The cover image of the 82-page booklet may have looked celebratory—silhouettes of two strapping mountain climbers high-fiving in front of a golden sunset—but inside, the message was blunt and serious: “Please do not delay,” read the introductory letter. “This should not sit in your in-basket or on the shelf for even a minute. Take the first step to saving lives as soon as you possibly can.”
Enclosed was a suicide prevention toolkit written in 2017 by four Colorado mental health workers at the Western Interstate Commission for Higher Education. Their target audience? Primary care physicians.
The letter continued: “Whether for an adolescent struggling with a life crisis, a war veteran suffering from PTSD or traumatic brain injury, a middle-aged worker with depression and alcohol dependence, or a lonely elder, your practice can soon have systems in place that will allow you to intervene effectively without significantly disrupting the flow of patients.”
That last part might puzzle some readers. Shouldn’t assessing and treating suicidality be left to mental health professionals? After all, they’re specifically trained to deal with this sort of thing, right?
Well, not entirely. According to the National Institute of Mental Health, nearly 68 percent of adults with a serious mental illness have one or more chronic physical conditions. Left untreated, they’re likelier to die between 13 and 30 years earlier than the general population. It makes sense that doctors treating patients’ physical health would want to address their mental health, too.
“Primary care settings are increasingly serving as the gateway for individuals with behavioral health needs,” reads the toolkit. “Many primary care providers are integrating behavioral health care services into their practices.”
Don’t worry—this doesn’t mean psychotherapists are becoming obsolete. On the contrary, there’s an increasingly popular model that combines primary and mental health care. Slowly but surely, it’s winning adherents for being altogether accessible, cost-efficient, and effective. If adopted on a wider scale, it could save the US healthcare system an estimated 26 to 48 billion dollars annually—up to a 10 percent decrease in overall costs. And in this model, psychotherapy isn’t just an afterthought in caring for one’s health: it’s a crucial component.
Meet integrated behavioral healthcare.
You’ve probably encountered integrated behavioral healthcare before in one form or another. Centers embracing this model are hiding in plain sight, including those run by the US Department of Veterans Affairs—the largest integrated care delivery system in the nation—and Kaiser Permanente and the Mayo Clinic, the two largest private providers. Then there are countless smaller operations. Washington, DC alone has about 60 such centers, serving approximately 200,000 residents.
It helps to think of integrated care as a sort of one-stop-shopping approach to treatment. Collaboration between specialists is a cornerstone of integrated care, so it’s not uncommon for integrated care settings to feature primary care physicians, pediatricians, psychiatrists, addiction specialists, nurses, case managers, teachers, and therapists all working under the same roof. In fact, in a single trip to an integrated care center, a patient could theoretically visit a doctor for back pain during the first half-hour, see a therapist for anxiety in the second, and have a dentist fill a cavity in the third. Although operations and services offered vary from location to location, all recognize the importance—and effectiveness—of treating the body and the mind together.
Sound unusual? Hardly. A growing body of research from authorities like the Centers for Disease Control and Prevention, the Substance Abuse and Mental Health Services Administration, the National Institute of Mental Health, and the American Psychological Association is underscoring the relationship between chronic physical conditions like hypertension, headaches, stomachaches, chest and back pain, insomnia, obesity, asthma, diabetes, and cancer, and psychological conditions like anxiety, depression, and trauma—as well as the importance of treating them more comprehensively.
This might not come as a surprise to clinicians, but what’s probably novel is how easily and often integrated care doctors refer to in-house therapists. Considering that between 75 and 90 percent of primary care patients continue therapy when a referral is in-house, compared to roughly 25 percent of patients when that referral is offsite, it’s a no-brainer.
Is the nation moving toward integrated care? Some signs point to yes. A 2015 American Psychological Association study found that the typical therapist engages in an average of 2.3 collaborative care activities with other healthcare specialists in the course of their daily work, and most report “high levels of confidence” in working with them. The United States Department of Labor estimates a 20 percent increase in behavioral health social workers will be needed by 2024 to meet a growing demand for integrated care.
So if it makes such a difference, why don’t more people use integrated care?What does therapy in an integrated care setting actually look like? And considering that nearly half of all therapists work in private practice, shouldn’t they be recognizing what this model could mean for the future of the field?
A Movement Begins
Enter Dan Mullin, a clinical psychologist in the Department of Family Medicine and Community Health at the University of Massachusetts’s School of Medicine, and director of its Center for Integrated Primary Care. Mullin has been working in integrated healthcare settings for nearly 17 years, and currently offers trainings for mental health professionals interested in working with primary care doctors. Simply put, he says, integrated care exists because it must. And not just because of the inextricable relationship between the physical and psychological.
“For better or worse,” he explains, “the de facto mental health system in America is the primary care system. In most communities, the access to mental health treatment is completely inadequate.” So what do many people do instead? They go to the only person who can see them: their primary care doctor.
“Traditionally, mental health services, including private practices, are pretty rigid about how and when they’ll see patients,” Mullin says. “That’s very different from primary care, where the expectation is you can see your doctor at a time that works for you.” What’s more, Mullin adds, most primary care doctors have a basic understanding of mental health problems, and are comfortable prescribing antidepressants and antianxiety medications. In fact, they prescribe the vast majority of them each year.
But as most people are well aware, meds can only go so far. Therapists’ expertise is desperately needed in primary care, especially since 80 percent of people with a behavioral health issue will visit a doctor every year—hence the growing popularity of integrated care. But how, exactly, did therapists first join the healthcare fray?
The short answer: not easily.
Let’s time-travel back to 1966. Dissatisfaction with the state of American medicine is growing due to a shortage of physicians, the inaccessibility of services in rural areas and inner cities, high costs, and increased depersonalization and fragmentation in care. Sound familiar?
In response, the American Medical Association creates a commission to investigate possible solutions, which soon produces the Millis Report. In it, the commission lays out its vision of the model physician, one “who focuses not upon individual organs and systems but upon the whole man, who lives in a complex setting [and] knows that diagnosis or treatment of a part often overlooks major causative factors and therapeutic opportunities.” In essence, a good integrated care doctor.
The Millis Report is revolutionary for its time. It’s also polarizing, evoking the rancor of older, “establishment” doctors and therapists, many of whom fear competition, believe their respective roles are specialized and best kept separate, or deem the whole thing complicated and unnecessary. Those in the world of integrated care refer to this aversion as “the clash of cultures.”
But in the wake of the civil rights movement, the peace movement, and Vietnam War protests, the time is ripe for a heightened sense of social responsibility. Other agencies, including the American Public Health Association and the National Health Council, soon follow suit, issuing their own reports with similar judgments. Just three years later, a discipline called family medicine is born, with that model doctor at the helm.
Over the next decade, family medicine grows and flourishes. Large, bustling city hospitals in particular are staging grounds for what will soon become integrated care, thanks to two new concepts: continuity and coordination of care. For the first time, many patients are not only seeing the same primary care physician from visit to visit, but, with the help of case managers, are being referred to specialists—including psychotherapists.
Helping bring the Millis vision closer to fruition, the 1980s witness the rise of another concept: patient-centered care. Under this model, doctors are urged to approach treatment with a wider lens, to consider patients’ individuality and the influence of societal factors that could be contributing to their symptoms. And to help them adopt this approach, more therapists are being brought on board at prestigious hospitals.
For the most part, Mullin says, collaboration between doctors and therapists proves to be a happy marriage. “It’s not like everybody just stays in their lane,” he explains. “What happens is when you have a counselor and a doctor working together as part of a team, over time the doctor gets better at counseling and the counselor gets better at medicine. The counselor might look at a patient’s lab report and comment on how their blood sugar could be affecting their mood, and the doctor might think more about how to do brief counseling.”
Not only are doctors moving from being gatekeepers to comprehensive healthcare providers, Mullin says, but, taking a cue from the pace of primary care, the therapists they work alongside are starting to do therapy differently, too.
It’s faster, more streamlined, Mullin explains. “There tends to be an emphasis on solution-focused interventions like CBT, problem-solving therapy, and ACT,” he says. “This isn’t to say there’s never a place for more relational work, but therapists in integrated care tend to be pretty focused on getting people functioning—getting back to work or taking care of their kids again. We don’t spend much time in the world of assessment.”
By the 1990s, countless smaller integrated care centers have sprung up nationwide. In Washington, DC, where the city’s most vulnerable residents are growing impatient with high fees and long waitlists at private practices, one clinic is about to hit its stride after the newly formed DC Primary Care Association takes the burgeoning center under its wing, along with a few dozen similar clinics in the district.
Come 2010, the Affordable Care Act will give an unofficial endorsement to thousands of integrated care centers across the country, mandating that all insurance sold through the ACA must include behavioral health benefits. This includes the once-small clinic, now a robust, respected, and well-oiled integrated healthcare machine.
Let’s Get Integrated
There’s a fantastic, if unapologetically corny, TV commercial for Reese’s Peanut Butter Cups that first hit airwaves in the early ’80s. A cocky young man struts down a sidewalk, munching on a chocolate bar and grooving to the sounds of a cassette player clipped to his waistband, oblivious to the pedestrians and shopkeepers around him. As he rounds a sharp corner—wham!—he collides with a young woman lost in her own reverie, scooping a gob of peanut butter from an open jar. “Hey! You got chocolate in my peanut butter!” she exclaims. “You got peanut butter on my chocolate!” the man retorts. A moment passes before they take a bite of the tasty combo and smile at their new creation. Crisis averted!
Looking at the headquarters of Mary’s Center, a sprawling, diamond-shaped brick building on its own sharply angled street corner, it’s easy to imagine a time before integrated care, when a therapist and physician could’ve rounded that corner and bumped into one another with similar shock and distaste, only to realize how well they could work together.
Judging by the center’s exterior alone, you’d be forgiven for saying not much has changed over the last three decades. Calling it nondescript is an understatement. The two-story slab of weathered brick and monotone concrete is almost Brutalist, save for a tiny violet placard with the center’s logo—a sketch of a mother cradling her infant child—-and a few graffiti scars bathed in the red neon light of a nearby laundromat sign. Two parking lots pock the complex on either side, closed off from the street by a long chain-link fence. If you didn’t know what you were looking at, it’d be easy enough to write off the building as just another free clinic. Or maybe the DMV. How wrong you would be.
As you make your way toward the center’s behavioral health wing and swing open the glass front door, you suddenly find yourself in a clean, bright waiting room. It’s filled with dozens of patients from the surrounding neighborhood, afloat in the messy tidal wave of gentrification affecting so many urban areas these days. But here, flipping through magazines and scrolling through phones, in high heels, work boots, pea coats or old military jackets, everyone seems comfortable.
Social worker Gretchen Gates works a few offices down the hall. She’s got a big smile and an equally big title—Senior Clinical Manager of Behavioral Health and Medical Integration. True to the integrated care model, she currently oversees the center’s medication-assisted treatment and maternal mental health programs, which rely heavily on the input of doctors and other medical specialists.
She relaxes into her chair underneath a canvas print of an old record shop and a corkboard covered with photos of dogs in Halloween costumes, and takes a sip from her coffee cup. “This isn’t the most common destination for an aspiring therapist,” she admits, thinking back on her six years at the center. “A lot of people I went to graduate school with had paths that were a little more traditional,” she laughs. “But once I got here, I knew Mary’s Center was on the cusp of something big.”
Sure enough, Mary’s Center is a little different from most integrated care centers. In 2005, it received the status of a federally qualified health center—which means that in exchange for tax-exempt status, federal grants, and enhanced reimbursement from The Health Resources and Services Administration beyond Medicare and Medicaid benefits, it must treat an underserved population, offer a sliding scale based on patients’ ability to pay, provide holistic health and social services, and, most notably, appoint patients to the majority of its board of directors. Yes, patients.
“From the moment somebody walks in here, we’re breaking down stereotypes about treatment,” Gates explains. “I’ll tell them, ‘You’re human, and you’re experiencing symptoms precisely because you’re human. We can guide you in some new ways of thinking and help you build skills to manage these symptoms. Let’s talk about it.’”
If all of this sounds different from what most clinicians are probably used to, it’s because, well, it is. Social change, breaking barriers, and innovation are terms Gates drops often when describing the center. It sounds socially—and even politically—progressive, and extremely patient centered. In fact, most therapists here, she says, refer to their first patient assessments as red-carpet rollouts.
It’s easy to see why skeptics of more traditional therapy environments, critical of what they consider to be dry formalities, impenetrable boundaries, and rigid hierarchy, would prefer coming to a place like this for treatment. Low costs? Easy access? Friendly staff? Check, check, and check. What’s not to love?
Gates offers a caveat. “Practically speaking,” she says, “doing therapy in an integrated care setting takes a certain type of skill set.”
From Checkup to Therapy
It’s only a few weeks after Christmas, and further down the hall, several of the office doors are plastered with colorful, glossy wrapping paper. Strings of holiday lights grace the olive-green walls, clattering as employees make way for a nurse wheeling a small cart to a pediatric exam room nearby. Inside hangs a long poster of a giraffe doctors use to measure height, its neck stretching a comical length above its diminutive cartoon body.
Gates puts her ear to a door and gives it a gentle knock. It eases open, and a young woman with dark hair and a big orange sweater emerges.
“Hey, are you busy?” Gates asks.
“Not at all, come on in,” she replies.
The woman is Yuly Rios, the center’s resident integrated behavioral health therapist—essentially the bridge between the doctors and therapists here. Every Mary’s Center clinic has one. Rios took over the position two years ago from Gates after her promotion.
Initially, Rios says, most visitors come in for physical issues and get what’s referred to in integrated settings as establishment of care, which can mean anything from an annual physical to treatment for a specific medical complaint. They go through screening processes for depression, substance abuse, and domestic violence, among other things. A separate screening may be used with new or expecting mothers to detect mood changes and postpartum depression. A different one is used with children and measures overall behavioral health.
Here’s where things get interesting. If the evaluating doctor suspects there might be a psychological component to whatever’s brought the patient in that day, assuming it wasn’t a mental health issue to begin with, they move to the referral phase, known as the warm handoff—or WHO, as staff often call it. Sometimes, it’s a delicate process.
About two months ago, a middle-aged Latino man who spoke no English walked into Mary’s Center complaining of chest pain. He’d seen doctors at several other clinics and spent hundreds of dollars on treatments he couldn’t afford, but the problem persisted.
During his assessment at Mary’s Center, with the help of an onsite translator, the man told a doctor about an incident that had happened a few weeks earlier. While standing in front of his house one evening, two men had approached him from behind, put a gun to his head, and demanded his car keys. He’d only been able to sleep three or four hours a night since then, he told the doctor. When the sun went down, he’d become panicky. “I feel like I’m having a heart attack,” he said.
“It seems like you might be experiencing some anxiety,” the doctor replied. “We’ve actually got a behavioral health provider here. Would you like to meet with her today?” The man nodded.
Rios was in the middle of a session when the doctor knocked on her door. “I’ve got a WHO for you,” he said. Rios stepped outside for a moment while the doctor filled her in on the details. “I apologize for this,” Rios told her patient. “I need to take a five-minute break, but I’m going to give you those five minutes back.”
Rios and the doctor made their way down the hall to the exam room, where the man was waiting. “Hi, I’m Yuly Rios, the IBH therapist here at the clinic,” she said. “I talked to your medical provider and heard you’re having some anxiety. I’ve only got a few minutes right now, but let’s hear what’s going on.” After he told her, she asked if he wanted to meet to talk further, and they set up an appointment for later that afternoon.
“We got right to it,” Rios recalls. They began with grounding exercises like deep breathing that she assured the man would calm his nervous system. “Think of it like taking a hot shower,” she told him. He nodded. They also watched YouTube videos about how trauma affects the body. In moments when the man would panic while describing the carjacking, Rios slowed him down and used diagrams of the brain and body to normalize what he was feeling. “What you’re experiencing right now isn’t a heart attack, and we don’t have to go to the emergency room,” she told him reassuringly. “I promise.”
As they continued their work together over the next few weeks, Rios made sure the man had a good support system in place. She asked about his family, about friends he could connect with at the local church he attended. She asked about the coping skills he’d found helpful in the past, and about how he might use jogging, a favorite activity, to manage his anxiety. By their eighth session, not only was the man no longer experiencing chest pain, but he’d developed valuable skills and knowledge about self-care to carry with him in the future.
On an average day, Rios fields about four warm handoffs and has sessions with about 10 patients. Many cases unfold like this one. So what works for Rios, and why does it work?
In essence, Gates says, the warm handoff balances speed with a human touch. And this, she adds, means patient buy-in is high from the very beginning.
“We’re not just handing people a piece of paper and telling them to go find somebody else,” she says. “We’re putting a face to a name, and that’s incredibly important for someone who’s never thought about their mental health before, or someone who comes from a culture where there’s a lot of stigma associated with getting help.”
There’s another reason for the success of therapy in integrated care: sessions are very free form.
Although most integrated therapists follow an eight-session format, many patients receive therapy on an as-needed basis. It’s sort of like primary care in that sense, Gates explains. If you’re not feeling well, come on in. If you’re feeling okay, feel free to come back if things change. Patients are free to return for follow-up visits after their recommended eight sessions are through. And because interventions are designed to target specific symptoms from the start, sessions are usually brief—no longer than 30 minutes, she says.
Right now, more than a few therapists are probably shaking their head. But good therapy takes time, they might say. How can you accomplish anything worthwhile in 30 minutes? Especially with such an erratic schedule!
Dan Mullin has an answer: simply put, therapists can work faster. They need to work faster.
“There’s no research at all to support that the 50-minute counseling session is any better than a 30-minute one,” he says. “That’s just an old convention from psychiatric practices dating back to the 1940s, totally based on the convenience and lifestyle of professionals in private practice.”
And those irregular meetings? Mullin, like Gates, points to the effectiveness of primary care, where appointments are scheduled as needed. “We don’t open and close charts in integrated care,” he says. “I have people who I see four or five times and then might not see again for three years. When they come back, they don’t need a new intake. They don’t need permission to be put on my schedule. They can come see me whenever they want.”
But what about interrupting a session in progress? skeptics might say. That’s not exactly therapeutic.
On the contrary, Gates says, most patients are more than comfortable taking a short break while their therapist steps out to chat with a doctor—what’s called a curbside consultation—or for a warm handoff. In fact, many of their therapy patients were warm handoff recipients themselves.
Again, she says, doing therapy in integrated care takes a certain skillset. “Flexibility is key. If you’re the type of person who needs to close your door and not be interrupted, or needs structure and likes to work alone, then integrated care probably isn’t your cup of tea. But if this fits your personality and what you care about, if you like a fast-paced environment and working with lots of different individuals with different perspectives, you should absolutely give doing it some thought.”
“This is a good fit for me,” Rios chimes in. “It’s a good match for my personality. I’ve got a lot of energy and can move between places fast.”
You might guess that by looking at Rios’s office. It pops, to say the least. In one corner, two stuffed animals—a brown bear and a gray bunny wearing a silky pink bow—are nestled against one another, next to a jar of colored pencils and a small basket filled with toy cars. On the other side of the room, a basketball hoop adorns a closet door plastered with poems, a list of commonly used stress relievers, and a whiteboard. On the windowsill sits a diffuser, a handful of tiny cacti, a small statue of the Buddha in a lotus pose, and a poster of an elderly Native American woman with her fist raised under the words We the resilient have been here before.
Rios is ready for anything. But when she joined Mary’s Center, were the doctors here ready for her—or does the clash of cultures between medical and behavioral health, a seeming relic of a bygone era, still exist?
Can’t We All Just Get Along?
Daniel Smith works across the hall from Rios. He’s one of the center’s family doctors and runs its addiction services department. He looks far more down-to-earth and approachable than most doctors you’ve probably met. At least for now, he’s traded a white lab coat for a red-checkered button-down shirt, although a stethoscope still dangles around his neck.
Smith has been with Mary’s Center for nearly five years, and in integrated care for eight, if you count residency. After all this, he says he can’t imagine a world in which doctors and therapists didn’t work together.
“With the time constraints of primary care, there’s no way medical providers can offer the quality counseling services a trained therapist can,” he says. Plus, he adds, there’s so much gray area in who manages services like substance abuse treatment that care needs to be collaborative. “My practice really lies in that place between medical and behavioral,” he says.
But what about the clash of cultures? How would he respond to some people’s assertion that a therapist’s work is less crucial to the healing process than that of a physician?
“I completely disagree with that notion,” he says. If anything, more primary care practices are warming to integrated care. He’s seen plenty of doctors in nonintegrated settings not only express curiosity, but specifically request that their employers bring a therapist on board. “It’s almost expected now,” he says. “Everywhere I’ve worked, therapists were inundated because primary care doctors loved and needed to have them around.”
As for Mary’s Center, he says, “Any provider here will tell you they can’t fathom how important the work is that these therapists do. Yuly, Gretchen, and I see each other as peers.”
Rios agrees. While some days might be tougher than others, she says, and there’s the occasional tension—say, a doctor wants a warm handoff done faster than the therapist can accommodate—it’s nothing you don’t see in any other workplace. “That’s where my psychoeducation comes in,” she says. “I regulate my own emotions, then tell the doctor, ‘Okay, this person can wait a minute. Just have them sit in the waiting room and I’ll be there soon.”
Does it feel like they’re equals? “Yes, I think so,” Rios says. “The doctors here respect me and think my job is as important as theirs. We have a good relationship.”
None of this is to say that a new doctor or therapist coming on board doesn’t face an initial adjustment period, Gates clarifies. “As with any kind of relationship where you’re bringing two separate worlds together, there’s an initial acclimation period and some back-and-forth teaching. But we’ve become really good at moving through that.”
Is there anything she’d like other therapists to know about working with doctors? “It’s not scary,” she says. “It’s just different. It’s a new model and takes some getting used to.” But whether you’re ready for it or not, integration is the future of healthcare, Gates believes. “We need to take care of the whole person,” she says. “We can’t keep treating people in silos the way we’ve been doing.”
An Integration Renaissance
During one of his CBS Evening News segments, Walter Cronkite once famously quipped, “America’s healthcare system is neither healthy, caring, nor a system.”
It’s a perennial complaint, which transcends political, racial, economic, and so many other boundaries. Our healthcare system is broken, critics say. It’s dysfunctional. It’s unequal. It’s unaffordable. This would never happen in Sweden.
Bit by bit, the successes of integrated care seem to be changing people’s minds.
You often hear a singular phrase from those working in integrated care: This makes sense. It makes sense to have a single practice that takes care of the whole person. It makes sense to have therapists and doctors collaborate in an environment where they can better understand each other. It makes sense to work faster and smarter, not harder, assuming clients don’t necessarily want or need a 50-minute session.
And yes, integration makes financial sense too. Thanks to low-cost, bundled payment models subsidized by federal and state grants, it’s not only patients who benefit. Since subsidies are based on outcomes, doctors make more when their patients aren’t coming in often. “In a fee-for-service model, I make more when my patients are sicker,” Mullin says. In that sense, integrated care is the opposite of private practice: it offers a monetary incentive for patients to get better.
Still, challenges remain for personnel and patients alike. Plenty of stigma still surrounds integrated care, with a lack of awareness that it even exists and a shortage of centers in rural parts of the country. And yes, on some level, the clash of cultures remains. Too few graduate programs teach about integrated care, holding to the old view that the medical and mental health disciplines are best left separate.
Slowly but surely, however, attitudes are shifting. “Thirty years ago, we weren’t talking about therapists working alongside doctors,” Gates says. “As our industry is becoming more aware of integrated practices and what it has to offer, we’re reaching more people and decreasing stigma.”
Sure enough, Gates says her team is hearing from more therapists who thrive in fast-paced, challenging work environments who want to join Mary’s Center. They’re seeing more affluent families choose integrated care once they realize the services are just as good as those in private practice, if not better. And patient by patient, they’re changing the way people think about therapy.
“There’s something I often see with patients that makes everything worthwhile,” Gates says. “It’s that perfect moment when someone walks through our doors for the first time and goes from being skeptical to ready to engage in care. It’s really special to be that front-line person who can say, ‘You’re not crazy.’ We’re offering people an open door, a safe space where they can finally heal.”
The next time somebody tells you our healthcare system is broken—that it’s “neither healthy, caring, nor a system”—ask them to imagine one that’s more accessible, affordable, comprehensive. Ask them to imagine mental health care playing a central role, and doctors and therapists working hand in hand. Ask them if they’re aware of other treatment models, including one that’s hiding in plain sight. And when you tell them about integrated care, don’t forget to add one thing.
This makes sense.
All photos © SAM LEVITAN
Chris Lyford is the Senior Editor at Psychotherapy Networker. Previously, he was Assistant Director and Editor of the The Atlantic Post, where he wrote and edited news pieces on the Middle East and Africa. He also formerly worked at The Washington Post, where he wrote local feature pieces for the Metro, Sports, and Style sections. Contact: firstname.lastname@example.org.