This post was inspired by a recent CFHA listserv discussion. If you are reading this and not a CFHA member, the listerv is one of the many amazing benefits of CFHA membership!
It usually looks something like this:
A face I know well pops into my office door—another staff member in the clinic where I spend my days as a behavioral health consultant. This face lacks the bright “just popping in to say hi” or frazzled “we need you right now a patient is in crisis” look. It is more cautious, mingled with a sad or hopeful furrowed brow.
A voice soon follows, starting with an attempt at an upbeat, “can I ask you a question?” and a pause and then, in a softer, sometimes shakier voice, “it isn’t about work….”
The words that follow vary, but there are consistencies. They, or someone they love, are struggling with a mental health or substance use issue. They have tried to get help but have run into problems accessing or using that help. I am the only person they know personally who has the “inside scoop” on the fractured, difficult to navigate mental health and addictions care in our community and they are desperate to access it. They want the name of a good therapist.
The above scenario was one of the most surprising aspects of my new role when I began working as a behavioral health consultant. I was accustomed to exclusively working with other mental health providers, not being the lone mental health provider in my workplace. I was also used to an almost reverent relationship to the ethical guidelines ground into mental health professionals in graduate school and practicums: in particular, the expectation that we keep our personal lives very separate from work and that we do not engage in dual relationships. This makes sense, particularly since we know how to access mental health care for ourselves and our families (not that we always do this, but that is a topic for another day). I quickly learned that boundaries look very different in the medical setting. The medical staff and providers may agree with and support our boundaries once we make them clear, but dual relationships tend not to be front and center for them in the same way they are for mental health professionals.
The request for referrals often came with additional information about personal or family problems. In my setting, where staff and providers are also patients in our clinic, sometimes these conversations occurred in the context of a scheduled behavioral health appointment because the staff member was referred to me by their provider (and, initially lacking other protocols or knowledge of how to handle this, I saw them). In either scenario, I soon found myself to be the holder of a great deal of both information and concern about my co-workers. I felt honored to be considered worthy of the trust implicit to their request, hopeful I could help, and overwhelmed at the prospect of managing all of these concerns in addition to my patient load. If I am honest, I also felt a sense of loss. We BHCs want and need collegial relationships as much as anyone. It changes the power dynamic to see someone as a patient or know personal details of others’ lives without a friendship to contextualize that information. It immediately requires a more mindful approach to that relationship. It means we are working even when we are taking a break, needing to always hold this power in balance with the joking and fun-having that is a part of a healthy workplace.
My response to this situation has been multi-faceted. I certainly do not have all the answers, but I will share some advice and information on where I am currently landing:
1. Seek Supervision: My supervisor had experience with this issue in a different group of clinics. It was applicable to my clinics and eventually helped me to formulate a practice standard for the team I supervise. In the interim, it gave me a place to process what I was experiencing and gain support and ideas.
2. Talk to Human Resources: I recommend having a conversation with HR prior to encountering this situation if possible. Your clinic’s HR director probably has an opinion about the best steps to take when a colleague comes to you with a mental health or substance use problem. Their stake in employee well-being is significant and they very likely have resources that you will find useful. They may also want you to direct employees with significant issues applicable to work performance directly to HR.
3. Know employer-sponsored resources: See item #2 above. HR will likely give you information on an Employee Assistance Program, possibly a physician/provider specific counseling resource and services covered by the employer-sponsored health insurance plan. Keep an easy to access, updated list of these resources as many employees are unaware of them. This list is always my go-to and can quickly reroute a conversation that would otherwise become much more in-depth.
4. Refer internally but offsite if needed and possible: For my team, it has made sense to create a practice standard that asks that employees seek behavioral health care from a BHC at another physical location within the company when referred. Again, this may not be relevant for all, depending on whether employees are also clinic patients. Because most of my colleagues are accessing healthcare within our clinic, it makes sense that behavioral health be available to them as a part of their care. In my group of clinics we have the luxury of being a group of 5 BHCs. We are spread across a large geographic area but it is possible to have a colleague simply access care from a BHC at another location.
5. Except it isn’t always simple: Even with all of the above options, sometimes people just need help right away or can’t get it any other way. Maybe they work 8-5 Monday-Friday and there aren’t appointments available to them when they can attend. Or there is a 3 week wait for a new appointment and that is too long. Sometimes resources are too far away to be realistic. Often the person assigns so much shame or stigma to accessing mental health/addictions care that they will not access them without support. So, I try to be flexible within our practice standard, recognizing the key role behavioral health plays in filling gaps in mental health/addictions care. At times, that has meant that I have been flexible and seen an employee for a few visits as a bridge, a warm-up to accessing care, or for stabilization. At other times it has meant I have looked around for therapists meeting their needs for appointment time, insurance accepted and location and passed these referrals on to them.
6. State your boundaries and check for understanding: When I have ended up seeing a colleague for an appointment or having more extended conversations, I have gotten better at defining my role and boundaries upfront. I tell colleagues that taking someone on as a patient or having specific information about their situation can change our relationship and I try to provide some clarity about what this means. I am very, very clear about my mandated reporting responsibility. I share my priority for finding them ongoing care. And then I listen.
Maybe it’s the new year, but while writing this post I spent a lot of time reflecting on our role as BHCs. It left me feeling more than a little bit grateful to the many folks out there who have and are contributing to the development of this field. With all its complexity, integrated behavioral health truly has the potential to be one of the answers to the national conversation about how to increase access and decrease stigma surrounding access to mental health and addictions care. Thanks to all of you for being a part of this movement. And Happy New Year!
Katie Snow, LCSW is a Behavioral Health Consultant and Clinical Supervisor for Women’s Healthcare Associates, a group of OB/Gyn clinics in the Portland, Oregon metro area. Katie started out as a BHC in 2014, with 16 years of experience working in varied community mental health settings and 0 years’ experience working in integrated care. That number would have stayed at 0 without the incredible support of the LifeWorks Northwest Integrated Medical Services team and the genuine trust and support of the staff and providers of Women’s Healthcare Associates.