Common Factors & Time Management
Mental health problems fall into categories, just like all health problems.
Mental health symptoms can be assessed like all symptoms: severity, frequency, duration, impact on functioning, what makes them better, worse.
Mental health disorders emerge in a predictable way, based on family history and age of onset risk.
Certain skills are effective for addressing all kinds of mental health problems.
Mental health triage is similar to medical triage.
The SOAP note
- Evaluation can be therapeutic as well as diagnostic.
- By taking concerns seriously and tuning in to what the patient or parent seems most concerned about, you begin the therapeutic process.
- People feel better when they feel heard.
You can begin by setting the agenda.
- “What are your biggest concerns today?”
- Elicit perspectives from everybody in the room
- Express interest and concern
- Gentle, non-judgmental curiosity
When you set an agenda up front you show your interest in and respect for those in the room, and hopefully prevent doorknob questions. Clarify concerns with gentle, non-judgmental curiosity, following directly on what people say: for example, “What’s that like for you? How does that affect your ability to get to school, or get along with your mom?”
Then pursue your history and physical.
- What’s going on?
- Duration, intensity, setting, what makes it worse or better
- Pertinent positives/negatives
- Scan for related conditions: mood/anxiety/psychosis/trauma/substances
Objective (mental status exam)
- How is the child’s behavior, relatedness, mood, affect, clarity of thought, insight, judgement at this time?
- Are there current suicidal or homicidal thoughts/intention?
- What are we dealing with, and how serious is it right now?
- This may not be a diagnosis, but a statement of the problem and what’s contributing to it.
- Triage based on your risk assessment
- Join with patient and family to make a plan.
You use the same funnel-shaped process as for any history; first listening broadly, then adding questions to shape the chief complaint, pertinent positives, negatives, and possible comorbid conditions or differentials.
Your mental status exam is ongoing as you take your history: does the child appear relaxed, evasive, cheerful, hostile? Is speech pressured, normal, or with long pauses? Does she make eye contact? Does she seem to understand her situation? Specific key questions about suicidal or homicidal thoughts are addressed here if not previously.
All this leads to your assessment, which does not need to be a diagnosis, but simply a statement of the problem as you see it, level of severity, and major contributing factors, if any. Finally, you move toward a plan.
But before the plan, assess readiness for treatment.
Readiness for Treatment
None of what we have discussed so far works unless patients and families are ready for it to work. Mental health disorders can be deeply entrenched in the worldview and behavioral patterns of children and their families. The stages of treatment in motivational interviewing apply as much in these situations as they do in smoking cessation or adopting an exercise plan.
No matter how frustrating a mental health disorder appears to you as the clinician, you won't be able to treat it until the patient and family are ready (unless the situation involves immediate danger and you must intervene). You can suggest brief interventions, and you can make referrals to therapy, or offer a prescription, but these will be effective only if the patient and family are ready to accept and act on them.
Keep control of the time
One fear is that when people talk about mental health, they talk forever. You can control your time and the flow of conversation in a visit by remembering that people keep talking because they want to feel heard. If you can acknowledge that you hear them, and then guide them to a plan, you will both be more satisfied. Here are some suggestions on time-managing phrases that will help you do that.
- "What you’re saying is really important."
- "I want to be sure that we have time to talk about what we are going to do about this issue."
- "I see that we have five minutes left– is this a good time for me to share some ideas with you?"
- "We have about 5 minutes left. Would you like to try address Issue A now and set up a time to come back and work on the other ones?
The AAP has developed a mnemonic, HEL2P3 to summarize components of “common factors” communication skills that can be applied across diagnoses and populations. These skills help build a therapeutic alliance, address barriers to behavior change and help seeking, and keep discussion focused and practical.
H = hope. Hope facilitates coping.
Foster hopefulness by acknowledging the strengths and assets of the child and family and realistically describing the possibility of improvement.
- “You’ve handled difficult things before. Remember when…”
- “These symptoms are tough but they are treatable.“
- ”I am impressed that you have been able to do as much as you have, given the circumstances.”
E= empathy. Listen attentively and acknowledge distress.
- "This has been really difficult."
- "Depression hurts. It’s painful, and it makes dealing with school and family painful."
- "You haven’t gotten much help with this yet.”
- “That must be really frustrating”
L2 = language, loyalty
When you have heard enough to give you a sense of what is going on, formulate the problem as you understand it, using the child or family’s own language. Ask for verification of that understanding. If there is more than one thing going on, consider writing down what you hear to be the main issues, and then ask those present to prioritize which is most important to them.
- “What I hear you both saying is…”
- “Tell me if I have this right...”
- “Can we all agree that...”
- “Let me write down the list of things you’ve mentioned. I’ve heard say that Alex is having trouble with sleep, getting schoolwork done, not following rules at home, and losing his temper. Which feels the most important right now?”
Communicate loyalty to the family. Let them know you will help them now and be available to help them in the future.
P3 = permission, partnership, plan
Ask the family’s permission to further explore the issue or to explore management strategies. Don’t assume that you know what they would like you to do.
- "What are you hoping for here?"
- "What solutions have you looked at?"
- "How can I help?"
Partner with the child and family to identify achievable steps to address the problem and to identify barriers or resistance to taking those steps.
Develop a plan based on the child’s and family’s preferences and their sense of urgency and motivation. The plan may include an action or gathering more information about the problem, or simply scheduling a return visit to further discuss the issue with you.
Plans should include SMART goals.
- Small to begin with
- Related to behavior rather than feelings or attitudes
- Related to doing something rather than not doing something
- Related to people in the room, or factors over which people in the room have control
Resources & References
Common Factors Approach: HEL2P3 to Build a Better Alliance. AAP Practice Tools
Common Elements Approaches: Brief Interventions for Common Pediatric Primary Care Problems. AAP Practice Tools