July 14, 2025 • 46 mins
In this episode, Dr. Casey Grover explores how integrating behavioral health and addiction services into primary care settings can transform healthcare delivery and dramatically improve access to treatment. Dr. Grover speaks to psychologists Patti Robinson and Jeff Reiter about their work creating integrated primary care practices and clinics.
• Healthcare in the US is siloed, forcing patients to navigate separate systems for physical health, mental health, and addiction
• Mental health specialization creates artificial barriers when generalist counselors could help many addiction patients
• Integrated care places behavioral health providers in primary care settings with same-day, brief (15-30 min) appointments
• Primary care doctors welcome the support while mental health providers need retraining to adapt to the flexible model
• Physical clinic design matters—providers should be within 15-20 feet of each other for true integration
• "Pathways" can be created for specific populations like those with opioid use disorder
• Patients overwhelmingly appreciate the convenience and comprehensive approach of integrated care
Visit speaktoyourdoctor.com for resources to share with your medical provider about implementing integrated behavioral health services.
To contact Dr. Grover: ammadeeasy@fastmail.com
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Welcome to the Addiction Medicine Made Easy
Podcast.
Hey there, I'm Dr Casey Grover,an addiction medicine doctor
based on California's CentralCoast.
(00:22):
For 14 years I worked in theemergency department seeing
countless patients strugglingwith addiction.
Now I'm on the other side ofthe fight, helping people
rebuild their lives when drugsand alcohol take control.
Thanks for tuning in.
Let's get started.
Today's episode is differentthan anything I have done before
(00:44):
on this podcast.
Normally we cover a topicaround the diagnosis and
treatment of substance usedisorders.
We might review a patient caseor discuss how a medication can
reduce drug cravings.
But today we are going to zoomway out and look at the
healthcare system in general,specifically around how
healthcare is delivered.
I had the pleasure ofinterviewing Dr Patty Robinson
(01:07):
and Dr Jeff Reiter, who are bothpsychologists and they work on
integrating mental health andaddiction into primary care.
Why this topic and why doesthis matter?
So healthcare in the UnitedStates is very siloed, meaning
that most healthcare providershave their specific area of
expertise and they don't addressanything outside of that area
(01:31):
of expertise.
But human beings arecomplicated.
Let's say a person hasdepression, high cholesterol and
an alcohol use disorder.
This person might have to seethree different clinicians in
order to address all of theseissues with three different
appointment schedules.
Jeff and Patty help set upintegrated primary care, which
(01:54):
involves putting mental healthprofessionals with expertise in
a wide range of mental healthconditions, including addiction,
in with primary care providersand clinics.
So now, with behavioral healthintegrated into primary care,
this person with depression,high cholesterol and an alcohol
(02:14):
use disorder can have all ofthese problems addressed in a
single visit, with a plan forongoing follow-up.
It's brilliant and we reallyneed this here in the United
States, as our healthcare systemis very fragmented, with poor
access to services for mentalhealth and addiction.
Before we get into my interviewwith Jeff and Patty, I wanted to
(02:35):
make one clarification.
Jeff and Patty talk aboutgeneralists, and what they mean
by that is they're referring tomental health providers, such as
psychologists or therapists,who can treat a wide range of
mental health conditions,including addiction.
All right With that, let's digin.
All right, jeff and Patty, goodmorning, so glad to have you
(03:01):
with me.
I usually start with who youare and what you do, patty.
Why don't you start?
And then, jeff, you can tell usyour side of the story too.
Speaker 2 (03:08):
Okay, well, I'm Patty Robinson.
I'm a psychologist and I livein Portland, oregon, and in a
little tiny house outside thecity with my partner of 40 years
and our two dogs, mac and Molly.
I have been working in thefield of health care since the
1980s, first as a scientist thatwas looking at how can we get
(03:36):
more behavioral health servicesmeaning both mental health and
substance abuse servicesavailable to people, because
clearly most people that wouldlike to receive them can't.
So that question has been on mymind for decades.
Casey and I met Jeff, and we'veworked together on three
(03:59):
different books.
We're pretty excited about thethird edition of a book that
really is a how-to guide forbehavioral health providers
mentalitment Therapy, which is aversion of acceptance and
(04:30):
commitment therapy developed inthe context of primary care
clinics, and it's helpful topeople with issues with use of
substances of a variety of kinds, and so I look forward to
talking with you about it today,jeff.
Speaker 3 (04:50):
Yes, so, jeff Reiter, I'm also a clinical
psychologist and I live inToledo, ohio, northern Ohio.
I got into doing this work inintegrated primary care
behavioral health which, asPatty was mentioning, is about
integrating behavioral healthprofessionals into primary care
services to help improve accessto behavioral care.
(05:14):
I got into that back in 2002and have been really pretty much
just living, eating, breathingit ever since then, and what
drives me is what Patty wastalking about, which is the need
for us to improve access tocare for people who are trying
to get care for mental health aswell as addiction services.
(05:38):
So, yeah, thanks for having uson to talk about all that today.
Speaker 1 (05:43):
So I don't know which one of you has a better answer
for this, but can you share someof the background why mental
health has been segregated as aseparate specialty and
discipline?
We all know that healthcareinvolves all parts of the human
body.
There's a history why dentistryis separate.
There's a history why podiatryis separate.
Do either of you know thehistory of why we segregate
(06:04):
mental health?
Speaker 3 (06:07):
history why podiatry is separate.
Do either of you know thehistory of why we segregate
mental health?
I don't necessarily know howthat came to be, but I agree
that it's a huge problem.
I think it's probably thebiggest problem that we have
actually when it comes tohelping people to access care
for substance abuse services,because it ends up that those
silos end up creating a numberof problems.
One is that you've gotaddiction medicine specialists
(06:32):
whether we're talking abouttherapists, counselors,
physicians who end up beingperceived as the only people who
can really help people withaddictions, which in reality is
not the case right, especiallyin our field in mental health.
I mean, any general counselorcan help a person with a
substance use problem, but wehave carved out these
(06:55):
specialties substance abusecounseling, psychologists, with
an emphasis in substance abuseand it's to the point where the
general counselors out theredon't feel able to work with
substance abuse problems.
So, even though many of thepatients that they're seeing for
therapy or marital problemswhatever they're coming in for
(07:16):
have substance use problems,they don't feel able to help
with that, even though theycould.
They have to all try to referthem to this relatively small
pool of professionals who dowork with these problems and it
just creates a huge accessproblem.
And then you've got on top ofthat the issues around payment
being separated and so forth.
So I wish I was a betterhistorian of my field.
(07:37):
Maybe Patty knows more than Ido about how this all came to be
, but my guess is that it'sprobably tied to moral judgments
around substance use and thestigma around substance use,
just that it's always beentreated, and still is treated,
as something different from ahealth problem, which is
ludicrous.
But that's my guess about theorigin of it.
(07:59):
But I don't know if you haveanything to add to that, patty.
Speaker 2 (08:01):
I don't know if you have anything to add to that,
patty.
Yeah, I think my perspectiveand understanding of the history
of the evolution of medicine issuch that we moved from a
collectivist kind of societythat viewed health in a quite
different way than it's viewedin today's world.
So a much more holistic view ofhealth mental, physical, social
(08:27):
, emotional was just health andthe health of the individual was
the health of the family, thecommunity.
So people were not separatedout and compartmentalized into
having physical health problemversus a mental health problem
versus a behavior problem.
(08:48):
So what happened over time andit's really quite recent was we
had the emergence of groups ofpeople with expertise in
specific areas.
They were studying and theywere figuring out how to help
with one thing and the modelthat kind of pulled, trained and
(09:08):
trained specifically in abiomedical model where they're
(09:29):
looking at the biological kindsof qualities associated with
illness.
In fact the originaldefinitions of health were the
absence of physical healthproblems and we all know that's
not true for most of us, even aschildren or teenagers.
(09:50):
So the progression has been.
I think the first inroads wereto start to pitch a
biopsychosocial model and say,hey, we are complex, and now
what we're trying to do ischange systems so that primary
(10:13):
care, which was the level ofhealthcare set up to be
accessible to all people, anyage, any problem.
It's the first door.
It's the right door for anyonetrying to influence them towards
a biopsychosocial model and tosucceed in walking with our
(10:34):
medical colleagues towards thatview.
We realize we need to be rightthere because your training
doesn't help you do that so manytimes.
It's changing now, casey, butit is a huge impact in the care
that's received when people gosee their doctor.
Speaker 1 (10:58):
We have so much to unpack here.
This is going to be fun.
Okay, jeff, let's start with afollow-up on what you said.
I literally last week referreda patient for counseling and
they said no, we don't doaddiction.
And my response was I'm anaddiction medicine doctor.
I'll handle the addiction, butmost of my patients have some
(11:19):
sort of traumatic lifeexperience.
Many of them have PTSD.
And my question to thetherapist was why can't you work
on the PTSD?
I'll handle the addiction part.
And you mentioned, jeff, thatsometimes counselors say, whoa,
I can't do addiction.
Can you talk to me about thatfrom a psychology or LMFT
perspective?
Speaker 3 (11:38):
Yeah, Well again, yeah, it's a huge problem.
That counselor that youinteracted with there is
representative of how mostpeople in my field think.
I think Psychologists, socialworkers, other sorts of
counselors this falsedistinction between biological
(12:02):
health, mental health, substanceuse.
We've kind of created thesethree silos.
Mental health problems aresiloed as well, right, not only
substance abuse problems butmental health problems as well.
But within the mental healthfield, substance abuse problems
are then given another layer ofsiloing.
So you have the mental healthprofessionals that feel
(12:25):
uncomfortable working withsubstance abuse problems.
So I think that our field hasgotten really specialized over
time.
The mental health field, mentalhealth counseling field, have
gotten really, reallyspecialized over time.
You have people who specializein working with kids, people who
specialize in working with PTSD, people who specialize in
(12:46):
working with PTSD in kids moreand more specialized a lot of
which I think is driven actuallyby that biomedical perspective
than the original DSM.
Right, it's just loaded withall sorts of new conditions now,
(13:08):
new diagnoses now that didn'texist in the early days of the
mental health field, and so whenyou have this growing number of
problems to treat, then you getmore and more specialization to
treat those problems, I think.
So we've had this trend for anumber of years in the mental
health field towardsspecializing.
(13:29):
And it's unfortunate, though,because you know, what we do as
mental health providers is notthe same as what medical
providers do.
There are some overlaps here,but, you know, if a person goes
in to see their primary careprovider with a sore throat and
a sprained ankle, those areprobably not connected.
(13:50):
Those are probably twodifferent problems to address
there.
But if a person comes in to acounselor or maybe they come
into the emergency room or totheir primary care provider with
relationship problems and adrinking problem and depression,
those are all related, right,everything that we work with in
(14:12):
the mental health field isrelated, but we act as if we're
treating discrete problems.
We act as if we're treatingthis discrete diagnostic entity
from the DSM-5 that we've gottenhighly specialized training in,
and we act as if we're doingsomething different than what we
would do with any other problemthat a person comes in with.
(14:33):
But in reality, that's not true, right.
I mean the same strategies thatI, as a therapist or a
counselor, use with a personwith depression or relationship
problems or addiction problems.
I'm gonna use the samestrategies for all of them.
I might use motivationalinterviewing, I might use
cognitive therapy approaches, Imight use mindfulness approaches
(14:53):
or any number of approaches,right?
But we've created this sort ofidea, this myth amongst
ourselves as mental healthprofessionals, that we need to
be highly specialized to addressall of these different problems
that are out there.
But in reality we don't need tobe highly specialized, but
there's that, I guess,perception out there, so that
(15:16):
makes people afraid to work withproblems that they feel like
are outside of their area ofexpertise.
If my area of expertise isrelationship problems and
somebody has a drug problem, butI'm seeing them for a
relationship problem, many, manypeople feel the need to refer
out to an addiction specialist.
In that scenario they feel like, well, that's a separate
(15:37):
problem from the marriageproblem, right?
So I need to send them to aspecialist in that problem, when
in reality, again like no,these are connected problems.
It's all happening to the sameperson, same body, same mind and
same relationship and and andin fact, the relationship is
probably influencing the druguse and the drug use is probably
(15:59):
influencing the relationshipproblem.
So we can take them on bothtogether, right?
So in my mind, that's a hugepart of the problem is that
specialization that we'vecreated for ourselves.
It doesn't need to exist, butit does exist in counselors'
minds and that then becomes areally big access barrier for
(16:20):
them.
So if we could wipe that out,we could just open the door to
loads more access to mentalhealth care for people.
Right, because you wouldn'thave gotten the response from
that counselor that you gotright, and so, anyway, that's my
take on that.
Speaker 1 (16:38):
Yeah, as we were speaking about before the
podcast started, my backgroundis in emergency medicine, as we
were speaking about before thepodcast started.
My background is in emergencymedicine and healthcare
providers.
When they're in that silo, whenthey get a problem given to
them that's outside of that silo, there tend to be two responses
One is go see your primarydoctor and two is go to the
emergency department, and bothparts of our healthcare system
(17:01):
are hugely overwhelmed.
So, patty, you had talked aboutintegrating behavioral health
into primary care.
Primary care in America ishorribly overloaded and I just
am curious what does integratedbehavioral health into primary
care look like?
And, most importantly, how doesit help the primary doctor,
help the patient, primary?
Speaker 2 (17:22):
doctor help the patient.
All right, Great questions,Thank you.
It looks different in form andit looks different in function.
So the behavioral health ormental health provider that goes
into primary care needs specialtraining, a lot of retraining,
(17:48):
needs special training, a lot ofretraining.
They become a generalist.
So typically, Jeff and Iprovide training.
We provide a training all overthe world, and when an
organization decides to movefrom siloed care to integrated
care, it's big.
Everybody needs retraining,including the primary care
provider and the nurses and theperson at the front desk.
(18:09):
Everybody's workflow andmessage to patients is going to
be different.
So this newly arrivingbehavioral health provider could
be any licensed health careprovider.
I've worked a lot in New Zealand.
So they have occupationaltherapists and they have, of
(18:31):
course, counselors, socialworkers, psychologists, mental
health nurses, and they gothrough an intensive training
and, speaking specifically ofNew Zealand as well as other
systems that I've worked with,this training is really
intensive.
It's like four or five days,all day long, and they learn how
(18:54):
to work in a new way and theylearn how to provide a new
psychotherapy or therapeuticintervention called focused
acceptance and commitmenttherapy.
So the way it looks is thisperson is trained to be the
first door for any kind ofproblem for any person.
(19:16):
Alcohol may not be working intheir life or marijuana may not
be working in their life, butthey come in with all kinds of
problems.
They might say I have chronicpain, or I have problems in my
family, or we can't communicate.
So this generalist is trainedto respect the problem that the
(19:37):
person wants to work on at thatmoment and to do what we call a
behavioral analysis.
So they're really looking atthe triggers for the behavior,
what the behavior looks like,the consequences, what the
person is trying, how that'sworking relative to that
(19:58):
person's values, what matters tothem.
That's a lot to do and it takesa lot of training.
Not only that, but they areworking in a brand new way.
They're sitting with the teamin the team space that might be
with nurses or in some primarycare clinics.
We have a hub for primary caredoctors and behavioral health
(20:19):
providers and nurses, dieticians.
They're all sitting togetherand they plan their day as it
starts and they check in witheach other throughout the day.
They co-refer and co-care forthe people that are scheduled
and the people that show up.
So visits are 15 to 30 minutesin length, whatever time the
(20:44):
person has available andfollow-up is up to that person.
So the schedule for thebehavioral health provider is
such that every other visit isthe same day visit.
So very accessible care.
That's for initial visits aswell as follow-up.
Speaker 1 (21:04):
So, jeff, I feel like this would help me enormously
in my practice.
So people come in and they'reangry at their landlord, they're
angry at their mother, theyjust had an altercation with
someone in the parking lot andthat just gets verbal diarrhea
all over me and the 20-minuteappointment gets taken up by
that and I don't even have timeto talk with them about their
(21:24):
Suboxone.
In my practice we have peersupport specialists, so we try
to create at least some sort ofco-management.
How does it actually look like?
I mean, I'm going to go toclinic next week.
What would it look like for me,for that patient?
They've got opioid use disorder.
They've got some familydysfunction.
They've got some impulsivityopioid use disorder.
They've got some familydysfunction.
(21:45):
They've got some impulsivity.
They have trouble controllinganger and regulating emotions.
What would that look like?
We'll call this fictitiouspatient Sam.
What would it look like if Samhad an appointment with me next
week and we had this integratedbehavioral health approach?
With my practice it's a littledifferent because I'm addiction
medicine but a lot of patientsconsider me their primary doctor
because they can trust me.
So let's pretend I'm a primarydoctor with an expertise in
(22:07):
addiction.
What does that look like?
Speaker 3 (22:10):
Yeah, I encourage primary care providers to bring
in somebody like myself, abehavioral health consultant, if
there's something that comes upin their visit with their
patient that they would like tohave more time to discuss.
Maybe they feel like there'ssome issue going visit with
their patient that they wouldlike to have more time to
discuss.
Maybe they feel like there'ssome issue going on with the
patient that they feel like theycould discuss.
(22:30):
They feel like they couldhandle this and could help the
patient with this problem, butthey just plumb, don't have
enough time, right.
So in that capacity then, inthat scenario, I'm sort of like
an extender, an extension of theprimary care provider, right?
So the primary care providermaybe has some skills in
motivational interviewing andmaybe feels like that would be
(22:51):
helpful for this patient rightnow, but, just like I say, it
just doesn't have any time.
So they might bring me in tothat visit then to do that
motivational interview that theythemselves don't have time for,
right?
Or the other scenario wherethey might pull me in is if they
feel like the patient,whatever's going on with the
patient in that moment, issomething that maybe they don't
(23:13):
feel like they have enoughtraining to help the patient
with.
Like, maybe they feel like thatas patients really struggling
with being able to make thischange we want them to make and
I'd like for them to get somemotivational interviewing help
around this.
But I don't really havetraining and motivational
interviewing myself, so I'mgoing to bring jeff in to help
with that.
So one scenario is where you,you, you feel like as the
(23:36):
primary care provider, you couldhelp the patient but you don't
have time.
The other scenario is maybe youfeel like the patient needs
some more specialized help thanwhat you you've had training in
as a primary care provider,right?
So those are the two scenarioswhere the primary care provider
might bring me in.
Every patient you're going tosee in addiction medicine has
some sort of, by definition,behavioral health issue going on
(23:57):
, right?
So we don't say thatnecessarily.
I don't assume, as a behavioralhealth provider, that I need to
be involved in every one ofyour visits.
But if you feel like one ofthose two scenarios comes up,
seamless connection that you asthe primary care provider, make
(24:27):
to me as a behavioral healthprovider, right?
So I'm sitting there in theclinic in the same space where,
like Patty was saying, where allthe rest of the team sits and
if you would like my help, youwant my help.
You ping me on a team's messageor you physically come and tap
my shoulder and say, hey, jeff,can you help with this patient.
Or you send somebody to comeget me or, however it works, you
(24:48):
grab me real time.
I go into the exam room.
If I've never met the patientbefore, you introduce me to them
, and then you leave the room,go on to your next patient.
I stay in that same exam roomwith the patient.
If that works out, the examroom's available and whatnot.
I stay in that same exam roomwith the patient.
If that works out, the examroom's available and whatnot.
I stay in that same exam roomand just continue your visit,
(25:08):
but with the particular focusthat I'm bringing right to
helping that patient.
So that's the way that we tryto make it look.
There's not eight pages ofpaperwork you have to fill out
to see us as the behavioralhealth person on the team.
There's no wait, it's juston-demand care.
We practice in ways that makeus super accessible, like that,
all throughout the day.
And then the beauty of primarycare is that it's all built
(25:32):
around this idea of a long-termrelationship that you establish
with patients right, which youwere talking about before.
We got onto the air here theimportance of the relationship
and working with people withsubstance use problems.
And that's why I love workingin primary care, because that's
when primary care is at its best, is when those long-term
relationships are built withpatients.
That's the secret sauce ofprimary care.
(25:53):
That's why I love being there,because then we have the
opportunity to build theselong-term relationships too with
patients that I never had,frankly, when I worked in a
mental health clinic.
So now that you've introduced meto that patient, I'm starting
getting to know them.
The next time they come back tosee you, sometimes that same
patient might say hey, you knowwhat that Jeff guy that Dr
(26:14):
Grover had me talk to last timeI was in there.
He was pretty helpful.
I'm going to make anappointment to see him on the
same day as Dr Grover, rightbefore Dr Grover.
So the next time they're inseeing you, it might pop into
their mind that they want totalk to me again while they're
there and you work me in againreal time to see them.
Or maybe a new issue comes upand you want my help and you
bring me in.
But that's what it looks like.
Speaker 1 (26:35):
So, Patty, I'm going to give you a magical $100
million and you get to build theperfect clinic.
What does the ideal physicalsetup look like?
And then I know you wanted toadd something.
Speaker 2 (26:47):
So, after you tell me what the ideal physical space
is, I'd love to hear what youwanted to add, I have been able
to work with systems, forexample the San Francisco Public
Health Department, who wereasking this question what does
(27:10):
it look like?
And so I think it depends onthe population served in that
clinic in that community.
So the staffing ratio ofbehavioral health providers to
primary care providers dependson the population served.
So in a clinic that servespeople that don't have houses,
that are extremely vulnerable,the setup might be to have a
(27:32):
couple of behavioral healthproviders supporting every
physician or PA, every primarycare provider.
If we move into other clinics,for example commercial systems
serving people, it depends onthe mix of people coming to that
clinic.
(27:53):
But I would say roughly, you'regoing to want to have one
behavioral health provider forevery team, but the principle
that's the same about thephysical environment is
togetherness.
So we don't want anybody tohave to walk more than 15, 20
(28:17):
feet to run into a behavioralhealth provider, because more
than that is a deterrent tousing a person you're going to
use a lot every day.
The other thing that I was goingto add Jeff so beautifully
described our general model forindividual consults.
(28:38):
In addition to that way ofassisting and supporting the
work of our primary careproviders, we have something
different called pathways,primary care, behavioral health
pathways.
Pathways target a particularpopulation.
What population?
The population of greatestconcern in that clinic and what
(29:04):
that clinic then decides as agroup is how can we better serve
that population?
So, people struggling withopioid use disorder, that's a
great population to target inmany primary care clinics and
those that do develop apathwayday introduction to all
(29:27):
members of the team, that werepossible and that would include
a behavioral health provider.
So usual care for that personwould include the behavioral
(29:52):
health provider.
So on a day of a visit with aprimary care provider that would
have been covered in the huddle, so-and-so is coming for an
appointment, so you may want tostop in and say hi, or you may
have, in addition to individualvisits with their primary care
provider or addiction medicineand primary care provider, there
(30:16):
often are groups that theperson can drop into and that
the person routinely attends.
It depends on what phase ofrecovery that they are in.
It might be weekly, it might betwice a month, it might be once
a month.
With a condition like thatwe're looking at, probably most
(30:38):
people can recover, but we'relooking at five years or
something.
So we really need to have aprogram that's feasible, that's
accessible, that people canstart and restart with ease and
that is multidisciplinary.
That's described in the pathway.
The details are decided basedon the resources in the clinic.
(31:02):
What does the clinic have andwhat's the evidence for us to
get that to these people?
Speaker 1 (31:19):
has a central corridor of patient rooms and
there's a left door and a rightdoor, and then the doctor comes
in on one side and thebehavioral health folks come in
on the other side.
I was really impressed, jeff.
I'm going to ask you the nextquestion when you are trying to
create these integrated primarycare clinics, what sort of
pushback do you get from thehealthcare providers?
Speaker 3 (31:35):
Well, it depends on which healthcare providers
you're talking about.
Speaker 1 (31:38):
You tell me.
Speaker 3 (31:40):
Well, it depends on which healthcare providers
you're talking about.
You tell me every day ofpatients whose health is being
affected by behavior in one wayor another, whether it's
(32:06):
addiction or depression or someother problem, and they don't
get a lot of training to workwith mental health problems
either, right, and they havelots of other medical issues to
help patients with too.
So there's typically verylittle pushback from the primary
care providers.
They welcome the help.
They're rather desperate forhelp.
Frankly, the pushback usually,if you get it, it's going to
(32:27):
come from the mental healthproviders, because we are asking
them to practice in a waythat's fundamentally different
from how they typically practiceright.
How they typically practiceright, I mean, most mental
health professionals therapistsare accustomed to hour-long
visits that are, with a lot ofthe same people, scheduled on a
fairly regular weekly basis,that sort of a thing for a long
(32:50):
period of time.
And so when we take them fromthat environment and we plop
them down in primary care andsay, okay, the way that we
practice in primary care is wehave 30-minute visits, and
actually 30 minutes is just howit looks on the template,
because in reality we're workingpeople in all throughout the
(33:13):
day for unscheduled visits likeI was describing before, and so
we might end up just seeingsomebody for 10 minutes or 15
minutes, 20 minutes, and thenthe follow-up is planned
differently.
Most primary care patients yourtypical primary care patient
with either some sort ofaddiction or some sort of
behavioral concern, is not allthat interested in following up
(33:34):
regularly, certainly not forweekly hour-long visits, and so
the follow-up often looksdifferent.
You have to adjust to theprimary care context where you
rely on developing theselong-term relationships with
patients, grabbing a little bithere with them, a little bit
there with them over time,building those relationships
over time with them.
So it's a different way offollowing up and it's much less
(33:56):
predictable of a workflowthroughout the day too.
Right, because again, we'reworking people in all throughout
the day.
That very rarely happens.
If you're in a mental healthclinic.
People don't just hop in to amental health clinic.
I'm going to see them right now.
It doesn't work that way, orvery rarely anyway.
So I'll say that and some ofyour listeners will say well,
that's not true.
We practice this way in mentalhealth, but it's rare.
(34:17):
So in general it's not true.
We practice this way in mentalhealth, but it's rare.
So in general, it's a much lessflexible environment in mental
health.
So that's where the pushback ifyou do get any usually comes
from is from the mental healthprofessionals who really have to
practice in a way thatunderstand that.
(34:41):
The goal of what we're trying todo is we're not trying to get a
huge volume of visits to asmall group of people, we're
trying to reach a large numberof people and what that means is
(35:03):
that we might end up havingshorter visits with them.
We might end up having, like Iwas saying before, a different,
different structure to ourfollow-up than we would
otherwise.
But what we're trying to do isjust to reach people right, just
to reach people and get startedbuilding those relationships
with them.
And if you have somebody whounderstands that goal right,
then that's great.
They're usually open to makingthese changes and they can flex
(35:25):
and go from there with a littlebit of training, like Patty and
I provide.
But yeah, that's where it tendsto come from Occasionally.
Primary care providers maybe youmight get a little resistance
there for one reason or another.
Maybe it's more skepticismbecause they've maybe worked
with mental health professionalswho have practiced in a very
inflexible way in the past.
(35:46):
More typical counseling approachright with being selective in
who they're going to see andneeding to see people every week
for hour-long visits for a longperiod of time.
So if they've had a lot ofexperience with that system and
they've been frustrated by theaccess problems just like you
were frustrated the other daywith that patient you were
trying to get in to see thecounselor if they've had a lot
of those kinds of experiences,then a lot of times they're
(36:09):
skeptical coming into all ofthis that this is really going
to add anything or really goingto be helpful.
But once they see howaccessible we really are in this
model and that we practice ageneralist we don't practice as
these uber specialized peoplewho are going to say I'm sorry,
I can't help with this addictionproblem because it's out of my
scope, that's not what we do.
(36:30):
We practice like generalists,like primary care providers Then
that skepticism starts to fadeaway and usually they are 110%
on board.
Speaker 1 (36:39):
Patty, next question for you what's the patient
experience when behavioralhealth and addiction services
are integrated into primary care?
Do people get upset because thevisit takes longer?
Do they find that they're ableto work on issues that they
didn't know they had?
What's the patient experiencelike?
Speaker 2 (36:55):
Yeah, good question.
I think this goes back totraining.
So we have to train the primarycare providers to identify
people even before the daystarts, with scheduled patients
that they want to involve us in,and so they can start the
(37:17):
length of their visit becausethey're not trying to do
everything which they are sofrustrated with, because they
usually have two or threemedical problems plus all of the
other issues mental health,substance abuse.
So that isn't a hard sell forthem to go in, but it takes
(37:38):
training and then training onworkflows.
But when people are trained andwe have signage in the clinic
that says, oh, we have a healthimprovement practitioner or
whatever you call this person,we have a health improvement
practitioner.
They help with sleep, stress,family problems.
(37:58):
If you'd like to see them today, let your doctor know.
So really, even when a doctorgoes into the room and the
patient could say, hey, do youthink I can see this person?
So then the doctor's going toadjust to the patient's request
and shorten their visit and getthem involved with the
(38:21):
behavioral health provider.
So for them, some clinics whenthey start providing primary
care behavioral health services,they send out letters or push
messages through the healthcareportals announcing it so that
people are informed that theirhealthcare team is improving.
(38:42):
And people I would say 90% arelike oh my goodness, are you
kidding me?
Because what's to push back onif a PCP says I'd like you to
meet a new member of our team?
They help with a lot of things,including this problem you're
struggling with right now.
They may be available right now.
(39:04):
Their visits are short.
I get really good feedback fromother people that I recommend to
Patty or recommend Patty to soyou don't get pushback.
Sometimes you'll get somepeople that think they need
therapy and so they're like ohwell, wait, is this therapy?
(39:28):
And so we have to train and sayno, no, it's in the moment,
consultation on how to get yourlife in track, how to address
common life problems, becausewe're not doing therapy,
diagnosing and treating andrequiring people to come back an
X number of times.
Because people don't do that.
They come when they're hurtingand they go away when they're
(39:52):
not.
So with that group we just say,if that's what you want, I want
to help you find it, but sinceyou're here today, let me help
you as much as I can.
And a lot of those people comeback and say I don't want
therapy, I want what you'redoing.
Speaker 1 (40:14):
Behavioral Consultation in Primary Care.
A Guide to Integrating Services, third Edition.
It's a textbook.
Wow.
I've always wanted to be anauthor.
I'm very impressed that you'vebeen doing this for enough times
to have a third edition.
Well, regrettably I have to gosee patients and I'm sure y'all
are busy too.
Jeff, why don't you close usout with whatever wisdom you'd
(40:35):
like to share, given yourperspective, and then Patty will
come back to you as well,Anything you'd like to share
about your work or wisdom topatients or providers alike.
Speaker 3 (40:51):
We have a serious problem in this country with
people being able or unable toaccess care behavioral health
care for mental health andsubstance abuse problems and I
really do fear that if we don'tsolve this access problem well,
we'll never completely solve it,of course, but if we don't
lessen the severity of thisaccess problem soon, my
(41:14):
profession really risks beingviewed from a public health
standpoint and by policymakersas irrelevant.
I fear that, and so we need todo a better job in the mental
health professions of beingaccessible, and that means we
need to back off of this ideathat we can only help with
(41:37):
certain problems.
We need to recognize that wecan be generalists.
Many more of us need to beworking in primary care settings
where these people show up, andif we can practice these ways
and practice more flexibly toget away from the requirement
for an hour-long visit everyweek into perpetuity right, Be
(41:57):
more flexible to meet peoplewith what works for them.
There are lots of otherapproaches single session
therapy, solution focus therapyand so forth Focus, acceptance
and commitment therapy that canhelp.
So I hope that my profession.
Moving forward will embrace theaccess challenge and be able to
lessen it.
Speaker 1 (42:15):
Patty final thoughts.
Speaker 2 (42:18):
Just final thoughts are if you don't have this
service Integrated BehavioralHealth or you have it and it
doesn't work quite the way we'retalking about and you want it
to, and most people in Americado not have access to clinics
that have primary carebehavioral health services.
(42:38):
If you don't have it, rememberthis URL speaktoyourdoctorcom.
Speaktoyourdoctorcom.
Go there, it's about our book,but there is a tab that says
speaktoyourdoctorcom.
You can click on that.
There's an information sheetthat you can use, that you can
(43:00):
take to your doctor and say look, this is the kind of health
care I want.
Let's partner together and getthis started in our community
and then I think things aregoing to get better for the very
many, many people among us thatare struggling with use of
substances, because we'll havethe primary care team staffed
(43:25):
right and primary care providersare going to be a lot more
willing to say well, bob, I knowusing alcohol is an issue and
you're here today with somestomach problems and I'm just
wondering if you'd like to seePatty just to talk about
improving your health in general, because we need to hook people
(43:46):
in what they care about andthey care.
They care a lot about theirfamilies, they care about their
well-being.
They want a better life.
We just got to offer theservice and make it really
available in a way that says hey, you're one of us and we want
(44:09):
to help.
Speaker 1 (44:11):
Well, Jeff and Patty, I have to say I will be a
better doctor next week inclinic, having to spoken both of
you trying to really partnermore.
Sometimes I feel like I getisolated in my little clinical
exam room, like I get isolatedin my little clinical exam room
and I forget to walk my patientsover to my peer support team.
We actually do have an LMFT inthe office with us.
I've got a number of folks thatsee myself, peer support and
the therapist on the same day.
So I think, while you areexperts in this, I came to this
(44:34):
a little more organically, butthe patients, like you've said,
they just appreciate having moresupport and being able to
address more issues when theycome in.
This was awesome.
I appreciate both of you and Iwill be certainly sending your
work off to some of theleadership at my hospital.
So thank you for joining metoday, Thanks so much.
Speaker 3 (44:51):
Thanks so much, and thanks for your work too.
Speaker 1 (44:56):
Before we wrap up, a huge thank you to the Montage
Health Foundation for backing mymission to create fun, engaging
education on addiction, and ashout out to the nonprofit
Central Coast OverdosePrevention for teaming up with
me on this podcast.
Our partnership helps me getthe word out about how to treat
addiction and prevent overdosesTo those health care providers
(45:19):
out there treating patients withaddiction.
You're doing life-saving workand thank you for what you do
For everyone else tuning in.
Thank you for taking the timeto learn about addiction.
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
treated.
Together, we can make it happen.
Thanks for listening andremember treating addiction is
(45:40):
treated Together.
We can make it happen.
Thanks for listening.
Speaker 2 (45:55):
And remember treating addiction saves lives.
Welcome to the Addiction Medicine Made Easy
Podcast.
Hey there, I'm Dr Casey Grover,an addiction medicine doctor
based on California's CentralCoast.
(00:22):
For 14 years I worked in theemergency department seeing
countless patients strugglingwith addiction.
Now I'm on the other side ofthe fight, helping people
rebuild their lives when drugsand alcohol take control.
Thanks for tuning in.
Let's get started.
Today's episode is differentthan anything I have done before
(00:44):
on this podcast.
Normally we cover a topicaround the diagnosis and
treatment of substance usedisorders.
We might review a patient caseor discuss how a medication can
reduce drug cravings.
But today we are going to zoomway out and look at the
healthcare system in general,specifically around how
healthcare is delivered.
I had the pleasure ofinterviewing Dr Patty Robinson
(01:07):
and Dr Jeff Reiter, who are bothpsychologists and they work on
integrating mental health andaddiction into primary care.
Why this topic and why doesthis matter?
So healthcare in the UnitedStates is very siloed, meaning
that most healthcare providershave their specific area of
expertise and they don't addressanything outside of that area
(01:31):
of expertise.
But human beings arecomplicated.
Let's say a person hasdepression, high cholesterol and
an alcohol use disorder.
This person might have to seethree different clinicians in
order to address all of theseissues with three different
appointment schedules.
Jeff and Patty help set upintegrated primary care, which
(01:54):
involves putting mental healthprofessionals with expertise in
a wide range of mental healthconditions, including addiction,
in with primary care providersand clinics.
So now, with behavioral healthintegrated into primary care,
this person with depression,high cholesterol and an alcohol
(02:14):
use disorder can have all ofthese problems addressed in a
single visit, with a plan forongoing follow-up.
It's brilliant and we reallyneed this here in the United
States, as our healthcare systemis very fragmented, with poor
access to services for mentalhealth and addiction.
Before we get into my interviewwith Jeff and Patty, I wanted to
(02:35):
make one clarification.
Jeff and Patty talk aboutgeneralists, and what they mean
by that is they're referring tomental health providers, such as
psychologists or therapists,who can treat a wide range of
mental health conditions,including addiction.
All right With that, let's digin.
All right, jeff and Patty, goodmorning, so glad to have you
(03:01):
with me.
I usually start with who youare and what you do, patty.
Why don't you start?
And then, jeff, you can tell usyour side of the story too.
Speaker 2 (03:08):
Okay, well, I'm Patty Robinson.
I'm a psychologist and I livein Portland, oregon, and in a
little tiny house outside thecity with my partner of 40 years
and our two dogs, mac and Molly.
I have been working in thefield of health care since the
1980s, first as a scientist thatwas looking at how can we get
(03:36):
more behavioral health servicesmeaning both mental health and
substance abuse servicesavailable to people, because
clearly most people that wouldlike to receive them can't.
So that question has been on mymind for decades.
Casey and I met Jeff, and we'veworked together on three
(03:59):
different books.
We're pretty excited about thethird edition of a book that
really is a how-to guide forbehavioral health providers
mentalitment Therapy, which is aversion of acceptance and
(04:30):
commitment therapy developed inthe context of primary care
clinics, and it's helpful topeople with issues with use of
substances of a variety of kinds, and so I look forward to
talking with you about it today,jeff.
Speaker 3 (04:50):
Yes, so, jeff Reiter, I'm also a clinical
psychologist and I live inToledo, ohio, northern Ohio.
I got into doing this work inintegrated primary care
behavioral health which, asPatty was mentioning, is about
integrating behavioral healthprofessionals into primary care
services to help improve accessto behavioral care.
(05:14):
I got into that back in 2002and have been really pretty much
just living, eating, breathingit ever since then, and what
drives me is what Patty wastalking about, which is the need
for us to improve access tocare for people who are trying
to get care for mental health aswell as addiction services.
(05:38):
So, yeah, thanks for having uson to talk about all that today.
Speaker 1 (05:43):
So I don't know which one of you has a better answer
for this, but can you share someof the background why mental
health has been segregated as aseparate specialty and
discipline?
We all know that healthcareinvolves all parts of the human
body.
There's a history why dentistryis separate.
There's a history why podiatryis separate.
Do either of you know thehistory of why we segregate
(06:04):
mental health?
Speaker 3 (06:07):
history why podiatry is separate.
Do either of you know thehistory of why we segregate
mental health?
I don't necessarily know howthat came to be, but I agree
that it's a huge problem.
I think it's probably thebiggest problem that we have
actually when it comes tohelping people to access care
for substance abuse services,because it ends up that those
silos end up creating a numberof problems.
One is that you've gotaddiction medicine specialists
(06:32):
whether we're talking abouttherapists, counselors,
physicians who end up beingperceived as the only people who
can really help people withaddictions, which in reality is
not the case right, especiallyin our field in mental health.
I mean, any general counselorcan help a person with a
substance use problem, but wehave carved out these
(06:55):
specialties substance abusecounseling, psychologists, with
an emphasis in substance abuseand it's to the point where the
general counselors out theredon't feel able to work with
substance abuse problems.
So, even though many of thepatients that they're seeing for
therapy or marital problemswhatever they're coming in for
(07:16):
have substance use problems,they don't feel able to help
with that, even though theycould.
They have to all try to referthem to this relatively small
pool of professionals who dowork with these problems and it
just creates a huge accessproblem.
And then you've got on top ofthat the issues around payment
being separated and so forth.
So I wish I was a betterhistorian of my field.
(07:37):
Maybe Patty knows more than Ido about how this all came to be
, but my guess is that it'sprobably tied to moral judgments
around substance use and thestigma around substance use,
just that it's always beentreated, and still is treated,
as something different from ahealth problem, which is
ludicrous.
But that's my guess about theorigin of it.
(07:59):
But I don't know if you haveanything to add to that, patty.
Speaker 2 (08:01):
I don't know if you have anything to add to that,
patty.
Yeah, I think my perspectiveand understanding of the history
of the evolution of medicine issuch that we moved from a
collectivist kind of societythat viewed health in a quite
different way than it's viewedin today's world.
So a much more holistic view ofhealth mental, physical, social
(08:27):
, emotional was just health andthe health of the individual was
the health of the family, thecommunity.
So people were not separatedout and compartmentalized into
having physical health problemversus a mental health problem
versus a behavior problem.
(08:48):
So what happened over time andit's really quite recent was we
had the emergence of groups ofpeople with expertise in
specific areas.
They were studying and theywere figuring out how to help
with one thing and the modelthat kind of pulled, trained and
(09:08):
trained specifically in abiomedical model where they're
(09:29):
looking at the biological kindsof qualities associated with
illness.
In fact the originaldefinitions of health were the
absence of physical healthproblems and we all know that's
not true for most of us, even aschildren or teenagers.
(09:50):
So the progression has been.
I think the first inroads wereto start to pitch a
biopsychosocial model and say,hey, we are complex, and now
what we're trying to do ischange systems so that primary
(10:13):
care, which was the level ofhealthcare set up to be
accessible to all people, anyage, any problem.
It's the first door.
It's the right door for anyonetrying to influence them towards
a biopsychosocial model and tosucceed in walking with our
(10:34):
medical colleagues towards thatview.
We realize we need to be rightthere because your training
doesn't help you do that so manytimes.
It's changing now, casey, butit is a huge impact in the care
that's received when people gosee their doctor.
Speaker 1 (10:58):
We have so much to unpack here.
This is going to be fun.
Okay, jeff, let's start with afollow-up on what you said.
I literally last week referreda patient for counseling and
they said no, we don't doaddiction.
And my response was I'm anaddiction medicine doctor.
I'll handle the addiction, butmost of my patients have some
(11:19):
sort of traumatic lifeexperience.
Many of them have PTSD.
And my question to thetherapist was why can't you work
on the PTSD?
I'll handle the addiction part.
And you mentioned, jeff, thatsometimes counselors say, whoa,
I can't do addiction.
Can you talk to me about thatfrom a psychology or LMFT
perspective?
Speaker 3 (11:38):
Yeah, Well again, yeah, it's a huge problem.
That counselor that youinteracted with there is
representative of how mostpeople in my field think.
I think Psychologists, socialworkers, other sorts of
counselors this falsedistinction between biological
(12:02):
health, mental health, substanceuse.
We've kind of created thesethree silos.
Mental health problems aresiloed as well, right, not only
substance abuse problems butmental health problems as well.
But within the mental healthfield, substance abuse problems
are then given another layer ofsiloing.
So you have the mental healthprofessionals that feel
(12:25):
uncomfortable working withsubstance abuse problems.
So I think that our field hasgotten really specialized over
time.
The mental health field, mentalhealth counseling field, have
gotten really, reallyspecialized over time.
You have people who specializein working with kids, people who
specialize in working with PTSD, people who specialize in
(12:46):
working with PTSD in kids moreand more specialized a lot of
which I think is driven actuallyby that biomedical perspective
than the original DSM.
Right, it's just loaded withall sorts of new conditions now,
(13:08):
new diagnoses now that didn'texist in the early days of the
mental health field, and so whenyou have this growing number of
problems to treat, then you getmore and more specialization to
treat those problems, I think.
So we've had this trend for anumber of years in the mental
health field towardsspecializing.
(13:29):
And it's unfortunate, though,because you know, what we do as
mental health providers is notthe same as what medical
providers do.
There are some overlaps here,but, you know, if a person goes
in to see their primary careprovider with a sore throat and
a sprained ankle, those areprobably not connected.
(13:50):
Those are probably twodifferent problems to address
there.
But if a person comes in to acounselor or maybe they come
into the emergency room or totheir primary care provider with
relationship problems and adrinking problem and depression,
those are all related, right,everything that we work with in
(14:12):
the mental health field isrelated, but we act as if we're
treating discrete problems.
We act as if we're treatingthis discrete diagnostic entity
from the DSM-5 that we've gottenhighly specialized training in,
and we act as if we're doingsomething different than what we
would do with any other problemthat a person comes in with.
(14:33):
But in reality, that's not true, right.
I mean the same strategies thatI, as a therapist or a
counselor, use with a personwith depression or relationship
problems or addiction problems.
I'm gonna use the samestrategies for all of them.
I might use motivationalinterviewing, I might use
cognitive therapy approaches, Imight use mindfulness approaches
(14:53):
or any number of approaches,right?
But we've created this sort ofidea, this myth amongst
ourselves as mental healthprofessionals, that we need to
be highly specialized to addressall of these different problems
that are out there.
But in reality we don't need tobe highly specialized, but
there's that, I guess,perception out there, so that
(15:16):
makes people afraid to work withproblems that they feel like
are outside of their area ofexpertise.
If my area of expertise isrelationship problems and
somebody has a drug problem, butI'm seeing them for a
relationship problem, many, manypeople feel the need to refer
out to an addiction specialist.
In that scenario they feel like, well, that's a separate
(15:37):
problem from the marriageproblem, right?
So I need to send them to aspecialist in that problem, when
in reality, again like no,these are connected problems.
It's all happening to the sameperson, same body, same mind and
same relationship and and andin fact, the relationship is
probably influencing the druguse and the drug use is probably
(15:59):
influencing the relationshipproblem.
So we can take them on bothtogether, right?
So in my mind, that's a hugepart of the problem is that
specialization that we'vecreated for ourselves.
It doesn't need to exist, butit does exist in counselors'
minds and that then becomes areally big access barrier for
(16:20):
them.
So if we could wipe that out,we could just open the door to
loads more access to mentalhealth care for people.
Right, because you wouldn'thave gotten the response from
that counselor that you gotright, and so, anyway, that's my
take on that.
Speaker 1 (16:38):
Yeah, as we were speaking about before the
podcast started, my backgroundis in emergency medicine, as we
were speaking about before thepodcast started.
My background is in emergencymedicine and healthcare
providers.
When they're in that silo, whenthey get a problem given to
them that's outside of that silo, there tend to be two responses
One is go see your primarydoctor and two is go to the
emergency department, and bothparts of our healthcare system
(17:01):
are hugely overwhelmed.
So, patty, you had talked aboutintegrating behavioral health
into primary care.
Primary care in America ishorribly overloaded and I just
am curious what does integratedbehavioral health into primary
care look like?
And, most importantly, how doesit help the primary doctor,
help the patient, primary?
Speaker 2 (17:22):
doctor help the patient.
All right, Great questions,Thank you.
It looks different in form andit looks different in function.
So the behavioral health ormental health provider that goes
into primary care needs specialtraining, a lot of retraining,
(17:48):
needs special training, a lot ofretraining.
They become a generalist.
So typically, Jeff and Iprovide training.
We provide a training all overthe world, and when an
organization decides to movefrom siloed care to integrated
care, it's big.
Everybody needs retraining,including the primary care
provider and the nurses and theperson at the front desk.
(18:09):
Everybody's workflow andmessage to patients is going to
be different.
So this newly arrivingbehavioral health provider could
be any licensed health careprovider.
I've worked a lot in New Zealand.
So they have occupationaltherapists and they have, of
(18:31):
course, counselors, socialworkers, psychologists, mental
health nurses, and they gothrough an intensive training
and, speaking specifically ofNew Zealand as well as other
systems that I've worked with,this training is really
intensive.
It's like four or five days,all day long, and they learn how
(18:54):
to work in a new way and theylearn how to provide a new
psychotherapy or therapeuticintervention called focused
acceptance and commitmenttherapy.
So the way it looks is thisperson is trained to be the
first door for any kind ofproblem for any person.
(19:16):
Alcohol may not be working intheir life or marijuana may not
be working in their life, butthey come in with all kinds of
problems.
They might say I have chronicpain, or I have problems in my
family, or we can't communicate.
So this generalist is trainedto respect the problem that the
(19:37):
person wants to work on at thatmoment and to do what we call a
behavioral analysis.
So they're really looking atthe triggers for the behavior,
what the behavior looks like,the consequences, what the
person is trying, how that'sworking relative to that
(19:58):
person's values, what matters tothem.
That's a lot to do and it takesa lot of training.
Not only that, but they areworking in a brand new way.
They're sitting with the teamin the team space that might be
with nurses or in some primarycare clinics.
We have a hub for primary caredoctors and behavioral health
(20:19):
providers and nurses, dieticians.
They're all sitting togetherand they plan their day as it
starts and they check in witheach other throughout the day.
They co-refer and co-care forthe people that are scheduled
and the people that show up.
So visits are 15 to 30 minutesin length, whatever time the
(20:44):
person has available andfollow-up is up to that person.
So the schedule for thebehavioral health provider is
such that every other visit isthe same day visit.
So very accessible care.
That's for initial visits aswell as follow-up.
Speaker 1 (21:04):
So, jeff, I feel like this would help me enormously
in my practice.
So people come in and they'reangry at their landlord, they're
angry at their mother, theyjust had an altercation with
someone in the parking lot andthat just gets verbal diarrhea
all over me and the 20-minuteappointment gets taken up by
that and I don't even have timeto talk with them about their
(21:24):
Suboxone.
In my practice we have peersupport specialists, so we try
to create at least some sort ofco-management.
How does it actually look like?
I mean, I'm going to go toclinic next week.
What would it look like for me,for that patient?
They've got opioid use disorder.
They've got some familydysfunction.
They've got some impulsivityopioid use disorder.
They've got some familydysfunction.
(21:45):
They've got some impulsivity.
They have trouble controllinganger and regulating emotions.
What would that look like?
We'll call this fictitiouspatient Sam.
What would it look like if Samhad an appointment with me next
week and we had this integratedbehavioral health approach?
With my practice it's a littledifferent because I'm addiction
medicine but a lot of patientsconsider me their primary doctor
because they can trust me.
So let's pretend I'm a primarydoctor with an expertise in
(22:07):
addiction.
What does that look like?
Speaker 3 (22:10):
Yeah, I encourage primary care providers to bring
in somebody like myself, abehavioral health consultant, if
there's something that comes upin their visit with their
patient that they would like tohave more time to discuss.
Maybe they feel like there'ssome issue going visit with
their patient that they wouldlike to have more time to
discuss.
Maybe they feel like there'ssome issue going on with the
patient that they feel like theycould discuss.
(22:30):
They feel like they couldhandle this and could help the
patient with this problem, butthey just plumb, don't have
enough time, right.
So in that capacity then, inthat scenario, I'm sort of like
an extender, an extension of theprimary care provider, right?
So the primary care providermaybe has some skills in
motivational interviewing andmaybe feels like that would be
(22:51):
helpful for this patient rightnow, but, just like I say, it
just doesn't have any time.
So they might bring me in tothat visit then to do that
motivational interview that theythemselves don't have time for,
right?
Or the other scenario wherethey might pull me in is if they
feel like the patient,whatever's going on with the
patient in that moment, issomething that maybe they don't
(23:13):
feel like they have enoughtraining to help the patient
with.
Like, maybe they feel like thatas patients really struggling
with being able to make thischange we want them to make and
I'd like for them to get somemotivational interviewing help
around this.
But I don't really havetraining and motivational
interviewing myself, so I'mgoing to bring jeff in to help
with that.
So one scenario is where you,you, you feel like as the
(23:36):
primary care provider, you couldhelp the patient but you don't
have time.
The other scenario is maybe youfeel like the patient needs
some more specialized help thanwhat you you've had training in
as a primary care provider,right?
So those are the two scenarioswhere the primary care provider
might bring me in.
Every patient you're going tosee in addiction medicine has
some sort of, by definition,behavioral health issue going on
(23:57):
, right?
So we don't say thatnecessarily.
I don't assume, as a behavioralhealth provider, that I need to
be involved in every one ofyour visits.
But if you feel like one ofthose two scenarios comes up,
seamless connection that you asthe primary care provider, make
(24:27):
to me as a behavioral healthprovider, right?
So I'm sitting there in theclinic in the same space where,
like Patty was saying, where allthe rest of the team sits and
if you would like my help, youwant my help.
You ping me on a team's messageor you physically come and tap
my shoulder and say, hey, jeff,can you help with this patient.
Or you send somebody to comeget me or, however it works, you
(24:48):
grab me real time.
I go into the exam room.
If I've never met the patientbefore, you introduce me to them
, and then you leave the room,go on to your next patient.
I stay in that same exam roomwith the patient.
If that works out, the examroom's available and whatnot.
I stay in that same exam roomwith the patient.
If that works out, the examroom's available and whatnot.
I stay in that same exam roomand just continue your visit,
(25:08):
but with the particular focusthat I'm bringing right to
helping that patient.
So that's the way that we tryto make it look.
There's not eight pages ofpaperwork you have to fill out
to see us as the behavioralhealth person on the team.
There's no wait, it's juston-demand care.
We practice in ways that makeus super accessible, like that,
all throughout the day.
And then the beauty of primarycare is that it's all built
(25:32):
around this idea of a long-termrelationship that you establish
with patients right, which youwere talking about before.
We got onto the air here theimportance of the relationship
and working with people withsubstance use problems.
And that's why I love workingin primary care, because that's
when primary care is at its best, is when those long-term
relationships are built withpatients.
That's the secret sauce ofprimary care.
(25:53):
That's why I love being there,because then we have the
opportunity to build theselong-term relationships too with
patients that I never had,frankly, when I worked in a
mental health clinic.
So now that you've introduced meto that patient, I'm starting
getting to know them.
The next time they come back tosee you, sometimes that same
patient might say hey, you knowwhat that Jeff guy that Dr
(26:14):
Grover had me talk to last timeI was in there.
He was pretty helpful.
I'm going to make anappointment to see him on the
same day as Dr Grover, rightbefore Dr Grover.
So the next time they're inseeing you, it might pop into
their mind that they want totalk to me again while they're
there and you work me in againreal time to see them.
Or maybe a new issue comes upand you want my help and you
bring me in.
But that's what it looks like.
Speaker 1 (26:35):
So, Patty, I'm going to give you a magical $100
million and you get to build theperfect clinic.
What does the ideal physicalsetup look like?
And then I know you wanted toadd something.
Speaker 2 (26:47):
So, after you tell me what the ideal physical space
is, I'd love to hear what youwanted to add, I have been able
to work with systems, forexample the San Francisco Public
Health Department, who wereasking this question what does
(27:10):
it look like?
And so I think it depends onthe population served in that
clinic in that community.
So the staffing ratio ofbehavioral health providers to
primary care providers dependson the population served.
So in a clinic that servespeople that don't have houses,
that are extremely vulnerable,the setup might be to have a
(27:32):
couple of behavioral healthproviders supporting every
physician or PA, every primarycare provider.
If we move into other clinics,for example commercial systems
serving people, it depends onthe mix of people coming to that
clinic.
(27:53):
But I would say roughly, you'regoing to want to have one
behavioral health provider forevery team, but the principle
that's the same about thephysical environment is
togetherness.
So we don't want anybody tohave to walk more than 15, 20
(28:17):
feet to run into a behavioralhealth provider, because more
than that is a deterrent tousing a person you're going to
use a lot every day.
The other thing that I was goingto add Jeff so beautifully
described our general model forindividual consults.
(28:38):
In addition to that way ofassisting and supporting the
work of our primary careproviders, we have something
different called pathways,primary care, behavioral health
pathways.
Pathways target a particularpopulation.
What population?
The population of greatestconcern in that clinic and what
(29:04):
that clinic then decides as agroup is how can we better serve
that population?
So, people struggling withopioid use disorder, that's a
great population to target inmany primary care clinics and
those that do develop apathwayday introduction to all
(29:27):
members of the team, that werepossible and that would include
a behavioral health provider.
So usual care for that personwould include the behavioral
(29:52):
health provider.
So on a day of a visit with aprimary care provider that would
have been covered in the huddle, so-and-so is coming for an
appointment, so you may want tostop in and say hi, or you may
have, in addition to individualvisits with their primary care
provider or addiction medicineand primary care provider, there
(30:16):
often are groups that theperson can drop into and that
the person routinely attends.
It depends on what phase ofrecovery that they are in.
It might be weekly, it might betwice a month, it might be once
a month.
With a condition like thatwe're looking at, probably most
(30:38):
people can recover, but we'relooking at five years or
something.
So we really need to have aprogram that's feasible, that's
accessible, that people canstart and restart with ease and
that is multidisciplinary.
That's described in the pathway.
The details are decided basedon the resources in the clinic.
(31:02):
What does the clinic have andwhat's the evidence for us to
get that to these people?
Speaker 1 (31:19):
has a central corridor of patient rooms and
there's a left door and a rightdoor, and then the doctor comes
in on one side and thebehavioral health folks come in
on the other side.
I was really impressed, jeff.
I'm going to ask you the nextquestion when you are trying to
create these integrated primarycare clinics, what sort of
pushback do you get from thehealthcare providers?
Speaker 3 (31:35):
Well, it depends on which healthcare providers
you're talking about.
Speaker 1 (31:38):
You tell me.
Speaker 3 (31:40):
Well, it depends on which healthcare providers
you're talking about.
You tell me every day ofpatients whose health is being
affected by behavior in one wayor another, whether it's
(32:06):
addiction or depression or someother problem, and they don't
get a lot of training to workwith mental health problems
either, right, and they havelots of other medical issues to
help patients with too.
So there's typically verylittle pushback from the primary
care providers.
They welcome the help.
They're rather desperate forhelp.
Frankly, the pushback usually,if you get it, it's going to
(32:27):
come from the mental healthproviders, because we are asking
them to practice in a waythat's fundamentally different
from how they typically practiceright.
How they typically practiceright, I mean, most mental
health professionals therapistsare accustomed to hour-long
visits that are, with a lot ofthe same people, scheduled on a
fairly regular weekly basis,that sort of a thing for a long
(32:50):
period of time.
And so when we take them fromthat environment and we plop
them down in primary care andsay, okay, the way that we
practice in primary care is wehave 30-minute visits, and
actually 30 minutes is just howit looks on the template,
because in reality we're workingpeople in all throughout the
(33:13):
day for unscheduled visits likeI was describing before, and so
we might end up just seeingsomebody for 10 minutes or 15
minutes, 20 minutes, and thenthe follow-up is planned
differently.
Most primary care patients yourtypical primary care patient
with either some sort ofaddiction or some sort of
behavioral concern, is not allthat interested in following up
(33:34):
regularly, certainly not forweekly hour-long visits, and so
the follow-up often looksdifferent.
You have to adjust to theprimary care context where you
rely on developing theselong-term relationships with
patients, grabbing a little bithere with them, a little bit
there with them over time,building those relationships
over time with them.
So it's a different way offollowing up and it's much less
(33:56):
predictable of a workflowthroughout the day too.
Right, because again, we'reworking people in all throughout
the day.
That very rarely happens.
If you're in a mental healthclinic.
People don't just hop in to amental health clinic.
I'm going to see them right now.
It doesn't work that way, orvery rarely anyway.
So I'll say that and some ofyour listeners will say well,
that's not true.
We practice this way in mentalhealth, but it's rare.
(34:17):
So in general it's not true.
We practice this way in mentalhealth, but it's rare.
So in general, it's a much lessflexible environment in mental
health.
So that's where the pushback ifyou do get any usually comes
from is from the mental healthprofessionals who really have to
practice in a way thatunderstand that.
(34:41):
The goal of what we're trying todo is we're not trying to get a
huge volume of visits to asmall group of people, we're
trying to reach a large numberof people and what that means is
(35:03):
that we might end up havingshorter visits with them.
We might end up having, like Iwas saying before, a different,
different structure to ourfollow-up than we would
otherwise.
But what we're trying to do isjust to reach people right, just
to reach people and get startedbuilding those relationships
with them.
And if you have somebody whounderstands that goal right,
then that's great.
They're usually open to makingthese changes and they can flex
(35:25):
and go from there with a littlebit of training, like Patty and
I provide.
But yeah, that's where it tendsto come from Occasionally.
Primary care providers maybe youmight get a little resistance
there for one reason or another.
Maybe it's more skepticismbecause they've maybe worked
with mental health professionalswho have practiced in a very
inflexible way in the past.
(35:46):
More typical counseling approachright with being selective in
who they're going to see andneeding to see people every week
for hour-long visits for a longperiod of time.
So if they've had a lot ofexperience with that system and
they've been frustrated by theaccess problems just like you
were frustrated the other daywith that patient you were
trying to get in to see thecounselor if they've had a lot
of those kinds of experiences,then a lot of times they're
(36:09):
skeptical coming into all ofthis that this is really going
to add anything or really goingto be helpful.
But once they see howaccessible we really are in this
model and that we practice ageneralist we don't practice as
these uber specialized peoplewho are going to say I'm sorry,
I can't help with this addictionproblem because it's out of my
scope, that's not what we do.
(36:30):
We practice like generalists,like primary care providers Then
that skepticism starts to fadeaway and usually they are 110%
on board.
Speaker 1 (36:39):
Patty, next question for you what's the patient
experience when behavioralhealth and addiction services
are integrated into primary care?
Do people get upset because thevisit takes longer?
Do they find that they're ableto work on issues that they
didn't know they had?
What's the patient experiencelike?
Speaker 2 (36:55):
Yeah, good question.
I think this goes back totraining.
So we have to train the primarycare providers to identify
people even before the daystarts, with scheduled patients
that they want to involve us in,and so they can start the
(37:17):
length of their visit becausethey're not trying to do
everything which they are sofrustrated with, because they
usually have two or threemedical problems plus all of the
other issues mental health,substance abuse.
So that isn't a hard sell forthem to go in, but it takes
(37:38):
training and then training onworkflows.
But when people are trained andwe have signage in the clinic
that says, oh, we have a healthimprovement practitioner or
whatever you call this person,we have a health improvement
practitioner.
They help with sleep, stress,family problems.
(37:58):
If you'd like to see them today, let your doctor know.
So really, even when a doctorgoes into the room and the
patient could say, hey, do youthink I can see this person?
So then the doctor's going toadjust to the patient's request
and shorten their visit and getthem involved with the
(38:21):
behavioral health provider.
So for them, some clinics whenthey start providing primary
care behavioral health services,they send out letters or push
messages through the healthcareportals announcing it so that
people are informed that theirhealthcare team is improving.
(38:42):
And people I would say 90% arelike oh my goodness, are you
kidding me?
Because what's to push back onif a PCP says I'd like you to
meet a new member of our team?
They help with a lot of things,including this problem you're
struggling with right now.
They may be available right now.
(39:04):
Their visits are short.
I get really good feedback fromother people that I recommend to
Patty or recommend Patty to soyou don't get pushback.
Sometimes you'll get somepeople that think they need
therapy and so they're like ohwell, wait, is this therapy?
(39:28):
And so we have to train and sayno, no, it's in the moment,
consultation on how to get yourlife in track, how to address
common life problems, becausewe're not doing therapy,
diagnosing and treating andrequiring people to come back an
X number of times.
Because people don't do that.
They come when they're hurtingand they go away when they're
(39:52):
not.
So with that group we just say,if that's what you want, I want
to help you find it, but sinceyou're here today, let me help
you as much as I can.
And a lot of those people comeback and say I don't want
therapy, I want what you'redoing.
Speaker 1 (40:14):
Behavioral Consultation in Primary Care.
A Guide to Integrating Services, third Edition.
It's a textbook.
Wow.
I've always wanted to be anauthor.
I'm very impressed that you'vebeen doing this for enough times
to have a third edition.
Well, regrettably I have to gosee patients and I'm sure y'all
are busy too.
Jeff, why don't you close usout with whatever wisdom you'd
(40:35):
like to share, given yourperspective, and then Patty will
come back to you as well,Anything you'd like to share
about your work or wisdom topatients or providers alike.
Speaker 3 (40:51):
We have a serious problem in this country with
people being able or unable toaccess care behavioral health
care for mental health andsubstance abuse problems and I
really do fear that if we don'tsolve this access problem well,
we'll never completely solve it,of course, but if we don't
lessen the severity of thisaccess problem soon, my
(41:14):
profession really risks beingviewed from a public health
standpoint and by policymakersas irrelevant.
I fear that, and so we need todo a better job in the mental
health professions of beingaccessible, and that means we
need to back off of this ideathat we can only help with
(41:37):
certain problems.
We need to recognize that wecan be generalists.
Many more of us need to beworking in primary care settings
where these people show up, andif we can practice these ways
and practice more flexibly toget away from the requirement
for an hour-long visit everyweek into perpetuity right, Be
(41:57):
more flexible to meet peoplewith what works for them.
There are lots of otherapproaches single session
therapy, solution focus therapyand so forth Focus, acceptance
and commitment therapy that canhelp.
So I hope that my profession.
Moving forward will embrace theaccess challenge and be able to
lessen it.
Speaker 1 (42:15):
Patty final thoughts.
Speaker 2 (42:18):
Just final thoughts are if you don't have this
service Integrated BehavioralHealth or you have it and it
doesn't work quite the way we'retalking about and you want it
to, and most people in Americado not have access to clinics
that have primary carebehavioral health services.
(42:38):
If you don't have it, rememberthis URL speaktoyourdoctorcom.
Speaktoyourdoctorcom.
Go there, it's about our book,but there is a tab that says
speaktoyourdoctorcom.
You can click on that.
There's an information sheetthat you can use, that you can
(43:00):
take to your doctor and say look, this is the kind of health
care I want.
Let's partner together and getthis started in our community
and then I think things aregoing to get better for the very
many, many people among us thatare struggling with use of
substances, because we'll havethe primary care team staffed
(43:25):
right and primary care providersare going to be a lot more
willing to say well, bob, I knowusing alcohol is an issue and
you're here today with somestomach problems and I'm just
wondering if you'd like to seePatty just to talk about
improving your health in general, because we need to hook people
(43:46):
in what they care about andthey care.
They care a lot about theirfamilies, they care about their
well-being.
They want a better life.
We just got to offer theservice and make it really
available in a way that says hey, you're one of us and we want
(44:09):
to help.
Speaker 1 (44:11):
Well, Jeff and Patty, I have to say I will be a
better doctor next week inclinic, having to spoken both of
you trying to really partnermore.
Sometimes I feel like I getisolated in my little clinical
exam room, like I get isolatedin my little clinical exam room
and I forget to walk my patientsover to my peer support team.
We actually do have an LMFT inthe office with us.
I've got a number of folks thatsee myself, peer support and
the therapist on the same day.
So I think, while you areexperts in this, I came to this
(44:34):
a little more organically, butthe patients, like you've said,
they just appreciate having moresupport and being able to
address more issues when theycome in.
This was awesome.
I appreciate both of you and Iwill be certainly sending your
work off to some of theleadership at my hospital.
So thank you for joining metoday, Thanks so much.
Speaker 3 (44:51):
Thanks so much, and thanks for your work too.
Speaker 1 (44:56):
Before we wrap up, a huge thank you to the Montage
Health Foundation for backing mymission to create fun, engaging
education on addiction, and ashout out to the nonprofit
Central Coast OverdosePrevention for teaming up with
me on this podcast.
Our partnership helps me getthe word out about how to treat
addiction and prevent overdosesTo those health care providers
(45:19):
out there treating patients withaddiction.
You're doing life-saving workand thank you for what you do
For everyone else tuning in.
Thank you for taking the timeto learn about addiction.
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
treated.
Together, we can make it happen.
Thanks for listening andremember treating addiction is
(45:40):
treated Together.
We can make it happen.
Thanks for listening.
Speaker 2 (45:55):
And remember treating addiction saves lives.
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