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The Fifteen Minute Hour

Preface to the Fourth Edition

The publication of the fifth edition of The Fifteen Minute Hour by Radcliffe Publishers Ltd. is a source of great satisfaction to us. Our purpose in writing this book, which has not changed since our first edition in 1986, is to convince you that by routinely incorporating therapeutic talk into your practice, you can solve and often prevent many problems. During the years since publication of the first edition, many things have changed. In earlier editions we speculated about a number of mind-body connections that have since been substantiated by research. The increase in terrorism around the world has compromised people's basic sense of safety. Evidenced-based medicine, electronic communications, the plethora of information on the internet, cost control, cultural diversity, and other societal trends have affected the delivery of medical care. In spite of all these changes, the importance of the practitioner-patient relationship remains a constant. The approaches described in this text are designed not only to enhance the therapeutic relationship, but also to make your practice more productive and pleasurable.

The book has grown out of our combined 80+ years of clinical practice and experience in training residents, practicing physicians, nurse practitioners, and other primary care providers in the art of therapeutic talk. In the 28 years since the publication of the first edition of The Fifteen Minute Hour, we have heard from many enthusiastic practitioners in the United States, Australia, Brazil, Canada, Denmark, Israel, Malta, the United Kingdom, and elsewhere who have assimilated our techniques into their practices. We were delighted when the second edition was translated into Japanese, and the third edition was translated into Korean, because this attested to the multicultural relevance of our techniques. The overwhelming consensus is that the strategies work: patients respond, practitioners save time, provider-patient relationships become richer, and everyone feels a little less stressed out.

Although our techniques will certainly increase your ability to recognize and treat emotional problems, this is not a psychiatry text. It is also not a text on providing in-depth psychotherapy or long-term counseling although it will enhance your ability to recognize and manage common emotional conditions resulting from the stress of living in the 21st century. You will be able to address patients' concerns often at an early and manageable state. Incorporating useful knowledge from psychology and psychotherapy into your clinical practice will help you become more effective in dealing with the emotional component of problems patients bring to the primary care practitioner and leave you feeling more satisfied.

When The Fifteen Minute Hour was first published, addressing psychological issues related to the patient's health status were not seen as critical. Max Planck has been quoted as explaining that "a new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it." We have been preaching this "gospel" for over 28 years. You are our new generation. We hope that you will master our simple techniques to deal effectively with the psychological dimensions of patient care. If you already focus on patients' psychosocial problems or would like to do so more efficiently, this book will provide you with background material to help you apply universal principles. We will point out what actually works in practice to improve patients' functioning. Furthermore, we will provide specific suggestions, approaches to therapeutic interventions, and particular phrases that we have developed, practiced, taught, and tested for over 30 years. We now have evidence to document that our techniques increase patient satisfaction1,2improve practitioner-patient relationships3 without adding significantly to the length of the visit.4

Our way is not necessarily the only true, good, or beautiful way to make therapeutic interventions, but it is a pragmatic and flexible approach that is easily learned, and it works! Also, it is designed to fit into a regular office visit of 15 minutes or less.

We strongly recommend that you read this book from beginning to end. Early chapters provide the theoretical background and rationale, and subsequent chapters focus on putting this knowledge into action. In essence, this is a how-to book. We aim to help you develop skills that will benefit both you and your patient. We provide some effective tools for use in your practice, and we explain exactly how to use them. These tools require less investment of time and energy than you might imagine.

There are many schools of therapy. We are not preaching a dogma, nor do we have the need to establish a true religion in this area. We are quite comfortable with practical eclecticism because it works, and primary care practitioners desperately need techniques that work. We invite you to apply our techniques and empirically confirm their usefulness for yourself. In essence, we are saying, "Try it, you'll like it."

John Godfrey Saxe, a Vermont lawyer and humorist, wrote "The Blind Men and the Elephant"5 over 100 years ago. This poem was based on an Indian tale thought to date back thousands of years. It still seems most applicable.

                It was six men of Indostan
                    To learning much inclined,
                Who went to see the Elephant
                    (Though all of them were blind)
                That each by observation
                    Might satisfy his mind.

                 The First approached the Elephant,
                    And happening to fall
                Against his broad and sturdy side,
                    At once began to bawl:
               "God bless me! but the Elephant
                    Is very like a wall!"

                The Second, feeling of the tusk,
                    Cried, "Ho! what have we here
                So very round and smooth and sharp?
                    To me 'tis mighty clear
                This wonder of an Elephant
                    Is very like a spear!"

                The Third approached the animal,
                    And happening to take
                The squirming trunk within his hands,
                    Thus boldly up and spake:
               "I see," quoth he, "the Elephant
                    Is very like a snake!"
 
               The Fourth reached out an eager hand,
                    And felt about the knee
               "What most this wondrous beast is like
                    Is mighty plain," quoth he;
                "'Tis clear enough the Elephant
                    Is very like a tree!"

                The Fifth who chanced to touch the ear,
                    Said: "E'en the blindest man
                Can tell what this resembles most;
                    Deny the fact who can,
                This marvel of an Elephant
                    Is very like a fan!"

                The Sixth no sooner had begun
                    About the beast to grope
                Than, seizing on the swinging tail
                    That fell within his cope,
               "I see," quoth he, "the Elephant
                    Is very like a rope!"
 
               And so these men of Indostan
                    Disputed loud and long,
                Each in his own opinion
                    Exceeding stiff and strong,
                Though each was partly in the right,
                    And all were in the wrong!
Different schools of psychology and psychiatry view the patient and the patient's problems from different perspectives. Each provides a small piece of useful insight. Collectively these fragments form a tool kit which can be used to reduce patients' suffering, prevent many physical and psychological illnesses, and help patients structure more satisfying lives for themselves and their loved ones.

In writing this book, we have tried to present a coherent whole. Each chapter builds on the previous one, and illustrative clinical examples appear throughout the text. The case material, including all new examples, is based entirely on actual encounters, although we have changed names and altered some details to guarantee patients' confidentiality. In revising the text for the current edition, we have considered the many thoughtful critiques of The Fifteen Minute Hour, and we have cited numerous new studies, clarified important sections, and eliminated extraneous material.

Chapter 1 presents important background material. We discuss how the current understanding of the body/mind connection supports the need to address medical patient's psychological issues, why the primary care practitioner is qualified to enter this realm, and how our therapeutic interventions differ from those of a traditional psychiatrist. Chapter 2 details patients' reactions to stress and provides a theoretical basis for the effectiveness of the type of interventions we are promoting. We bring together research findings from a variety of sources, some of which may be new to you, and try to establish a strong foundation.

Chapter 3 now introduces the BATHE technique as a basic structure to obtain psychosocial data, support patients and build a therapeutic relationship. We have moved this material closer to the beginning of the text, because this easily learned "procedure" is essential for obtaining critical information while providing comfort and insight to patients. As Dr. Vikram Gupta recently put it: "BATHE is the most valuable tool in my 'art of medicine' toolbox and I use it everyday and all day."6

Chapter 4 provides examples of small interventions that have large benefits. This material is drawn primarily from Cognitive Behavioral Therapt (CBT) and other modalities that lend themselves for use in a brief office visit. We discuss the elements common to all schools of psychotherapy and bring in several new concepts to simplify the process of indicing positive change. Chapters 5, 6 and 7 provide a rich variety of techniques that can be used in brief, follow-up counseling sessions with patients. We have included material dealing with hypochondriasis, anxiety, depression, grief, potential suicide, and issues related to children and teens.

Chapter 8, which was created for 4th Edition, presents material from the field of Positive Psychology and shows how to potentially enhance patients' health by focusing them on the affirmative aspects of their lives and relationships. We introduced the Positive BATHE which has received enthusiastic response. It is our hope that the techniques and applications we outline will enrich the experience of both practitioners and patients.

Chapter 9 suggests ways that incorporating our material will improve the office environment, increase patient satisfaction, and prevent staff and practitioner burnout. Throughout the book, we have added new evidence-based material related to behavioral medicine. Chapter 10 projects our vision of what is possible for primary care practice given widespread acceptance and application of these ideas.

We hope you will enjoy reading The Fifteen Minute Hour. Please have fun with it. Your patients will thank you many times over.

Marian R. Stuart, Ph.D.
Joseph A. Lieberman III, M.D. MPH.
December 2014

REFERENCES:

1. Jones K, Major G, Marvel K. Counseling patients for lifestyle change: a comparison of two methods. Proceedings from the Society of Teachers of Family Medicine, Seattle, WA. May, 1998.

2. Leiblum SL, Schnall E, Seehuus M, et al. To BATHE or not to BATHE: Patient satisfaction with visits to their family medicine physician. Fam Med. 2008;40(6):407-11.

3. Kallerup, H. Patient's and doctors considerations about using communications strategies. Proceedings from the 24th Annual Meeting of the North American Primary Care Research Group, Vancouver, BC, Canada, Nov 3-6, 1996.

4. Searight HR Efficient counseling techniques for the primary care physician. Prim Care Clin Office Pract. 2007;34:551-570.

5. Saxe, JG. Clever Stories of Many Nations: Rendered in Rhyme. Boston: Ticknor & Fields, 1865. 6. Vikram Gupta, MD, personal e-mail, June 1, 2014.