In­te­grate be­hav­ioral health with pri­mary care

Modern Healthcare - - COMMENT - By David Wood­lock David Wood­lock is pres­i­dent and CEO of the In­sti­tute for Com­mu­nity Liv­ing, a New York-based hu­man ser­vices agency spe­cial­iz­ing in be­hav­ioral health.

Mod­ern Health­care’s re­cent se­ries, “Chan­nel­ing Choice,” as­serted that “help­ing people change their be­hav­ior is the work of our century.” If this is true, be­hav­ioral-health providers have ex­per­tise that can help.

Psy­chother­a­peu­tic in­no­va­tions such as mo­ti­va­tional in­ter­view­ing and trauma-fo­cused ther­apy have been shown to im­pact a wide range of health out­comes, but have had limited im­ple­men­ta­tion in main­stream health­care.

One rea­son might be stigma. More than half of Amer­i­cans have emo­tional dif­fi­cul­ties that af­fect their health, but it is more so­cially ac­cept­able to see a foot­ball coach for coun­sel­ing than a psy­chi­a­trist. Stigma has led to the marginal­iza­tion of be­hav­ioral health, with treat­ment for de­pres­sion (fore­cast to be the leading cause of disability world­wide) of­ten seg­re­gated from the rest of health­care by reg­u­la­tory and re­im­burse­ment bar­ri­ers.

Mod­ern Health­care’s ar­ti­cles (Nov. 25, Dec. 2 and Dec. 9, 2013) high­lighted the im­pact of health lit­er­acy on health be­hav­iors. Two other ap­proaches, mo­ti­va­tional in­ter­view­ing and trauma-in­formed care, ad­dress fur­ther bar­ri­ers to change.

The first bar­rier is am­biva­lence—a nor­mal re­ac­tion to change. Mo­ti­va­tional in­ter­view­ing helps in­di­vid­u­als ex­plore what they will gain or give up with ev­ery change, har­ness­ing in­di­vid­u­als’ life goals and val­ues as driv­ers of mo­ment-to­mo­ment change. Be­hav­ioral health has ex­per­tise in this form of ther­apy that can be read­ily shared. For ex­am­ple, emer­gency physi­cians and pe­di­a­tri­cians trained to pro­vide brief MI in­ter­ven­tions have achieved re­sults in re­duc­ing al­co­hol use and teen smok­ing.

Trauma, sur­pris­ingly per­va­sive in our com­mu­ni­ties, is an­other bar­rier to change. In a mid­dle-class sur­vey sam­ple, the Ad­verse Child­hood Ex­pe­ri­ences, or ACE, Study found that 22% of re­spon­dents were sex­u­ally abused and 66% of women ex­pe­ri­enced other trau­mas in child­hood. The long-term ef­fects of ACEs went well be­yond men­tal health, in­creas­ing the like­li­hood of med­i­cal prob­lems in­clud­ing car­dio­vas­cu­lar and liver dis­ease, di­a­betes and even early death. ACEs also in­creased un­healthy be­hav­iors in­clud­ing smok­ing, sub­stance use and sex­ual promis­cu­ity—all mal­adap­tive ways that people cope with trauma. What trauma-in­formed care helps people do is to ex­plore the ef­fects of trauma on their health and be­hav­ior, de­velop pos­i­tive ways of cop­ing and ar­tic­u­late their path to re­cov­ery.

In­creased in­te­gra­tion of be­hav­ioral health into pri­mary care through provider train­ing and care co­or­di­na­tion will im­prove health out­comes, not only for those with men­tal ill­ness, but for ev­ery per­son who strug­gles to change health be­hav­iors. New, in­no­va­tive part­ner­ships are our path for­ward, and be­hav­ioral-health providers across the na­tion stand ready to help.

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