1. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Building Behavioral Health Teams: Medical Family Therapy and Family Medicine Residency Cross Training Jay Brieler, MD, Max Zubatsky, PhD, Danielle Thomas, MS, PLPC, Betsy Wan, MD

2. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Disclosures 1.No financial conflicts of interest 2.No potentially distressing content 3.No off-label uses

3. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Goals and Objectives 1.Define Behavior Health Integration 2.Describe characteristics of effective Behavioral Health Consultants 3.Describe unique characteristics of the field of Medical Family Therapy 4.Discuss the training environment for future Behavioral Health Consultants 5.Identify opportunities to train residents outside the traditional medical model of mental health

4. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Behavioral Health Integration What is the problem? – Majority of mental health care delivered in the primary office – There are significant gaps in the care provided – Availability of specialty mental health care is limited (especially in some geographic areas) – Training of primary care providers in mental health care is extremely variable in amount, type, and quality

5. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Behavioral Health Integration A possible solution? – Bring mental health providers to the primary care office – Behavioral health assessment and referral in real time – Broaden the training background of providers – Address the taboo of mental health care for both patients and providers

6. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Behavioral Health Integration What does it look like? – Co-located psychiatry, therapist, psychologist? – Shared appointments? – Warm handoffs? – Shared records? – Mental health only? Chronic illness?

7. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Behavioral Health Integration SAMHSA stages – Do you have a behavioral health provider on site? – Is there enough provider time to meet clinic need? – Mental health screening for all patients? – Access to psychiatry? – BH involvement in chronic disease care? – CQI / population health for behavioral issues?

8. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Role of the Behavioral Health Consultant – Assist in Diagnosis – Perform family and social systems assessments – Perform or refer for more extensive psychological testing when needed – Assist in formulation of treatment plans – Short term therapy – Coordination with outside agencies / schools

9. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Medical Family Therapy – SLU Where did Medical Family Therapy Start? Integrative Care Family Therapy Family Medicine

10. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Medical Family Therapy A meta framework of approaches in viewing patient care – Pays conscious attention to medical illness and its role in the personal life of the patient and the interpersonal life of the family – Combines biopsychosocial and family systems perspectives and uses these approaches to work simultaneously with patients, families, professionals and the community

11. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Medical Family Therapy at SLU – Trains doctoral students to work collaboratively with health care professionals in primary care, integrative care and specialty clinics. – Offers opportunities for students to work side by side with family medicine residents – Provides ways for students to synthesize clinical work and research interests throughout the program

12. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Med FT training Saint Mary’s Hospital (SSM) – Behavioral Health Consultant – Patient Rounds Family Care Health Center – Behavioral Health Consultant – Interventions – Cross-train with residents – Continuity of Patient Care

13. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Med FT training Behavioral Health Consultant – Serve as a member of the Family Care Health Center’s healthcare team who assists the primary care managers and residents in managing the overall health of the population – Precept with Jay Brieler, MD in Family Medicine – Provide comprehensive care from a biopsychosocialspiritual model – Offer brief interventions (30 minute sessions)

14. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Med FT training Cross training with residents – Peer to Peer – Student atmosphere – Learning facility – Ongoing collaboration Assessment – Red Flags

15. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin FM Residency BH Training Traditional mental health training in medicine – DSM primary mode of diagnosis – Psychopharmacology emphasis – Inpatient heavy – 3 rd year clerkship as medical student – One month rotation as FM resident

16. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin FM Residency BH Training On-site BHC (Behavioral Health Consultants) Includes Child/Adult Psychologists, Psychology Graduate Students, and MSWs Same day consults for crises Quicker referral to appropriate provider “Warm hand-off” —> higher show rate Still have more traditional BH referrals through central coordinator

17. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin FM Residency BH Training, cont. 1 month of dedicated “Behavioral Health” in PGY-2 Includes working with Psychologist, FM-Psych MD, and as BHC Weekly class with MFTs: training in attachment theory, affect regulation, family systems, and couples therapy

18. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin FM Residency BH Training, cont. New perspective on common mental health disorders (MDD, BPD, anxiety, borderline PD) Allows for more empathy and understanding of how patients’ histories have influenced their current mental health disorders Observation of family therapy sessions followed by discussion at the next class

19. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin FM Residency BH Training, cont. Attachment theory Begins with relationship b/w primary caregiver and infant Any emotion/experience that seems to threaten this bond can trigger the child’s threat detection system and cause anxiety. Can become conditioned response. Loss of attachment figure results in pathological mourning -> disturbed development, emotional detachment, inability to love and trust, and depression Infant strange situation experiment (4 attachment styles: secure, anxious avoidant, anxious resistant, disorganized-disoriented) Parenting styles can affect brain development, and abuse can worsen emotional distress

20. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin FM Residency BH Training, cont. Affect regulation Infant turns to caregiver to mirror affect responses —> caregiver co-regulates with the infant —> internalized co-regulation —> self-regulation of affect Anxiety Unconscious biophysiological activation pattern Part of unconscious threat detection system Can be triggered by objective, imaginary, and/or psychological threats Multigenerational transmission (through conditioning, those feelings/experiences become paired with anxiety and can be triggered later) Family systems: quantitative and qualitative measures (transgenerational history, FACES, genogram, family drawing, etc), treating the couple, and family transitions and impact on health

21. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Characteristics of Effective Team Care – Primary Care and BHC speak the same language – Frequency and mode of communication – Co-ownership of patient cases – Overlapping skill sets – Familiarity between providers regarding special skills – Adaptability to the team and environment

22. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Characteristics of Effective BHC – Availability in real time – “No wrong door in.” – Coordination of BH services Embrace the primary care role – Broad based knowledge and experience Age Culture Diagnosis Acute and chronic

23. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Role of the Medical Provider in BHI – Recognition of illness, provisional diagnosis – Entry into the behavioral health system (warm handoff, referral, coordination) – Initiation and titration of psychotropic medication within comfort level (+/- help from psychiatry) – Suicide / Homicide risk assessment – Ongoing ownership of the patient case

24. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Our clinic experience – Onsite Behavioral Health Consultants at virtually all clinic sessions (often both pediatric and adult) – Real time, warm handoffs for at least introductory visit – Availability of Psychiatry / Mental Health specialist consult for med management – Short term therapy by psychology within grant parameters – Limited availability of longer term therapy with graduate therapists – SBIRT available at most all clinic sessions, universal screening (risky substances and PHQ-2 or 9)

25. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Summary / Future Directions Direct alignment of graduate student and resident training schedules Long term assigned team care Care of the severe and persistently mental ill Training residents in therapy skills Formalizing curriculum in Primary Care for behavioral health providers

26. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin References http://www.integration.samhsa.gov/integrated- care-models/behavioral-health-in-primary- care#integrated models of BH in PC http://www.slu.edu/medicine/family-and- community-medicine/medical-family-therapy- program