1. Behavioral Health in the Primary Care Setting

2. 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.

3. Traditional psychotherapy is based on the 45- 60 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.

4. 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

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.

17. 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)

18. 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

19. 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

20. 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)

21. 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)

22. 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

23. 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)

24. 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.

25. 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.

26. 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.

27. 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

28. 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

29. 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.

30. 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.

31. 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