Integrating behavioral health

FigureOne can find many problems with our current healthcare system. It is far from perfect. Some changes, such as electronic health records, have created benefits and challenges. It is easy to complain and cast blame. I do not believe the politicians, insurance companies, drug companies, or any single entity alone could make changes that would fix healthcare, let alone transform it. Change will have to come from many areas, and some of those changes are up to us as clinicians. Transforming healthcare Healthcare is both an art and a science. Much of the “care” in healthcare has been lost. It has become more mechanized and prescribed, almost as if we work from a cookbook or checklist. That is considered the science of healthcare. But healthcare is much more than a science, and we must not forget the art. When I was younger, I would see medical buildings with signs that read “Kettering Center for Medical Arts.” Now we have “medical centers” or “centers for health,” but have we lost the art of healing, the care in healthcare? Our healthcare system needs more than change: it needs a transformation. Simply fixing an inefficient and ineffective system is not enough. Healthcare needs an overhaul, a transformation, a change in how we do and how we pay for healthcare. It might even be helpful to look back to some of the strengths we had before technology and politics were so ingrained in the system. The trend has been to treat patients as a population and not as individuals. We have guidelines for certain age groups or groups of people who meet certain criteria. Yet patients are all individuals with unique risks, strengths, individual goals, and values. They are part of a population, but we must use population health guidelines as just that—guidelines, not a template or a mandate. Beyond facts, fear, and force Our current system focuses on “what” we do, be it the number of patients we see, normalizing blood pressure, weight, cholesterol levels, or other markers. We use facts, fear, and force to help, encourage, and even coerce patients to change. This may not result in better metabolic parameters as we might think. These tactics may even discourage patients to the point we start calling them “nonadherent,” which I believe is more our way of trying to shed our own responsibility or protect our ego than helping patients. There is something beyond information and fear that influences change. It is beyond logic, beyond facts, beyond the numbers—it has to do with the heart. Building relationships, making connections, and sharing information with patients are keys to transforming healthcare. It is what I call a “relationship of hope.” We need to build relationships that accept, encourage, and affirm our patients for who they are. This helps our patients find meaning and hope in life, something they need before we will see durable behavior changes. There are no boxes we can check off for building this relationship, no legislation that can require it, and probably no way to quantify it. It is part of the art of healing. Building a relationship of hope with our patients means we believe in them, we accept them just as they are while helping them to believe in themselves. We can be someone there to listen to them, not judge them. By first acknowledging their reality and hearing their perspectives, we can connect, understand, and then affirm them, motivate them, and inspire hope. Building a relationship of hope Everyone is seeking meaning and purpose in life. We all want to find something that brings us hope, which makes us feel useful or valuable. People who do not find meaning or purpose in life often struggle. There may be past experiences that have dashed hopes or crushed self-esteem. Still, looking for meaning or purpose, or simply trying to drown out the feelings of hopelessness, despair, depression, guilt, fear, or anxiety, some end up in unhealthy patterns of behavior. Overeating, poor self-care, unhealthy relationships, drugs, alcohol, and risky behaviors become ways to cope with life or to find relief. These usually make the problems worse and can lead to deeper despair and isolation. How do we cultivate a relationship of hope? First, believe in each person. See beyond the patient who may seem like a complainer, drug seeker, or hypochondriac for example. These patients are also looking for hope, meaning, or purpose in life. They drink, use drugs, complain, or are seeking something to find happiness, to take away the hurt in their past or present. Many have had traumas, abuse, or losses in their past. They may have given up on themselves. If we believe in them, listen, and affirm their gifts rather than point out their failings, they begin to believe and hope in themselves. This is one of the greatest gifts we can give. Ask your patient about his or her biggest challenge in dealing with diabetes or whatever the condition may be. Ask, “What would you change if you could change one thing in your life today?” This can lead to what really is important to them the most that day. Another helpful question that can lead to insight and direction is, “How was your childhood?” I have had patients I have known for years who never told me about the traumas of their childhood until I ask this question.1 Next, acknowledging what the patient says. This means putting aside our own agenda of finding solutions or treating numbers and listening to try to hear from the patient's perspective. Maybe the patient does not care about blood glucose control (our agenda) because of challenges in his or her personal life. Listen, acknowledge, and then find something to affirm. There have been many times patients have shared stories of pain and abuse. As we talk, I hear stories of perseverance, strength, and love. When I simply respond to these patients, “You are a good person, you have done some amazing things in life,” they often break down in tears. They have never heard these kinds of positive and affirming words. And it is these very affirmations that help begin to build a relationship of hope. Make connections Another technique to build a relationship of hope is to make connections with your patients. We feel more hope when we feel connected. Use your patient's first name when talking, say the name as you speak. We all love to hear our name, and having it used in conversation builds a connection. Inquire about hobbies, interests, pets, and children, and take notes so you remember these and can bring them up at future visits. Maybe you have something in common with your patient (a hobby or interest), so share that with him or her. We tend to feel more connected to others who have something in common with us. Understanding the past Simply looking forward at the weight, BP, or the lifestyle goal we desire for our patients can make us miss out on one of the most useful tools we have: past experiences. Past experiences help us know and better understand our patients' perspectives. Then, we can accept them, encourage them, and help them to move forward. Knowing where they have been and what they have attempted in the past gives us keys on how they might move forward. An experience from my own life helped me recognize that where we have been may be more important than where we are going. Years ago, I rode my bicycle across the United States. After pedaling several thousand miles, I was nearly home (only about 400 miles from my destination). While taking a break at a park, a man saw my loaded down bicycle and came to talk with me. He asked where I was heading and I told him, “I'm going to Dayton, Ohio.” (I was in Wisconsin at the time.) The response was, “You can't bicycle there from here!” Had he known I had started my trip in Alaska and had already pedaled thousands of miles, he may have had a different response, a different perspective. Finding out where people have been, about past experiences—both positive and negative—gives a context for where they may be going. Integrating behavioral health The challenge, especially in our current system, is that building relationships takes time. There is pressure to see more patients and to spend less time or to have other ancillary staff do more so clinicians can see patients faster. In my practice, the extra time spent helping patients find hope and building relationships with them has resulted in dramatic reductions in diagnostic testing, referrals, and medications for these patients. It has also resulted in weight loss, lifestyle changes, and patients who feel better. The healthcare system, politicians, and payers will one day realize that the 15 extra minutes spent with patients is an excellent investment. There is a move to integrate behavioral healthcare into primary care. As the behavioral health clinicians say, “The head is not separate from the rest of the body.” Whether we are in primary care or a consultant practice, the head, the mind, and the emotional heart are always part of what is going on with the physical body. The true integration of behavioral health is not just integrating behavioral health workers into our clinics but integrating behavioral health into our practice, into each patient encounter. This by no means eliminates the need for behavioral health workers; there is still a role for them, but every patient we see has a behavioral health component. Building relationships with our patients, making connections, and most of all, building hope can transform healthcare. But more importantly, it can transform the health of our patients. When we believe in our patients, they will believe in themselves.

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