We have all cared for patients and families reporting long wait times to see a therapist. And we know that for most patients with moderate-severe mental health concerns, the combination of medication and therapy works better than either intervention alone. Other BHCS newsletters address medication initiation for various behavioral health concerns, but what about non-medication therapeutic interventions that can be introduced in a PCP’s busy office? In this newsletter, we will review four brief therapeutic interventions that you can initiate in your office while your patient seeks more definitive mental health support. This introduces your patient to the idea of therapy and gives them a taste of concepts they can expect to learn from cognitive-behavioral therapy (CBT) or dialectical-behavioral therapy (DBT).
- Behavioral Activation
If you isolate yourself and stop engaging in activities that you once enjoyed, you lose opportunities to experience meaning, a sense of purpose, and connection with others, which makes you feel even more depressed – a vicious cycle. Behavioral Activation refers to increasing engagement with activities and relationships that are rewarding and meaningful to break the cycle of avoidance and inactivity, allowing you to experience improvements in mood and overall well-being. Simplified, the idea is to “fake it ‘til you make it.” Even if it is hard to motivate yourself at first, setting aside time every day to engage with other people or do something that makes you feel happy or accomplished helps to interrupt the vicious cycle of depression.
- Identifying and Addressing Cognitive Distortions
Everyone engages in cognitive distortions or thinking errors sometimes – below are ten common examples. However, individuals with anxiety or depression often engage in this distorted thinking more frequently. Share these examples of cognitive distortions with patients and encourage them to catch themselves when they are falling into a distorted pattern of thinking. Then, encourage them to “fact check” or reframe the distortion into a more positive, or at least neutral, thought (e.g. “I did so badly on that test and I’m totally going to fail this course” can be reframed to “I didn’t do as well as I hoped on that test, but realistically I can pull my grade up before this course ends.”)
- Mindfulness and Grounding Exercises
Mindfulness and grounding exercises can help to interrupt moments of distress or serve as healthier alternatives to destructive coping strategies like self-harm or substance use. Invite patients to try different ones to find what works for them. One example of a grounding technique is the “5-4-3-2-1” exercise – encouraging the patient to pause when they feel distressed and try to identify 5 things they can see, 4 things they can feel, 3 things they can hear, 2 things they can smell, and 1 thing they can taste. They could consider keeping a “sensory box” containing objects that help them with this exercise, such as photographs they like to look at, something fuzzy or textured that they can feel, a bottle of perfume that smells nice, etc. An example of a breathing exercise is Box Breathing – inhale for a count of four, hold it for a count of four, exhale for a count of four, and hold it for a count of four. It can be helpful to practice diaphragmatic breathing lying down with a stuffed animal on your stomach, so that you can watch the animal go up when you inhale and down when you exhale.
- Self-Compassion
Self-compassion refers to treating yourself with kindness, the way that you would treat a friend who was in a similar position. Encourage your patients to catch themselves engaging in negative self-talk and instead talk to themselves the way they talk to others (e.g. reframing “I’m so dumb” to “I’m not dumb, I have a hard time with math but I’m good at other things”), and to recognize that they are not alone in having strong emotions (e.g. “I’m really sad that I broke up with someone, but anybody else in this situation would feel sad too”).
We hope these brief interventions will assist you in starting your patients on their therapeutic journeys, even in a busy office setting. The visuals can help with explaining the strategies. If your patient or family is having a difficult time finding additional support, please refer them to the SmartCare BHCS Parent Line at 858-956-5900. And please call us at the SmartCare BHCS Provider Line at 858-880-6405 for real time consultation for your patients with behavioral health needs.
AUTHORS:
Charmi Patel Rao MD, DFAACAP
Medical Director, Vista Hill Foundation
Voluntary Assistant Clinical Professor, UCSD Department of Psychiatry
Maya M. Kumar, MD, FAAP, FRCPC
Associate Professor of Pediatrics
Division of Adolescent and Young Adult Medicine
University of California San Diego
Rady Children’s Hospital