We need more behavioral health treatment in primary care

by | November 29, 2018

A COUNTRY DOCTOR, MD | CONDITIONS | NOVEMBER 8, 2018

MEDPAGE TODAY’s

KevinMD.com

I don’t know how many times a patient has told me, “I was in therapy once, and it didn’t help.”

My response is always: “That’s like saying ‘I saw a movie once and I didn’t like it’.”

That usually breaks the ice just a little.

In primary care, we certainly run into a few patients with chronic mental health problems that could use some long-term, in-depth counseling. But usually, patients in my practice have a specific problem they need help with.

So I went to my director of behavioral health and asked: “Would you be able to offer a couple of sessions for people with insomnia, retirement quandaries, illness in the family … you know, typical life change stuff”.

He got inspired and came back to me a few weeks later with rough outlines for more than two dozen structured interventions for common psychological scenarios.

A month later, he mused about the concept of “a dose of behavioral health treatment,” like a treatment plan for any medical condition where cure or remission is anticipated: ten days of penicillin, five weeks of radiation, several courses of chemotherapy or whatever.

Mental health agencies around me are struggling with how to adapt to the times we live in. Neither patients nor insurance companies want decades of psychoanalysis. Today, it’s all about solution-focused therapy. My behavioral health guy is ahead of the curve by structuring interventions for common problems with a “curriculum” to show patients, insurers and referring clinicians.

We are doing that with chronic pain. Any patient who needs ongoing pain medication is required to attend four individual sessions to learn about what pain is, how the brain is the center of the pain experience, and how our pain experience can be altered by internal and external factors. We don’t use “pain scales” for the simple reason that pain is never objective.

We now have formalized treatment plans for a long list of common psychological symptoms, centered on one-on-one assessment and education with heavy doses of between session assignments.

Like the now so popular “coaching” modality, we explore drivers of thoughts and behaviors and challenge patients to get out of the ruts they feel so trapped inside.

The title of a 1996 book I bought around then at the Harvard Coop, skimmed through and put on a shelf, is frequently on my mind. I need to get back to it and see if it is really about what we are now doing. But even if it’s not, the title itself is beautifully inspiring: Doing What Works in Brief Therapy by Ellen K. Quick.

“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.

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