Interestingly the word “Jenga” does not mean “angst derived from a predestinated tower of calamity.” Jenga’s roots are in Swahili from the word “kujenga” meaning “to build” (“Jenga”, 2025).

Jenga got me thinking about integrated care on one of these fun Saturday nights. We take the warm handoff on the behavioral health side (or provide the handoff on the care side). The “patient” * is facing something that feels wobbly in their life and is hoping for more stability. It can be nerve-wracking for the patient, sitting down, facing the problem, worried everything might topple over. The problem is assessed from various angles. The visit discussion eventually turns to finding an answer, option, resource, tool, or treatment that might help build on, or anchor, their sense of balance, and often, when we listen carefully, illustrate the problem, and look toward past times of balance and strength for the patient, an idea is generated. The visit’s move or actionable item to put in place at the end of the visit may even come from the patient’s “own stack of blocks”— resources, actions, or strategies they have turned to in the past for support, or are a strategic return to routine and habits of stability and balance.

I’ve started to use the term “Reverse Jenga” to describe this process in Primary Care Behavioral Health trainings (McIntosh & Cos, 2024). Whether we are doing COCM or BHC work, using a 5As (Robinson and Reiter, 2025), functional contextual (Cahill et al, 2024), or your own visit organizing structure, every visit comes to a decision-point, a moment that is the intersection of expertise: the patient’s lived insider experience and the clinician’s insightful outsider knowledge. Reverse Jenga raises the following questions: “What can we do in this moment AND what will have the most potential for an impactful outcome in the person’s life, with the easiest investment of time and energy?” In other words, instead of stacking stressors, life’s surprise curveballs, intrusive thoughts, feeling overwhelmed, and unsuccessful coping attempts on a life that feels unmoored, how can we reverse the process, and take from the blocks of skills and resources to reinforce the wobbly aspects of one’s life, warmly and parsimoniously, in the context of a brief primary care intervention?

Reverse Jenga is an ideal consideration as a practice philosophy. A person has a strong base, resources that have gotten them through this point of their life, and moving toward what matters in their life and their demands on them with balance. How do we optimize this new need for steadying from their existing stack of blocks, or supplement with additional support?

To be a true Reverse Jenga master, we need to work in tandem to help a patient with whatever experienced imbalance is occurring in their own configuration of their life tower. But what other essential clinician characteristics are needed? Clearly, opinions may differ, and I would humbly suggest that the core Reverse Jenga tenets are built on:

1. listening closely to hear

2. fostering a collaborative spirit

3. appreciation of patient context (and dare I say, relevant patient values)

4. an orienting philosophy and approach toward organizing information the clinician receives

5. sharing the subsequent conceptualization back in an understandable narrative to the patient

6. and the wisdom of knowledge that might help, and furthermore, when to be additive in suggestions or options and/or when to repurpose what has already worked for the person

With those guiding principles as one’s mindset, the move to build the tower up toward grounded stability in a primary care visit is advanced by the power of connection, being heard, and creative collaboration. There are some discrete core clinical competencies that may level up one’s Reverse Jenga game, including:

● Rogerian attending skills

● Motivational Interviewing spirit and approaches

● Have a good grounding in what differentiates common DSM-5 conditions

• (e.g., how PTSD (reliving past events/ triggers from past trauma of perceived danger/ feeling unsafe) and panic (fear of another panic attack and how that can generalize to similar settings) may fuel avoidance differently, and therefore, lead to different education and offered solutions)

● Being well-grounded in common factors

• (e.g. poor sleep can worsen mood, anxiety, pain; insufficient stress coping can snowball into other problems; problems with communication, trust, and perceived distance in a relationship can contribute to sexual health and relationship challenges)

● Patient goal-orientation, “what are the person’s goals right now in getting better?”

• Building strengths in SMART Goals

● Scanning across patient goals and making the “wise move”

• And “what could I do today that might target, simply, multiple wishes or goals”
• Or “If I had time to address one of these patient concerns today, would it help the other concerns as well” (e.g., common factors)

● Conceptualizing problems within a personally established explanatory framework (i.e., CBT, biopsychosocial broadly, or process-based) and translating that into practical understandable patient story and psychoeducation

● Developing a wealth of brief single-session interventions and multiple visit approaches for common factors and presenting concerns

• Brief: grounding skills, relaxation skills, behavioral activation, sleep change education and approaches, solution-focused, writing/ journaling, assertive and communication skills
• Extended: problem-solving interventions; CBT/ ACT/ DBT approaches that can be conducted over a series of visits toward addressing a common factor (e.g. anxiety, psychological inflexibility/avoidance, distress intolerance); COCM management skills and education

● Focus on functional outcomes

• Can you think of personally relevant, small movements to help a person reach their target?
• Outcome-based care, both objective measures (i.e., PHQ-9) and behaviorally focused tracking for the patient (e.g., can I walk 5 blocks after my AM coffee, three days a week)

● Humility to go with what works for the patient, not needing to “interventionalize” each encounter, rather using additional skills, techniques, and medications tactically as needed. Parsimony, perceived effectiveness, and patient buy-in are the golden standard in this decision-making and humility

Using Reverse Jenga, we can listen, focus on context, and consider what feels balanced and where the unease/ “rocking” is experienced most for the patient. We can look toward what “block” we can move, including 1. insightful solutions that the patient may generate after discussing their problem, 2. helping encourage returning to past “solid” structures of daily functioning or own coping repertoire; and/or 3. introducing new supportive blocks including psychoeducation, brief skills or therapeutic moves, medication, and as warranted, treatment referrals. A good functional assessment, that includes signs of what are the key stability factors (e.g. daily activities, support system, sleep, substances, preferred hobbies, spirituality, and work/school/volunteer), can help maximize success in stabilizing and making effective moves.

Hope this metaphor of Reverse Jenga gives a helpful framework to consider how to be most effective in organizing your Assessment, collaboratively engaging in Advise and Assist, and Arranging next steps (if you engage in the 5As model). As a final exercise, I’ve included a few guided questions to look at your Reverse Jenga skills and self-reflect on opportunities to master your strategy and moves toward a balanced effective collaborative practice.

Self-Reflection

Review the list and rate yourself 0 to 5 (Anchors: 0 not at all; 3 okay, some room for growth; 5 doing well, generally)

How well, during my primary care visits, do I

● Clarify the core concern with the person: ___

● Prioritize the person’s chief concerns: ___

● Readily identify what might be contributing to, or maintaining the problem(s) (conceptualization skills on the fly, during the visit): ___

● Have a diverse skill set of interventions to apply in the primary care context: ___

● Successfully apply an intervention parsimony, targeting what will have the most impact, across multiple domains, within primary care (“Reverse Jenga”): ___

● Co-creating concrete and personal functional outcomes with the patient, relevant to the problem(s): ___

● Explaining and effectively putting Functional Outcomes into action with the person: ___

Awareness: After reviewing your self-ratings, what area(s) would you most like to improve? _________________________________

Openness: What might you need to learn, attend, seek supervision, or practice to get better at “Reverse Jenga” in your visits? ______________________________________

Engagement 1: What would be your ultimate goal(s), what functional improvement would you want to see in your visits? ___________________________________________

● (e.g., I want to better understand and share back what the patient is experiencing during their visit; I want more tools in my inventory to help the patient in the moment).

Engagement 2: What are one or two practical steps to show progress to your ultimate goal(s) aka Functional Outcomes ______________________________________

● (e.g., I will ask and take 90 seconds in a visit to repeat the narrative I am hearing before we move toward an intervention; I will practice using some journaling approaches and grounding techniques with several patients).

References

Cahill, A., Martin, M., Beachy, B., Bauman, D., & Howard-Young, J. (2024). The contextual interview: A cross-cutting patient-interviewing approach for social context. Medical Education Online, 29(1), 2295049. Jenga (2025, August 8). In Wikipedia. https://en.wikipedia.org/wiki/Jenga

McIntosh, J. & Cos, T. (Oct. 2024). How to practice integrated care effectively, efficiently, and expertly: Targeted skills and practice session. Annual conference of the Collaborative Family Healthcare Association, San Antonio, TX.

Robinson, P. J., & Reiter, J. T. (2025). Assessment and Intervention in Primary Care Behavioral Health. In Behavioral Consultation and Primary Care: A Guide to Integrating Services (pp. 223-252). Cham: Springer Nature Switzerland.

* Patient is used as the term for the person receiving assistance, as current medical parlance dictates

Disclaimer

The contents of this essay, and the ideas put forth, do not represent the views of VA or the United States Government.

Photo by Valery Fedotov on Unsplash