verbally and non-verbally. This skill is particularly relevant when we are reviewing distressing symptoms or problems in living, but empathy should be a component throughout the encounter.

An empathic response includes the following components:

• Name, describe, or communicate that you understand the patient’s emotional experience
• Communicate concern for the patient’s feelings or experiences, or
• Express that a patient’s emotions or experiences are normal, expected or understandable.

A poor demonstration of empathy is conveyed by the following elements of a response:

• Treat the patient’s feelings as insignificant,
• Give advice on how to view the problem or what to do about it, or
• Communicate negative judgement about a patient’s feelings or behavior.

REFLECTION

Reflection is a core component of the therapeutic alliance. We restate what patients have said on those occasions where we want to highlight their experience, and in particular ensure their awareness of the link between distressing behavioral health symptoms or behavior and a particular life circumstance or problem in living.

A good reflection includes the following components:

• Repeat or restate the patient’s feeling or experience,
• Repeat or restate life context issues, problems, or stressors, or
• Draw a connection between life circumstances and the patient’s behavioral health symptoms.

A poor demonstration of reflection might contain the following elements:

• Misinterpret or make incorrect assumptions about the patient’s experience,
• Refocus attention away from the patient’s emotional experience by asking concrete questions
• Refocus attention away from the patient’s emotional experience by probing past experiences or origins of the problem

CULTURAL RESPONSIVENESS

Cultural responsiveness is a core component of the therapeutic alliance. We want to interact with patients and deliver our interventions in a way that is responsive to and congruent with the patient’s cultural identity, context, and preferences. One aspect of cultural responsiveness is recognizing collectivist orientation and the importance of family (and extended family) for many cultures in our conceptualization and treatment, in contrast to the individualistic culture of middle-class White America.

A culturally responsive response may include the following components:

• Maintain a curiosity and openness to the aspects of cultural identity that are most important to the patient
• Have a knowledge base of a patient’s cultural identity and is responsive and sensitive to this identity
• Incorporate a strengths-based approach by reframing distressing emotions and experiences as opportunities for resilience and building positive coping skills

A response that is less culturally responsive may include the following components:

• Assume an overgeneralized (“one-size-fits-all”) understanding of culture
• Adopt an (over)reliance on the values of the surrounding dominate culture
• Interact with patient from a place of disrespect or ignorance, which includes minimizing the patient’s feelings or experience

AGENDA SETTING

The purpose of agenda-setting at all encounters is to collaboratively structure how time and effort gets spent. Agenda-setting involves patient input in determining ahead of time how to both focus the intervention and ensure that patient priorities are addressed. Setting an agenda at the start of each encounter helps to manage time throughout the encounter. Agendas typically include behavioral health symptom review, homework review, and new goal setting and homework.

Elements of agenda setting include the following components:

• Set agenda collaboratively with the patient as first topic of the meeting, or as early as possible,
• Ask patient if they feel they have improved since the beginning of treatment, and
• Briefly review the symptom questionnaire or behavior checklist, and ask the patient which symptoms have bothered them the most.

Less helpful ways to start a session in the absence of agenda setting include the following examples:

• Ask unfocused, open-ended question about the past week,
• Review symptoms or behavior checklists before setting an agenda, or
• Review homework before setting an agenda.

REDIRECTION

At times during our encounters with patients, we may need to redirect them back to the task at hand. We use redirection skills to ensure that patients focus productively on one issue at a time. Good time management starts with agenda-setting at the beginning of an encounter and is maintained by ongoing redirection and focus throughout the encounter.

A helpful redirection will include the following elements:

• Reflect or briefly summarize the patient’s concern,
• Talk about the connection, or lack of connection, between the patient’s new concern and the task at hand, and
• Suggest returning to the task at hand, or prioritizing the current concern as more important

Qualities of responses that do not redirect the patient include:

• Ask follow up questions about the new concern,
• Let the patient keep talking without interrupting them, or
• Ignore the patient’s concern and abruptly return to the task at hand

ENHANCING MOTIVATION

Patients are often ambivalent about making changes in their lives. We use a variety of strategies to enhance patient motivation and “elicit change talk” to promote positive behavior change. These strategies are particularly helpful before assigning homework in order to ensure patient readiness and agreement.

Strategies that can enhance patient motivation include:

• Ask permission to provide psychoeducation or feedback about a patient’s behavioral health symptoms,
• Discuss the treatment rationale or ensure patient input in treatment,
• Ask questions about the pros and cons of a behavior from the patient’s perspective
• Asked questions about patient readiness for change.

Ineffective strategies to attempt to enhance patient motivation include:

• Decide on treatment course without asking for patient input or preferences,
• State the benefits of changing a behavior or the negatives of maintaining a behavior only from a paternalistic perspective, and
• drop the focus on a distressing symptom or behavior and move on prematurely to a new concern.

ASSIGNING HOMEWORK

After providing adequate psychoeducation to the patient about their behavioral health symptoms and about the intervention, we then need to structure the encounter in a way that will be most beneficial to helping the patient learn new skills, all while staying within our time limit. To do this, we focus on setting specific goals, teaching and illustrating therapeutic skills, detailing homework, and anticipating obstacles.

To adequately assign homework, we should work with patients/clients to sequentially:

• Set specific goals and action plans in collaboration with the patient,
• Ensure the patient will be successful by predicting obstacles and planning realistic strategies to overcome them, and
• Explain how to evaluate whether the plan was successful or not.

Less helpful ways to assign homework include:

• Identify a goal or activity without creating a specific action plan that covers the necessary steps the patient will need to do, or
• Set an unrealistic goal or action plan.

REVIEWING HOMEWORK

Patients will be more likely to complete their action plans if the provider reviews them at the start of each encounter, discusses the patient’s satisfaction with their efforts, and troubleshoots any obstacles. This discussion of successes helps patients acknowledge and feel good about their accomplishments, even if they are still not functioning as well as they were since their behavioral health symptoms began. Reviewing homework also reinforces for the patient the link between their efforts and improvements in behavioral health symptoms and functioning.

A thorough homework review will do the following in sequence:

1. Ask the patient what they have accomplished, or how satisfied they were with themselves and their efforts,
2. Give appropriate praise for patient efforts,
3. Emphasize the relationship between the patient’s efforts and their symptoms improving,
4. Ask patient about challenges with the previous homework or activities, and
5. Help the patient consider what they could do differently next time.

An ineffective review of homework will:

• Ask open-ended question about past week,
• Move on too quickly to schedule new plans without addressing any difficulties from last homework,
• Encourage patient to drop an activity if they didn’t accomplish, or
• Encourage patient to redo homework that they didn’t accomplish without addressing any difficulties.

ASSESSING SUICIDE RISK

When patients endorse item 9 on the PHQ, or when they report any thoughts of death or suicide, the provider must follow up with a series of questions around thoughts patients may be having in the past month. Risk level range from:

• None
• Mild (wishes to be dead)
• Moderate (thoughts of suicide without a specific, detailed plan or intention; or current wishes to be dead with lifetime history of a suicide attempt)
• High (specific, detailed plan or intention to end one’s life; or any suicidal behavior in the past 3 months).

A thorough and complete assessment of suicidal ideation involves inquiring into each of the below areas in sequential order:

1. Ask about wishes to be dead in the past month
2. Ask about thoughts of suicide or ending one’s life in the past month
3. If reports any thoughts of suicide in past month, ask about:
   • specific detailed plan and intention
   • suicidal behavior or preparation (over patient’s lifetime and also specifically in the past 3 months)
   • context and stresses
   • reasons for living and protective factors
4. Accurately categorize the suicide risk level of the patient

Ineffective or poor strategies to assess suicide risk include:

• Skip ahead, or move on prematurely
• Minimize patient feelings or experiences
• Convey disapproval or negative judgment about patient experience
• Ask questions that lead patient toward denying suicidal thoughts
• Do not inquire specifically about suicidal thoughts in the past month
• Do not ask about suicidal behavior or preparation for both lifetime and past 3 months
• State that will seek out supervisor without completing full suicide risk assessment

MANAGING MILD TO MODERATE SUICIDE RISK

Providers must take the appropriate actions after they determine suicide risk level to be mild to moderate.

A thorough and complete action plan involves addressing each of the below areas:

• Convey that provider will inform Behavioral Health supervisor or PCP to discuss treatment plan
• State follow up appointment date and importance of regular sessions and ongoing monitoring of risk level
• Help patient identify self-management strategies in response to suicidal thoughts
• Help patient identify family or friends for support, including possible participation in conjoint sessions
• Provide care team numbers, hotline, 911, and 988 if thoughts become more severe
• Discuss importance of keeping environment safe by limiting access to firearms and medications

Ineffective or poor strategies to manage mild to moderate suicide risk include:

• Fail to communicate action plan or reasons for action plan to patient
• Call family member without patient permission
• Convey that patient is at high risk for suicide and will arrange emergency services

MANAGING SEVERE SUICIDE RISK

Providers must take the appropriate actions after they determine suicide risk level to be high.

A thorough and complete action plan involves addressing each of the below areas:

• Communicate care and concern
• Convey that provider will consult with the Behavioral Health supervisor or PCP, or arrange emergency services to ensure patient safety
• Convey that a care team member will remain with the patient until emergency services arrive

Ineffective or poor strategies to manage severe suicide risk include:

• Convey disapproval or disrespect toward the patient
• Communicate unclear emergency services plan to patient
• Recommend any other action than immediately arranging consultation from the Behavioral Health Supervisor or PCP, or emergency services