Download Behavioral Health in the Primary Care Setting

Behavioral Health in the Primary
Care Setting
• It is important to recognize the difference
between the role of a BHC and that of a
traditional mental health professional.
• There are several misconceptions that both
mental health clinicians and the PCP make
about the role.
• There is a paradigm that comes with BHC work
that distinguishes it from the more traditional
model practiced in psychotherapy.
• Traditional psychotherapy is based on the 4560 minute session and explores in depth the
patient’s psyche and issues around pathology
that is causing the patient distress
• BHC’s focus is broad in the sense that it
addresses the biopsychosocial spectrum of the
patient’s needs but it is fine tuned toward the
health of the patient.
Stats from the World Health
Organization 2009-10 Report
• One million people commit suicide every year
worldwide
• Depression is ranked as the leading cause of
disability worldwide and globally affects 120
million people
• Mental illnesses affect and are affected by
chronic conditions such as cancer, heart and
cardiovascular diseases, diabetes and HIV/AIDS.
Untreated they bring about non compliance with
prescribed medical regimens, diminished immune
functioning and poor prognosis
• Barriers to effective treatment include the lack
of recognition of the seriousness of mental
health illness and lack of understanding about
the benefits of services, both on the part of
the health care system and the patient.
• There is significant discrimination between
physical and mental health problems. Many
patients still believe there is a stigma to
receiving any type of mental health care.
• Mental Disorders are among the risk factors
for communicable and non communicable
diseases and contribute to both intentional
and non intentional harm.
• Health is defined by the WHO as a state of
complete physical, mental and social
wellbeing and not merely the absence of
disease or infirmity.
How Behavioral Health is Supposed to
Work
• Relationship: There has to be a working
relationship between the PCP and the BHC. If you
have no relationship or there is mistrust or
misunderstanding about the BHC’s role you
cannot bring the best effective treatment to
patients.
• All referrals have to come from the PCP and work
from the PCP’s treatment plan. There is not a
separate plan for mental health issues in
integrative care.
• There has to be an understanding that if the
patient relates something about the other
provider in terms of service, good, bad or
confusing, that there will be communication
between the two parties and the patient is
made aware of the connection between the
providers. Otherwise, care can become
disjointed and lack the support structure
needed to maintain integrative care integrity.
What a BHC Visit Looks Like
• There is a misconception that you cannot
perform quality work in a 30 minute or even a
15 minute session.
• BHC work is designed to look at the individual
from a biopsychosocial paradigm and quickly
be able to arrive at an assessment that is
comprehensive and concise. This work is done
better by a seasoned professional who is
comfortable in their own diagnostic abilities.
The Chicken or the Egg?
The Case for Integrative Care
• The medical model makes a clear distinction
between mind and body and often PCP’s do
not like to delve into the realm of a person’s
emotional makeup and functioning.
• Primary Care does not always afford the PCP
to have the time to deal with intricate mental
health connections to physical health.
• The BHC looks for underlying issues that drive
poor health and positive self consideration on the
patient’s part.
• Address the issues that are prohibiting optimal
functioning and contributing to health related
problems.
• The BHC has to be able to understand the basics
of major health issues and how they impact
emotional or social health as well as physical
health.
• The BHC has to have a working knowledge of
medications, especially psychotropic meds, and be able
to recognize side effect reactions and know when to
alert the PCP to issues.
• They also have to be able to make reasonable
recommendations about specific medications that may
be helpful to a patient.
• Again, they are NOT there to impersonate the PCP or
interfere where they are not appreciated. All and any
actions on the behalf of the BHC are to support the
PCP, the health of the patient and aid in adherence to
their treatment regimen.
• Brief exam consultation (15 minutes) can be
helpful in identifying issues that can be land
mines for the PCP. Performing standardized
assessments for anxiety, depression or
substance abuse can identify patients who
need more care and constitutes a referral for a
more comprehensive exam either by the BHC
or a specialty service in the community.
• BHC work is meant to be a brief component to
maintaining the patient’s health. The patient
does not have a separate chart for BHC
documentation which is helpful with
maintaining a team approach to treatment.
The chart is always open and there is no
termination of services. It also means that a
patient with chronic issues can come in for
maintenance support on as needed basis and
new issues addressed as they arise.
What Is EMDR?
• Eye Movement and Desensitization and Reprocessing is
a comprehensive treatment approach that contains
elements of several therapeutic models in structured
protocols that are designed to maximize treatment
effects. It is an Information Processing Therapy that
addresses the experiential and body centered
therapies.
• It was discovered and the protocol designed by a
physician (Eileen Shapiro) and has undergone 16
random controlled and 8 non randomized studies that
show that it is an effective modality for treating
trauma. It is recognized by the Dept. of Veteran Affairs
as a legitimate treatment for PTSD.
EMDR and BHC
• BHC and the EMDR modality of treatment can
be used together to address a variety of
issues, both emotional and physical.
• EMDR by definition requires narrowing down
and addressing treatment targets and
addressing them in a concise, time efficient
manner that gives quick relief from the issue.
• EMDR has been identified as an effective
treatment of chronic pain, phantom pain by
several clinical studies
• Logical extension that EMDR is also helpful
with other health related issues and also with
medically unexplained symptoms (MUS)
• Health issues and pain can be treated like
other traumatic events (Carol Forgash, Van
Rood, de Roos, 2009, Scaer, 2005, 2007)
• For clients with somatic complaints,
reprocessing the underlying emotional issues
can effect a reduction of physical symptoms
• EMDR repairs the impaired linkage in the
adaptive information processing system
• Even when the physical condition is
permanent, EMDR can improve the quality of
life, stress levels and negative self beliefs
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Potential Client Populations:
Chronic illness
Those with injuries or victims of accidents
Current health problems arising from early
trauma experiences
• Those facing surgeries, life threatening or
terminal illness
• Those with complex PTSD or Dissociation
• Trauma survivors often either are avoidant of
treatment and health problems go untreated
or ignored resulting in increased cost to the
healthcare system when they do seek help or
• They overuse the system and are a source of
stress for the health care professional
• Often self medicating, self harming and suffer
from compulsive disorders
• Have many chronic/pain issues. (Forgash)
• Truama survivors tend not to link current
difficulties with treatment with previous trauma,
resulting in retraumatization in the medical
setting
• Do not understand their own level of anxiety
about health issues
• May not be able to ask for help and
• Frequently dissociate in the PCP’s office and
appear to be confused or disoriented about their
problems. (Forgash)
• Do not believe they deserve good care or
good health
• Many aspects of healthcare may be triggering
of original traumas
• Have issues about authority figures including
doctors or dentists.
• Cycles of negative emotions/stress/pain/self
defeating beliefs perpetuate physical
problems
• ACE Study: Results of study reveal that early
childhood trauma is linked to the
development and prevalence of risk factors for
disease and poor social wellbeing throughout
the life span: Truama>Social, emotional and
cognitive impairment>Adoption of health risk
behaviors>Disease, Disability, Social Problems
and Early Death (Felitti and Anders)
What EMDR Does
• It attends to the past experiences that have
set the groundwork for pathology that are
expressed as current issues. These issues are
brought up by emotional triggers, beliefs or
body sensations the patient experiences from
that past experience. EMDR also aids the
patient to gain the resources needed to
enhance future adaptive behaviors and
mental health.
• EMDR uses bilateral stimulation, right/left eye
movement, tactile or auditory sounds to encourage
information held in both hemispheres of the brain to
be shared and understood.
• We know that traumatic experience is recorded
differently in each side of the brain but is not often
“put into order” or arranged in a way that makes
sense. The brain is constantly trying to piece the
experience together in a coherent fashion but cannot
achieve what is needed to heal from an event. This
results in the symptoms of PTSD or other affective
disorders.
• EMDR helps the brain release emotionally
charged responses that are trapped in the
nervous system and helps the
neurophysiologic system to connect mind and
body sensations recorded during a traumatic
event. Then the brain is able to heal itself.
• It does not alter the event but it often changes
how a patient is responding physically or
emotionally to an event.
• There are 8 phases to the treatment protocol.
• The most time consuming is the history gathering
that you need to be able to identify targets.
• You also have to make sure the patient is stable,
both physically and emotionally to be able to
endure the intense processing mode.
• Helping the client to identify and use resources
for dealing with strong emotions or daily
functioning is necessary.
• This can often be completed in 3 or 4 30 minute
sessions
• Goals of treatment with complex truama
surviors or complex health issues:
• Used phased treatment approach as indicated
for stabilization/reduction of symptoms and
affect management, teach appropriate skills,
desensitize and reprocess memories and
issues that impede the patient from dealing
with health issues
• The work looks simple enough when observed
but is extremely powerful and can do damage as
well as repair it.
• The work is powerful, yet subtle in its effect so
that patients do not always understand the
connection between emotional change or actions
and the processing they completed.
• In my clinical experience it effects some kind of
change or positive movement in about 85-90 % of
the patients who elect to try it.
To be able to perform using this modality
requires certification and completion of a two
part program(56 hours of instruction and
practice), additional consultation hours and to
master the protocol or move into a
consultation position requires an additional 13
hours of CEU credits, 20 hours of consultation
and 50 recorded clinical hours.
• Does not exclude or preclude other forms of treatment and
can be used in conjunction with any other modalities.
• Most EMDR experts say that sessions should last for 1 and
½ hours and there has not been any work that any of my
trainers know of that reflects the work done in a BHC
setting.
• I have not found that the work is impeded in any way when
using the 30 minute time period as long as all the protocol
is adhered to . It may take several sessions before
processing is performed but the effect in the end is just as
effective.
• Case examples/questions