Our bodies are made up of complex systems. Not being a physician, I cannot explain the intricacies of our neurological system, respiratory system, endocrine system, digestive system and so on. I can however tell you that when I experience a stressor, I have a thought and depending on that thought my breathing may change, my stomach may gurgle, and my body may secrete a variety of hormones in response as well. Come to think of it, maybe it is the thought that generates the emotion that propels those system dominoes to react? Maybe our bodies even know it before we can consciously give language to the experience….or maybe it is all of the above. One thing we know for sure is that it is complicated.
I have had many instances of experiencing the mind-body connection in my life. They began when I was very young. One summer that stands out to me was the summer before 7th grade. I was spending the summer with my Dad as I typically did since my parents’ divorce. I loved my time with my Dad. However, this summer was the summer before middle school. I would attend a new school with new kids as our elementary school life ended. I was also aware of one of my teacher’s younger sons dying of leukemia. There were also some friendship issues—being out of touch and out of the loop of the friendship happenings that summer was probably hard for the first time as my need for peer acceptance increased in the pre-teen years (author disclosure: this was in the 1980’s so there was no FaceTime, no social media etc. When you were gone, you were out of sight and out of mind except for the handwritten snail mail letter.) Suffice it to say, this summer I found myself with my Dad at multiple doctor’s appointments. Doctors tried to figure out vague and somewhat chronic symptoms, ultimately with no clinical diagnosis. It is clear to me now, that in all likelihood what I was experiencing was mild stress and anxiety that my body was trying to bring to my attention.
Fortunately, we have seen a shift in awareness towards the connection between our mind and body. We see providers of all types tuning in to all the parts of a person’s health AND their interactions. For example, learning how anxiety can make pain worse. Or how insufficient rest can create a craving for carbohydrates, leading to frustrating weight gain, leading to depression and the cycle just continues. We are making progress as a healthcare system in truly seeing and healing the whole person. May is Mental Health Awareness month, and we want to lift up the reality that our mental health has always been and will always be intimately connected to the whole.
In the behavioral and mental health space, we talk often about the biopsychosocial (BPS) model that was developed in the 70’s by psychiatrist Dr. George Engel. As we move in to 2023, some might reference the BPS model when talking about whole person care, a phrase that is firmly taking hold in healthcare overall. Our healthcare systems are acknowledging that there are elements beyond the physical domain that need to be taken care of if we are going to see improvements in a person’s overall health and well-being. However, we all seem to still be working on incorporating one more component of truly whole person care, and that is spirituality. In 1996, quite some time after Dr. George Engel wrote about this new BPS framework, a group of clinicians (Wright, Watson, & Bell, 1996) emphasized the importance of beliefs and of making meaning around illness and health, adding in effect, the spiritual component to the biopsychosocial-spiritual framework. It is time we embrace this idea of spirituality even more and see the benefits it can add to our mental health.
Spirituality is often confused with the idea of religion or religiosity. For most people religiosity represents a concept that is based in an organization, whereas spirituality sits more within the individual and the meaning that the person makes around their life. Spirituality, however a person defines it, can be incredibly important to consider when thinking about mental wellbeing. Most people are looking for a sense of connection, a sense of meaning and greater purpose and a sense of where they belong in the world. All of these types of questions and explorations often bring conversations back to a spiritual part of life.
Often when a person is suffering with a bout of depression or anxiety, they can have a deep sense that they are alone in that experience. It can indeed feel incredibly isolating when those symptoms appear. It is important that we talk about building a skill set or coping tools to use when they feel that sense of disconnection. It can be quite helpful and that tool kit can involve elements of spirituality. For example, thinking about getting connected through community service, especially one where you work with others on a shared project (ie: packing boxes for a food bank). Speaking from personal experience, when I have had the opportunity to work with complete strangers on doing something good for people I will never meet…well, it did a world of good for my mental wellbeing and my sense of connection to a greater purpose. If a person is not quite ready to engage with people, spending time with nature outside can be an incredibly soft entry point to stepping into our sense of interconnectedness. Spending time outside observing the activities of local birds and wildlife, looking for the many patterns, or fractals, that can be found in nature. Spending time self-reflecting and journaling, though I acknowledge writing is not enjoyable to everyone, spending time thinking about things a person is grateful for can also help them get in touch with their connection to others and the deeper meaning of their life.
Spirituality can seem really personal, even when you are amongst friends, but often times I find that people have more in common with their beliefs than they have different. If we can see these commonalities then it can help foster an even greater sense of connection and deeper meaning.
May is Mental Health Awareness Month and it cannot be denied that mental health has become a focal point of many broader discussions in our state and country over the last few years. There is no question that the COVID-19 pandemic worsened the state of mental health in North Carolina and beyond. According to Mental Health America, approximately 1 in 5 adults in our state are experiencing a mental illness.
Mental illness used to be surrounded by significant stigma, as something that people had a tough time understanding. There was a misconception that mental health concerns or illness could happen to “others” but not you or your family. For better or worse, this lack of understanding is becoming a thing of the past. For many people, the COVID-19 pandemic exacerbated a myriad of issues and mental health was certainly one of them. Isolation, fear of sickness, actual sickness, and loss were universal reasons that people across the globe came to understand what it was like to feel anxious or depressed. For those not doing well with their mental health, their symptoms tended to worsen over the course of the pandemic. And for those who did not have mental health symptoms before the pandemic, many began to experience these symptoms. Now that the world has seemingly picked up where it left off, many are still left with a feeling that things are not quite how they used to be before the pandemic. Mental health exists on a continuum and depends on several factors including, but not limited to, life circumstances, genetics, zip code, trauma, and resilience. Today, you may find yourself at a point on the continuum of mental wellbeing that you did not anticipate.
Recognizing the Signs
It can be difficult to recognize the signs and symptoms of a mental health disorder. Research shows that it can take upwards of ten years from the onset of symptoms to beginning treatment (NAMI) This common delay in receiving treatment, for whatever reason, makes it critical that we begin to recognize in ourselves and in our loved ones when we might need a little extra support.
People often miss these symptoms because they manifest physically such that they land in their primary care office wondering why they have periods of racing heartbeats or daily headaches. Gastrointestinal upset and even difficulty breathing can be physical symptoms of moving towards the illness side of that mental health continuum. This is not to say that these symptoms are always indicative of mental health concerns, but to consider that possibility when taking in the bigger context of a person’s life.
Stomach pain
Back Pain
Fatigue
Poor hygiene
Stomach upset
Headaches
Weight changes
Repetitive tics
Sore/tense muscles
Insomnia
Hyperactivity
Restlessness
Other symptoms might be less surprising, such as feelings of sadness for two weeks or more, or an increase in drinking or using substances, often to self-medicate or escape the thoughts that might be upsetting. So, what does a person do when they notice these in themselves or a loved one?
Examples…
“I knew I was struggling when I had several weeks when I would finish work for the day and just wanted to go straight to sleep to get the day over with and go to the next one. There was nothing that I looked forward to or found joy in, and I wanted time to pass me by.”
“I was so fixated on my family’s safety, to an extreme level. I would panic when they would go to school and work and could not sleep at night thinking of all the ways I needed them to be safe. My body and mind were on edge 24/7.”
“I could feel myself being reactive and irritable towards my friends, coworkers, and partner. I was so annoyed with everyone. I just wanted to be alone. Then I would feel terribly guilty and try to re-engage, only to find myself so irritable again with no emotional energy to give to my relationships.”
Connection
Conversations about coping and toolboxes are often found in a therapist’s office, but there is no reason those conversations cannot be had among your support system, including friends, family, and colleagues. True connection with others makes a difference in our lives.
What do you do when you start feeling not quite yourself? When you find yourself worrying about a bunch of stuff or feel like a lead balloon and can’t quite get out of bed? These are the conversations that can help you feel validated about your emotional experience and prevent the slide down the continuum towards more severe mental health challenges. Connection is one of the best protective factors for managing and mitigating mental health concerns.
Coping
What could some of those tools or coping strategies be to help you stay in the mental wellness part of the mental health continuum?
Keeping with the idea of whole person health, often strategies that ground a person in their body can be very helpful. Research has shown that getting into nature and getting outside can really provide a myriad of cognitive and psychological benefits. Walking, stretching, simply moving our bodies can also be extremely helpful as a coping tool.
Developing a sense of connection either through personal relationships or volunteering can be helpful.
Setting very realistic and achievable goals can be the first step towards deciding how to find what works for you.
Of course, these are techniques for when you just notice a slide into worsening mental health. If symptoms become more serious then additional support like talk therapy and medication may be in order. Many people are caught off guard when their mental health takes a hit, and they find themselves in what we would call a clinical distress category. A clinical level of distress is when symptoms impair functioning, such as mental health symptoms disrupting your work or home life. Having that level of disruption in your life indicates that professional support is needed. However, we do not want to wait until we are feeling that bad to start taking steps to take care of our mental health.
In fact, as much as exercise and nutrition have become integrated into conversations about our overall health, mental wellbeing management should become a part of that conversation as well. Let’s start talking about how we take care of ourselves and when we need additional support and help reduce the prejudice and discrimination that often still exists if professional support, such as therapy and evaluation for medication, is still needed.
In celebration of mental health awareness month, as licensed therapists ourselves, we will be sharing our insights into the bits and pieces that can help support mental wellness for the rest of the month and hope you will join our conversation.
While the month of May flew by, the idea of mental health awareness, is here to stay. Now more than ever, Americans are talking about their mental health in a way that is forcing the conversation around the unnecessary stigma of seeking support. No longer in the shadows of healthcare, mental health is slowly gaining parity in terms of the conception of when and how people can seek support. Prevention is no longer just for our physical health, but it should be for our mental health as well. This month’s blog entries focused on the development of a young adult who benefitted from systemic changes in our healthcare system that provided him access to preventive mental health services. The Foundation for Health Leadership and Innovation has brought these words to life in this cartoon sketch of Alex. Let’s all take a minute to envision a life where our children are able to live a life of intentional wellness rather than a life of reactivity.
*For the month of May, honoring Mental Health Awareness, the Center of Excellence for Integrated Care, a program of the Foundation for Health Leadership and Innovation, will host a series of blogs following Alex. These weekly journal entries from Alex begin in 2032 when Alex is 18 years old. Over the month Alex will reflect on the benefits gained from living in a system with preventive mental health policies as they grew up.
*Week 4 flashes forward to Alex reflecting on life moving forward with a new family.
“Life has been sooo busy lately. I barely have time to really sit back and appreciate all that has happened in my life. I guess the biggest update is that Frankie and I got married, and we are expecting a baby in the next five months. I can hardly believe I will have that level of responsibility – to actually take care of another human being and be responsible for that person…it feels a little overwhelming at times. My running and working out continues to help me when I feel overwhelmed. The other day I ran the farthest I have ever gone, and I am considering training for a marathon. I know it always helps me to have a goal to work towards, plus I have found some good friends in the running group I joined who also have young families. I don’t know how they find the time to train and take care of their families, but they are so encouraging and supportive that it seems possible.
Frankie has felt a little more stressed than I have, understandably so, but we are working through this change in our relationship together. We sought out a therapist who specializes in couples and family relationships just to help us navigate our expectations and this shift in our relationship. It has been helpful to talk about how we see parenting and how we balance the parenting responsibilities while maintaining our relationship as a couple. I have a feeling we will see our therapist a bit more even after the baby is born just to help with the adjustment. I have learned that talking about our relationship on a preventive basis really helps us just be the best we can be for each other and for the other people in our lives. I have watched co-workers go through separations and divorces and it just seems so hard. I learned so much growing up talking with Sam over the years, that I figure why not do the same sort of preventive work with my marriage and soon-to-be new family. I am also grateful to know that we have the support of a therapist when the baby is born who will be focused on our attachment and relationship dynamics with the baby, as well as each other, and who will also be there for the baby as they grow up. Knowing we have that support during those preventive mental health well child exams built into our life is beyond reassuring.
I am so glad our world is far beyond the days when going to therapy was such a big deal. It really has been an amazing help to me over my life and will pay dividend for years to come.” Later, Alex
*For the month of May, honoring Mental Health Awareness, the Center of Excellence for Integrated Care, a program of the Foundation for Health Leadership and Innovation, will host a series of blogs following Alex. These weekly journal entries from Alex begin in 2032 when Alex is 18 years old. Over the month Alex will reflect on the benefits gained from living in a system with preventive mental health policies as they grew up.
*Week 3 flashes forward to Alex in their late 20’s and fully engaged in adult life in their community. Alex is employed and continues in a serious relationship considering future plans with that person.
“Life is plugging along nicely. I haven’t gotten a chance to write in this journal as much as I would like. Life is busy now that I have gotten the promotion I was hoping for and Frankie and I have been traveling so much. Things are getting serious with Frankie and I am excited. I feel like we have found our groove as a couple, and we have the support of those around us as well if we decide to move forward.
When I graduated college, I realized I had actually made quite a good space for me there. Leaving college felt like I was leaving another nest or family of people who understood me and who shared a common goal. I felt like I floundered a bit looking for work and then meeting Frankie helped me not feel so lost out in the adulting world. Also finding other community groups that I took an interest in helped a lot as well with my overall wellness. Long ago during my pediatric days, I remember talking to Sam about being involved with groups or events around me to help me not get stuck inside my own head or in sort of an anxious state. In high school she got me to be involved in some clubs even when I did not want to, and what I probably liked most about those clubs was the community service. Now I volunteer even as an adult with a community food bank. Being involved and being helpful in that way always makes me feel useful and connected to others and somehow life seems more manageable. Yet another tool in my mental health toolbox that really doesn’t seem like a “tool” anymore, just seems like a part of my life that I enjoy and that makes my life more enjoyable.
I also finally found a church that fits for me as well. It might be a little different than what I grew up with, but I had to find a church that I felt good about and that I wanted to be connected with. It just so happens this church does a lot in the community as well and even serves as a distribution site for the food bank I volunteer with. I have been involved with a young adult group through the church as well and might be considering leading a group, but I am just not quite sure I am there yet. We’ll see what the future holds. It feels so good to talk to my parents about where I am in life and how well things are going. I think they were worried about how I would do moving from such a small town to a bigger area in the state. We talk a lot about how grateful they are for Sam’s role and my pediatrician’s role in preparing me to launch out on my own.
Well, who knows when I will get time to sit down and write again – but life is good! “ Thanks, Alex
*For the month of May, honoring Mental Health Awareness, the Center of Excellence for Integrated Care, a program of the Foundation for Health Leadership and Innovation, will host a series of blogs following the perspective of an individual who is found in the future but who was a child. We invite you to meet Alex, who will begin their journey at age 18 and over the month of May Alex will reflect on the benefits gained from living in a system with preventive mental health policies.
*When we hear from Alex this week, they will have graduated from their undergraduate studies and been living in a medium size city after finding a job in their field. Alex has been in a serious relationship over the last six months and writes this journal entry reflecting on that relationship.
“What an amazing few months it has been! Meeting Frankie has really been a dream come true. I had no idea I could feel this way about a person. The first few months were of course our honeymoon stage, not the “I do” kind of honeymoon, but the most romantic and on cloud 9 I have ever felt. I may as well have said I do! I knew to expect those kinds of feelings though when it started. Sam, my therapist, talked to me over the years when I met with her for my annual appointments. I met with Sam a few more times when I was in some of my first relationships just a few years ago and she taught me a lot about what a healthy relationship looked like. What stood out the most in our conversations was the importance of being treated with respect and having a balance of yourself and your own interests plus the relationship in your life. In other words, when I felt myself getting pulled into a relationship too deep, she would remind me to stay involved in the parts of my life that make me who I am as an individual. For example, keeping up with my school work, my hobbies, and spending time with my family and other friends are all part of who I am as an individual. It is easy to get sucked into that one relationship and have it sort of become your entire world, but I think after our annual, and sometimes more, meetings I finally understand. I think those talks really helped me be a better partner from the start with Frankie too.
My relationship with my parents also really was stronger because of those meetings with Sam. Not only have I seen my parents have a strong relationship with each other, but our relationship changed as I got older and somehow though they were not as involved in every decision I made, our relationship seemed to grow stronger. Sometimes my parents would come to my appointments with Sam. She helped us navigate our relational boundaries so that they learned to trust my decisions more, and I also learned to stay open to their feedback without feeling defensive. I think even this lesson in boundaries has helped my relationship with Frankie have a healthy balance.
I just continue to be amazed how those meetings with Sam over the years have really had a lasting impact in my life. Knowing what to expect in a healthy relationship before you get into a relationship at all has been super helpful. Who knows, maybe Frankie will be the one, but I know I stand a better shot at making sure this relationship is healthy and strong thanks to those conversations with Sam and my strong relationship with my parents.” – Signed Alex
*For the month of May, honoring Mental Health Awareness, the Center of Excellence for Integrated Care, a program of the Foundation for Health Leadership and Innovation, will host a series of blogs following the perspective of an individual who is emerging into adulthood and received preventative mental health services as a child. We invite you to meet Alex, who will begin their journey at age 18 and over the month Alex will reflect on the benefits gained from living in a system with preventive mental health policies.
by Dr. Lisa Tyndall, LMFT, Dr. Amelia Muse, LMFT, and Mrs. Sara Herrity, MS, LMFT
*Alex recently graduated high school and is a first-generation college student at a University approximately two hours from home.
“Whew, the last few months have been an adjustment. Never having been away from my family longer than a week before, and not having them around at the end of the day has been hard sometimes. Not sure I quite fit in here with so many people around me having a lot more than me, at least cars and nicer clothes. I have met a few people who I like from towns and backgrounds like mine and that has been helpful.
I have to be honest though, there have been times I just want to hide out in my room scrolling on my phone or trying to study in the library. Sometimes things can feel so out of my control and I can feel really small. Studying or playing my video games or scrolling can seem like the only thing I know to do in order to feel okay. I knew getting my head in the books and in classes would help for a bit, but I was also glad to remember some of the things I learned over the years with my therapist and pediatrician.
Dr. Johnson and Sam were so helpful at my annual appointments each year. I honestly cannot remember a time that they were not in my life. One thing I remember is they said the same thing, but would talk about it differently. Dr. Johnson would talk to me about staying active for my health. Sam would talk to me about staying active too, and it seemed to reinforce what Dr. Johnson said, but would then add how it helped with my stress and mood. I learned that sometimes when I went through times that I felt anxious or down about life, a good workout was always something that helped, and I was able to really get out of my head. Sam would share with me how talking out the stress, like with her, my parents or my good friends, also helped. My check-ins with both of them gave me the coping tools and support to take charge of how I feel.
I am grateful though that I had the benefit of talking to Sam and Dr. Johnson both because I know it was not always this way. My parents have said that no one used to go to therapy unless things were really bad, then the pandemic of 2020 happened, and some things changed. I am grateful that there is not stigma any more around people talking to their therapist, that even my friends have talked about having to go to therapy sometimes, and that my insurance has made it possible for me to get that support before I technically needed it. Now, along with other tools that I learned over the years, I check in with the student counseling center on campus once a month or so just to get grounded again. My parents say that now it seems like finally the systems around us have acknowledged how important it is to take care of all the parts of our health. I’m glad I do not have to wonder what it would have been like to grow up without people like Dr. Johnson and Sam.
Jamie: My background has always been in integrated care. From training through licensing, I lived, ate, and breathed integrated care! Coming from a rural community with limited healthcare services, behavioral health and physical health existing in the same space has always just made sense to me. But after a few years of my focus being on behavioral health integration in primary care, I became really curious about how these models of care were being implemented into completely different settings, like in allergist offices, pediatric obesity clinics, and complex care settings, for example. Again, this wasn’t surprising to me and just seemed like a common-sense way to improve patient care outcomes, as well as provider satisfaction. But I will never forget the day I saw a job posting for the role I have now! On one hand, I thought to myself, “Behavioral health integration at the dentist?! How is that going to work?” And on the other hand, I thought, “I’ve got to get in on this!”
Lisa: Oh, I am so glad I am not alone in my curiosity about integrating behavioral health care into oral health care! To be honest, when I first heard about integrating behavioral health into oral health I just wasn’t sure how it would work. At first I thought, well that would be helpful because personally I experience a lot of tension around going to the dentist. I am always up for someone talking to me and helping me feel more relaxed, so that was my initial take on the role of behavioral health in oral health. I thought, when I sit down and feel nervous about my procedure, or about what the dentist is going to say, a behavioral health person could help me manage that stress. But then I learned there was so much more and so many other reasons why behavioral health should be connected and integrated into oral health.
Jamie: Absolutely! At UNC we have done dentistry education without behavioral health for more than 50 years…so I don’t think you’re alone in feeling slight hesitation at the sound of “behavioral health in dentistry.” Changing the way teams are developed and work together, as well as the way patient care is viewed and delivered, is NO small feat. I had a dental colleague put this simply for me one day. He said to me that dentists are incredibly technically skilled professionals. For that reason, they historically have looked at patients and their needs with a 2mm point of view. They are using magnification tools to zoom in on that particular cavity, or that crown. As a behavioral health clinician, I am asking them to back that view up to about a 100-yard view of the patient and ask about their life, their health behaviors, and their own perspectives on their care. This is uncomfortable for most dental providers to think about in the beginning. But as I attend more morning huddles, discuss more patient cases with providers, and meet with more patients in the operatories, I see our dental providers — both learners and faculty — gain a greater understanding of how expanding their care to be more person-centered improves the patient’s experience, as well as theirs.
Lisa: That is very cool, Jamie. I am just fascinated with this whole movement of really connecting ALL of the parts of the body and mind. As an integration specialist, I really have always believed and advocated for whole-person care, but it took a bit of self-education and talking to others in the oral health field to understand the connection between the mouth, the body, and the mind more fully. It is almost a little embarrassing to say, but it also shows how entrenched everyone still can be in their silos, even if there is some overlap with those silos. It is exciting to hear about the work being done at the training level to tear these silos down and create a total culture shift.
While I do think those in training right now — including behavioral health, dentists, and primary care providers — are getting more exposure to whole-person care, I think it is important to share with those currently practicing all of the many reasons that oral health and behavioral health intersect.
An inter-professional oral health team discusses patient needs and a treatment plan.
Jamie: When I explain the “why” behind integrating behavioral health into dentistry, I like to focus on specific patient presentations that dental providers will see in the dental chair. What we are seeing, especially in NC with the rise of the opioid epidemic, is that substance use and behavioral health can impact everyone, across all socioeconomic levels. So, regardless of where a dentist is practicing, if they came to me and said that they aren’t seeing behavioral health issues in their practice, or these issues are not impacting their patients’ care, I would kindly argue that they just simply aren’t paying attention. The mouth is the messenger for all sorts of things happening in the body, so if you aren’t receiving those messages, then you’re doing something wrong.
Some of the most commonly used substances in our state include cannabis, opioids, and methamphetamines. Cannabis can lead to increased risk of oral cancer and gum disease, use of opioids is associated with tooth loss and decay, and methamphetamine use can cause teeth grinding, tooth wear, and rampant decay. With that being said, poor oral health can also have an impact on substance use. Untreated oral pain can exacerbate factors that lead to substance misuse, or impede recovery from a substance use disorder. As for opioid prescribing patterns, oral health providers have been among the top prescribers of opioids in recent years, including for individuals 10-19 years old (this often happens after wisdom teeth removal). Another example of this is when we see people who are seeking care for oral health problems in emergency rooms being prescribed pain medications instead of receiving comprehensive oral care. Interestingly enough, we have actually seen a very rapid increase in recent years of dentists working in emergency rooms, with the goal being to provide more comprehensive urgent dental treatment in the ER setting.
As for mental health, one of the most interesting things I’ve learned since being in this setting is the significant impact of dry mouth on overall oral health. As you know, anti-depressants and anti-psychotics often cause xerostomia, or dry mouth. Saliva acts as a protective coating on the teeth, and when it is in scarce supply, the teeth and more susceptible to caries and decay. I’ve seen patients here who are high in socioeconomic status start a new anti-depressant medication and come in for their six-month cleaning with significant changes in their oral health. There is also ample evidence in the mouth for eating disorders (tooth erosion), bipolar disorder and OCD (patients get overzealous with brushing and flossing), and trauma or anxiety (habitual teeth grinding and clenching, TMJ disorders). There is also a lot of evidence that poor oral health can exacerbate cognitive decline and functioning, which was a new concept to me! The last connection I’ll mention won’t be a surprise to any behavioral health clinician. When patients experience tooth loss or poor oral health, they see multiple impacts on their quality of life. Their self-esteem is low, their relationships are impacted, it can be difficult to find employment, this list goes on and on.
Lisa: I have to be honest, before talking to you and doing my own research, I just had no idea about so many of these connections. Even though these connections are evident, I would imagine that whenever a new workflow or paradigm shift happens in healthcare, it can feel overwhelming to those practicing because of all that they juggle already to keep their operation flowing smoothly. Is there a framework that can help providers figure out where to start their change process to address some of these issues you’ve talked about?
Jamie: I really like this example framework below developed by the Center of Excellence for Integrated Health Solutions/National Council for Behavioral Health. This framework shows how even minimal integration — such as staff education or screening for needs — can be a big step towards improving patient care outcomes. I’m curious though…as an integration specialist, what are your thoughts on this framework?
Lisa: Well, change for practices, in my opinion, is not a lot different than change for people. We have to figure out where we are, start small, and evaluate the changes to keep moving forward. This framework reminds me of other integration continuum charts that can help providers figure out what part of the puzzle they can put into place in their practices. Even if a dentist is practicing in private practice with no behavioral health professional on site or nearby, and even if a behavioral health clinician is practicing in a traditional private practice, steps can be taken to help heighten the coordination and awareness of the relationship between oral health and behavioral health so that patients start feeling better both physically, orally, and mentally more quickly.
For example, oral health providers can receive mental health first aid training while behavioral health clinicians can receive training on oral health issues. On another deeper level of involvement, oral health providers could receive more intensive training about interventions such as motivational interviewing to help patients with brief interventions if it was clinically appropriate in their appointments, and behavioral health providers can include oral health questions about hygiene and utilization in their biopsychosocial assessments. Integrating behavioral health into oral health can certainly go as far as bringing in a behavioral health clinician into the dentist office, but I think it is a mistake to think that it has to be all or nothing. How would you encourage clinics to get started, Jamie?
Jamie: I agree with you completely on that! Students often ask me what they are supposed to do “in the real world,” meaning if they start their professional career in a setting where they do not have a behavioral health clinician on their team. There really is no wrong way to get started! Maybe I’m thinking a lot like a social worker, but I would say the key is to seek resources, resources, resources. If you are not the expert on your team, it is always good to acknowledge that and stay in your lane. Locate your local experts, or resources, like your local LME-MCO, Mobile Crisis Unit, Crisis Lines, Department of Social Services, 211, etc. Keep a flyer or binder of those resources at the front desk. Ask a staff member to be responsible for connecting with those organizations, learning about what they do, and periodically updating them if needed. North Carolina is fortunate in that it now has an easy-to-use, integrated, state-wide resource network called NCCARE360 that serves as an electronic one-stop-shop for all of the resources available within the local community. This way, you feel confident as a provider knowing that if you ask a patient a question about their behavioral or emotional health, or if a patient brings this up on their own, you know who to direct them to. No matter what type of healthcare you are providing, patients should be assured that there is no wrong door for accessing care and support.
Systemic Change to Build Post-Pandemic Resilience in North Carolina Children, Adolescents, and Families
April 1, 2021
Children are amazing and resilient. Yes, children and adolescents can often handle more than we care to realize. However, 2020 and the beginnings of 2021 have been more than any of us could have ever imagined. Even the leaders running the world had no idea how much, how long, and how impactful the events of this past year would be to our country and our children. If someone had said a year ago that some children would be out of school for a full year, we would have said that there is absolutely no way that can happen. And yet, here we are.
Fortunately, there is finally a glimmer of hope on the horizon.
What often makes children’s resilience possible is the involvement of at least one caring and available adult. That caring adult can be a caregiver in the family, a family friend, a teacher, a youth group leader, a healthcare provider/therapist, or coach. This past year, as children watched for clues on how to handle all of the changes that were happening, the adults they normally turned to were likely trying to manage the chaos themselves. These adults, despite their best efforts, could very well have been emotionally unavailable due to their own stress, and quite possibly physically unavailable. We will not know the long-term impacts that this period of time has had on our children for a while; however, we do know that as the fog clears, it will be everyone’s responsibility to help ensure that resources are available for healing and recovery.
There is not a single sector of our society that can handle all of the needs of our children on its own. We cannot expect families to manage on their own. We cannot expect school systems to jump in and miraculously fill the entire gap. We cannot expect that regular visits to the pediatrician for sore throats and stomach aches will not be tangled up with the emotional turmoil that trauma can bring. We cannot expect to return to the status quo of how we have previously taken care of children in North Carolina.
The well-child exam is a natural place to provide an additional layer of support to children/adolescents and their families. For years now, this exam has been valuable in catching developmental warning signs, providing vaccinations, and addressing parental concerns. The concerns are often behavioral in nature, such as temper tantrums, developmental progress, attention deficit, and sleep hygiene, to name just a few. As childhood moves into adolescence, age-appropriate screeners transition into more adult questions focusing on substance use and sexual activity.
It is in these appointments that there is space and some time for patients and their caregivers to ask questions about mood, substance use, stress management, and coping with overall worries about life. It is in these appointments that we can be even more purposeful around our conversation with patients (and each other) around mental health and relational health to help nurture the whole child. Now is the time to capitalize on those valuable patient interactions in primary care offices to help provide additional support to these kids who have been through so much.
At the Center of Excellence for Integrated Care, we have been exploring system and policy changes that can integrate even more behavioral health support for children and adolescents than is already offered. Integrating behavioral health into practices not only helps provide a more robust offering of whole person care, but it also has been shown to help providers feel supported and improve their overall satisfaction with their work. It is time that our protocols and policies provide the support both our providers and our pediatric patients need in the aftermath of this past year. It was needed before now, but now it is undeniable. We look forward to sharing more as our partnerships around this idea evolve!
