Welcome. We're psychotherapists here, so we're going to actually do the psychotherapeutic thing and start right on time. I'm David Mintz at the Austin Riggs Center. I'm the Director of Psychiatric Education. I'm also the past chair of the Psychotherapy Caucus of the APA. I'm going to start by talking about the inclusion of psychotherapeutic expertise in psychotherapy. Now, I just want to start with this. If you look up, does the arrow show up over there? Can you see that? That's just for me. So, American Psychiatric Association, medical leadership, leadership, right, that's important, for mind, brain, and body. So, I think it's really important for us to think about, well, how does the mind fit into our work as psychiatrists when consulting to integrative care systems? I'm going to start just with this slide about the collaborative care model. This is right from the APA webpage. What it emphasizes is that the members of the care team should all be empowered to work at the top of their licenses. And, you know, what does it mean to work at the top of your license when you're a psychiatrist? I first started hearing this term, working at the top of your license, at the APA, maybe five or six years ago. And when I heard it, it was usually from an early career psychiatrist or a graduating resident who was hoping to do some psychotherapy in their practices. And their employers were saying, you're a psychiatrist. You can prescribe. The social workers and psychologists can't prescribe. So, you should be prescribing because that's the top of your license. I want to raise a question about that because I think very strongly, actually, I feel that is not the top of our license, right, because if you think about our training, we are trained in pharmacotherapy for sure, and that is what differentiates us as psychiatrists from psychologists and social workers. But we also have substantial training in psychotherapy, which is what differentiates us from PAs and NPs. I would argue that prescribing is the top of the PA and NP license. But there's a reason we learn psychotherapy. And I think it is the unique ability to integrate the dual skill sets of pharmacotherapy and psychotherapy that represents the true top of the psychiatric license. This is what allows us, and I want to emphasize, this is not just that we're doing psychotherapy, but we understand the dynamics of people. We understand how to intervene in a way that brings us into an alliance. And so, we have these psychotherapeutic skill sets that we can leverage in our work with the most challenging patients we treat. Our training involves, as I said, extensive exposure to psychotherapy. We did a survey of programs participating in the 2020 Psychotherapy Fair, and we get 175 to 200 hours of just psychotherapy didactics, which does not include psychotherapy case conferences, psychotherapy journal clubs, process groups, or psychotherapy supervision, which way more than doubles that amount. We also have a lot of clinical experience doing psychotherapy. So again, in that program, about, in that survey, it looks like about 625 hours of supervised psychotherapy over the course of training. So that's a lot of psychotherapy training that we get. NP is also, it's within their scope to do psychotherapy, but when you look at the amount of psychotherapy they get, it's a small fraction of what we're getting as psychiatrists. So, as I said, psychotherapy, I think, gives us skills for working with the most complicated patients. And, you know, if we think about who we treat in integrated care, right, first of all, we are treating patients who are at the edges of the evidence base. Most of the patients that we're consulted on, who have five or six diagnoses, personality stuff that's interfering with the ability to use treatment, et cetera, et cetera, have failed multiple trials already. These are patients who've been excluded from most medication trials in which the efficacy of medications are established. So our patients, the patients we see, really the evidence base barely applies to them in a strict sense. Are these patients? Turn up the volume? I can move the mic closer. There. Okay. So we're typically, our patients are complex and comorbid. Only 26% of depressed patients have no comorbid disorder. So single disorders in our populations is very rare and the people that have single disorders, very often they're treated by their primary care doctors without ever seeing a psychiatrist. A third of patients have three or more comorbid disorders and comorbid personality disorders are particularly associated with treatment non-response. So by the time we are consulted, right, most patients would be categorized as treatment resistant. And I'm curious about actually your own sense of this. My sense is that a lot of the time it's not simply the problem of inadequate medications, although there is some of that, but that the patients we're consulted on, I think, often have complicated relationships with medications, with caregivers or treatment, and even complicated relationships with health. And I'm curious, how many of you experience that in your practice? The patients are, so a handful of you, and I suspect a great deal more who didn't raise their hands. And also we're consulted when patients are causing distress in the primary care team, right? So it's not just that their illness or the patient's distress, but ultimately it's often the primary care team's distress that is the focus. So when we think about what do we do when you get treatment resistance, and in this case this is an algorithm for treatment resistant depression. If there is no comorbid personality disorder, no non-compliance, no complicated and confounding factors, you make sure the patient has an adequate trial and an adequate dose for an adequate length of time. If that doesn't, I mean you all recognize this algorithm. If that doesn't work, or there's a partial response, you may try augmenting or combining, maybe go to ECT. If you've gone through several trials with no response, you start to wonder if your diagnosis is maybe incorrect, you go to ECT, etc. But what do the algorithms say to do if there is comorbid personality disorder or non-compliance or complicated and confounding factors? Manage accordingly. So thank you very much for coming to my talk. So I think this box of manage accordingly is where the psychotherapeutic skills of the psychiatrist come in. Now back to what the APA says about the collaborative care model, they also emphasize that the team implements a care plan based on evidence-based practice. Of course we all want to do evidence-based practice. And focuses particular attention on patients not meeting their clinical goals. I think that's a very subtle thing in there, that we're working with the patient to understand their particular goals. Now in terms of, I'm not going to go into this in detail, but just to say, in terms of the evidence base, when we look at placebo research, alliance research, readiness to change research, expectations of treatment research, provider variable research and provider variables, all of those things, when you put those psychosocial factors up against actual medications in placebo-controlled trials, the evidence suggests that the psychosocial aspect of treatment, in terms of its clinical impact, outweighs the effect of our medications, so much so that in a study by Ankerberg and Falkenstrom, they concluded that treatment of depression with antidepressants is primarily a psychological treatment. And so we're working that psychological edge around medications all the time, if we want to be as effective as we can be. And so skilled consultation addresses not only what to prescribe, but also how to prescribe to optimize outcomes. Said in another way, psychotherapy skills in everyday practice, this is the milestones for psychotherapy training, which suggests that we should establish and maintain a therapeutic alliance with patients for psychotherapy, but this is of course true for pharmacotherapy, which gives us skills to help the team form effective alliances with complicated patients. The study also suggests that a competent psychiatrist needs to select appropriate psychotherapeutic modalities based on case formulation, and tailors the therapy to the complex patient. Again, we have skills for understanding why the patient is not responding to treatment as usual, based not just on, you know, are they sleeping, et cetera, et cetera, but also understanding the deeper dynamics. So we've been in a position to say, you know, this young man you're treating with an authoritarian father, you have to give this young man choices. If you don't give him, you know, you don't give him three antidepressant choices, he's not going to end up taking the medications you give him, because he's going to respond to you as his father. So we have those skills. And so that guides our decisions, not just about what to prescribe, but how to prescribe. And the last in the milestones for psychotherapy is identifying and reflecting core feelings, key issues, and what the issues mean to the patient within and across sessions. So as I said, it gives us a way of understanding potential resistances to the healthy use of medications. In terms of psychodynamic contributions to patient-centeredness, right, so if we want to do, we also are experts, I think, potentially in patient-centered care. With illness-centered care, the prime aim is to find a localizable fault, diagnose it as an illness, and then treat it. But Bolland says in addition to trying to discover a localizable illness or illnesses, the doctor also has to examine the whole person in order to form what we call an overall diagnosis. So understanding why, in a broader sense, the patient may not be responding. And this, I think, we're at a choice point in the field, right, because we can be the person who either comes into primary care and says, give that guy lithium, add some Seroquel, you can double the Lexapro, or we can also be the person who comes in and says, as I did, this young man really needs choices because his psychology otherwise will lead him to resist the treatments you have to offer. And hopefully we're doing this because we're hoping to nudge people in the latter direction. How are we with time? Two minutes? Okay, perfect. So I just want to say something about some psychodynamics of treatment resistance, because I tend to think of this as falling into three different buckets. Treatment resistance to medications, treatment resistance from medications, and then our own contribution to treatment resistance. Treatment resistance to medications generally stems from the patient's ambivalence, and patients, as I suggested, can be ambivalent about medications, they can be ambivalent about treaters, they've had a lot of experiences of early adversity which lead them to distrust that caregivers are really there or really intend to help or reliable, or a lot of our patients are ambivalent about, well, actually, let me ask, how many of you have patients that seem to be ambivalent about getting better? Right? Patients, you know, patients, once they get sick, as people do, they figure out how to make some lemonade from those lemons, and then once they've done that, now they're ambivalent about getting better. So this shows up with non-response, non-adherence, side effects that interrupt treatment. In contrast, patients who are treatment resistant from medications, these are patients who don't fight us, at least manifestly, they desire medications, they want medications, they ask for more medications, but something happens in us, I think there's a counter-transference response to these patients, where you don't want to give them medications. Right? Something feels bad, something feels wrong, and that's because these are patients who are, in an unconscious way often, have turned medications to serve some counter-therapeutic end, responsibility, used defensively in some way, as a replacement for their own emotional controls, et cetera, et cetera. Which is, I think, the most underappreciated problem, actually, of psychiatry. And we're in a position to help primary care teams demedicalize some of these more psychosocial issues. And lastly, our treatment approach can also spark treatment resistance, where we're overly biologizing in ways that patients feel dehumanized and they resist us, or we don't pull the pieces together in an integrative way, so we're treating the whole patient, or when we're prescribing because the patient has filled us with hopelessness or helplessness, and so we're actually, the medications are intended to help us as much as the patient, and typically that does not work. Last slide, because I don't have time, and we're ready for our next speaker. I'm Sherry Katz-Bernat. I'm a SEAL psychiatrist at Columbia and I'm in private practice in New York City. How many SEAL psychiatrists are there here? Okay, not so many. So I'm going to be talking to you about something that I do all the time and I'm doing it more now with the primary care teams and not just in the hospital as a consultant but I'm doing it now more with as a part of this new wave of integrative care teams and I'm going to take you back to 1949. Psychodynamic ideas in SEAL psychiatry. In 1949 Michael and Enid Ballant, Hungarian, he was a Hungarian immigrant and his wife was English, organized these Ballant groups through this Tavistock clinic to talk to primary care physicians about their patients and one of the most interesting things that he found was that the doctors' responses to their patients was a key element of whether the patients, the doctors felt the patients did well or they didn't do well and that it was a key part of the interaction and when they formulated their books, which feel very relevant, if you go back and read the case reports they feel like they could be happening today so I recommend them to you. They're the doctor and his patient and there's another one that I have in the references. They had three points. The development of a systematic psychological understanding of the patient is an essential part of the medical care just as important as developing a systematic part of the differential diagnosis or any systematic treatment schedule. The physicians feelings about the patient are significant and valuable and in fact the physician's capacity to have a positive feeling about the interaction was critical to whether the physician felt satisfied with the interaction even if the patient felt they got better or was satisfied. If the doctor didn't feel good about the interaction, was angry or disappointed with the patient, he felt bad about it and it didn't matter whether the patient was satisfied. Okay in 1978 James Groves, how many are familiar with taking care of the hateful patient? Oh not so many. You got to read this paper. It's really, really, really, really important. New England Journal of Medicine, look it up. It's on Google Scholar. It's really, really, really important. He was vilified and almost drummed out of the profession for writing this paper in 1978. He was told that he shouldn't be a physician anymore if he could say taking care of the hateful patient because he admitted that there are hateful patients who induce in us hateful and negative feelings. Okay and now this seems like a commonplace but it was quite something in the day, back in the day. So you got to read this paper. He divided up the patients in a certain way. I'm going to divide the patients up in a different way because I'm going to divide them up in a way where I'm going to because I want to teach skills so that we can take care of these patients. So I'm dividing them up slightly differently so that we can feel better about them instead of just hating them. But you got to read this paper. It's really, really important. It completes your education in a certain way. Okay yeah it's not it's not a long paper but it says a lot. All right so the word countertransference, how many people are familiar with this? Okay so I'm not going to I'm not going to belabor this. It's our reaction to what to what is happening and it's a combination of things we're aware of and things we're not aware of. I use this because it's a kind of a code word and if people feel like it's jargon or gobbledygook I won't use it but I like to teach my teams about this word because it's a code word that quickly allows us to be talking about the same thing right and and I nobody gets offended when I use it. All right who are the difficult patients and why are they difficult? Key concept, a review of the literature in the United States and in the UK because those are I really can only read the literature in English I'm sorry if I could read other languages effectively I would but I don't so it says between 15 and 25 percent of patients are labeled as difficult usually these patients are character disordered have a low functional status and frequently present with medically unexplained symptoms. Who's surprised? Nobody's surprised right but let's turn this on its head and say who are the doctors who report the higher than usual number of patients with higher percentages of patients who are difficult? Aha these clinicians are less experienced describe themselves as having less training in communications of course who gets communications trainings now anyway but feel they have a greater workload feel more oppressed and feel they have less time for patients okay what an opportunity what an opportunity for us because what are we experts in communication training we can do nothing about time but we can do a lot because we don't have one of those Hermione things you know that we can give them extra time but we can teach people about how to communicate better right so this is our in this is our place where we can intervene we can identify the the feelings that make it difficult for the clinicians to provide clinical care and then we can direct that ah this is my pitch to you suggest or provide clinical skills training to cope with the clinical problems for the individual clinician and the team so here we go this is my pitch I'm going to give you four examples these are the way I've divided up the patients because this is these the four areas that I've identified where I can give you concrete things that you can teach your teams talk to your teams about give them concrete things that they can do concrete things that they can say concrete things that they can organize to do better with their most difficult patients okay first the clinging hypochondriacal patient okay first of all the clingy hypochondriacal patient common clinical problems say that four times fast first of all recognizing and coping with anxiety and anxiety contagion the hypochondriacal patient experiences a change in their body and is frightened by that frightened that it signifies an illness of some kind the physician via several possible mechanism gets catches the anxiety and is induced to order a myriad of tests some of which have clinical significant morbidity okay that the patient then sends tomes through the portal which makes the doctor crazy failure and then fails to be reassured and leaves dissatisfied and the clinician feels untrusted and frustrated the patient may be told implicitly or explicitly it's all in your head or the test may reveal a problem which sets off a secondary barrage of catastrophizing contact contacts leaving the clinician and the team exhausted and then the patient we say go away I'm referring you to somebody else right okay all right so here are the solutions I help the clinicians develop a recognition of and a resistance to anxiety contagion I help them learn to contain the anxiety so we talk about containing the anxiety through mentalization through relaxation through breathing all right we also discuss the contribution of this patient is making you anxious because their anxiety makes you think that you might be missing something right so if you think you're being a bad doctor and you might miss something and then you're going to get sued you're going to order a million tests so let's develop a rational way of testing this patient that begins with high yield low morbidity testing right and then go on from there right so we talk about the psychological not just mentalization and breathing and you know and that sort of thing but we go into what are the kinds of ways that you can deal with this anxiety with algorithms and clinical strategies okay understanding with these patients apropos whoops apropos of what David said that as frightened as patients are that you will uncover an illness they're also disappointed that you do not okay and that certain patients are actually going to be happy that you find something develop a rational and formal plan reviewed with staff to limit the frequency and length of document review as well as an active plan of how you go over test results okay this is very important how many days it's going to be who's going to be the designated point person so that you have a plan and everybody knows what the plan is it's documented in the chart this helps okay labeling as a strength you notice things before other people that's why it's very unlikely that you are going to meet we are going to miss something but remember our machinery is more limited than your sense that there's something wrong so we are going to keep testing but we have to do it at intervals we can't do it every day it doesn't mean there's nothing wrong it just means you have to give our machines a chance to catch up okay utilize rehabilitation services you have no idea how important it is for these patients they are so sensitive to being told that it's all in their head it's not in their head it's in their body use utilize rehab rehab gives patients markers right and in fact if they're not getting better despite utilizing rehab religiously clinicians will watch that and actually will pay attention I helped a patient get diagnosed for the MS that she actually had because she was a dedicated patient in rehab and she was not getting any better and they were not going to give this obese woman obese african-american woman an MRI because of the cost until she went religiously to rehab and she was not getting any better okay so lesson learned when suggesting mentalization or relaxation is particularly useful to reframe them as rehab again patients are very sensitive to being told it is in their head okay next the entitled demanding angry patient come common clinical problems how many people know what I'm talking about here please okay all right as long as we're on the same page please don't be shy because if I if you don't know who I'm talking about I got to know because I got to spend more time talking to you about these patients but if we all know who we're talking about we're good okay team members respond with heart sink when these patients name appear we know who we're talking about we know who we're talking about okay the patients or their proxy approach staff to make requests which may or may not be reasonable in a tone that is counterproductive hmm right they are not nice they treat everybody like the hired help the patient or proxy will complain if they are not treated with special deference all team members must understand that the difficulty for these patients lies in the realm of their self-esteem regulation these patients lack a capacity for the sturdy establishment and modulation of self worth and therefore regard every interaction as a measure of their worth this needs to be discussed with the staff in advance of their visit as it is necessary to deal with the patient's entitlement without confronting the defense as the patient needs the defense to negotiate the experience okay everybody is entitled to be treated respectfully but this is not the patient who will get who will have good manners much less gratitude professionalism is a key here and you've got to get your team on board a safe harbor statement is a really good idea all right you are entitled to the best of care which we always try to provide we are sorry if we fall short but it is not because we do not care we will always try to do our best for you as we do for all of our patients repeat early and often okay in as calm a tone of voice as possible all right these pay now we're on to the non-adherent patient with chronicle chronic medical illness these are the chronic these are the common clinical problems so I'm talking about obesity hypertension even patients who drew you know who have problems with alcohol who show up who don't show up for their regular appointments but they show up needing urgent care for serious complications of their illnesses so we're talking about the diabetic who doesn't show up for their regular appointment but they show up in DKA or with a bad infection in the foot or you know they show up in hypertensive crisis a show of hands who's got who knows these patients okay this is a real problem they don't show up for their regular appointments partially because they know that they're going to be hectored about their underlying patient problem you need to lose weight you need to stop eating salt you need to and they do not want they do not want to be talked to about these underlying problems but when they're really sick they have pneumonia they got an infection or something they show up and then they need to be seen okay both because the appointment is squeezed in and because of the urgent nature of the presenting problem the clinician doesn't have the time or the bandwidth to address the underlying problem as it impacts the acute problem the clinician is frustrated and ultimately is apathetic about addressing the issue and just essentially gives up becomes nihilistic about it all right using the lens of attachment theory I try to explain that these are the patients who most clearly demonstrate the principle of ambivalent or dismissive attachment style who's who here understands has that lens not so many okay so what you've got is people who have a solid attachment style the best you're going to get in terms of adherence to taking medication somebody who has a solid attachment who's had good parenting and good attachment to their primary caregiver the most you're going to get actually is 75 they're going to take their medication 75% of the time hate to break it to clinicians patients don't take their medicine 100% of the time nobody takes their medicine 100% of the time but the best you're going to get is maybe 75 80% of the time but with patients like this they mostly have trauma in their history in one way or another you're going to get between 15 and 20% of the time they're going to take their medicine so you have to understand that by working with them on becoming attached to you you're going to get better compliance with your medication so that just by working on connecting with these patients you're going to get better results what's the key here the communication style the communication style is motivational interviewing I can't say this strongly enough motivational interviewing is the way to go with these patients it's a form of communication that is not hectoring just the way David Mintz said if you have a patient who's had an authoritarian father you give choices because if you say to that patient this is what you're going to have to take you lose that patient that's the way to go with these patients is motivational interviewing you teach it you give courses you'd give whatever you can the last patient I'm going to talk about is the help rejecting complainer these are my our most difficult patients and you know they want everything and then they tie your hands the thing I'm going to say is it's projective identification I don't have time to go into it today because I'm at a time but I'm going to say these are the most difficult patients we have self-compassion is a very important part of and group compassion is a very important part of taking care of these patients strong teams are the way to to deal with these being able to set the hot potato aside and give it to some other team member is very important and to limit your exposure when you can so I thank you very much this is my reading list if you want to take a picture of that one that's great and if you want to take a picture of the second page it contains David's book and I thank you very much Hi, everybody. Who else was a camp counselor? Who else is a child psychiatrist? Who else believes there's no adults, it's just like kids in grown-up suits? Okay. So my name is Madeline Lansky, I'm a child adolescent and adult psychiatrist and freshly minted psychoanalyst, and I'm hoping to kind of pitch it that you can do community mental health work and have psychoanalytic training. And I was lucky to do so a couple years ago. I have a private practice in the San Francisco area, and Alameda County, which is where Oakland and Berkeley are and Hayward and Fremont and Union City, developed this innovative program for primary care to get embedded psychiatrists in these clinics to help them do psychiatry because the system is so overloaded with patients that we had to offset the pressure on what we call specially mental health for severely mentally ill people, and mild to moderate is now put in the primary care setting. So it's kind of like, I like to call it outpatient CL, but the CL people are like, put your hand down. So that's what I tell my dogs, is I do CL. So I do, not CL, I do primary care psychiatry consultation or integrated behavioral care, also called collaborative care, and the AIMS Center in Washington has done a lot around this. I originally applied for this job to do the adult piece. For those of us who do child, it can be incredibly exhausting to work in a system that ritually underserves kids and families, and very overwhelming to be asked to medicate children as the only option. I have found personally great relief in having a private practice in a very well-resourced area where I had the amazing opportunity to have these families basically give me free reign to just get their kids better. And so I actually feel like I really know how to get people better if I have unlimited resources. So my intention and aim with this job on the PCPCP team has been to try to bring that expertise into marginalized safety net populations that will never have access to a psychoanalytically trained UCSF psychiatrist, to maybe give them the same opportunity to have just maybe a more holistic or whole person care. What's amazing, and I want to kind of put this out there, was when I was interviewing for this job and I asked to do adult, they said, no, you speak Spanish, you do child, you're doing child. And I said, well, then I'm going to do it how I do it. And they were like, OK. So what they didn't know they were getting was a psychoanalytic approach in inner city primary care settings, but that's what's happened. And I share that with you to maybe inspire you to kind of push when you're at the negotiating table because there's so few of us and the need is so immense that I don't know that it's going to be the case that we're going to, I mean, maybe, but it seems like at least in this part of the world, there's a real interest in psychotherapy. And I think the more we talk about social justice and anti-racism work, just doing good evaluations and good treatments, believe it or not, I mean, like it's pretty simple that that's pretty anti-racist to just give people good care and not have tertiary or, you know, more medical systems. So if you've studied any psychoanalysis at all, you've heard of Wilfred Bion, you've heard of Donald Winnicott. Have you heard of these mid, middle school British psychoanalysts? So I'm not so tech, OK, I don't, OK. So in pediatrics, we talk about how integrative behavioral health care is making a medical home. And I love this model because it really emphasizes, I think, this very psychoanalytic idea that the clinic holds a family that holds a child. And I try to do my child work from actually a family perspective, which is to understand that multiple family members, probably with multiple psychiatric disorders and trauma, are impacting a child's mental health and to some degree, disimpacting the adult suffering can often relieve significantly the child psychiatric presentation. Also, just having a good relationship with pediatric staff in the literature can really decrease suicidality, depression significantly. So just because a kid looks outrageous doesn't mean you have to, like, hop to the antipsychotics. It's often a system that's kind of vibrating with a lot of unaddressed chaos. And if the, if you can kind of support the primary care clinics in seeing themselves as a container that's going to hold and digest chaos. So I give a whole teaching on Beyond's ideas about beta elements. It's actually called the Kitty Bunny Talk. I have a website, kittybunnytalk.com, to talk about how the staff has this opportunity to digest the crap that is swirling everywhere that comes from being traumatized, comes from being in systems of oppression, all of it comes from being human. And in this way, the staff gets to learn that just by being there, even if you're not necessarily doing anything, that has a healing impact and to even slow the staff down and to let go of equating beginning medications with delivering care. So it's creating a holding space. It's also my modeling for the staff, this kind of slower way of kind of slowing the role on everything and then assessing. I really love that story about the woman with undiagnosed MS, and I'm so sorry she had to do all that rehab. But just of slowing everybody down to get things in focus. And speaking to the suffering of the staff, as you so well said, I really like allowing the staff to vent countertransference. I also consult in schools and letting teachers vent too. I know it's a time where we're trying to be very inclusive and intersectional, so that's a little bit of a hard path to walk. But people need to... This is really hard to get on the front line every day for all of us. And I think it needs to feel safe in the back room to just talk about how much you feel like quitting every day. And I actually feel like that... I'm always trying to keep people on the front line. So it's kind of counterintuitive to say that complaining more will keep them, but I find that it does. And also making it safe enough to really talk about how people feel so that trust can develop. So it's really slowing things down enough so you can speed them up. Really trying to get the real story on the case and making the consultation a safe space to think. Oh, I'm so sorry. So what I try to do in this is I actually am trying to get the staff to get to three top differential diagnoses that I can then teach them on, because they probably had three or four weeks of mental health training in their whole careers. It's a lot of early career nurse practitioners, family care doctors, some pediatricians, a lot of medical assistants, nursing staff, just whoever staffs a clinic. A lot of times it's even teaching the primary care staff to listen to the support staff because they actually talk to the patients in the waiting room and really know the families and really know which families are suffering in which ways. Once you winnow down the top three diagnoses, then you can go into a more formal DSM-5 presentation model. But I try to actually personally position myself to say that once you can get into a differential diagnosis area, it's going to be pretty smooth sailing and it's not that hard to treat. It's actually smoothing and soothing all that chaos to get there. That's the real challenge. So I'm going to give a couple clinical examples. This is... How much time do I have? Oh, okay. So I love this case that happened. This was at one of our clinics in the East Bay. Right by Fruitvale Station, La Clinica de la Raza. And this was a six-year-old Mexican-American boy who was kind of in early diagnosis of hearing impairment. Big guy. And the pediatrician kept asking me, do you know what antipsychotic I should start for this six-year-old? And I was like, zero. And I think that was kind of irritating her. And so I spoke with her and she told me, no, this is a really scary kid. And which I was like, oh, great. You know, this racist doctor. I was kind of turned off. But she was like, you have to help me. And I said, fine. I want to meet... Why don't we all have a meeting? Mom, if you can get the teacher. You, what a therapist. You know, the hearing impairment specialist who comes from the special school. And she actually set it up. Everybody was in this room with this six-year-old who then blew me away because he was a really scary kid. He was like a really scary kid. I don't know if you've met six-year-olds who are really scary, but they exist. And he was like kind of mad-dogging everybody. And I have to actually apologize to the pediatrician and say, God, you're a pretty scary kid. But I know enough about child psychiatry, and I think this is something maybe people without child training don't always appreciate, is if people have learning disabilities, hearing impairments, visual impairments, or speech impairments where it's hard to process their environment, they can get very angry and aggressive because it's very humiliating and shaming to be in that position. So that was actually the interpretation I had of the boy. And he was doing terrifying things. He was like finding these hoses and spraying the kids down and hitting them with metal buckets in school. He was a very scary guy. But I actually started in TUNIV, which is a long-acting guanfacine. I don't like clonidine because it kind of flattens the kids, but I thought it would take his hyperactive edge off. And I actually spaced it out four times a day at a really micro homeopathic dose because I just could tell that everybody wanted him to be on a lot of meds. And it seemed like if we just did a little bit of in TUNIV all day long, it might help because the mom was exhausted. She'd had a partner who was abusing her, and the kid was copying her partner who she'd been able to get away from, but it was like pretty traumatizing for her. So we started the in TUNIV, and actually he got better. He just stopped assaulting people and being scary. It was sort of miraculous. And the pediatrician called me back and said that he would say to his mom, which meant can I have my medicine, which I thought was so moving because it showed a capacity to see his impact on other people, a desire to be a good guy, which I think is true in a lot of people, even if they're acting out or being scary. And then the big issue with monitoring him over time was just helping him maintain his school placement for hearing impaired kids, and also not running out the in TUNIV because he was still a little guy and he could only max at seven milligrams a day. But what I kept telling the pediatrician was if you have to increase the meds, go up to five times a day. Try to use the placebo of over, because once he gets into other areas where people haven't done this amount of work, they might start him on a Risperdal, and then he's going to get big. And what we want him to do is actually learn how to handle himself in these settings, not how to be chemically restrained. So this is really teaching about how the system holds the child, supporting the child and feeling proud of their personal kind of psychotherapeutic growth, and that also that the person who takes the pill is carrying the pressure of the system, and the psychopathology of the group can be concentrated into one individual. In this case, it was all this intimate partner violence had been concentrated into a six-year-old boy. And you can't substitute medication for ego development. How much time do I have? Three miraculous minutes. What? I have seven miraculous minutes. How y'all doing? Thumbs up? Middle? Sound? I just want to be a little more active. Okay. Okay. So this is a second case that with the pediatricians and pediatric nurse practitioners, I kind of try to name the patients these names that are just sort of neutral but fun so that we don't ruin their confidentiality. We call this kid Pinky because she wore like a full pink sweatsuit, which was so cute because the call I got on her was that she was also terrifying and assaultative and screaming and violent. Every child case, it's like kicking, biting, I want to kill myself, I want to kill you. Have I lost any of them? I hear voices. And I'm going to get kicked out of school, right? So it's like, welcome to the diagnostic. It's also, I think what I've had to explain to my colleagues is, because I'm the only child psychiatrist on my team, like have fun finding that diagnosis. So I actually find settling down the family system is very helpful in terms of trying to figure out, because also in pediatrics, a lot of the DSM only really acknowledges disorders after the age of 18. So it's a lot of prodromes and brewing things you're trying to head off at the pass. And I'm actually just trying to do a lot of like substance abuse consultation and teach the kids and families, you are not a candidate for cannabis. You are not a candidate for meth. You know, try to keep, try to preserve the neuroplasticity you have. So Pinky was doing this. The nurse practitioner was very scared. I was interviewing her on the phone, getting ready to go in to do like an elbow-to-elbow consultation where I see the patient with them. I never treat the patients. I just help them. I do indirect consultation. And I was trying to get the story on why this 14-year-old was so upset, but there was no story. And I said, well, how's the mom? She must be awful. And she's like, no, she's really nice and really appropriate. And I was like, there's no story. And I came into the room to interview the kid. She didn't have like, she wasn't even organized enough to swear at me. She just, you know, turned in and in her pink outfit. And so I actually was like, I think this kid's sick. I think this kid's sick. And it turned out she had Graves' disease. She had a TSH of zero. And it was just such a great example of organic illness. And such a wonderful teaching moment that just because someone's acting scary, it doesn't mean they have a psychiatric disorder. In fact, if it's a precipitous drop, if the basic milieu seemed pretty appropriate, the kid was like kind of an okay kid, and suddenly they look awful, it's much more of an emergency situation than it is, you know, time to start psych meds. It was time to start endocrine meds. And what I like to say to my consultees is if we can't find a formulation, right, a story, a medical story, a safety story, a family story, a school story, an environmental story, a self story about why they feel so bad, it's time to do a pretty aggressive medical workup. I feel like I have to do that as a psychoanalyst or else I'm going to be one of those people who told someone with MS they had depression, and then you're just kind of a, yeah. Okay. Number three. Okay. This is, we're talking about container-contained, and I keep trying to weigh, like, when I did my medical training, everybody just told every clinical story in all its full frightening detail, and now I've kind of learned as I have moved along the conveyor belt of time that that can be pretty triggering or pretty traumatizing. So how full board do you want this story about what happened to an eight-year-old? Okay. Well, I don't know about you guys, you're not saying anything. Okay. Okay. So this is the, hopefully, a version that, one, there's a couple of pediatricians who are just so into this now that they've devoted their lives to ACEs, which is adverse childhood events and screening, advocating for child safety in the home, and advocating for early intervention with trauma. I really try to teach that probably most of the kids we work with are, the first diagnosis is trauma, and it's exacerbating whatever diagnosis, so that's what we need to treat. So this is one of my PCPs who, a couple of us now meet, actually, in, like, a psychoanalysis and pediatrics consultation teams and are working on bringing ballot groups, actually, into Oakland for staff, so it's really exciting how excited they are. So this was a pediatrician who's used to working in this way, but unfortunately, her eight-year-old patient had been the victim of a sexual crime, and in this, I have set it up so I have hour-long meetings once a month with PCPs so they can just kind of do what we do in psychiatry training, just kind of let it all hang out with you and complain and track the cases and get it all out. So what she wanted to do in this meeting was basically go through the chart in very, very intense detail about how this eight-year-old was from another country, Latin America, happy kid, happy family, fought with dad, went to walk the dog, was abducted, pulled into a vehicle and dosed and then assaulted, came to, and then, weirdly, was helping the guy with the van navigate where to drive because I guess he wasn't very high-functioning, but actually got out of the van, got herself to safety, got to an ER, and in more detail than I'm saying, the pediatrician went step by step of seeing what had happened to this kid and then was asking me, what do I say to this family? Because all she saw in the chart was the kids want to go back to their country of origin and hate it here now. So we basically, believe it or not, what we talked through was what it's like to grow up with a female body, female presenting body, what it's like to get attention you're not ready for when you're really young and you feel like a little kid but people think you're sexual, how girls are taught or not taught how to refuse attention, how horrible it feels to lose innocence just when somebody was walking or how bad it feels to just be fighting with your dad and suddenly have a whole series of terrible events happen. This is what we talked about over the course of the hour and then the official recommendation I gave was try not to hound them too much, give them some breathing room, maybe leave a voicemail that says, I want to let you know I've read the chart and I know what happened, you tell me what's next, then step back and create a holding space, be receptive and ready, that's actually the action, which she did and which has been remarkable and then actually it's kind of amazing, some of the adult psychiatrists on my team, unfortunately this happens pretty routinely to kids that they get attacked out of nowhere, of learning how to hold the staff and managing just the terrible feelings of being exposed to that amount of trauma. So you're hearing me formulate treatment, I did all my slides, yay, this is me, a couple stories of me quickly formulating cases that maybe would have ended up getting really different treatments that probably wouldn't have been what they needed. I'm really hoping for the eight-year-old that this is what she needed and that she's, as I was saying to the pediatrician, seeing how she got free, seeing how she survived, got herself to safety and I'd love to interact with anybody about this. I have a website, MadelineLanskyMD.com and you can see a short documentary we did about our PCPCP team in Oakland and also have been making this talk on beta elements for primary care staff using kitties and bunnies to talk about power disparities in primary care clinics and how to navigate that and thank you for your kind attention. So, good morning. I'm Dr. Elizabeth Green. I'm an assistant professor of psychiatry at the Uniformed Services University of the Health Sciences, which if you don't know, that's the military's medical school out in Bethesda, Maryland. And like my colleagues, I want to talk about using psychotherapy within primary care consultation, and specifically about teaching primary care providers to use basic psychotherapy interventions themselves. Before I really get started, I have to tell you that I don't have any relevant financial relationships to disclose to you. I'm also required to tell you that the opinions and assertions in my talk belong to me. They're not the official policy or position of the Uniformed Services University of the Health Sciences or the Department of Defense. I have a couple different objectives for us today. I want to talk about some of the why, so the possibilities, the limitations, the why of psychotherapy interventions provided by primary care physicians. I want to identify that teaching brief psychotherapy interventions to primary care clinicians is a key part of our primary care consultation skill set. I'd like to use my own experiences just to illustrate a couple examples of teaching brief psychotherapy interventions, and then I'm actually going to ask you guys to wake up a little bit and role play. I know it's early in the morning, but experience is often the best teacher, so I'm going to ask you guys to play with this a little bit. Starting with why, this is a little bit older data from 2010, but this was data that suggests that at that point in time, 20% overall of primary care visits had some mental health component, a diagnosis, a medication, a referral. There was some mental health touch point within that primary care visit. 20% is a lot. That's one in five. This is newer data, which really ends up communicating very similar things. The 2021 reference is a study that looked at national data and suggested that primary care providers are actually providing the majority of care for people with anxiety, depression, or what they categorized as any mental illness, and one-third of the care for people with serious mental illness. The headline I grabbed from the article from Rotenstein and colleagues basically was a study that said from 2006-2008, primary care visits, about 10.5% of them were mental health related, and that's accelerated. In 2016-2018, when they pulled the data again, it was about 16%. This is not only something that our primary care colleagues are doing a lot. It's something that is increasing over time, and I'm guessing that's probably not going to surprise anybody because of this next slide. We've all been talking about there's not enough of us. There's a mental health shortage. I don't know how you could not have heard that information at this point in time, but here's just a couple graphical representations of it. The graph is from an article in 2018, which shows that there will be a nadir of psychiatrists coming up still in 2025, so we have not hit the bottom point yet, I'm really sorry to say. It should, in theory, start getting better then, so by the time it's 2050, which I don't know, I may be retired by then, y'all may be too, but things should be better in 27 years, so good luck. The more recent data in 2023, this is from the Health Resources and Service Administration, and this is a different way of looking at the data, but it suggests that 160 million Americans, that's a really big number, live in a mental health, health care provider shortage area, so people are having trouble getting access, so that's my second why. We need help. We need our primary care colleagues to be helping us with mental health care, because there are absolutely not enough mental health care providers of any kind, and then my third reason for suggesting that we should be teaching our primary care colleagues to do psychotherapy interventions is because a lot of them are doing these interventions already, so bathe is actually a primary care psychotherapy technique that's part of family medicine education. Family medicine stands for asking the patient about the background, hey, what's going on in your life? Asking the patient how they're feeling, so the A is for affect, but how are you feeling about that? Asking them what's troubling you about that? And then how are you handling that? And then concluding with an expression of empathy, wow, that is really tough, right? That's a hard thing to go through. So that's a very basic family medicine psychotherapy supportive intervention that is pretty routinely taught, but a lot of primary care providers say, yeah, I know it, I've heard it, I don't have the expertise or the confidence I'd like to have to really use it. There's other literature supports for primary care psychotherapy, so supportive psychotherapy is an intervention that is easily applied in a primary care setting, and supportive therapy could focus on helping patients express their emotions. It could focus on helping them develop a more sort of realistic and helpful narrative about their illness. It could focus on developing their coping skills, or it could help focus on sort of recruiting their support system. And then finally, motivational interviewing, which my colleague mentioned earlier, and then frames and five A's are kind of three techniques that really focus on health behavior change. So how do you work with people in a therapeutic way to encourage them to decide what changes they want to make? So our primary care colleagues are already doing a lot of these, and you might notice all of these have certain characteristics. So for psychotherapy to really work in a primary care setting, it needs to have a couple things. First of all, it has to be something you can do quickly. So my primary care colleagues at my institution have 20 minute visits. That's actually a huge luxury, right? They are blessed to have 20 minutes, and they are pretty aware of it. And a lot of other places, like where I go for my care, it seems to be more like 10 minutes. You also want interventions that are effective quickly, right? So this isn't something where you want to spend 8, 9, 10 sessions. You want something that can help somebody ideally within one session. So those are the kinds of interventions that my colleagues are looking for. So my experience with this really started in a teaching consultation clinic. So the hospital I work in has a family medicine residency, and they do a behavioral health rotation. And part of their behavioral health rotation is what we call pop-up clinic, because it pops up out of nowhere, at least our felt experience of the clinic. But in this clinic, we have a team approach where there are two family medicine residents and then a teaching consultant. And I'm one of the teaching consultants. And we work together to see referrals that were sent in by primary care providers. And usually these referrals are, can you please help me develop a treatment plan because I cannot get my patient into mental health care because they can't get access to services, right? That's pretty much the experience we're all having these days. So we're taking these referrals as one-time consultations, and we really have two goals. The first is that care of the patient. Let's develop something that the primary care physician can do because they're going to have to be taking care of this patient. They're going to hold on to responsibility for this patient. And then our second goal is teaching. How can I teach psychotherapy skills? How can I teach psychopharmacology skills? How can I teach patient interaction skills to the family medicine residents on their behavioral health rotation that they can then continue to carry forward into their practice? And I will tell you, this clinic, honestly, it's just a lot of fun, right? This is one of my like, yay, I get to do this today things. And the residents really enjoy it too. And they will actually come to the clinic with questions. So we have a pre-brief before we start seeing patients, and we'll talk about who we're going to see and what the questions are and what we might want to get done. And a lot of times they'll say, hey, Dr. Green, can you teach me something? I'm like, well, yes, that's why I'm here, right? That's the point. What do you want to know? How do I talk to somebody about sleep hygiene and improving their sleep without medication? Okay, cool. We can do that. How do I teach somebody how to calm themselves down if they're feeling really, really anxious? All right. We can talk about that. Hey, Dr. Green, what's CBT and can I do it? Okay. Let's talk about that, right? So they want to know. There's a hunger there for them. So I'm going to talk about kind of three interventions that I've used in this setting that I've actually taught to the family medicine residents. The first one is our opportunity for role play. All right. So grounding is actually one of the really common interventions that's requested by my colleagues. How do I help this person gain skills to calm themselves down? And most recently this happened. I was working with two residents and we knew that the patient that we were going to see was having a lot of anxiety, but we also knew that this patient had had some not so great experiences with medications and was not particularly enthusiastic about another trial of medications. And so the resident said, hey, are there things that we can teach the patient, right, that will help this patient? And I said, yes, absolutely. Let's talk about how to do this. So let's talk about how to do this. When I teach grounding and mindfulness or really almost anything, I talk to the patient about why does this work? And especially with something like, hey, I'm going to teach you paced breathing or I'm going to teach you five senses, sensory grounding. A lot of times those don't feel like real interventions to patients, right? It feels like we're not taking them seriously. It feels like, oh, go away, just breathe, right? That doesn't feel very good. So when I start with these interventions and I start with why, why is this going to work? Why do I think this is a specific real intervention that will help you? And I found that patients are very interested in this kind of teaching. If I start talking to them about this is your nervous system and let's draw a quick picture. And this is the part of your nervous system that controls your reaction to danger. And we call it the sympathetic nervous system. And this is the part of your nervous system that helps you calm down and rest and rebuild your tissues. And we call that the parasympathetic system. And when you're having a lot of anxiety, a lot of times your balance is shifted towards that alarm system. We're going to teach you ways to bring it back into the rest system. When you give people that explanation, they're like, oh, now this kind of makes sense, right? This isn't just my physician trying to make me go away. This is my physician trying to teach me something they really think will help me. We also emphasize practice, right? So the analogy I use with patients is learning a musical instrument. You would not expect to take one piano lesson and then sit down and play a beautiful sonata. That is not the typical experience for most people. You would expect to have to continue to practice, to practice regularly, and then eventually you would get to the place that you could play beautifully. And the same thing with grounding skills or mindfulness skills or relaxation skills. These are skills. Skills require practice, right? You can't expect to take one lesson with me or with your primary care doctor and then when you're in the midst of an acute anxiety episode to have these skills work beautifully. You need to practice them regularly so they become part of your repertoire. So that's kind of the introduction to the skills. And then I teach the skills themselves. And when I'm teaching this with primary care, what I typically do is I teach them the introduction and then I teach them the skill. And so a very simple skill is sensory grounding. And I say, okay, let's talk about sensory grounding. This is a great skill when somebody is preoccupied with worries about the future or when somebody is sort of caught up in ruminations and distress about the past. This is a skill to come back right now into the moment. And I teach four senses grounding because sometimes a sense of taste is hard to get, especially in the past few years where we're wearing masks a lot. So I say, tell your patient to look at four things they can see and name them out loud. And then three things they can hear and name those out loud. Two things they can touch or sense, name those out loud. And one thing they can smell or taste and name it out loud. So four, three, two, one, sensory grounding. I also teach paced breathing. And there's a lot of different ways to do paced breathing. A really simple one that a lot of people have heard of and appreciate is box breathing. Box breathing is very simple. You inhale for a count of four, you hold for a count of four, you exhale for a count of four, you hold for a count of four. So if you can kind of imagine your breath and your holds are creating a box. So I'll teach the residents that intervention. And then I do a teach back with them. I say, okay, I taught it to you. Now I want you to practice by teaching it back to me. And so they'll do that. The most recent time, I actually was perfect because I had two residents. So I taught it to them. Then they each taught it back to me, right, and their colleague. So by the time we were done, and it didn't take very long, maybe 10 or 15 minutes total for everybody to go through, you know, their teach back, they had gotten the intervention essentially three times, right? And so then we went into the consultation and they were able to do a beautiful job connecting with the patient, explaining the intervention and teaching it to the patient who was able to say, yes, I like this. And yes, I will practice this. I don't have follow up on that particular case to know if they actually did. It's always a question, but the residents did a great job. So I actually want you guys now to practice doing the same thing. So this is the role play part. Okay. I want you guys to pair up. This will work better in pairs. If there's odd numbers and somebody needs to be in a group of three, it's just going to take you a little longer, but go ahead and pair up. Don't be too shy. Come on. All right. So as people are moving around and getting paired up, I'm going to give you guys the instructions for what you're going to do. One person in the pair is going to be the psychiatrist, the consulting psychiatrist. So consulting psychiatrist, your job is to pick one intervention. It can be four senses, sensory grounding. It can be box breathing. If you have a quick grounding or relax exercise that you love, feel free to use that. But I want you to teach it to your partner. Your partner is going to role play a primary care physician. So you're going to teach it to your partner. You're going to tell them why it works. You're going to tell them that they need to practice it and kind of expand on that so they understand why to practice. And then you're going to teach them the skill. And then when you've done that, you're going to switch. And the person who is role playing the primary care provider is going to do the teach back. So you're going to do the same thing. Why does it work, the importance of practice, and teach the intervention. I'm going to give you guys just a few minutes to do this. It will actually not take very long. You'll be surprised at how quick this goes. So go ahead and start. I'll let you know in a couple minutes to switch if you haven't. All right. I'm going to call everybody back together. I'd like to know how many people were able to get through both parts of the intervention, the teach and the teach back. See a couple hands. How many people were able to get through at least the teaching part? So most of the hands. So I gave you guys 3 and 1 half minutes because we only have just so much time in our session. So I can't give you all too long to do this. But what I want you to see is that this doesn't take a long time. It's not something where you're like, oh, I don't have time to teach these skills, and my colleague doesn't have time to learn them. There's time, right? 3 and 1 half minutes feels like a really long time when you're standing up here waiting for everybody, but it's not actually a really long time. A couple other just interventions that I've taught. One is cognitive reframing of panic. So a lot of times, my colleagues don't have time. Even if I teach them what CBT is, they don't have the time or bandwidth to do full CBT sessions. But they can absolutely learn some basic cognitive reframing, and this is one that comes up a lot. We see a lot of patients who have panic disorder, and sometimes they are very engaged with emergency medical services, which is not what we would like. So this is an intervention I use, kind of first just asking the patient, like, what are your thoughts about panic? What's coming up for you? What are you afraid of? Is it okay if I teach you a couple things about panic? And it's interesting when you ask people, like, may I teach you some things? People always say yes. I've never yet, I mean, I suppose it could happen, but I've never yet had anybody say, no, no, I don't want you to teach me anything. But it's a great way to get some buy-in, right? May I teach you something? And I give a pretty detailed medical explanation of panic. What's going on? Why is your heart rate sped up? Why is your breathing sped up? Why do you have those funny tingles in your hands, in your feet, and around your mouth? What's happening, right? And I'm trying to frame it as this is uncomfortable, but it's not dangerous. This is something your body is doing. Your body's perfectly capable of doing this. This is not something that's gonna hurt you, right? And then I write it down. And I say, here, just like with mindfulness skills and relaxation skills and grounding skills, cognitive reframing requires practice. I want you to take this home and I want you to read it to yourself. And I want you to rehearse this new information so that when you're having panic, this information is more accessible to you, right? And you can remind yourself that even though this is very uncomfortable, it's not dangerous, right? You don't need to call 911. Just wait it out, right? So that's a quick intervention, again, that primary care physicians can do. And I've seen that be helpful to patients. Again, obviously getting the patient's buy-in first. And then the last intervention that I wanna talk to you guys about is actually a little bit more psychodynamic. It's a process intervention. And it's a really basic learning to check and ask for patient feedback, which is not comfortable, right? But learning to say to a patient, like, is this okay? Or what concerns do you have about this plan? Or how do you think this might not work? Or even sometimes in a blunt way, are you agreeing with me just to agree or because you actually want to do this? Which I found actually usually elicits both a laugh and some honest responses. And what I'm trying to teach my colleagues is that some patients will defer outwardly to authority, right, they're not going to argue with you, but they're also not gonna do what you say, right? So they won't argue, they won't act, right? And so kind of recognizing that that's a very real thing and that you want to elicit that from the patient before they walk out of the room. And it's uncomfortable. So part of what I'm teaching is the skill of being comfortable with discomfort and saying it's much better to be uncomfortable for a minute or two right now, letting the patient disagree with you than to be really, really uncomfortable at the next visit when they've done absolutely nothing that you suggested and you're super frustrated and they're also annoyed at you, by the way, they're just not telling you so. So to kind of sum it up, psychiatrists can, and I would even maybe offer should, I don't really like the word should, but I'm gonna use it, teach psychotherapy skills to primary care providers as part of primary care consultation. Primary care providers are very open to learning these interventions, they use them, they tell me later when I see them that they use them, they're very pleased with their skills. And there are a lot of specific skills, but the ones that I talked about were cognitive reframing, mindfulness, and even some very brief process interventions. So with that, this is our time for questions for anybody on our panel of speakers. Thanks. Oh, yes, I was just reminded, if you have questions, because the session's being recorded, if you could please come up to the mic, that way that your question can be heard by the people who are listening to the recording later, and then we'll speak into the mics too so our answers are heard. And hopefully it all works. Yay, technology. Thank you. I guess I'll go to the front of the line if I have to beat a lot of people here. My name is Arthur, I'm one of the fourth year residents at University of Louisville in Kentucky. So I will say collaborative care is something that is very interesting to me in general and something that I really want to learn more about. The problem is our university and actually really most of Kentucky doesn't have much of a collaborative care model in practice. Part of it I think is insurance billing, they don't have the proper CPT codes and what not and I know that's an issue. And I've looked more into the APA's training on this, I'm not sure if you guys have information, are there good outside resources for collaborative care teaching and how to learn to do proper collaborative care? Yes. You can look to our model at Alameda County Behavioral Health System, the PCPCP team. You can look to the AIMS Center at the University of Washington. There are CPT codes, there's emerging support for collaborative care. What happened at our county system was that millionaire tax dollars were used. There's 1% millionaire tax in California that was used for innovative mental health programs. So within our system a bunch of people said we should really do collaborative care and put it together themselves. So what I've learned over and over is if you think something should happen just start to make it, just start to find the other people around the country who are making it, find out how they funded it and then just do it. But a lot of people won't know what you're talking about until you make it. Also say that the APA does have on their learning center a pretty comprehensive training for collaborative care. It's about seven hours. It was free when I took it. Hopefully it's still free to members. I thought it was quite good. So and the APA is actually advocating for some of the things you're talking about, making sure that people are aware of CPT codes, that insurers are actually imbursing them. So that's something the APA is really working on. And if it isn't free, send an email to Dr. Levin and say that it's behind a paywall because it shouldn't be. Gotcha. It is free. Still free. Still free? You said it's just on the website? Thank you. I haven't checked. Thank you. Thank you. I appreciate that. Thank you so much. I was wondering, I did my first two years in combined family medicine and psychiatry and I missed the whole bathe thing. And maybe that was where I was learning or, but I'd like you, if you could tell me where that, was that in Seawright or Welton or is that somewhere else? Or just what, what were the, the five? Sure. So it was part of my family medicine training, so I'm a fellow dual trained provider. So there's actually a really good book called the 15 minute hour. I am blanking on the author's names, but I have it actually on my phone. If you want to ask me after the session, I'll get you the authors. They go through it in detail. But to kind of go over the five elements are just background, affect, troubling, like what's troubling you about this, handling, how are you handling it, and then an expression of empathy. And the whole intervention can go fairly quickly. That's actually designed, like when you ask for the background, you don't then ask them to elaborate further. You just say, oh, okay, how are you feeling about that? Right? And then again, you don't ask them to elaborate, you just say, what's troubling you? So it can go like really just maybe 60 to 90 seconds. But it helps you get at the psychosocial part pretty early in the visit so that you're not finding out as you're walking out the door that the patient has some crisis in their own tears and it's going to take you an extra 20 minutes. Sounds great. Thank you so much. Absolutely. Hi, my name is Katie. I'm a psychiatrist and I practice collaborative care in the traditional sense of our company provides psychiatrists and care managers. And then we also do kind of an expanded collaborative care where we integrate nutrition and fitness as part of the treatments. But probably the main challenge that we face is not that it's not effective. It's that the collaborating physicians in whatever specialty they're in, cardiology or primary care, seem to be relatively uninterested in collaborating. So they are willing to send us the referral and they are not willing to meet with us very much. And we don't actually provide a lot of medication recommendations because the patients get better with much of the interventions that you guys discussed. And I know I can make their lives better. I know I can decrease their burnout. I know that I can improve the quality of the interactions they have with their patients. But I have a hard time reaching them. Any ideas on how we might do that? I would print out Taking Care of the Hateful Patient by James Grose, 1978, New England Journal of Medicine, five pages long, and just wait for them to get explosively upset at patients and be like, no, you're right. Let's talk. You have a reason to be upset. And take that as your, it's like a sales, like a car salesperson. You know, just get ready to grab them. Grab them by the, grab them by the tears. Yeah. I really like that. I would say something similar. I would say the Pollyanna atmosphere that pervades, you know, everybody's happy so nobody needs you. That's a giant defense. That's a manic defense. I mean, you know, I think it was a Jean Bureson who would say, grab them through their plane. That you know, they've got patients they're mad at, they've got patients who are not doing well. Lawsuits. And, you know, they're afraid of lawsuits. So maybe a lunchtime talk titled. Bring them a cup of coffee when they're going frazzle-fram about a patient, you know, and walk down the hall and say, yeah, uh-huh, uh-huh. And I would just want to echo that, that I think one of my teaching pearls is when you're dealing with somebody who's kind of skeptical of a more psychological approach, you teach to their suffering. Yes. So you address them there. And if you provide something that offers some containment for that and helps reduce their suffering, people seem to become much more interested in it. So that's, I think, that's kind of all of us have said the same thing in different ways. Be also prepared. I wish we had talked about this more on my team. Just something for you to prepare for is people present their family members first. These kinds of physicians actually will present their family members and see how you sound. And then they'll kind of vet you that way, which just feels kind of ethically weird. But then if they think you nailed something, they'll trust you more. I'm going to say something a little bit different. I know for me, the one of the ways I was able to really connect with the primary care team is showing up to stuff. So if they have routine briefings or meetings or education, hey, can I get in on that? And let me just give you a quick talk on the latest information about using SSRIs. Or if you have a morning huddle, can I start showing up? It doesn't have to be every day, but on some schedule they can count on so that I'm present. And then the more they saw me, the more questions they asked. So another challenge is that we're fully remote. That is challenging. Yes. And I'm seeing those invitations I've tried before, so I think I'll work more on that too. Yeah. For all parties. Yeah. Well, if you can show up for lunch once a week or show up for a conference once a week so that people can curbside you so that they don't have to formally address you and they can curbside you while you're eating your yogurt at the table, and they can talk to you and they can see you and they can see you don't have an arm growing out of your head, and they can see that you're not weird. And they can just sit there with you and you're not going to jump on them in some weird way. But I agree. I saw the mother of the head of the oncology program long before she would talk to me about anything. Thank you so much. I appreciate it. Be sneaky. Yeah. Bring cookies. Be subtle. Yeah. Feed people. We do have to wrap up. Thank you guys so much for being here for our session.

psychotherapy

primary care

integrated care

pharmacotherapy

countertransference

attachment theory

motivational interviewing

family dynamics

holistic care

cognitive reframing

mental health

practitioner shortage