Applied Evidence
Unhealthy drug use: How to screen, when to intervene
Recognizing and helping patients at risk for a substance use disorder doesn’t have to be time-consuming. Here’s how to make screening and...
Putting SFBT into action
CASE › A physician who wants to use SFBT to help Mr. G might start by asking an “exception” question (“When have you been able to eat in a more healthy way?”) and following up with a “difference” question (“What was different about those times?”). Perhaps Mr. G remembers that previously he had improved his diet by buying and keeping a bag of apples in the car to snack on. He additionally recalls that he ate less at night if he brushed his teeth right after dinner.
Mr. G decides to revisit the apple and brushing strategies. Mr. G’s physician commends him for wanting to be there for his kids and identifying the apple and brushing strategies. She helps him design a small “experiment” in which he would use these strategies and observe the outcomes. They arrange to speak in one month to discuss how things are going.
Cognitive behavioral therapy
CBT is a practical, goal-directed, action-oriented treatment that focuses on helping patients make changes in their thinking and behavior.23-28 A basic premise of CBT is that emotions are difficult to change directly, so CBT targets distressing emotions by focusing on changing thoughts and/or behaviors that contribute to those emotions. CBT can be useful when the patient and FP can find a link between the patient’s thoughts and a troubling behavior. After thoroughly assessing situations that bother the patient, the FP provides the patient with an empathic summary that captures the essence of the problem. CBT practitioners typically conceptualize problems and plan treatment by working with the patient to gather information on the patient’s thoughts, feelings, and behaviors.
By exploring patterns of thinking that lead to self-destructive behaviors, an FP can help the patient understand and challenge strongly held but often limited patterns of thinking. For example, a patient with depression-related overeating might think, “I am worthless. Nothing ever goes right for me.” A patient with anxiety-related smoking may believe, “I am in danger.” Through a collaborative, respectful relationship, patients learn to test their “hypotheses,” challenge their thoughts, and experiment with alternate ways of thinking and behaving. Patients are given homework assignments, such as tracking their thoughts and behaviors, practicing relaxation techniques, and challenging automatic ways of viewing themselves and the world around them.
Putting CBT into action
CASE › An FP who wants to implement CBT to help Mr. G would begin by trying to understand his patient’s view: “Tell me how your weight is a part of your life.” Next, he would offer Mr. G an empathic summary: “You’re worried that your weight could cause some of the same health problems your dad has and that will prevent you from being the kind of active father you want to be. You sometimes eat when you are feeling stressed and tired, but then you feel worse afterwards.” He would assign Mr. G homework: “Notice and write down your thoughts when you are eating due to stress rather than hunger. Bring this in and we can look at it together.” The FP might also teach Mr. G relaxation breathing, and encourage him to try doing 5 relaxation breaths when he feels stressed and wants to eat.
Narrative techniques
NT can be effective for patients who are in the Precontemplation or Contemplation stages of change.29-33 NT focuses on the patient’s story, context, and language. FPs explore connections, discuss hypotheses, strategize, share power with the patient, and offer reflections in order to understand the patient’s illness experience. This approach fits well with the complex way that many behaviors are woven into the concerns that patients bring to their FPs. As a patient’s story unfolds, the diagnosis and treatment can occur simultaneously. The FP involves the patient in choices about how to proceed and what to focus on together.
NT avoids unsolicited advice and interpretations and rarely imposes the FP’s agenda on the patient. This approach invites the FP and patient to co-create an understanding and narrative of what the symptoms mean, why they are there, and what can be done about them. Ultimately, this approach can result in a new narrative that puts the patient on the path to healing.29-33
Putting NT into action
CASE › A physician might implement an NT approach with Mr. G to co-create a narrative about health and life goals by asking him: “Tell me about how losing weight fits into your goals for being there for your children. Tell me about how you see yourself avoiding some of the health problems your dad has faced.”