Building alliance to address
mental health in primary care
Larry Wissow, MD MPH
Johns Hopkins School of Public
Health, Baltimore, MD
Goals
• Learn about the importance of alliance
(patient-doctor; patient-staff; patient-office)
in promoting the care of mental health
problems
• Learn some techniques for fostering patientdoctor alliance
• Using the alliance to ask about things that
patients/parents might not expect you to ask
about
Disclosure
• No conflicts to report
• Grateful to funders and collaborators
– Duke Endowment
– National Institute of Mental Health
– Dr. Anne Gadomski (Bassett Healthcare)
• Oregon Pediatric Society
Cases to think about
• Foster parent brings in the bag of pills and
says they aren’t working
• Parent seems depressed or has revealed
problems on a screening form
• In the middle of a short medical visit the
family raises a mental health issue
Background/philosophy
• Pediatric practices see same range of
severity as child psychiatrists
– But distribution varies
• Many different ways to cope
– Good triage
– Develop your own skills
– Co-locate with mental health
Core needs
• Efficiently rule out emergencies
• Provide immediate relief and advice
• Develop a mutually agreeable plan for
next steps
• Stay in control of the visit and balance the
needs of this patient with the needs of
others
To meet core needs
• Core capability for any solution might be
called “alliance” with family
– Partnership, engagement…
• Data from adult primary care studies of
depression treatment
– Relationship with provider predicted
engagement and outcome
Van Os TW. J Affect Disord 2005;84:43-51. Frémongt P. Encephale 2008;34:205-10.
Why start with a focus on alliance?
• Advice alone isn’t enough
– < 50% of psychosocial concerns disclosed
– < 50% of mental health referrals kept
– < 50% of children who start mental health
treatment finish
• Evidence from psychotherapy
– Predicts outcome over and above any
specific treatment (including medications)
Elements of alliance in
psychotherapy
• Agreement on nature of problem
• Agreement on what to do (and when to do
it)
• “Affective bond” with provider
– Trust
– Optimism
– Relief
Why alliance especially with mental
health issues?
• Particularly stigmatizing
• Doubt and equivocation part of the
“illness”
• Not sure that you’re the one to tell
• Afraid to hear the answer
What builds alliance?
• Evidence that process starts with initial
interaction with office
– Image of relationship built from staff as a whole,
not just the pediatrician
– Patients value flexible, open staff who can
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pinch hit for each other
help trouble shoot problems
speed things up when needed
realize when the patient’s context has changed
Ware NC. Psychiatr Serv. 1999;50:395-400.
Pulido R. Arch Psych Nursing 2008;22:277-87.
Patient trust and practice climate
• Adult primary care patients’ trust in provider
related to:
– Physicians and staff reporting better collaboration
with each other, more autonomy, ability to
delegate to each other
• Trust then relates to:
– Attribution of influence over healthy behaviors to
provider recommendations
Becker ER, Medical Care 2008;46:795-805
Alliance building 1:1
1. Feeling heard and understood (the bond)
2. Seeking agreement on a working formulation
of the problem
3. Seeking permission to offer advice
1. Feeling heard and understood
• Heard: active listening
– Creating the illusion of taking time
– Verbal and non-verbal indicators of paying
attention
– Actions that “co-construct” the story
• Understood: agreement on the nature of
the concerns and the highest priorities
2. Seeking agreement on a working
formulation of the problem
• Asking for permission to gather more
information
– Opportunity to open up more sensitive areas,
rule outs, emergencies
• Asking for permission to offer a preliminary
idea of the problem
– Asking if you’ve got it
– Cycling back to more questions
3. Seeking permission to offer advice
• Ready to act?
– If not, what would it take?
• What can we do now?
• What might we need to do next?
• Responding to “no”
1. Feeling heard and understood
Shaping concerns and managing time
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Open-ended questions
Anything else?
Breaking into the story
Managing the two-patient visit
Skills for rambling (co-construction)
1. “I want to make sure we don’t run out of
time…”
2. Summarize your understanding and ask
for additional concerns
3. Specifically ask for focus
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“Which one of those is hardest?”
“Pick one of those to start with.”
Ask for a specific example
“Pick one”
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Two in the visit: skills when turn-taking
interrupted
•
Possible tactics
Shift in body language
• Acknowledge and re-direct
• Reminder of “rules”
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Considerations
Timing
• Status of person interrupting or interrupted
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“Enforcing” taking turns - child
Skills when participants are angry
at each other
• Rationale
– Want to manage negative affect in the visit (and help
people move on to problem solving)
– Want to demonstrate that dialog is possible
• Several “flavors” of extreme statements
– “Black or white” statements leave no room for
discussion
– Critical comments about family members
– Set-ups involving vague, value-laden goals
Responding to “black or white”
• Characterized by “always,” “never,” or
similar words
• Point out and ask for restatement
– Be prepared if you choose to challenge the
generalization
– Alternative: ask for “something easier to hear”
Responding to “black or white” with
“say something easier”
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Common issues in agenda setting
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Parent and child/youth have different
priorities
Family priorities not same as yours’
Opportunities for additional visits are
limited
•
You really do want to accomplish more than
you have time for!
Skills for agenda setting
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Making sure this process is clear to
patient/parent
Playing back the list of concerns
Asking for priorities
Getting agreement from all parties
Openly and collaboratively problem solve
about limitations on follow-up visits
2. Getting to agreement on a working
formulation
• Why ask for permission to get more
information?
• What is it that you want to know?
– Sensitive but important details
– Data related to possibly urgent treatment
needs (including overall level of function)
– What they think might be the underlying
cause
Small group task
• Pick a common condition (ie, depression)
• Brainstorm most efficient ways to ask about:
– Overall function and possible indicators of need
for urgent care
– Sensitive but possibly important information
related to the child or family
– Initial somatic causes/rule outs
– What child/family has already thought about as
cause/underlying issue
Reports from groups
• Focus on the first 2-3 minutes worth of
questions that will help you decide where
you are going with this problem
Hint about severity/function
• Questions from “SDQ”
– Do the difficulties you mentioned distress you
(teen) or your child (younger child)?
• How much?
– How much do they interfere with life?
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At home
With friends
In school
In other activities
3. Asking for permission to offer
advice
• Summing up your thinking and checking
for agreement
– May need to cycle back to get more
information
• Do they still agree that this is something
they want to do something about?
– If no, what should be monitored, what would it
take?
Giving advice
• Rationale
– Being directive can fail even when people want help
• Anxiety, ambivalence, shame, loss of control
– Medical provider is usually not the first person in the
chain of consultation
• People come with prior ideas and opinions (about cause,
condition, treatment) that need to be incorporated
– People will accept advice they can’t follow
• Need to actively identify barriers
Asking about readiness to act
• People may be aware of a problem but not
yet ready to act on it
– The kind of advice needed depends on this
“stage of change”
– Mis-matched advice likely to be rejected
• If ready: get permission to give advice
• If not ready: what would motivate action?
What would be grounds to act?
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When you get to give advice
• Ask for permission
– Helps patients maintain sense of control
• Ask for their ideas
• Offer advice as set of choices
– Preferably include their ideas among choices
• Frame as short and long term plans
– What might help now
– What diagnostic steps to take
Asking about barriers
• Easy to skip this step in a quick visit
• Evidence suggests even motivated
patients appreciate help with logistics
• Asking allows people to think through and
get more committed to plan
• Opportunity to build alliance and anticipate
“resistance”
Responding to “resistance”
• Overall, emphasize choice and time to
discuss
• Apologize for getting ahead
• Agreeing with a twist
• What would it take?
Getting information: apologize for
“getting ahead”
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Getting information: what would be
grounds to act?
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Agree “with a twist” and inform
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Summing up
• Evidence suggests these skills are worth the
time it takes to use them
– Also suggests they don’t take that much time
• It’s a team effort – worth thinking about who
on the team does what part best
• Only a part of building a larger system of care
– But may be an essential part
Much thanks