It is relatively easy to treat body-based problems: a wound will heal if kept clean; an infection will succumb to antibiotics; and pain will yield to pharmacologic intervention even if the source is not known. Yet most illness experiences are a complex blend of mind-body interaction, of whole-person dynamics. For example, depression, anxiety and stress interfere with the improvement of chronic illnesses such as diabetes and hypertension. Of the 15 leading causes of death in the United States in 2010 (Centers for Disease Control, 2013, table 10), 11 were associated with behavioral/lifestyle practices and stressors that conspired in the progression of the illness.
In 1994, Antonio Damasio, a research neurologist, challenged the mind-body dichotomy that was so prevalent in health care (1994). Through exquisite neurobiological research, he offered an explanation of how the organism (person) works to regulate interactions with its environment. First, connected to the modern, information-processing sectors of the brain are regulatory circuits involved in the “business” of organism survival. Second, the “goodness and badness” of any situation experienced is regularly signaled to these regulatory circuits. Finally, third, the regulatory circuits’ reactions to the “goodness or badness” influence continuously, so that they can enhance the organism’s survival in the best way possible. This model explains how individuals’ health states are influenced by negative life experiences and stress, particularly trauma.
After more than five decades of mounting evidence, health care reform has rediscovered the “mind” and its role in the health-illness equation. The Affordable Care Act, for example, recognizes the need for “integrated care,” sometimes interpreted to mean adding a behavioral health consultant to the team. Some are referring to this recent policy shift as mind-body parity but that is a misnomer since we need to think of mind and body as a complex, integrated entity, not as additive. Tacking on mind or behavioral health interventions in health care reform is an improvement, but it is not integration.
The Drexel University Eleventh Street Family Health Services health center staff has evolved a system of integrated care that mirrors Damasio’s model. This cross-disciplinary model of care considers the biopsychosocial root causes and complexity of health and illness experiences and promotes healthy living through the integration of a wide range of interventions and disciplines based on the unique needs of patients and the collective assessment and recommendations of the cross-disciplinary team in partnership with individuals and families.
Consider the following case illustration of the Eleventh Street approach to integrated care involving numerous members of the cross-disciplinary team, a nurse practitioner, a behavioral health consultant (BHC), a psychologist, a dance/movement therapist (DMT) and a mind-body practitioner specializing in yoga.
Lorraine, now 63 years old, came to her first Eleventh Street primary care appointment in 2009. She reported pelvic pain and depressive symptoms. During her visit with the nurse practitioner, Lorraine fluctuated between heavy crying spells and grandiose excitement. She was not clear on the origin of the pain in her pelvic region, but said she had experienced chronic pain for years in that area. The nurse practitioner concluded that Lorraine was experiencing more than medical symptoms and therefore asked the primary-care BHC, who is based in primary care, to meet with her. The BHC quickly assessed that Lorraine was suffering from behavioral health symptoms and arranged a series of appointments so that they could build rapport, establish trust and work on immediate goals. Meanwhile, the BHC made a referral to an outpatient behavioral health psychologist and psychiatrist for long-term treatment. Lorraine struggled to make it to her BHC appointments, like most patients in crisis do. However, with encouragement and follow-up by the BHC, Lorraine completed her initial series of appointments, preparing her for the responsibility of making weekly outpatient behavioral health appointments. After seeing an outpatient psychologist and psychiatrist, Lorraine was diagnosed with borderline personality disorder and prescribed medicine to assist her with mood management. Lorraine began to see many changes over the next two years, including improved mood regulation with adherence to her medication regimen, college enrollment, the purchase of her own home, social engagement with peers and the development of a long-term romantic partnership.
Lorraine’s psychologist noted, however, that she remained unable to address her history of childhood sexual abuse, which was impeding her psychological healing, preventing her from connecting to her body and perpetuating her chronic pelvic pain. On the cross-disciplinary team’s recommendation, Lorraine was referred to yoga as a body-based practice that would engender a deeper connection of her past experiences to her movement. Once Lorraine and the yoga practitioner concurred that she felt good about using her body in a healthy way, the psychologist referred Lorraine to the center’s dance/movement therapist. Lorraine simultaneously continued talk therapy once a week, and the psychologist and DMT worked collaboratively to help support the vulnerability that can accompany the process of past embodiment. Lorraine has been working in individual, weekly DMT for three years. DMT has enabled her to reconnect safely to her body and decrease the regular disassociation that would occur in response to the psychological and emotional pain caused by previous abuse. She recognized that while her father once invaded her boundaries, as an adult she could now reclaim her sense of self and set boundaries regarding intimacy. She was able to embody her unconscious memories through movement instead of through talk therapy, which was too painful. Through DMT, Lorraine re-experienced the unbearable pain that she felt as a child. She was finally able to generate self-compassion and let go of self-hate and blame. Because of Lorraine’s significant improvement, the dance/movement therapist will be discharging her soon. Prepared to move on, trusting in all the tools she has learned, Lorraine wrote this about her DMT experience:
DMT has allowed me to become very aware of how my body reacts to different circumstances. I’ve learned that I’ve suppressed a lot of situations into various parts of my body. Talk therapy is good; however I’ve learned that even though I talked about things, I had not released them. DMT allows me to know when I have to let go of an issue, because after our work, I find that if I talk about the issue I no longer feel the weight that usually comes with it. With pain or issues, I now acknowledge it, pursue it, release it and then grow from it. This is very different than being stuck with it, and constantly re-burying it.
Lorraine’s case is an example of what can be done when mind, body and behavior are fully addressed in an integrated way by those who understand the power of mind-body integration to improve health states. The Mental Health Parity Act leveled the insurance playing field for mind and body. However, the health care system remains structured to perpetuate fragmentation. There needs to be a fuller understanding that patients do not fit neatly fit into straightforward biomedical categories or strict psychosocial rubrics. Rather, people are individuals who span the biopsychosocial spectrum and may not be responsive to the standard regimens suggested by aggregate-level evidence. Further, DeGruy asserts that “systems of care that force the separation of ‘mental’ from ‘physical’ problems consign the clinicians in each arm of this dichotomy to a misconceived and incomplete clinical reality that produces duplication of effort, undermines comprehensiveness of care, hamstrings clinicians with incomplete data, and ensures that the patient cannot be completely understood” (1996, 286).
The Eleventh Street staff tailors care to the individual needs of patients using a wide array of biopsychosocial interventions based on individual and community need. The center’s target population is the residents of four public housing developments in lower North Philadelphia who are primarily African American, with an average income of $10,645. A 2008 replication of the original 1997 Adverse Childhood Experiences (ACES) study in the adult population at Eleventh St. revealed more than three times the amount of childhood trauma/adversity found in the original study (Felitti & Anda, 1998). These findings illustrate the potential impact of ongoing domestic and community violence on the children and adults seen at the center. Having learned that Eleventh Street patients are highly likely to have had four or more adverse childhood experiences, the center has adopted two models of care: 1) a family-centered health home model that treats mental health as a primary component of health “normalizing,” including making behavioral health services a part of primary care, resulting in more timely receipt of service; and 2) the Sanctuary Model®, a theory-based, trauma-informed, evidence-supported, whole-culture approach that has a clear and structured methodology for creating or changing an organizational culture that will predispose it to managing trauma in the patient population.
The addition of integrated behavioral health in primary care is based on the traditional behavioral health consultant model of managing the psychosocial aspects of chronic and acute diseases and addressing lifestyle and health risk issues. Through research collaboration with the Treatment Research Institute, the BHCs are also implementing the Screening, Brief Intervention, Referral and Treatment model for substance abuse.
Traditional outpatient behavioral health services are provided on-site through the center’s linkage with the Family Practice and Counseling Network. The center’s holistic approach to treatment goes beyond the BHC and long-term talk therapy to include a full spectrum of care for the physical, mental and emotional needs that can arise anytime throughout the life span. The center combines conventional Western medicine with alternative or complementary treatments, such as Reiki, yoga and stress reduction techniques, in the effort to treat the whole person. The Mindfulness Based Meditation program has resulted in significant improvements in participants’ quality of life, as measured by the SF-36 Health Survey and in patients’ self-reported anxiety, which decreased by 50 percent. The creative arts therapies—music, art and movement—have been embraced by patients and are particularly effective in addressing trauma in both children and adults.
In direct response to the large number of patients affected by chronic pain, the staff developed a group program called Power over Pain (POP). Co-led by a clinical nurse, the BHC, the physical therapist, a complementary and integrative therapist and a creative arts therapist, the group meets weekly to help patients learn to live with and manage the different aspects of the pain experience. POP creates a safe and open learning environment where there is no judgment and helps to empower patients to manage their own pain when they are at home doing the things they want to do. This program is a prime example of the need to integrate physical, mental and emotional care into a cohesive program to address a complex issue, such as chronic pain.
The center also provides programs that focus on prenatal and early childhood, two critical periods in development. The pediatric team, consisting of a nurse practitioner, a behavioral health consultant and a child and family support coordinator, helps ensure that children get the proper assessments and screenings. This prevention strategy identifies and ameliorates conditions that lead to mental health problems and thereby impede development. The goal is to strengthen caregiver attachment, build protective factors and eliminate toxic stress in the home. At Eleventh St, all children 0 to 5 are seen with their parent/caregiver either individually or in the Growing Together parenting group. Services are provided that address both the physiological and psychosocial aspects of health and help parents understand the relationship between ongoing healthy physical development, positive behavioral health and the long-term significance of behavioral health supports for their child's overall health care.
In summary, the center has designed a practice environment that responds to the complexity and individuality of consumers and to the integration of mind and body, providing one-stop shopping for physical and behavioral health. The success of this integrative model is not only rooted in structure and programs but in the staff's belief in integrated care. The collaboration among providers through the array of services fosters flexibility, individualization and cooperation to improve care. Patients are referred to integrative services through primary care to enhance the comanagement of medical and mental health problems and to encourage individual accountability for care, self -empowerment and independence.
Patricia Gerrity, Ph.D., RN, FAAN is Associate Dean for Community Programs and Executive Director of the Eleventh Street Family Health Services at Drexel University. Lindsay M. Edwards, MA, R-DMT is Director of Creative Arts Therapy at Eleventh Street Family Health Services of Drexel University.
References
Centers for Disease Control. (2013). Leading causes of death. FastStats deaths: Final data for 2010. Atlanta, GA. Retrieved from http://www.cdc.gov/nchs/fastats/lcod.htm
Damasio, A. R. (1994). Descartes’ error: Emotion, reason, and the human brain. New York, NY: Grosset Putnam Books.
de Gruy, F. (1996). Mental health care in the primary care setting. In M. S. Donaldson, K. D. Yordy, K. N. Lohr, & N. A. Vaneslow (Eds.). Primary care: America’s health in a new era (pp. 285–311). Washington, DC: National Academies Press.
Felitti, V. J., & Anda, R. F. (1998). The relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–58. Retrieved from http://acestudy.org/yahoo_site_admin/assets/docs/LaniusVermetten_FINAL_8-26-09.12892303.pdf