Addiction Medicine Made Easy | Fighting back against addiction

When Mental Health Meets Primary Care: Transforming Addiction Treatment

• Casey Grover, MD, FACEP, FASAM

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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



Speaker 1:

Welcome to the Addiction Medicine Made Easy Podcast. Hey there, I'm Dr Casey Grover, an addiction medicine doctor based on California's Central Coast. For 14 years I worked in the emergency department seeing countless patients struggling with addiction. Now I'm on the other side of the fight, helping people rebuild their lives when drugs and alcohol take control. Thanks for tuning in. Let's get started.

Speaker 1:

Today's episode is different than anything I have done before on this podcast. Normally we cover a topic around the diagnosis and treatment of substance use disorders. We might review a patient case or discuss how a medication can reduce drug cravings. But today we are going to zoom way out and look at the healthcare system in general, specifically around how healthcare is delivered. I had the pleasure of interviewing Dr Patty Robinson and Dr Jeff Reiter, who are both psychologists and they work on integrating mental health and addiction into primary care. Why this topic and why does this matter?

Speaker 1:

So healthcare in the United States is very siloed, meaning that most healthcare providers have their specific area of expertise and they don't address anything outside of that area of expertise. But human beings are complicated. Let's say a person has depression, high cholesterol and an alcohol use disorder. This person might have to see three different clinicians in order to address all of these issues with three different appointment schedules. Jeff and Patty help set up integrated primary care, which involves putting mental health professionals with expertise in a wide range of mental health conditions, including addiction, in with primary care providers and clinics. So now, with behavioral health integrated into primary care, this person with depression, high cholesterol and an alcohol use disorder can have all of these problems addressed in a single visit, with a plan for ongoing follow-up. It's brilliant and we really need this here in the United States, as our healthcare system is very fragmented, with poor access to services for mental health and addiction.

Speaker 1:

Before we get into my interview with Jeff and Patty, I wanted to make one clarification. Jeff and Patty talk about generalists, and what they mean by that is they're referring to mental 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 dig in. All right, jeff and Patty, good morning, so glad to have you with me. I usually start with who you are and what you do, patty. Why don't you start? And then, jeff, you can tell us your side of the story too.

Speaker 2:

Okay, well, I'm Patty Robinson. I'm a psychologist and I live in Portland, oregon, and in a little tiny house outside the city with my partner of 40 years and our two dogs, mac and Molly. I have been working in the field of health care since the 1980s, first as a scientist that was looking at how can we get more behavioral health services meaning both mental health and substance abuse services available to people, because clearly most people that would like to receive them can't. So that question has been on my mind for decades. Casey and I met Jeff, and we've worked together on three different books. We're pretty excited about the third edition of a book that really is a how-to guide for behavioral health providers mentalitment Therapy, which is a version of acceptance and commitment therapy developed in the context of primary care clinics, and it's helpful to people 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:

Yes, so, jeff Reiter, I'm also a clinical psychologist and I live in Toledo, ohio, northern Ohio. I got into doing this work in integrated primary care behavioral health which, as Patty was mentioning, is about integrating behavioral health professionals into primary care services to help improve access to behavioral care. I got into that back in 2002 and have been really pretty much just living, eating, breathing it ever since then, and what drives me is what Patty was talking about, which is the need for us to improve access to care for people who are trying to get care for mental health as well as addiction services. So, yeah, thanks for having us on to talk about all that today.

Speaker 1:

So I don't know which one of you has a better answer for this, but can you share some of the background why mental health has been segregated as a separate specialty and discipline? We all know that healthcare involves all parts of the human body. There's a history why dentistry is separate. There's a history why podiatry is separate. Do either of you know the history of why we segregate mental health?

Speaker 3:

history why podiatry is separate. Do either of you know the history of why we segregate mental health? I don't necessarily know how that came to be, but I agree that it's a huge problem. I think it's probably the biggest problem that we have actually when it comes to helping people to access care for substance abuse services, because it ends up that those silos end up creating a number of problems. One is that you've got addiction medicine specialists whether we're talking about therapists, counselors, physicians who end up being perceived as the only people who can really help people with addictions, which in reality is not the case right, especially in our field in mental health.

Speaker 3:

I mean, any general counselor can help a person with a substance use problem, but we have carved out these specialties substance abuse counseling, psychologists, with an emphasis in substance abuse and it's to the point where the general counselors out there don't feel able to work with substance abuse problems.

Speaker 3:

So, even though many of the patients that they're seeing for therapy or marital problems whatever they're coming in for have substance use problems, they don't feel able to help with that, even though they could. They have to all try to refer them to this relatively small pool of professionals who do work with these problems and it just creates a huge access problem. And then you've got on top of that the issues around payment being separated and so forth. So I wish I was a better historian of my field. Maybe Patty knows more than I do about how this all came to be, but my guess is that it's probably tied to moral judgments around substance use and the stigma around substance use, just that it's always been treated, and still is treated, as something different from a health problem, which is ludicrous. But that's my guess about the origin of it. But I don't know if you have anything to add to that, patty.

Speaker 2:

I don't know if you have anything to add to that, patty. Yeah, I think my perspective and understanding of the history of the evolution of medicine is such that we moved from a collectivist kind of society that viewed health in a quite different way than it's viewed in today's world. So a much more holistic view of health mental, physical, social, emotional was just health and the health of the individual was the health of the family, the community. So people were not separated out and compartmentalized into having physical health problem versus a mental health problem versus a behavior problem. So what happened over time and it's really quite recent was we had the emergence of groups of people with expertise in specific areas. They were studying and they were figuring out how to help with one thing and the model that kind of pulled, trained and trained specifically in a biomedical model where they're looking at the biological kinds of qualities associated with illness. In fact the original definitions of health were the absence of physical health problems and we all know that's not true for most of us, even as children or teenagers. So the progression has been.

Speaker 2:

I think the first inroads were to start to pitch a biopsychosocial model and say, hey, we are complex, and now what we're trying to do is change systems so that primary care, which was the level of healthcare set up to be accessible to all people, any age, any problem. It's the first door. It's the right door for anyone trying to influence them towards a biopsychosocial model and to succeed in walking with our medical colleagues towards that view. We realize we need to be right there because your training doesn't help you do that so many times. It's changing now, casey, but it is a huge impact in the care that's received when people go see their doctor.

Speaker 1:

We have so much to unpack here. This is going to be fun. Okay, jeff, let's start with a follow-up on what you said. I literally last week referred a patient for counseling and they said no, we don't do addiction. And my response was I'm an addiction medicine doctor. I'll handle the addiction, but most of my patients have some sort of traumatic life experience. Many of them have PTSD. And my question to the therapist was why can't you work on the PTSD? I'll handle the addiction part. And you mentioned, jeff, that sometimes counselors say, whoa, I can't do addiction. Can you talk to me about that from a psychology or LMFT perspective?

Speaker 3:

Yeah, Well again, yeah, it's a huge problem. That counselor that you interacted with there is representative of how most people in my field think. I think Psychologists, social workers, other sorts of counselors this false distinction between biological health, mental health, substance use. We've kind of created these three silos. Mental health problems are siloed as well, right, not only substance abuse problems but mental health problems as well. But within the mental health field, substance abuse problems are then given another layer of siloing. So you have the mental health professionals that feel uncomfortable working with substance abuse problems. So I think that our field has gotten really specialized over time.

Speaker 3:

The mental health field, mental health counseling field, have gotten really, really specialized over time. You have people who specialize in working with kids, people who specialize in working with PTSD, people who specialize in working with PTSD in kids more and more specialized a lot of which I think is driven actually by that biomedical perspective than the original DSM. Right, it's just loaded with all sorts of new conditions now, new diagnoses now that didn't exist in the early days of the mental health field, and so when you have this growing number of problems to treat, then you get more and more specialization to treat those problems, I think. So we've had this trend for a number of years in the mental health field towards specializing. And it's unfortunate, though, because you know, what we do as mental health providers is not the same as what medical providers do. There are some overlaps here, but, you know, if a person goes in to see their primary care provider with a sore throat and a sprained ankle, those are probably not connected. Those are probably two different problems to address there. But if a person comes in to a counselor or maybe they come into the emergency room or to their primary care provider with relationship problems and a drinking problem and depression, those are all related, right, everything that we work with in the mental health field is related, but we act as if we're treating discrete problems. We act as if we're treating this discrete diagnostic entity from the DSM-5 that we've gotten highly specialized training in, and we act as if we're doing something different than what we would do with any other problem that a person comes in with. But in reality, that's not true, right. I mean the same strategies that I, as a therapist or a counselor, use with a person with depression or relationship problems or addiction problems. I'm gonna use the same strategies for all of them. I might use motivational interviewing, I might use cognitive therapy approaches, I might use mindfulness approaches or any number of approaches, right?

Speaker 3:

But we've created this sort of idea, this myth amongst ourselves as mental health professionals, that we need to be highly specialized to address all of these different problems that are out there. But in reality we don't need to be highly specialized, but there's that, I guess, perception out there, so that makes people afraid to work with problems that they feel like are outside of their area of expertise. If my area of expertise is relationship problems and somebody has a drug problem, but I'm seeing them for a relationship problem, many, many people feel the need to refer out to an addiction specialist. In that scenario they feel like, well, that's a separate problem from the marriage problem, right? So I need to send them to a specialist in that problem, when in reality, again like no, these are connected problems.

Speaker 3:

It's all happening to the same person, same body, same mind and same relationship and and and in fact, the relationship is probably influencing the drug use and the drug use is probably influencing the relationship problem. So we can take them on both together, right? So in my mind, that's a huge part of the problem is that specialization that we've created for ourselves. It doesn't need to exist, but it does exist in counselors' minds and that then becomes a really big access barrier for them. So if we could wipe that out, we could just open the door to loads more access to mental health care for people. Right, because you wouldn't have gotten the response from that counselor that you got right, and so, anyway, that's my take on that.

Speaker 1:

Yeah, as we were speaking about before the podcast started, my background is in emergency medicine, as we were speaking about before the podcast started. My background is in emergency medicine and healthcare providers. When they're in that silo, when they get a problem given to them that's outside of that silo, there tend to be two responses One is go see your primary doctor and two is go to the emergency department, and both parts of our healthcare system are hugely overwhelmed. So, patty, you had talked about integrating behavioral health into primary care. Primary care in America is horribly overloaded and I just am curious what does integrated behavioral health into primary care look like? And, most importantly, how does it help the primary doctor, help the patient, primary?

Speaker 2:

doctor help the patient. All right, Great questions, Thank you. It looks different in form and it looks different in function. So the behavioral health or mental health provider that goes into primary care needs special training, a lot of retraining, needs special training, a lot of retraining. They become a generalist. So typically, Jeff and I provide training. We provide a training all over the world, and when an organization decides to move from siloed care to integrated care, it's big. Everybody needs retraining, including the primary care provider and the nurses and the person at the front desk. Everybody's workflow and message to patients is going to be different. So this newly arriving behavioral health provider could be any licensed health care provider.

Speaker 2:

I've worked a lot in New Zealand. So they have occupational therapists and they have, of course, counselors, social workers, psychologists, mental health nurses, and they go through an intensive training and, speaking specifically of New 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 to work in a new way and they learn how to provide a new psychotherapy or therapeutic intervention called focused acceptance and commitment therapy. So the way it looks is this person is trained to be the first door for any kind of problem for any person. Alcohol may not be working in their life or marijuana may not be working in their life, but they come in with all kinds of problems. They might say I have chronic pain, or I have problems in my family, or we can't communicate. So this generalist is trained to respect the problem that the person wants to work on at that moment and to do what we call a behavioral analysis. So they're really looking at the triggers for the behavior, what the behavior looks like, the consequences, what the person is trying, how that's working relative to that person's values, what matters to them.

Speaker 2:

That's a lot to do and it takes a lot of training. Not only that, but they are working in a brand new way. They're sitting with the team in the team space that might be with nurses or in some primary care clinics. We have a hub for primary care doctors and behavioral health providers and nurses, dieticians. They're all sitting together and they plan their day as it starts and they check in with each other throughout the day. They co-refer and co-care for the people that are scheduled and the people that show up. So visits are 15 to 30 minutes in length, whatever time the person has available and follow-up is up to that person. So the schedule for the behavioral health provider is such that every other visit is the same day visit. So very accessible care. That's for initial visits as well as follow-up.

Speaker 1:

So, jeff, I feel like this would help me enormously in my practice. So people come in and they're angry at their landlord, they're angry at their mother, they just had an altercation with someone in the parking lot and that just gets verbal diarrhea all over me and the 20-minute appointment gets taken up by that and I don't even have time to talk with them about their Suboxone. In my practice we have peer support specialists, so we try to create at least some sort of co-management. How does it actually look like? I mean, I'm going to go to clinic next week.

Speaker 1:

What would it look like for me, for that patient? They've got opioid use disorder. They've got some family dysfunction. They've got some impulsivity opioid use disorder. They've got some family dysfunction. They've got some impulsivity. They have trouble controlling anger and regulating emotions. What would that look like? We'll call this fictitious patient Sam. What would it look like if Sam had an appointment with me next week and we had this integrated behavioral health approach? With my practice it's a little different because I'm addiction medicine but a lot of patients consider me their primary doctor because they can trust me. So let's pretend I'm a primary doctor with an expertise in addiction. What does that look like?

Speaker 3:

Yeah, I encourage primary care providers to bring in somebody like myself, a behavioral health consultant, if there's something that comes up in their visit with their patient that they would like to have more time to discuss. Maybe they feel like there's some issue going visit with their patient that they would like to have more time to discuss. Maybe they feel like there's some issue going on with the patient that they feel like they could discuss. They feel like they could handle this and could help the patient with this problem, but they just plumb, don't have enough time, right. So in that capacity then, in that scenario, I'm sort of like an extender, an extension of the primary care provider, right? So the primary care provider maybe has some skills in motivational interviewing and maybe feels like that would be helpful for this patient right now, but, just like I say, it just doesn't have any time. So they might bring me in to that visit then to do that motivational interview that they themselves don't have time for, right? Or the other scenario where they might pull me in is if they feel like the patient, whatever's going on with the patient in that moment, is something that maybe they don't feel like they have enough training to help the patient with. Like, maybe they feel like that as patients really struggling with being able to make this change we want them to make and I'd like for them to get some motivational interviewing help around this. But I don't really have training and motivational interviewing myself, so I'm going to bring jeff in to help with that. So one scenario is where you, you, you feel like as the primary care provider, you could help the patient but you don't have time. The other scenario is maybe you feel like the patient needs some more specialized help than what you you've had training in as a primary care provider, right? So those are the two scenarios where the primary care provider might bring me in. Every patient you're going to see in addiction medicine has some sort of, by definition, behavioral health issue going on, right? So we don't say that necessarily. I don't assume, as a behavioral health provider, that I need to be involved in every one of your visits. But if you feel like one of those two scenarios comes up, seamless connection that you as the primary care provider, make to me as a behavioral health provider, right? So I'm sitting there in the clinic in the same space where, like Patty was saying, where all the rest of the team sits and if you would like my help, you want my help. You ping me on a team's message or you physically come and tap my shoulder and say, hey, jeff, can you help with this patient. Or you send somebody to come get me or, however it works, you grab me real time.

Speaker 3:

I go into the exam room. If I've never met the patient before, you introduce me to them, and then you leave the room, go on to your next patient. I stay in that same exam room with the patient. If that works out, the exam room's available and whatnot. I stay in that same exam room with the patient. If that works out, the exam room's available and whatnot. I stay in that same exam room and just continue your visit, but with the particular focus that I'm bringing right to helping that patient. So that's the way that we try to make it look. There's not eight pages of paperwork you have to fill out to see us as the behavioral health person on the team. There's no wait, it's just on-demand care. We practice in ways that make us super accessible, like that, all throughout the day.

Speaker 3:

And then the beauty of primary care is that it's all built around this idea of a long-term relationship that you establish with patients right, which you were talking about before. We got onto the air here the importance of the relationship and working with people with substance use problems. And that's why I love working in primary care, because that's when primary care is at its best, is when those long-term relationships are built with patients. That's the secret sauce of primary care. That's why I love being there, because then we have the opportunity to build these long-term relationships too with patients that I never had, frankly, when I worked in a mental health clinic.

Speaker 3:

So now that you've introduced me to that patient, I'm starting getting to know them. The next time they come back to see you, sometimes that same patient might say hey, you know what that Jeff guy that Dr Grover had me talk to last time I was in there. He was pretty helpful. I'm going to make an appointment to see him on the same day as Dr Grover, right before Dr Grover. So the next time they're in seeing you, it might pop into their mind that they want to talk to me again while they're there and you work me in again real time to see them. Or maybe a new issue comes up and you want my help and you bring me in. But that's what it looks like.

Speaker 1:

So, Patty, I'm going to give you a magical $100 million and you get to build the perfect clinic. What does the ideal physical setup look like? And then I know you wanted to add something.

Speaker 2:

So, after you tell me what the ideal physical space is, I'd love to hear what you wanted to add, I have been able to work with systems, for example the San Francisco Public Health Department, who were asking this question what does it look like? And so I think it depends on the population served in that clinic in that community. So the staffing ratio of behavioral health providers to primary care providers depends on the population served. So in a clinic that serves people that don't have houses, that are extremely vulnerable, the setup might be to have a couple of behavioral health providers supporting every physician or PA, every primary care provider. If we move into other clinics, for example commercial systems serving people, it depends on the mix of people coming to that clinic. But I would say roughly, you're going to want to have one behavioral health provider for every team, but the principle that's the same about the physical environment is togetherness. So we don't want anybody to have to walk more than 15, 20 feet to run into a behavioral health provider, because more than that is a deterrent to using a person you're going to use a lot every day.

Speaker 2:

The other thing that I was going to add Jeff so beautifully described our general model for individual consults. In addition to that way of assisting and supporting the work of our primary care providers, we have something different called pathways, primary care, behavioral health pathways. Pathways target a particular population. What population? The population of greatest concern in that clinic and what that clinic then decides as a group is how can we better serve that population? So, people struggling with opioid use disorder, that's a great population to target in many primary care clinics and those that do develop a pathwayday introduction to all members of the team, that were possible and that would include a behavioral health provider.

Speaker 2:

So usual care for that person would include the behavioral health provider. So on a day of a visit with a primary care provider that would have been covered in the huddle, so-and-so is coming for an appointment, so you may want to stop in and say hi, or you may have, in addition to individual visits with their primary care provider or addiction medicine and primary care provider, there often are groups that the person can drop into and that the person routinely attends. It depends on what phase of recovery that they are in. It might be weekly, it might be twice a month, it might be once a month. With a condition like that we're looking at, probably most people can recover, but we're looking at five years or something. So we really need to have a program that's feasible, that's accessible, that people can start and restart with ease and that is multidisciplinary. That's described in the pathway. The details are decided based on the resources in the clinic. What does the clinic have and what's the evidence for us to get that to these people?

Speaker 1:

has a central corridor of patient rooms and there's a left door and a right door, and then the doctor comes in on one side and the behavioral health folks come in on the other side. I was really impressed, jeff. I'm going to ask you the next question when you are trying to create these integrated primary care clinics, what sort of pushback do you get from the healthcare providers?

Speaker 3:

Well, it depends on which healthcare providers you're talking about.

Speaker 1:

You tell me.

Speaker 3:

Well, it depends on which healthcare providers you're talking about. You tell me every day of patients whose health is being affected by behavior in one way or another, whether it's addiction or depression or some other problem, and they don't get a lot of training to work with mental health problems either, right, and they have lots of other medical issues to help patients with too. So there's typically very little pushback from the primary care providers. They welcome the help. They're rather desperate for help. Frankly, the pushback usually, if you get it, it's going to come from the mental health providers, because we are asking them to practice in a way that's fundamentally different from how they typically practice right. How they typically practice right, I mean, most mental health professionals therapists are accustomed to hour-long visits that are, with a lot of the same people, scheduled on a fairly regular weekly basis, that sort of a thing for a long period of time. And so when we take them from that environment and we plop them down in primary care and say, okay, the way that we practice in primary care is we have 30-minute visits, and actually 30 minutes is just how it looks on the template, because in reality we're working people in all throughout the day for unscheduled visits like I was describing before, and so we might end up just seeing somebody for 10 minutes or 15 minutes, 20 minutes, and then the follow-up is planned differently. Most primary care patients your typical primary care patient with either some sort of addiction or some sort of behavioral concern, is not all that interested in following up regularly, certainly not for weekly hour-long visits, and so the follow-up often looks different. You have to adjust to the primary care context where you rely on developing these long-term relationships with patients, grabbing a little bit here with them, a little bit there with them over time, building those relationships over time with them. So it's a different way of following up and it's much less predictable of a workflow throughout the day too. Right, because again, we're working people in all throughout the day. That very rarely happens.

Speaker 3:

If you're in a mental health clinic. People don't just hop in to a mental health clinic. I'm going to see them right now. It doesn't work that way, or very rarely anyway. So I'll say that and some of your listeners will say well, that's not true. We practice this way in mental health, but it's rare. So in general it's not true. We practice this way in mental health, but it's rare. So in general, it's a much less flexible environment in mental health. So that's where the pushback if you do get any usually comes from is from the mental health professionals who really have to practice in a way that understand that.

Speaker 3:

The goal of what we're trying to do is we're not trying to get a huge volume of visits to a small group of people, we're trying to reach a large number of people and what that means is that we might end up having shorter visits with them. We might end up having, like I was saying before, a different, different structure to our follow-up than we would otherwise. But what we're trying to do is just to reach people right, just to reach people and get started building those relationships with them. And if you have somebody who understands that goal right, then that's great. They're usually open to making these changes and they can flex and go from there with a little bit of training, like Patty and I provide. But yeah, that's where it tends to come from Occasionally.

Speaker 3:

Primary care providers maybe you might get a little resistance there for one reason or another.

Speaker 3:

Maybe it's more skepticism because they've maybe worked with mental health professionals who have practiced in a very inflexible way in the past.

Speaker 3:

More typical counseling approach right with being selective in who they're going to see and needing to see people every week for hour-long visits for a long period of time. So if they've had a lot of experience with that system and they've been frustrated by the access problems just like you were frustrated the other day with that patient you were trying to get in to see the counselor if they've had a lot of those kinds of experiences, then a lot of times they're skeptical coming into all of this that this is really going to add anything or really going to be helpful. But once they see how accessible we really are in this model and that we practice a generalist we don't practice as these uber specialized people who are going to say I'm sorry, I can't help with this addiction problem because it's out of my scope, that's not what we do. We practice like generalists, like primary care providers Then that skepticism starts to fade away and usually they are 110% on board.

Speaker 1:

Patty, next question for you what's the patient experience when behavioral health and addiction services are integrated into primary care? Do people get upset because the visit takes longer? Do they find that they're able to work on issues that they didn't know they had? What's the patient experience like?

Speaker 2:

Yeah, good question. I think this goes back to training. So we have to train the primary care providers to identify people even before the day starts, with scheduled patients that they want to involve us in, and so they can start the length of their visit because they're not trying to do everything which they are so frustrated with, because they usually have two or three medical problems plus all of the other issues mental health, substance abuse. So that isn't a hard sell for them to go in, but it takes training and then training on workflows. But when people are trained and we have signage in the clinic that says, oh, we have a health improvement practitioner or whatever you call this person, we have a health improvement practitioner. They help with sleep, stress, family problems. If you'd like to see them today, let your doctor know. So really, even when a doctor goes into the room and the patient could say, hey, do you think I can see this person? So then the doctor's going to adjust to the patient's request and shorten their visit and get them involved with the behavioral health provider. So for them, some clinics when they start providing primary care behavioral health services, they send out letters or push messages through the healthcare portals announcing it so that people are informed that their healthcare team is improving. And people I would say 90% are like oh my goodness, are you kidding me? Because what's to push back on if 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. Their visits are short.

Speaker 2:

I get really good feedback from other people that I recommend to Patty or recommend Patty to so you don't get pushback. Sometimes you'll get some people that think they need therapy and so they're like oh well, wait, is this therapy? And so we have to train and say no, no, it's in the moment, consultation on how to get your life in track, how to address common life problems, because we're not doing therapy, diagnosing and treating and requiring people to come back an X number of times. Because people don't do that. They come when they're hurting and they go away when they're not. So with that group we just say, if that's what you want, I want to help you find it, but since you're here today, let me help you as much as I can. And a lot of those people come back and say I don't want therapy, I want what you're doing.

Speaker 1:

Behavioral Consultation in Primary Care. A Guide to Integrating Services, third Edition. It's a textbook. Wow. I've always wanted to be an author. I'm very impressed that you've been doing this for enough times to have a third edition. Well, regrettably I have to go see patients and I'm sure y'all are busy too. Jeff, why don't you close us out with whatever wisdom you'd like to share, given your perspective, and then Patty will come back to you as well, Anything you'd like to share about your work or wisdom to patients or providers alike.

Speaker 3:

We have a serious problem in this country with people being able or unable to access care behavioral health care for mental health and substance abuse problems and I really do fear that if we don't solve this access problem well, we'll never completely solve it, of course, but if we don't lessen the severity of this access problem soon, my profession really risks being viewed from a public health standpoint and by policymakers as irrelevant.

Speaker 3:

I fear that, and so we need to do a better job in the mental health professions of being accessible, and that means we need to back off of this idea that we can only help with certain problems. We need to recognize that we can be generalists. Many more of us need to be working in primary care settings where these people show up, and if we can practice these ways and practice more flexibly to get away from the requirement for an hour-long visit every week into perpetuity right, Be more flexible to meet people with what works for them. There are lots of other approaches single session therapy, solution focus therapy and so forth Focus, acceptance and commitment therapy that can help. So I hope that my profession. Moving forward will embrace the access challenge and be able to lessen it.

Speaker 1:

Patty final thoughts.

Speaker 2:

Just final thoughts are if you don't have this service Integrated Behavioral Health or you have it and it doesn't work quite the way we're talking about and you want it to, and most people in America do not have access to clinics that have primary care behavioral health services. If you don't have it, remember this 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 sheet that you can use, that you can take to your doctor and say look, this is the kind of health care I want.

Speaker 2:

Let's partner together and get this started in our community and then I think things are going to get better for the very many, many people among us that are struggling with use of substances, because we'll have the primary care team staffed right and primary care providers are going to be a lot more willing to say well, bob, I know using alcohol is an issue and you're here today with some stomach problems and I'm just wondering if you'd like to see Patty just to talk about improving your health in general, because we need to hook people in what they care about and they care. They care a lot about their families, they care about their well-being. They want a better life. We just got to offer the service and make it really available in a way that says hey, you're one of us and we want to help.

Speaker 1:

Well, Jeff and Patty, I have to say I will be a better doctor next week in clinic, having to spoken both of you trying to really partner more. Sometimes I feel like I get isolated in my little clinical exam room, like I get isolated in my little clinical exam room and I forget to walk my patients over to my peer support team. We actually do have an LMFT in the office with us. I've got a number of folks that see myself, peer support and the therapist on the same day. So I think, while you are experts in this, I came to this a little more organically, but the patients, like you've said, they just appreciate having more support and being able to address more issues when they come in. This was awesome. I appreciate both of you and I will be certainly sending your work off to some of the leadership at my hospital. So thank you for joining me today, Thanks so much.

Speaker 3:

Thanks so much, and thanks for your work too.

Speaker 1:

Before we wrap up, a huge thank you to the Montage Health Foundation for backing my mission to create fun, engaging education on addiction, and a shout out to the nonprofit Central Coast Overdose Prevention for teaming up with me on this podcast. Our partnership helps me get the word out about how to treat addiction and prevent overdoses To those health care providers out there treating patients with addiction. You're doing life-saving work and thank you for what you do For everyone else tuning in. Thank you for taking the time to learn about addiction. It's a fight we cannot win without awareness and action. There's still so much we can do to improve how addiction is treated. Together, we can make it happen. Thanks for listening and remember treating addiction is treated Together. We can make it happen. Thanks for listening.

Speaker 2:

And remember treating addiction saves lives.