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.
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.
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?
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?
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.
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
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
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.