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The Social Work Hat of Behavioral Health Consultation

Posted By Preston Visser, Thursday, December 26, 2013

This is part of an ongoing blog series by early career professionals and trainees. Check back each month for a new post by up and coming professionals!

Imagine with me for a moment that you are on a journey hiking through Yosemite National Park (the government stays open in this imaginary world). On day 2, a surprise snowstorm forces you to veer off your trail. On day 3, you have lost your map and are becoming increasingly convinced that each step you take gets your more lost. At the brink of desperation, to your great relief you spot someone wearing that iconic Park Ranger hat. The friendly Ranger gives you a map with directions to get back to your trail, and in a few minutes you are headed "True North” (the Ranger bore a striking resemblance to Kirk Strosahl). Technically, you are still far from your original trail. Also, the Ranger was too busy to accompany you, so you are alone again. Nonetheless, your brief encounter with someone that understands the park helped you make sense of things, which changed everything.

Each patient we encounter is on his or her own life course. While we do not choose this course, we can be of assistance in reducing unnecessary detours and pains. Unlike traditional therapists, behavioral health consultants (BHCs) are generally too busy to accompany patients for long on their journeys. Therefore, our best function is often to help patients get their bearings set. This process often occurs through brief interventions that help patients connect to values that guide their choices. Increasingly, however, I see that we also have a great opportunity to help patients understand, navigate, and even benefit from complicated social systems.

As an early career psychologist, the last few years of my clinical work have been dominated by efforts to rectify the great predicament affecting us all: how to address the tremendous need we encounter despite substantial limitations of time and resources. My struggles with this ubiquitous issue have helped me to broaden my own professional identity to include the belief that I need to maintain a good understanding of the systems and resources affecting patients in my community. I think of it as wearing a social work hat.

In an insightful CFHA blog series on the topic of "Professional Identity” earlier this year, Tom Bishop and Jeff Ellison reminded us that, perhaps more so than other professionals, we BHCs need to view ourselves broadly in the context of the diverse teams with which we work. My role in integrated care teams involves more than being a good therapist and diagnostician. As the BHC, I need to be able to help patients determine what factors, personal and systemic, can be altered to get them closer to the health they want.

Throughout graduate school, I had little experience interacting with social service agencies, insurance companies, residential treatment facilities, nonprofit organizations, and other entities that patients often engage during their treatment. I now fully recognize my ignorance in these matters, so I ask a lot of questions. I frequently call organizations to ask for guidance, and I am blessed with a spouse that is a social worker and with colleagues that work hard to obtain and share information about systems and organizations.
I need to maintain a good understanding of the systems and resources affecting patients in my community

Here are a few real-world examples of interventions that seem to involve a social work hat:

  • Patient is experiencing early to middle-stage Alzheimer’s symptoms, and family does not understand the diagnosis: Connect family to Spanish-speaking support groups and information
  • Family is dealing with alcoholic father: Provide information about Al-Anon group to attend
  • Patient with mental retardation (MR) describes major stressor is that the payee for his social security income is abusing him and stealing his money: File report of abuse with appropriate office, and contact Social Security Administration to learn about options for changing one’s payee
  • Elderly patient is suffering physically and psychologically due to difficulty caring for her niece that has severely uncontrolled schizophrenia: Assess available familial supports, help patient problem-solve about why her attempts to transfer niece to residential care have failed in past, and call hospital and legal authorities to help patient plan for transfer of care
  • Patient is considering applying for deferred action in order to attend college, but fears that she will be deported in future: understand White House executive order in order to help the patient explore pros and cons
  • Patient is distressed by unplanned pregnancy: connect to appropriate support services
  • Young adult obtains custody of 2 younger siblings after her mother and grandmother both pass away, and their house is in foreclosure: connect patient with appropriate social services
  • Patient’s primary concern is inability to find employment: help patient locate unemployment programs
  • Patient with schizoaffective disorder and alcohol dependence is fired from psychiatry for continued alcohol abuse: help patient locate a substance use program close enough to his home, and call patient periodically to encourage adherence to treatment plan
  • Patient feels stuck in relationship with violent partner due to fear of homelessness and deportation: Connect patient to "Mujeres Latinas en Acción,” an organization for such women
  • Mother is worried about academic performance of child that appears to have learning disability: Help mother to understand and follow protocol for requesting IEP evaluation
  • Mental Health Referrals: Unless you are fortunate enough to work somewhere with both integrated care and co-located therapy (ahem, Cherokee), then you will need to have a list of places to refer patients needing long-term therapy/psychiatry. In Chicago, maintaining such a list can be challenging, particularly since mental health resources seem to change frequently. Our department set aside admin time to create a large excel file with referral sources and relevant information, including insurances accepted, languages served, sliding scale fee, etc. We also took a field trip to the place that we refer most patients for psychiatry and therapy services. I wish we could take a similar trip to all of our referral locations.

By disposition and training, BHCs are generally good communicators and capable of helping patients connect to adaptive coping skills and guiding values. I believe we can maximize our impact by becoming comfortable wearing a social work hat. Better knowledge of systems and context will help us create better maps for getting patients back on trail.

Preston Visser is an early career psychologist working at a federally qualified health center located in an underserved neighborhood in Chicago, Illinois. He was part of the inaugural class of students in the integrated primary care psychology doctoral program at East Tennessee State University. Preston completed his predoctoral internship through the Chicago Area Christian Training Consortium, with his primary rotation at Lawndale Christian Health Center (LCHC). He later completed his postdoctoral fellowship at LCHC and is now a licensed behavioral health provider at the clinic. At LCHC, he works collaboratively with primary care providers to address behavioral health concerns of patients diverse in age, culture, and language (English and Spanish). Since graduating, he has been developing coping skills for managing withdrawal stemming from a lifelong dependence on school. He is 18 months sober, but with the RxP movement underway, relapse seems possible.

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