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Collaborative Follies 3

Posted By Jennifer Hodgson and Norm Rasmussen, Thursday, April 19, 2012

 

Jennifer Hodgson

 

Jennifer Hodgson, PhD, Family Therapist

East Carolina University

 I was setting up an integrated care clinic in a family medicine residency setting in Florida. It took a while to earn the trust of the residents and faculty but even harder were the nurses. They were the gatekeepers...protectors of the providers and patients.

My students struggled getting exam room time to see patients. The providers wanted us to see their patients but the patients were processed so quickly. Then one day it hit me like a brick. We were hanging out in the precepting room joining with the providers but completely neglected joining with the nurses.

One day, a nurse was upset about something personal. We asked her if she way okay. She shared her struggle and we sat with her in her pain. The next week we had received a referral to see a patient. We were so excited. When the behavior health provider exited the room he saw a note stuck to the door, "Do not disturb. Therapy in Progress."The referrals started pouring in from that point forward. We were schooled. In our haste to join with the "physicians" we neglected the critical role of the nurses.

I cannot imagine integrated care now without them; except for now we prefer the note,
"Therapy in progress. Please disturb."

 

Norm Rasmussen

 

Norm Rasmussen, EdD, Psychologist

Mayo Clinic

 Recently I modified my integrated behavioral healthcare (IBH) approach for service delivery and teaching residents in my position as a Behavioral Healthcare Provider (BHP) in the family medicine department at Mayo Clinic. For 25 years, I used the co-located model of collaborative healthcare. My office was in the family medicine clinic, the collaboration was called the Psychology Preceptorship, and my office space was in general referred to affectionately as the "annex.” I was linked to and accepted by the family medicine staff and residents because they value collaborative care.

The recent change that I devised has been re-named as the Main Street Model of IBH. There are two important methodological differences between the prior approach and the new Main Street model. First, I now am physically in the office space where the resident physicians are located and I sit at the table where the medical preceptors reside – thus, I have migrated from the annex to main street! Second, I now have the potential to provide a significantly increased number of same day or virtually immediate IBH services such as curbstone consultation, resident physician-psychologist co-visits in the patient exam room, and "warm handoffs” from staff and resident physicians.

The first two weeks in implanting the Main Street model, I assumed the role of sitting at the medical preceptor table but remaining quiet and waiting for an invitation to be involved. Big mistake! I had assumed the resident physicians and medical preceptors would know how to involve me in this new model – all they had to do was ask! Indeed I was "invited” one or two times per a four hour block. This was not working as I had envisioned. Thus, I decided to move my chair into close physical proximity of the resident physician-medical preceptor discussion to form a triad. Immediately the requests tripled for either a curbstone consultation, warm handoff, or invitation to accompany the resident physician back to the exam room to either do a brief and focused IBH intervention for the resident to observe or to observe and train the resident doing an intervention that they were learning in the didactic work that I was doing with them. The message was clear: BHP proximity and visibility were critical but insufficient. In this new model, I needed to "move in closer” and reconfirm my role as the BHP on the healthcare team. Don’t expect family physicians to find you – rather find them and show your interest and enthusiasm in being a member of the collaborative healthcare team. As we all know, one can never be too experienced, not just early in one’s career, to make a mistake involving foresight or judgment.


 

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Collaborative Follies 2

Posted By JoEllen Patterson and David Clarke, Thursday, April 12, 2012

JoEllen Patterson

 

JoEllen Patterson PhD, Family Therapist

University of San Diego

Several years ago, I was working with an elderly cancer patient and her husband. They had been referred to me by a wonderful physician in my collaborative care setting. The wife had received grueling chemotherapy and radiation. Her prognosis was bleak.

I knew the physician to be conscientious, kind, and exceptionally thorough. The physician eventually told the couple that there were no further treatments available to treat the patient’s cancer. The couple was furious at the doctor "for giving up” and spent their next therapy session criticizing the physician’s heartless care. They hoped that I "would be more caring than the physician.” I was unsure how to respond. Eventually, they implied that "we” had failed them. They did not schedule another session with me.

I wrote a brief note in the chart but failed to discuss the session with the physician. I also realized later that I had not known how to respond quickly to being triangulated into the conflict between the physician and the couple. The physician eventually learned that the couple sought alternative treatments in Mexico, and the women died a painful death in a Tijuana clinic. When I eventually told the physician about the session, he said he had no idea that they were so angry with him. Why hadn’t I told him?

I thought about this case for a long time and what I might have done differently. Here are some of my regrets:

  • I wish I had viewed the doctor-couple relationship as my patient, at least briefly. I would have encouraged the couple to talk to the physician about their feelings of abandonment instead of simply ruminating about his "indifference”. I could have even offered to facilitate the discussion.

  • I was sometimes too concerned about interrupting the overwhelmed physicians to talk about an individual patient. So, I would write a note in the chart instead of taking their time. In some cases, I should have "interrupted” the busy physician to talk about a specific patient situation. This was one of those times.

  • I wish I had found more ways to gradually give the couple "hope” even when the clinic could not offer them a cure. I think I was too focused on the medical prognosis to move the conversation to an emotional/spiritual prognosis.

 

David Clarke

 

David Clarke MD, Gastroenterologist

Oregon Health and Science University

I met Catherine thirty years ago during my Gastroenterology Fellowship at Harbor/UCLA. We spent only an hour together, but the encounter completely changed my career. In her mid-thirties she developed severe constipation, largely unchanged even with simultaneous administration of four different laxatives at double the usual doses. Diagnostic evaluation over two years by her family doctor and two universities was unrevealing.

When I asked if she had been under a lot of stress recently, as other doctors had asked her, Catherine shrugged and replied, "Just the stress from being sick.”

My next question was: "Were you under any stress earlier?” I was wondering if she had experienced a specific stress when her illness began two years before. She interpreted the question to mean the more remote past.

"Yes,” she replied calmly and with little hesitation. "My father molested me.”

This was the first time anyone had made this revelation to me and I had no idea how to respond. Without any childhood stress of my own to recall, or any medical training about how to relate this information to her illness, I was at a loss for words.

She went on to say her earliest memory of her father molesting her was at age four. The molestation continued regularly for the next eight years. When she began menstruating, he stopped. There were no other incidents of abuse or personal trauma in her life.

I was aware of a psychiatrist on our faculty, Harriet Kaplan, MD, who was also an internist with expertise in mind-body medicine and requested a consultation. Four months later, I ran into Dr. Kaplan in an elevator and asked how Catherine was doing. "Well, I haven’t seen her in over a month, Dave,” she replied. "Her bowels are working just fine now.” She had even stopped taking the medicines I had recommended.

I was shocked at the concept of alleviating a serious physical condition solely by a few months of counseling. Over the next few years, I learned everything I could from Dr. Kaplan and during 25 years of practice treated over 7000 such patients myself.

Dr. Clarke invites you to find out more about psychophysiologic disorders and an upcoming conference at www.ppdassociation.org and www.stressillness.com.

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Collaborative Follies 1

Posted By Susan McDaniel and Andrew Pomerantz, Thursday, April 5, 2012

Susan McDaniel

 

Susan McDaniel PhD, Family Psychologist

University of Rochester

One of my first medical referrals was from an obstetrician on faculty in Family Medicine . He requested a "psychological evaluation" of a thirty-nine-year old single female patient who presented for donor insemination to have her first child. The obstetrician said he always asked any single OB patients to see a therapist, both for his own protection and for the patient and her family to have the opportunity to discuss the request and its likely consequences.

I thought this a fairly simple, straightforward request and scheduled a session with the patient, her mother, and her sister to discuss the procedure. I asked to see the patient only for the first half of the session. It quickly became clear that she was quite ambivalent about the procedure and more interested in proving to her family that she was an "adult” than she was in actually raising a child. In the second half of the session, the woman told her mother and sister that she did not want to proceed with the insemination and the family ended by agreeing to open more communication and contact among themselves. It seemed a good use of 50 minutes. However, when I reported this outcome back to the referring physician, he became angry, saying I "talked this woman out of her last chance to have a baby."

Like a bolt from the blue, I realized that I had not explored this physician's view of the problem when he made the referral. It was several years before I saw another patient of his. One of those lessons I had to learn again: to spend time early soliciting the physician's view and discussing the possible outcomes of a consultation.

 

 

Andrew Pomerantz

 

Andrew Pomerantz MD, Psychiatrist

Veterans Health Administration

My second attempt at integrated care took place at the White River Junction VA medical center in Vermont in 1989 (the first was in 1974 when I was still a Primary Care physician in the community). A psychologist and I opened an office in the primary care clinic and told everyone we were there to bring mental health care to primary care so we could reduce stigma. For a month or so, we sat there one afternoon every week reading journals (and probably some magazines as well).

Finally a patient with PTSD and alcohol dependence was deposited on our doorstep. We double-teamed him weekly for a month, after which time he asked us why he couldn’t just go see us in the mental health clinic where it was quieter. We said it was because we were trying out a new way to provide care. A month later he moved to Montana. By that time primary care needed the space back and we folded our tent and moved back upstairs. I did hear from him a few years later when he returned to Vermont with end stage lung cancer. We had a few visits – in the mental health clinic.

It’s often said that a plan without action is a daydream and an action without a plan is a nightmare. In this case, all I knew what that I wanted to provide mental health services in primary care, so I put out my shingle and waited for them to come. I had no plan, just a dream that ran afoul of the details. Though it did not turn out to be a nightmare, it taught lesson one: Integrated care is not just about co-location. It is a different paradigm. It also requires education of the customers (in the commercial world, that’s called marketing). In this case the main customers were the primary care staff.

Over the next 15 years, I tried many different approaches, each building on the experiences of the previous one. Finally, a concerted planning effort that involved primary care leadership and all of our mental health clinicians fulfilled the dream and the program unveiled in 2004 soon became the gold standard for co-located collaborative care in the Veterans Health Administration and, more recently, a core component of the Patient Aligned Care Team, the VA version of the Patient Centered Medical Home. 

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Point / Counter-point 5

Posted By Randall Reitz and Leslie Lieberman, Thursday, March 29, 2012


Trauma History:

ACE in the Hole

or Futile Fact?

 

Randall Reitz


 

At this point in my education I am not easily awed, much less shocked. Discovering the Adverse Childhood Experience research was a shock and awe campaign to my clinical sensibilities.

For the uninitiated, the ACE study was n=17,000 research sponsored by the CDC. It looks at the effects of childhood trauma on adult health and behavior. Each research participant completed a 10-item childhood trauma screen. They also provided a thorough health and behavior history. The participants were stratified by trauma history ("ACE Score”) to assess whether it was predictive of health outcomes. Their data proved statistically significant to a degree rarely seen in the human sciences.

In each of the graphs below the numbers on the X-axis are ACE Scores (i.e. how many of the 10 traumas the person endured as a child) and the Y-axis is the percentage of participants with a particular health outcome as an adult. I apologize for the low quality of the graphs.

 

 

 

 

 

 

2 Conclusions:

  1. Negative early childhood experiences, especially those involving family members and other caregivers, have a profoundly detrimental effect on adult health.
  2. People with low ACE scores are amazingly free of these problems.

Fine.

No, that's a poor word choice. It is not fine, it's horrible.

Let's try that again, inspired from a song my kids love, but I hate: "whatever, it doesn't matter, oh well”.

No, that's not right either. It does matter. It matters deeply. BUT, as it relates to my adult patients who are already demonstrating the health sequelae of childhood traumas, I haven't been able to identify anything I can do with these data.

Knowing the fact that horrible parenting or a chaotic childhood placed the patient on a nearly inexorable path toward health destruction is diagnostic, but not therapeutic.

How do I intervene?

How do I make it better?

How do I advise my medical and nursing colleagues?

I have attempted 3 (inadequate) responses so that at least I feel like I'm not being callous:

1. Normalize their Experience: I can say: "I'm sorry, you've been through horrible experiences in your life, and unfortunately, science and my own clinical practice has shown us that these experiences help to explain many of your health problems”. This might assist the patient in piecing together a different health narrative, and the empathy that it implies might fortify our therapeutic relationship. But, I've never seen it go very far.

2. Protect the Innocent: I haven't had occasion to do so, but I've often imagined that a reasonable MedFT intervention would be to go through the ACE research with an abusive parent. These data might be the missing piece to dissuading him from passing along this horrible family legacy to his children. After all, this is exactly what we do with pre-contemplative smokers (i.e. "Were you aware that 2nd-hand smoke can cause more frequent illness, asthma episodes, and perhaps even lung cancer in your children?"). So, yes, this might help the next generation, but it doesn't turn back the clock for the abusive parent in the room who is already addled with her own health problems from her parents' abuse.

3. Educate the Clinicians: Patients who were traumatized as children are some of the least rewarding for healthcare providers. They come to the room with intractable health problems and behavior which looks like an Axis 2 diagnosis. These are the patients who quickly get labeled and often get fired from a practice. Perhaps having the patient complete an ACE screen will assist the clinician in having more compassion and in passing less judgment to the patient. If so, that would be wonderful.

OK, there might be some clinical advantage to screening for childhood traumas. However, I remain unconvinced that it is a clinically relevant tool. The ACE score should NOT be the 6th vital sign (or the 7th or 8th, or however many there are now that we therapists keep adding our soft scales to the hard science of checking patients-in). Perhaps I will continue to bust out an ACE 1-2 times per year, but it's not about to join the PHQ9, GAD7, and Vanderbilt in the pantheon of primary care screens.

 





Embracing the ACES and Trauma Informed Care: The Time is Now

Leslie Lieberman

Randall, I am very pleased that you raise awareness of the importance of the Adverse Childhood Experiences (ACES) research. However, I beg to differ with your conclusion that there is no place for translating the significance of the ACES findings into the design and provision of collaborative healthcare practice.

To recap, the ACE study surveyed more than 17,000 mid-life adults about 10 categories of adverse childhood experiences (all forms of abuse, witnessing violence, parental absence, incarceration, mental illness and substance abuse) then linked their responses and health histories. Key findings included: 1) a high prevalence of ACES – only 1/3 of those surveyed reported NO ACES - and 16% reported 4 or more ACES; 2) a very strong correlation between ACES and numerous health and behavioral health diagnoses, as well as high risk behaviors associated with poor health outcomes; and 3) a cumulative effect, four or more ACES translated into significantly higher rates of morbidity and mortality.

Results of the ACE study were first published in 1998 and there have been numerous replications since then. Additionally over the last 20 years there has been a plethora of neuro-scientific studies demonstrating the negative impact of toxic stress, trauma and adversity on health and development. In spite of this, few health and human services organizations, CFHA among them, actively advocate to integrate this research into practice. Trauma informed care (TIC) is an approach which both acknowledges the importance of the ACES and provides a framework for how organizations and systems must change in light of this knowledge. Fourteen years is long enough - it is imperative that all health and human services systems, including collaborative care models, become trauma informed now.

The concept of trauma informed care, first introduced by Fallot and Harris in 2001, requires that all services designed to assist vulnerable populations (health, behavioral health, education, housing, welfare etc…) acknowledge the prevalence of and pervasive impact that violence and victimization play in the lives of many consumers and recognize the presence of behaviors and symptoms associated with trauma. This understanding must then drive the design of services to validate trauma survivors, promote their resiliency and recovery, and reduce and eliminate policies and practices that may be traumatizing or re-traumatizing.

To promote trauma informed care, a number of individuals and organizations have defined core principles and developed models of TIC (Sandra Bloom, Sanctuary Model, Community Connections, The National Child Traumatic Stress Network to name a few) All have at their core safety first and safety for all (consumers, family members, employees). Additionally most advocate the importance of establishing cultures where collaboration, democracy, consumer choice and control, and establishing positive relationships are paramount.

CFHA is in an excellent position to be a strong advocate for trauma informed care. The core principles of TIC are embedded in the organization's self description which states: collaboration isn’t just a word in our name; it defines who we are, how we interact with each other and other organizations. We believe deeply that collaboration is an essential element necessary for re-visioning healthcare, specifically, and society, generally. And echoed in its mission to promote comprehensive, cost-effective integrated health care and achieves this mission through education,training,partnering, consultation,research and advocacy.

Randall your "shock and awe" in response to learning about the ACE research is noteworthy, yet your follow-up statement that you don’t know how to use the information is dismaying. You suggest that perhaps the ACES can be used to: 1) to normalize the trauma experience, 2) protect the innocent (prevent the transmission of trauma to the next generation), and 3) educate providers. These ideas are a good start toward becoming trauma informed, but much more needs to happen and CFHA can take a leadership role in ensuring that it does.

With CFHA's urging, ALL collaborative care providers and organizations can be sensitized to the prevalence and impact of violence and trauma, not only in consumers/patients but among providers/staff; they can learn to address secondary traumatic stress (the impact of exposure to traumatic material from consumers/patients); they can provide psycho-educational materials about trauma and toxic stress; they can integrate routine screening for trauma exposure and trauma symptoms; they can identify, refer to, and integrate evidence based trauma-focused treatment; they can closely and deeply examine and change their policies, protocols, standards and practices to ensure that they do not re-traumatize, and they can involve trauma survivors in the process of transforming services. Above all, each CFHA member can use his or her sphere of influence to be a champion for trauma informed care. Together we can shift the fundamental question that still permeates far too much of the health/behavioral health care services system from: What's wrong with you?" to "What has happened to you?" – the ACE study data make it clear why we must do this now.


Randall Reitz
Leslie Lieberman

Leslie Lieberman, MSW directs the Multiplying Connections Initiative in Philadelphia. This program's mission is to build and sustain a trauma informed system for young children using relationships and connections as the vehicles for change.  For more information visit their website at www.multiplyingconnections.org or contact Leslie at llieberman@healthfederation.org


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Point / Counter-Point 4

Posted By James B. Anderson and Jodi Polaha, Thursday, March 22, 2012


Empathy

       =

Non-Essential 

James B. Anderson


 

Em.pa.thy (\ˈem-pə-thē\)

1:the imaginative projection of a subjective state into an object so that the object appears to be infused with it.

2:the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner;also: the capacity for this.

-------------------------------------------------------------------------------------------------------

The importance of the relationship between therapist and client has long been recognized as a key to successful intervention. In his landmark work in developing his style of psychotherapy, Carl Rogers advocated a humanistic, client-centered approach to therapy. Central to Rogers' approach was the creation of the relationship between therapist and client. According to Rogers (1946):

If the counselor can create a relationship permeated by warmth, understanding, safety from any type of attack, no matter how trivial, and basic acceptance of the person as he is, then the client will drop his natural defensiveness and use the situation (p. 419).

Since Rogers' work, a strong therapeutic alliance has been reliably demonstrated to be associated with positive therapeutic outcome, regardless of type of therapy. Recognizing the importance of such a relationship, many clinicians have made the assumption that empathy is an essential component of effective therapy. Explicitly or implicitly, it seems that many assume that empathy serves as a mediating variable to achieve the coveted alliance so valuable to positive therapeutic outcome.

A prime example of this assumption can be found within Motivational Interviewing (MI). MI is a contemporary therapeutic approach that has been demonstrated to be efficacious when used to help patients make behavioral changes for a variety of health concerns (smoking, weight loss, diabetes, etc.). While certainly not a magic bullet approach (it's not a "panacea,” as founders William Miller and Stephen Rollnick repeatedly remind us), it is very clearly a very important approach to clinical care that has the potential to make primary care interventions more effective. Listed first amongst principles for an MI approach to talking with patients is the expression of empathy from the therapist towards the patient. While it is clear that therapeutic alliance is important to therapeutic outcome generally, and that expression of empathy may be an important path to such an alliance, I argue that it is the former component ("expression”) that is more vital than the latter ("empathy”).

What is vital to what happens in therapy is a result of what happens in therapy—that is, outcome is related to actions, not a hypothetical construct felt inside of the therapist. Certainly the relationship between the patient and the provider is important, as has been repeatedly demonstrated, but that relationship is an interaction of behaviors that have symbiotic influence on one another. When the construct of therapeutic alliance has been evaluated empirically, a number of variables that influence outcome and treatment retention have been identified, ranging from agreement between patient and clinician about treatment tasks, to level of patient arousal (energy and alertness) to the bond between clinician and patient as characterized by expressions of acceptance and confidence.

While one could argue that it is helpful for a therapist to truly have a subjective sense of what life feels like in his or her patient's shoes in order to exude behaviors typically interpreted by patients (or observers) as representative of clinician empathy, it is not necessary. In fact, a clinician might be able to effectively articulate his or her difficulty understanding a patient's motivations or circumstance to help the patient clarify values, recognize possible dissonance between actions and values, and assert and strengthen autonomy to make decisions even if they are not completely understood by another. The bottom line is that while a good working relationship is important (and perhaps vital) to successful treatment, the way that the therapist feels is not essential to creating such a relationship. It is the interplay of behaviors between individuals involved in this complex interaction is important, and ultimately the way that the patient thinks and feels as a result of the interaction is much more important to therapeutic outcome than the feelings of the therapist.





Empathy Shmempathy?

Jodi Polaha

Empathy Shmempathy?

Does the therapeutic alliance (with or without empathy included) predict positive outcomes in therapy? I called my good friend Trent Codd, III, Cognitive Behavior Therapist Extraordinaire, about the empathy issue. He pointed me to studies by DeRubeis and Feeley (1990) and Feeley, DeRubeis, & Gelfand (1999), examining early and late measurement of process variables, including factors specific to CBT as well as therapeutic alliance/facilitative conditions. The findings of these studies showed that "common factors” including alliance did not affect depression early in treatment (CBT factors did), but were, instead, the consequence of change. Since these common factors were traditionally evaluated at a point when a great deal of symptom change had already occurred they could not be considered causal. These results suggest the field needs to go back and redesign its studies, taking temporal factors into account. In the process, researchers could examine the definition of "alliance,” better operationalize "empathy,” and try to unbundle these to identify which elements have greatest impact (or, the MINC, Minimum Intervention Needed for Change) just like we are doing with multi-component evidence based interventions.

Is empathy relevant? It is an empirical question, which is the easy "out” for any academic with a full in-box. Therapists' assumption that empathy is effective or necessary might be driven by a history of real-world observations; the stuff upon which relevant science is based.

Still, when placing this question in the context of a field working to implement and disseminate our science in new and changing paradigms driven by a new group of consumers, I'm having a hard time empathizing with the issue as a whole. What is the place of empathy or even therapeutic alliance in integrated care? What about in mHealth or eHealth interventions, which are gaining popularity and an evidence base? Treatment in these contexts bears little resemblance to the kind of therapy upon which these concepts of empathy and alliance were originally conceived. Perhaps, for the readers engaged here, it's time to exnovate some of the research targets that made sense in days gone by and consider innovating fresh and relevant targets.


 

 


 

James Anderson PhD
Jodi Polaha PhD

James is a second-year UMass Fellow of Clinical Health Psychology in Primary Care. He received his BA from the University of Wisconsin- Eau Claire, research training from the Neuropsychiatric Institute of UCLA, and his PhD in Clinical Psychology at Western Michigan University.

Jodi is an Associate Professor in the Department of Psychology at East Tennessee State University where her primary professional interest is research, training, and workforce development in rural integrated practice.  


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Point / Counter-Point 3

Posted By Peter Fifield and Randall Reitz, Friday, March 16, 2012


A KISS to Make it Better: A Two Step Model of Behavior Change 


Peter Fifield



Why is it the more educated we become the more complicated we make things?

I was facilitating a Motivational Interviewing [MI] group the other day and during a discussion on the 5A's, the topic of Prochaska and DiClemente's Transtheoretical model [TTM] came up; specifically the stages of change. This got the entire group thinking about the complexities of behavior change and the most prolific model we use to describe it.

Since the 1980s when the TTM debuted, the stages of change have become the most widely used approach to explaining behavior change; thus it is the model most professionals [working on any sort of change process] have become familiar with. The substance abuse and medical worlds have been two sectors that have relied heavily on use of this model. Since its inception the TTM has been heralded as the kissing cousin of Motivational Interviewing [MI]. In all actuality, however, one of the originators of MI, William Miller, clarified in an article dubbed Ten Things that MI is Not [2009], that the stages of change where originally associated with MI only because, they provided a logical way of seeing how MI fits into the clinical process, but in the end, the stages of change model is not MI.

For substance abuse treatment, the TTM allowed for a fresh new look into addiction and allowed us to see how individuals made their way through phases regarding change behavior. One pivotal discovery birthed by this model was that patients needed motivational enhancement towards change more than they needed blame for their existing situation. Look at any substance abuse counseling program curriculum [and even some medical school curricula] and you are bound to find a class that mentions the TTM and its role in behavior modification. The insight that the TTM gave treatment professionals is absolutely extraordinary and subsequently the prevention world has coveted the TTM like a golden calf.

Leanardo Da Vinci has a famous quote that states "simplicity is the ultimate sophistication”. To me the TTM lacks this ultimate sophistication. Some may argue that you could not get a simpler model than one that has managed to reduce the complex nature of behavior change down to a mere five step process. However, I feel that the TTM is in need of one more round of distillation. According to the stages of change, people make their way from a precontemplative state, to contemplative, to preparation, then to action and after that they maintain: Then the cycle repeats [see below].

TTM

TTM Stages of Change Model


What this says to me is that what kind of Inaction the patient is in somehow matters more than the inaction itself. We are in constant flux and eternally making our way in and out of readiness regarding any behavior and quite simply it seems unnecessary to complicate the matter anymore than it needs to be. A simpler more therapeutically helpful perspective is that people are either in action or in ambivalence; nothing more.

Maybe it is we the therapist that is assisted most by the stages of change; not in that it teaches us more about the patient, but more about ourselves. Knowing that the patient is contemplative, in preparation or any other phase of the stage of change model may just be a way to help us feel better about the unknown nature of the situation. We resource the stages of change algorithm, place the patient in precontemplation and then [according to one manual] "encourage them to become more mindful of their decision making and more conscious of the multiple benefits of changing an unhealthy behavior”. This is stated like patient behavior is a forecastable action.


Ambivalence


What we typically find is that in action is not where we find most of our patients. I’d venture in saying that only about 10% of patients are in action mode; leaving 90% in ambivalence. For this 90% of the population we rely on motivational interviewing to work through the ambivalence, roll with the resistance and navigate a next step that derives from the patients wants and needs at that time. We don’t educate, advise or assist, we just sit there in the ambivalence with them, negotiating this unknown territory as if it were our own journey. We save the rest of the five A’s [Advice, Agree, Assist and Arrange] for the action phase: the other ten percent—a very small portion.

I once read, when people are in ambivalence it is like Linus without his blanket, we have nothing to hold on to. So we ourselves reach for something to grab hold of, to stabilize the spin. I think the complexity of the TTM merely gives providers a blanket to hold on to. It is an ameliorating agent for us; something to ground us as we flounder around looking for a way to help the patient out of their current predicament. What is a bit more difficult to master yet profoundly more therapeutic is to fully embrace that we are only accountable for the interaction with and not the outcome of the situation. In doing so we are able to commit to the patient without any expectation of an outcome and thus we can be more comfortable with their ambivalence. We then know that the best thing we can do is sit in the unknowness with the patient, experiencing the moment with them and not try to fix or right the situation.

The stages of change are very useful, but only if you use them cautiously. The problem that I have discovered is that they can facilitate an assumptive pattern, pigeonholing people into a mold that which we think they fit. This is done with such subtlety that we ourselves don’t even see it happening. Rechecking the manual I see that the patient is now contemplative so I must "encourage them to reduce their harmful behaviors and look for change within the next six months”. If this were true, my life would be quite boring, but a heck of a lot easier.

In the vein of Keeping It So Simple [KISS] I often think back to a childhood movie when Yoda explained to Luke one fateful day in the swamp. He said: "Do or do not, there is no try”. I think lil’ man Yoda may be on to something.





I Beg to Differ

Randall Reitz

 

Wow Pete, please take off your shoes when you address the Trans-Theoretical Model. It is a sacred calf and when you approach it you are standing on holy ground. Your heresy is that by dropping from 5 levels of readiness to 2, you are also dropping the model’s 2 greatest strengths: Hope and Change.

Hope. As astutely posited in your essay and supporting literature, MI is an evidence-based practice, but readiness assessment through the TTM is not. Fair enough, but how do you separate the 2 since they have been co-mingled since birth? How do you separate the science supporting MI from the science of TTM since most clinicians choose their MI interventions on how they gauge their client’s place on the TTM scale?

When you collapse the levels of TTM, you’re left with just 2 levels: abstinent or not. In the process you also take MI from a harm reduction model to an abstinence model. Yes, there is simplicity in this, but there is no hope. Once you carve out contemplation, preparation, and maintenance, clinicians will start turning Okham’s Razor on their own wrists in desperation. We need degrees of change to give us hope. We want morbidity and mortality. Imagine dropping all A1c values except a 7.0 for diabetes. Imagine dropping the quantitative PHQ9 and only keeping the binary PHQ2.

This is especially true with the dreary art of behavior modification. It is often cited that it takes the average person 7 smoking cessation attempts to actually quit the habit for good. Then, you tack on to this the much larger percentage of patients that I see every day who are not ready to attempt smoking cessation. My guess is that, as a result, only about 2-3% of the smokers I see in counseling will actually quit smoking in a given year and that only about 10-15% I see for tobacco specifically will be fully successful. With those difficult odds, if I had a binary approach I would feel quite depressed. If I keep the 5 levels alive then I can at least take comfort in the fact that a smoker moved from precontemplation to contemplation. This allows me to believe that I am the Johnny Appleseed of a tobacco-free world—planting seeds that I won’t harvest. Don’t kill Johnny.

Change. Prochaska and Diclemente’s "Stages of Change” model has brought change to medicine. The model fundamentally change is how clinicians consider their patients. Before 1990 was there a field that hated their clients more than the addictions field? The lingua franca that joined clinicians and clients was all about "drunks, alkies, boozers, winos, and junkies”. In using TTM, we remove the focus from pathologizing a person to describing their desire and readiness. I’d much rather be labeled as a "contemplator” (it’s so zen!) than a drunk. Who wouldn’t prefer to be a "preparer” than a junkie?

And, this is more than mere semantics. This language can saturate a clinical setting and reverse patient hating. It adds a narrative sense to the way clinicians describe their substance using patients. It challenges simple stigma and replaces it with a story of resilience and everyday heroics. It provides an arc with a beginning point (addiction) and an endpoint (harm reduction). It prevents us from viewing patients and the change process in black/white terms. In a circular way, this change instills more hope in both patients and providers and keeps them engaged in the process.

In conclusion, I like Yoda. Compared to other wizened pond frogs, he is incredibly wise. However, one of his axioms seems especially glib: "Size matters not. Look at me. Judge me by my size, do you?” Size does matter. In basketball, bed, and behavior modification a "5” will always be better than a "2”.


 Don't Kill Johnny!

 


 

Peter Fifield
Randall Reitz
Peter and Randall have been close friends and collaborators since 2006 when Peter was "Data Dude" and Randall was "El Jefe" at the Summit Community Care Clinic in Frisco, CO.

With CFHA, Peter writes the Re:Activation Blog and Randall  writes the CollaboBlog.


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Point / Counter-Point 2

Posted By Elizabeth Horevitz and Randall Reitz, Thursday, March 8, 2012


Biopsychosocial Collaborative Care: Innocent Until Proven Guildy


Elizabeth Horevitz




Overheard conversation between two psychology post-doctoral fellows:

Psychologist 1: "I was so frustrated when I got to my community-based placement because I realized that all of my patients needed serious case management. I couldn’t do any of the psychological interventions I was trained to do!”

Psychologist 2: "I had the same thing happen to me! So, what did you do?”

Psychologist 1: "I sent them down the hall to the social worker for case management”.

Psychologist 2: "Yeah, so frustrating. I would’ve tried to do some of it myself, but I just feel like case management is too far below our pay grade”.

Psychologist 1: "Yeah. It’s not what we were trained to do.”

As a clinical social worker, it is not the first time I’ve heard an allied profession dismiss case management as "less than”. Case management is broad term with multiple definitions[i]. In the field of social work, case management has been defined as "a method of providing services whereby a professional social worker assesses the needs of the client and the client’s family, when appropriate, and arranges, coordinates, monitors, evaluates, and advocates for a package of multiple services to meet the specific client’s complex needs… social work case management addresses both the individual client’s biopsychosocial status as well as the state of the social system in which case management operates”[ii]

Integrated behavioral health in primary care is the new frontier for behavioral health practice. If you’ve been following the CFHA facebook debates, you’ll recall this request for people to weigh-in on who they would hire as a behavioral health consultant if they were starting a new integrated clinic. Many people gave their opinions, and the general theme was that focus should not be placed on "guild of origin” (psychologist, social worker, family therapist, etc.), but rather on assessing the individual’s attitude, openness, curiosity and flexibility to be able to effectively meet the demands of this new frontier of integrated behavioral health practice.

Importantly, a general consensus about collaborative care is that a good behavioral health consultant should approach health and well-being from a biopsychosocial perspective which allows us to understand how biological/physiological factors; psychological factors; and social factors converge and act on each other to affect health, and to intervene accordingly.

Unfortunately, my experience has been that the field, in actuality, tends to emphasize the biological (physical health) and psychological (mental health) aspects of assessment and intervention ("biopsycho”), and dismiss or altogether ignore the social components.

Full disclosure: when I first started out as an MSW student, the idea of case management didn’t exactly have me champing at the bit like my classes on motivational interviewing or cognitive behavioral therapy. The fact of the matter is this: case management isn’t sexy. But what I learned right out of the gate, my first day of internship is that case management is just as important (and to be done well, requires just as much skill) as any other behavioral or psychological intervention. It goes back to Maslow’s hierarchy of needs- if a client doesn’t have their basic needs met, even the fanciest most in-depth psychological intervention for, say, depression will simply not work (let alone the brief psychological interventions we tend to offer in primary care).

Social workers are trained in the biopsychosocial model and take a person-in-environment approach to assessment and intervention. Because we are committed to working with vulnerable and underserved populations, a good social worker recognizes that helping a client navigate our fractured systems of care and access needed resources is a matter of social justice. The ability to engage in good case management and client advocacy is just as important as delivering the latest evidence-based psychotherapeutic intervention. You can’t have one without the other.

Try working with a depressed client on "maladaptive thinking” (or behavioral activation, for that matter) when she is unemployed and was just served an eviction notice. And she has three children. And she is about to run out of her diabetes medication. And she doesn’t speak English. Anyone worth their salt as a clinician would say that doing anything other than assisting her with immediate concrete needs would be silly and, in some cases (I would argue) unethical.

It isn’t that the two psychologists didn’t recognize the importance of case management for their clients (on the contrary); it was their perception that this activity, although necessary, was beneath their professional scope of practice that seems so antiquated in this new era of integrated care.

To be effective in behavioral health practice in integrated/collaborative care, case management must be part of every clinician’s toolbox, regardless of guild of origin. There are likely many reasons why case management and client advocacy have not been emphasized in the conversation in integrated/collaborative primary care; ranging from lack of reimbursement structures for case management to residual stigma about case management and the plight of behavioral health practitioners to be recognized as highly skilled professionals within a medically-dominated professional hierarchy.

With the passage of the Affordable Care Act, state and federal reimbursement will increasingly be linked to coordination of care and to "effective case management”[iii]. While it is likely that care teams will increasingly include specific positions for case managers, behavioral health consultants, regardless of guild, should have basic case management within their scope of practice. This is especially true given that we can expect to see an increase in patients with complex needs accessing the health care system in 2014 via the expansion of Medicaid coverage.

It is well known that health behaviors do not occur in a vacuum. Case management puts the "social” into the biopsychosocial model of practice and is a necessary component of improved patient outcomes. So, in addition to the list of requisite adaptations and skills for effective behavioral health practice in collaborative care settings (e.g., brief behavioral interventions, frequent interruptions during sessions, curbside consultation with medical providers), case management skills should be included on the list if we are going to be true to the biopsychosocial framework to which the we (proponents of collaborative care) lay claim. Otherwise, we risk reifying the very same professional ("that’s not my job”) and system-level silos that we have, and are, working so hard to overcome.



[i] For an excellent discussion of case management, its history and purpose, see Case Management: Uses, Critiques and Recommendations for Social Work Practice, Moore, M. (2010) unpublished manuscript available upon request meganmoore@berkeley.edu

[ii] National Association of Social Workers (1992). NASW Standards for Social Work Case

Management. http://www.socialworkers.org/practice/standards/sw_case_mgmt.asp

[iii] For a summary of the Affordable Care Act, see: http://www.govtrack.us/congress/bill.xpd?bill=h111-3590&tab=summary


 




I Beg to Differ

Randall Reitz

 

Elizabeth, while you make a very compelling and insightful case, I beg to differ.

I share your conviction that case management is a vital service in integrated settings, However, I don’t share your belief that clinicians and staff members of all stripes should embrace it equally. You see, this cantankerous collaborator is old-school beyond his years. I assert that the primary reason to integrate behavioral health and primary care is to expand access to different services in the same setting. The goal is not to have all clinicians and staff provide the same kinds of services.

Primary care is all about hierarchies of licensure and certifications: CNA, MA, LPN, RN, NP/PA, MD/DO. Each of these levels is qualified to do a different scope of medical/nursing care and is salaried based on the spectrum of what they are competent to do. While it is obvious that a CNA should not prescribe medications or order diagnostic tests, it should be equally obvious that it doesn’t make sense for an MD to do all the vitals on her patients. Yes, she is qualified to check vitals and should be willing to pitch-in and check-in a patient if things are backed up. But, in order for the clinic to run efficiently and economically, her principal concern needs to be doing things that only she is qualified to do.  She needs to "practice at the top of her license”.

The same is true for behavioral health services. Yes, I know a number of family physicians and pediatricians who are excellent counselors, but they should rarely, if ever, engage a patient in weekly 30-50 minute counseling sessions. As a behavioral health clinician, counseling sessions are at the top of my license.

I will grant to you that the behavioral health hierarchy is much more flat and fluid than the medical/nursing hierarchy (as are the income levels). But, the differences in training and credentialing are still important. Yes, a well-qualified case manager should engage in some motivational interventions, but should shy away from diagnostics and insight-based psychotherapy. Similarly, as I have worked in safety net settings my entire career, I am very well versed in community resources and governmental programs. I recommend them for patients all the time, and will often make a call to an agency myself to ensure the patient encounters "no wrong door”. With fragile patients I feel ethically bound to maintain the case management duties throughout because of the higher risk of things going awry.

However, the harsh reality is that a seasoned, licensed clinician of any behavioral health guild will command a salary that is 1.5 times what a case manager will make. At the doctoral level it is 2 times as high. As my clinic could hire 2 case managers for what they pay for me, if case management is the main job duty, then they should take away my badge, give me a cardboard box for my belongings, and hire 2 case managers.

This is especially true as it relates to "care management” (i.e. services to activate people with chronic illnesses through outreach and follow-up). Our doctors have really embraced the idea of sending care managers EMR "action items” to call a patient in 1 week to follow-up on a new medication, an exercise goal, or suicidal ideation. Our care managers spend hours on this every day, and have had amazing results. I will eagerly do it myself, but generally only if I already have a counseling relationship with the patient or if the physician judges that it is a sensitive situation.

And finally, even among licensed clinicians, we choose our specialty based on our passion and interests. Just as psychologists might not find case management "sexy”, I don’t find psychological testing sexy. (Nor is it relevant to primary care, but that is for a different blog post).

I have the fortune of working in a diversified setting that includes an LMFT, LCSW, addictions counselor, psychologist, and 2 case managers. In reality, all of us are generalist in scope and perspective. But, I would hope that if a patient requires sophisticated diagnostics, that the referring party would seek out the psychologist. If the patient needs family therapy, then all things being equal, they had better come find me. If the patient wants to break his wake and bake habit, then I hope they would seek out my addictions counselor colleague. If the case involves multiple agencies or is more socially-focused, then I'd hope they’d look for the LCSW. If the patient just needs a heads-up about how to apply for Medicaid or an outreach phone call, then the case manager should be the go-to person.

To do otherwise, would be lesser patient care, less financially wise, and wouldn’t promote the job satisfaction of the members of our team.


Elizabeth Horevitz
Randall Reitz
Elizabeth Horevitz MSW, is a doctoral candidate at the University of California, Berkeley.  Her research focuses on evidence-based primary care interventions for Latinos and other underserved populations.  In a previous CFHA blog post she cast aspersions at the "warm hand-off".

Randall Reitz PhD, is CFHA's Director of Social Media and the Director of Behavioral Science at the St Mary's Family Medicine Residency in Grand Junction, CO.  He does more case management than he cares to admit.

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Point / Counter Point 1

Posted By Randall Reitz, Thursday, March 1, 2012
Updated: Thursday, March 1, 2012


Dejected Views
on Family-Hating


Barry J. Jacobs



The surreptitious eye-roll is bearable. The low groan is regrettable but not worth reproaching. But what irks me most about the occasional reactions of my family medicine residents to their patients’ relatives is the smug, dismissive, professionally rendered character assassination, complete with technical terminology. "The spouse is in denial,” they point out to their fellow inpatient team members when an overwhelmed and grieving husband or wife is unwilling to change a patient’s code status. "The daughters are being manipulative,” they observe about adult children who are urging their mother to resist physicians’ recommendations to undergo surgery or take a new medication. "They’re over-stepping boundaries,” they claim about family members who call them repeatedly or accost them with concerns in the hospital or office hallway.

It’s not that other healthcare professionals are substantively more family-friendly. For many of my mental health colleagues, hate of (or at least discomfort with) families is a many splendored thing. They focus on individual dynamics and prerogatives, invoking the delicateness of the therapeutic alliance or the sanctity of confidentiality as justifications for eschewing family contact. They cringe at the prospect of family meetings. They regard family systems thinking as a relic of the ‘60s, unsupported by current research or modern expediency.

I’m incredulous at these attitudes; I take them personally. From my teenage years caring for my father with brain cancer to my middle-aged years caring for my aging mother and demented step-father, I know in my gut how families affect patients’ clinical outcomes and how patients’ illnesses affect family caregivers. Others, clearly, don’t share the same visceral conviction. So what do I make of the widespread phenomenon of family-hating? Here are some over-the-top theories:

We operate in evidence-reinforced comfort zones: Much of healthcare practice and consequently research is focused on individual patients. In an era when clinicians are reminded at every turn to treat according to evidence-based principles, family-centered practices—lacking the same degree of empirical support—therefore seems the riskier clinical gamble. This is compounded by the fact that many healthcare professionals do not receive much training in the nuts-and-bolts of working with patients’ family members—e.g., running family meetings, addressing family conflicts. The seemingly prudent and comfortable treatment approach is centered on patients, leaving family members in the wings.

We are rats in templated, encoded mazes: Medical care, especially primary care, is being increasingly shaped by the clinical pathways that are the basis for the templates of our electronic medical records. By clicking through those templates, physicians not only have the assurance of following the so-called highest standards of care but are also working toward completing their progress notes for medical sessions as quickly as possible. It should come as no surprise that those EMR templates reflect bias toward individually-focused treatments. Family-centered healthcare is off-the-templates.

At the same time, clinicians are under enormous pressure to maximize reimbursement for healthcare services. The billing codes—aka CPT codes—they use have a powerful effect on practice. CPT codes for individually-oriented treatments are reimbursed by insurance companies. CPT codes for meeting with patients’ family members are generally not. We follow the money and avoid the family members.

Beaten and bedraggled, we cling to our authority: I don’t need to tell you that every year healthcare providers are worked harder, blamed more for rising healthcare costs, and disparaged more frequently by angry patients and aggressive lawyers. Evoking Rodney Dangerfield, all we want is a little respect. Now comes the dawning age of the patient-centered medical home with its emphasis on team-based care and who wants a place at the decision-making table as partners in care? Family caregivers do. (For example, see this recent AARP Public Policy Institute report). I think it’s tough for us to give up some of our remaining power to family members. When I hear professionals complain that patients’ family members somehow obstruct the treatment plans of the healthcare team, I infer that they don’t want their scant authority challenged any more than it already has been.

We are all adolescents at heart: Many of us give lip service to the importance of family members to patients’ care. But in our own lives, in our heart of hearts, we feel ambivalently about families. We want their support but don’t want them to encroach on the individual’s rights and independence. It reminds me a little of the sentiment captured in the title of the 2002 book on teenager psychology, Get Out of My Life, but First Could You Drive Me and Cheryl to the Mall. We want family members to drive our patients to our offices but then don’t make a fuss in the exam rooms. We want them to help our patients adhere to our treatment plans but not have input into those plans. That’s not family-centered care. That’s not even respectful of what family members know and have to offer. It marginalizes families. It’s reflexively oppositional and hateful.

For more on this general subject, check out the seminal article, "The Trouble with Families: Toward an Ethic of Accommodation” by Carol Levine and Connie Zuckerman in the Annals of Internal Medicine, 1999, vol. 130, pages 148-152.

Also please see "Interacting with Patients’ Family Members During the Office Visit” in the Oct. 1, 2011 issue of American Family Physician; it’s a tepid, timid approach to incorporating family members into primary care but at least represents some effort to do so.




I Beg to Differ

David B. Seaburn

I beg to differ with my good friend Barry Jacobs’ blog posting entitled, "Dejected View on Family-Hating.” Not only is he (uncharacteristically) off-base, but he may not even be on the playing field.

He notes that family-hating is rampant in the medical field as well as in most mental health disciplines. While I don’t espouse family-hatred, I doubt that any well-trained family-oriented mental health professional isn’t at least ambivalent about families from time to time. They are messy and confusing and inconsistent and wonderfully Resilient in their efforts to get us to respect their integrity. Non-family-oriented healthcare professionals are not the only ones to unfairly label families. In moments of frustration, I have considered whether "borderline” might be an apt relational diagnosis, especially when I don’t know what to do with a family.

Which brings me back to Jacobs’ criticism of residents. If as an experienced family therapist (35 years), I, at times, label and very nearly hate a family, what can be expected of residents. Remember---these are medical professionals who have been trained almost exclusively in a paradigm that focuses on the life and death of an individual patient; who have been acculturated to think reductionistically ("Let’s find the single cause of this patient’s symptoms”); who then enter a healthcare system that mitigates against inclusion of families due to time (see what it’s like to care for four or more patients per hour), diagnoses and healthcare reimbursement. If that were my professional background, my professional culture, I would run the other way when I saw a complex, demanding, needy family coming my way, as well.

I was a residency educator for almost twenty years. Early in my tenure I learned that I was a visitor in a different culture and, as such, I needed to enter that culture with respect and an eye to learning as much as I could to be of value. At first I thought I needed to convert the heathens to a family systems paradigm. If they could only become like me! Soon I realized that that wasn’t what was needed. More than anything else, residents needed help with their most difficult patients. As a family systems professional, my help with challenging patients often (but not always) included involvement of the family as a resource to the resident or as an important source for understanding the patient’s problems. Once residents saw that family could be integral to care and that involving family in challenging patient situations made their lives easier, residents often caught the family system’s bug. For me the lesson was---Don’t preach family-systems, just do it. Making it work in the exam room is the best evidenced-based example you can provide.

The challenge for family-oriented residency educators is to be comfortable and creative taking a one down position (yes, even after all these years!) in a system that is slow to accept differences, let alone change. That means wielding power and influence differently, if, at times, not equally. Becoming a recalcitrant adolescent ourselves is not the answer. Instead, we must recognize that as a maturing member of the medical education family, family-oriented healthcare educators must demonstrate the capacity to be systems-oriented in our clinical, research, educational, administrative and policy-making endeavors. We must leave "evidence” of who we are everywhere we go. I think that the better angels of Dr. Jacobs’ nature recognize this.


Barry Jacobs
Dave Seaburn
Barry Jacobs and Dave Seaburn are family medicine educators and long-term collaborators. Barry is the Director of Behavioral Sciences at the Crozer-Keystone Family Medicine Residency in Springfield, PA and the author of The Emotional Survival Guide for Caregivers—Looking After Yourself and Your Family While Helping an Aging Parent. Dave recently retired from a distinguished career as the behavioral science faculty in the University of Rochester Family Medicine Residency and has taken to writing novels, including Charlie No Face.

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Pain Spikes and Sugar Spikes--A Consumer's Perspective

Posted By Al Hackley, Thursday, February 23, 2012
My name is Al Hackley. I’ll be 70 years old in May, and I have type 2 diabetes that is mostly a little high. In the process of trying to control it I started to look at the high spikes and when they seemed to jump with any change in my eating habits. It quickly became quite apparent that when my wife's pain level went up my own sugar levels also went up.

Let me explain why this might be. In 2008 my wife was bleeding badly. We went to emergency room at the local hospital and were told she had been diagnosed with colon cancer. The mass was too large to take out at that time, so they had her take chemo and radiation. The doctors said they might not be able to put her colon back together, but fortunately they did. The doctor said he was amazed that he could put the colon back together. But there was very little they could do other than painkillers to help with pain due to scarring and nerve tissue damage.
We learned to live with it (most of the time). However, sometimes her colon gets blocked. When this happens she needs to flush herself out. During these times she is in really bad pain and even her morphine does very little to help. There is nothing I can do to help her but just to comfort her. The pain she has becomes my mental pain. Not that I physically hurt, but that I feel so bad for her and sometimes scared. Of course, I don't let her see my fear. Anyway, at these times my readings can jump as much as 100 to 120 points over my normal readings.  A better way of saying this is my reading would jump from 220 to 310 and there seems so little I can do to relieve my anxiety.

"The pain she has becomes my mental pain...at these times my readings can jump as much as 100 to 120 points"
It is so great to have a dedicated family doctor who is connected with all my records and an excellent team. When we go for check-ups they have our medical records right there, whether it be her chemo doctor, my diabetic meetings, a health class, a dietitian class, or from so many other services. I really like the integrated care model and being able to go to diabetes classes and see a marriage counselor right there at my doctor's office. If not for places like this, a lot of uninsured and low income people would be totally without medical care.

The view expressed in the blogs and comments should be understood as the personal opinions of the author and do not necessarily reflect the opinions and views of the Collaborative Family Healthcare Association (CFHA). No information on this blog will be understood as official. CFHA offers this blog site for individuals to express their personal and professional opinions regarding their own independent activities and interests.

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Making Room for Behavioral Health

Posted By Margaret K. Peterson, Saturday, February 18, 2012

Fairmount Primary Care Center (FPCC) is not a big place. There’s a hallway for adult medicine with ten exam rooms, two apiece for each of five providers. There’s a hallway for pediatrics with four exam rooms for the two pediatricians. There are various support and administrative spaces—a waiting room, a front desk, an alcove full of medical records, a couple of triage rooms, a lab, a nurse’s station, a room full of computers where the providers sit to chart, storage closets for supplies and medications. And there is a behavioral health office, which until recently was a modestly-sized windowless room tucked in beside a back stairwell, next to the copy machine and a corridor leading to a bathroom that was usually out of order.

The behavioral health office was occupied by the director of behavioral health (my supervisor, Suzanne) and shared with the two behavioral health interns (me and my colleague Frank). It was furnished with a couple of computer work stations, a few chairs and a bookcase. We used it for consultations with patients who had been handed off to behavioral health by their providers, for scheduled followups with patients and family members, for charting and making phone calls, and for supervision. With all three of us using the room for all these purposes, it got a little crazy sometimes, like when more than one of us had a patient to see at the same time. Mostly, though, it was adequate.

Then the social worker quit. She was the latest in a string of social workers to quit after not very long on the job, and it fell to Suzanne to try and figure out why. Part of the problem, it appeared, was the location of the social worker’s office, which opened directly onto the waiting room and made the social worker vulnerable to limitless demands by both patients and staff. Suzanne hired a new social worker, and moved the new hire into the only other space available—the behavioral health office. It was a vast improvement for the social worker, who now had enough control over her time and space that it was possible for her to do her job.

It was not an improvement for behavioral health. Behavioral health couldn’t just move into the former social work office, since that office’s semi-public location would have made it impossible to safeguard patient privacy. But the office now shared between behavioral health and social work was now occupied by a rotating cast of patients consulting with the social worker. Suzanne and Frank and I couldn’t meet with patients there. We couldn’t make phone calls. We couldn’t talk with each other. We couldn’t even find places to put our coats. Right about the time this change happened, a consulting psychiatrist began coming to FPCC one morning a week. She, too, was supposed to work out of the behavioral health office. Guess how well that worked?

The space crunch highlighted a question that had been percolating along in the back of my mind for months: what exactly is the place of integrated behavioral health? Even at FPCC it’s not really clear how integral a part of the operation behavioral health is. Suzanne has been there for 17 years, and patients still occasionally report that when they return for followup visits with behavioral health, the front desk tells them that there is no such department. It strikes me that this may be less a problem with the front desk personnel than a realistic reflection of the medical care system as a whole. Everybody knows that medical offices are staffed with doctors and nurses. But behavioral health? What’s that?

"As much as I want there to be room for integrated behavioral health...it’s not clear how or whether that’s going to happen in any significant way."

On the mental health side of things, I don’t see much more evidence that integrated behavioral health is any closer to achieving mainstream status. It’s certainly not represented in the curricula of the majority of training programs in my field, marriage and family therapy. In the large and thriving master’s program in which I am enrolled, I have yet to hear the subjects of physical health and illness even mentioned, let alone explored. I got my internship at FPCC approved only with difficulty, and I have the sense that my faculty supervisors are less than enthusiastic about the work I’m doing there. After all, it’s not specialty mental health. And they’re right—it’s not. It’s primary care.

As much as I want there to be room for integrated behavioral health, both in the worlds of biomedicine and of mental health care, it’s not clear how or whether that’s going to happen in any significant way. It really seems like such a shame. Biomedicine is a fine thing, and so is specialty mental health care. But there is never going to be enough individual or family therapy to go around, and it’s more than lots of people need or want anyway. And part of the reason the medical care system is bankrupting us all is that we keep throwing more pills and procedures at problems that have at least as much to do with intrapersonal and interpersonal dynamics as they do with physical health or illness.

Just the other day I saw a patient for an integrated care visit. "What brings you in today?” I asked, as a prelude to my standard set of screening questions. She had pain in her shoulder, she said, radiating up her neck and down her arm and side; it had been this way for a couple of months. "What was happening a couple of months ago?” I asked. The patient couldn’t think of anything, but as we talked, more of the particulars of her life emerged: she was the single mother of two young children, going to school, negotiating details of child care with her mother, who was herself rearing two grandchildren close in age to the patient’s children.

It struck me that this patient’s pain might have a lot more to do with her mother than it did with her shoulder. "You know,” I said to the patient, "we don’t do ongoing therapy here, but we would be happy to meet with you on one or several occasions to discuss this further. You could bring your mother, if you liked, and we could all talk together.” "Really?” she said. "What would I say to my mother, to explain why I was bringing her in?” Later in the day I looked at the patient’s chart. The provider had found no organic basis for her pain, but noted that the patient had said she would like to follow up with behavioral health.

In ensuing days I found myself puzzling over that pain in the patient’s shoulder. If the pain was about her mother, why was it in her shoulder? A pain in the neck I could understand, but why a pain in the shoulder? An image came to mind of the patient and her mother, yoked together, rearing children of the same age, but being themselves of different generations, and one of them the parent of the other. No wonder they were having trouble pulling together. Behavioral health and biomedicine are having trouble pulling together, too. In the current culture of medicine, biomedicine is the established player and behavioral health the young upstart, and it is hard to learn to work together.

Will my patient come for a follow-up visit? Maybe she will. Maybe she’ll even bring her mother.If she does, we have a place to meet. After Suzanne and Frank and I and the social worker and the psychiatrist had spent a week falling all over each other in the behavioral-health-cum-social-work office, Suzanne said, "We have to do something about this!” The following week a corner of the office was partitioned off into a consult room. The office wasn’t big to begin with, and the new consult room is the size of a closet, and not a very roomy closet at that. But it has a door and a couple of chairs, and it’s definitely better than nothing. And in a sign that perhaps things are looking up, the bathroom down the corridor is even working.

The view expressed in the blogs and comments should be understood as the personal opinions of the author and do not necessarily reflect the opinions and views of the Collaborative Family Healthcare Association (CFHA). No information on this blog will be understood as official. CFHA offers this blog site for individuals to express their personal and professional opinions regarding their own independent activities and interests.

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