Family physicians face the challenging task of understanding and working in all three spheres of the biopsychosocial model. Patients often present with a complex mixture of physical and emotional problems. Ideally, physicians recognize the contribution of psychologic and social factors and incorporate them into the medical care of their patients.
Numerous studies confirm that emotional problems are prevalent in patients who present to family physicians.1 Few of these patients are referred for psychiatric care, in part because the current managed care climate discourages specialty mental health referrals. Even when patients are referred, they are often reluctant to follow through with mental health specialists for a variety of reasons. Therefore, family physicians should develop strategies to manage these patients while simultaneously tending to their medical problems. In particular, they need an effective method of incorporating psychotherapy into the patient visit.
The BATHE technique is a form of psychotherapeutic intervention that is designed to fit smoothly into a 15-minute appointment.2 The acronym BATHE refers to the components of the interview. This interview format allows the physician to assess the background situation, the patient's affect, the problem that is most troubling for the patient and the manner in which the patient is handling the problem. It concludes with a response that conveys empathy.
Using the BATHE Technique
The family physician can usually elicit the background situation for the patient visit with a simple statement such as “Tell me what has been happening.” This conveys the physician's interest and invites the patient to share any present concerns. At times, the physician can feel overwhelmed by the story that unfolds and may even regret soliciting the information. Therefore, after several minutes of careful listening, the physician should move forward and clarify the patient's emotional state. The physician cannot assume to know how the patient is feeling in response to a situation. Thus, the question “How do you feel about that?” often yields an unexpected answer. Similarly, the question “What troubles you the most about this?” helps the patient to focus and provides understanding and insight for both physician and patient. Based on the response, the central concern can often be identified.
The physician then asks how the patient is handling the situation. This question sends the message that the physician believes that the patient has been able to cope and respects the patient's method of dealing with the problem. The patient may wish to work with the physician to develop new coping strategies. The nonjudgmental neutrality and unconditional positive regard implicit in the BATHE technique create an excellent “work environment.”
The technique concludes with an empathetic response by the physician. A response of this type conveys understanding and support. Empathy is shown by authentic and sincere remarks, such as “That must have been difficult,” or “I can understand that you would feel angry.”3 Empathy is vital to establishing and maintaining a working relationship between patient and physician.
Within the simple framework of the BATHE technique, there is endless possible variation. The overly talkative patient benefits from the structure and focus that are provided as the physician moves from one question to the next, using statements such as “I hear there are many things happening right now, and it is important for me to understand how you feel about this.” Alternatively, the physician may ask, “Out of all of these problems, what is the most troublesome for you?”
The interview with a more silent patient proceeds in a similar fashion. In fact, the silent, anxious patient may appreciate the straightforward questions that are asked in the BATHE technique. A silent, angry patient may speak in order to correct the physician. In one particular case, a physician's inquiry about recent events was met with a surly response, “Not much is happening,” followed by a lengthy silence. The physician responded that the patient seemed to feel “down.” The patient quickly interrupted and informed the doctor that he felt frustrated. His most troublesome thought was that any new ventures were doomed to failure. The physician was able to empathize and agree that it might seem reasonable to handle this situation by staying silent. The patient felt understood and believed that the physician accepted and respected his silence.
Some patients insist that they cannot handle their problem or situation. In such cases, it is important for the physician to reassure the patient that he or she has coped to this point and then express an interest in learning about or understanding the strategies that the patient has developed thus far. For example, one woman presented to her physician describing high stress levels and resultant feelings of fear. She was troubled by the thought that she might choose to leave her home to escape the problems. The physician was able to empathize and then asked the patient how she was handling this situation. Several times the patient said that she could not handle the stress. The physician persisted, stating that it was important to understand how she had managed to this point. At this point, the patient sheepishly described using a simple, safe escape into detective novels. The physician was quick to accept and validate this type of escape, as well as the patient's need for other forms of refuge from her problems. As this case shows, persistent inquiry and genuine interest can help patients share the many creative and efficient strategies that they have developed to cope with their problems.
While the BATHE technique may appear elementary, it embodies many essential elements of successful psychotherapy.4,5 These elements include the establishment of a therapeutic alliance, empathy on the part of the clinician, identification of the central conflict, the development of insight and awareness, and the discouragement of dependency. In particular, the BATHE technique discourages dependency and encourages adaptation and the establishment of realistic coping strategies. This is crucial for the physician who must continue to see other patients and for the patient who must continue with the activities of the day.
Poor Social Skills
Functionally illiterate and socially disadvantaged patients frequently display emotional distress as a result of their inability to provide for their own needs (food, lodging, comfort, security and self-esteem). Intensive psychotherapy is not an effective use of resources for such patients. Rather, they benefit more from referral to appropriate life-skills programs, such as an adult literacy program, parent effectiveness training, a parent aid program, an options-for-change program for substance abusers or other educational and support programs offered through various community and social services agencies.
According to one recent study,6 family physicians have an extremely low rate of referral to life-skills programs, perhaps because they are not familiar with these resources or because their patients are reluctant to accept these remedial services. This is unfortunate, since the frustration and helplessness of functionally illiterate and/or socially disadvantaged patients can often be addressed in an educational framework.
Illustrative Case. A 23-year-old single parent was seen by her family physician for psychotherapy. No history of mood or anxiety disorder could be elicited. This patient described difficulties caring for her two preschool-aged children. Her childhood included many years of moving back and forth from home to foster homes because her parents were unable to provide for the family consistently.
The patient described prominent feelings of anxiety and frustration. When asked what was most troubling to her in her current life, she replied without hesitation, “I know nothing about how to be a parent.” Having listened to the history of her early childhood, the physician was able to empathize with this distress. Together, they discussed the community resources that would help in this area.
The BATHE technique was used successfully in this patient. First, the physician elicited information regarding the stress of caring for young children (background). The patient's anxiety (affective component) was then related to her lack of familiarity with parenting skills (most troubling problem). Thus, the physician could discuss reasonable strategies to remedy the situation (how she could handle the problem) and demonstrate genuine concern (empathy).
Patients who must deal with psychologic distress caused by chronic intractable pain or severe physical disability constitute another challenging group. In these patients, restoration of the previously healthy physical self may not be possible.
The physician can provide meaningful empathy regarding the loss of health and then help these patients work through the grieving process. This necessary grief work allows patients with chronic pain or severe disability to channel their feelings of anger and to deal with anxiety, denial and depression. Through this process, many patients mature and find new pathways. Without such care, patients with chronic illnesses can easily develop intractable anger or depression.
Illustrative Case. A 46-year-old man was followed by his family physician for problems related to transverse myelitis. The patient was the only child of hard-working immigrant parents, and his identity revolved around his career. His brief but regular visits with the physician allowed him to express his anger and sadness about his disability. The most troubling aspects of the patient's situation were his loss of productive employment, self-respect and self-esteem. Eventually, the patient was able to channel his anger and his drive to work into a successful woodworking business. Clearly, validation of the patient's feelings by the physician assisted in the restoration of self-esteem.
Frequently, disability or pain was the reason for this patient's visits to the family physician (background). In many of these visits, he displayed and expressed feelings of anger or sadness (affect). The core issue for this patient was disruption of his self-esteem (most troubling problem). He worked to restore his identity through the creation of a small-scale enterprise (method of handling the problem). In talking with the patient, the family physician expressed his understanding of the importance of work to self-esteem (empathy). The visits were useful in identifying the central issue and maintaining the patient's self-esteem.
Some patients have feelings of depression as a result of learned helplessness. In early childhood, these patients were exposed to trauma (i.e., abuse, deprivation, abandonment). Since they had no opportunity for escape from pain, they developed the “learned helplessness” response.7 Learned helplessness is most often accompanied by feelings of powerlessness and frustration. However, feelings of anger, resentment, shame, guilt, fear and anxiety can also be prominent. These patients are frequently refractory to conventional antidepressant drug therapy or psychotherapy.
In patients with learned helplessness, the BATHE technique validates assertive coping mechanisms and challenges self-defeating behaviors. The aggression or frustration identified in the affect is mobilized and rechannelled into self-fulfilling ways of being. The question concerning what is most troubling about a patient's situation often evokes responses that trace the pain of these patients to their early memories of trauma.
Expression of empathy is then possible, and these patients are encouraged to explore strategies to deal with their pain. The session serves to remind both patient and physician that the burden of responsibility for this work rests with the patient. Dependency is discouraged. Instead, the physician is a valued, concerned ally.
Illustrative Case. A 42-year-old woman was followed for depression and marital discord. Unipolar depression was diagnosed, and an antidepressant was prescribed.
In follow-up visits, the patient described a current abusive relationship, as well as severe physical and sexual abuse in the past. This patient spoke frequently of feeling fear and anxiety. She was most troubled by her belief that she had no way out—no escape. The patient related that when she was a child, she was locked in a closet for long periods. She remembered feeling powerless and fearful.
Given this picture, the physician was able to understand the patient's anxiety and inertia. In subsequent appointments, the patient requested information about women's shelters and employment programs. Options were considered and framed as doorways or opportunities, but the physician was careful to avoid pushing the patient toward ready-made solutions. The patient undertook full-time employment as her depression resolved.
This patient's situation was one of past and present abuse (background). Her most prominent feeling was anxiety (affect). The current situation, her abusive relationship, triggered the patient's belief that escape was impossible (most troubling problem) and that she would be better off to stay quiet and still (method of handling the problem). After listening to the story, the physician was able to understand and sympathize with her response (empathy). Consequently, the patient felt understood and respected. Following clarification of these issues, the patient gradually became eager to search for other coping strategies.
The effective physician listens to the patient's current reality and works with the patient to identify the predominant feelings and the central conflict. This facilitates empathy and positive regard for the patient. The responsibility for handling the problem remains with the patient. However, the physician may validate the patient's existing coping strategies or work with the patient to devise new methods of dealing with distress.