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Working with Medical Professionals: Enhancing Your Practice

by Nancy Breen Ruddy, Ph.D..

3 Credit Hours - $30
Last revised: 06/29/2017

Course content © Copyright 2009 - 2020 by Nancy Breen Ruddy, Ph.D.. All rights reserved.


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Course Outline


Learning Objectives

Primary Care Behavioral Health

What is Primary Care?

Patient centered medical home and mental healthcare

Prevalence of behavioral health issues in primary care

The Costs of Untreated Mental Health Disorders

The Case for Collaboration and Integrated Services

The status quo – and the problems it causes

Barriers to mental health referral

The Benefits of Collaboration       

How collaboration can improve patient care

How collaboration can improve professional satisfaction

How collaboration can help mental health professionals build a practice

Barriers to Collaboration


Time constraints

Devaluation of mental health input by medical professionals

Overcoming Barriers to Collaboration

Routine collaboration and practice and clinical strategies

Initial collaboration: Creating opportunities

Establishing a collaborative relationship

Other strategies for building a collaborative relationship

Making collaboration part of routine practice    

Intensive Collaboration

What types of patients need intense collaboration?

Difficult patients for primary care providers

Intensive Collaboration: Strategies and Techniques

Pre-referral collaboration

Post-referral intensive collaboration strategies

Collaboration of Mental Health Services into Primary Care

Integration of mental health services into primary care





Mental health professionals increasingly realize that they must begin to interface more effectively with the medical community.  Yet, many do not know how or where to begin this process.  This continuing education program serves as a “how to” collaborate with medical professionals. 


The goal of this continuing education program is to help mental health professionals learn how to build and maintain successful working relationships with other healthcare providers.   There is a specific focus on building such relationships with primary care medical professionals.  Towards this end, the program reviews models of collaborative care and the research literature on the prevalence of mental health issues in primary care, quality of care issues in primary care mental health, and the evolution of various models of care delivery.   It will outline the collaborative relationship primary care medical professionals typically have with medical specialists, in contrast to the poor communication and collaboration that often plague the primary care/mental health professional referral model.  The program will offer an analysis of the impact of this fragmentation on patient care, with case examples to illustrate common issues.  The benefits of, and barriers to, collaborative relationships with other healthcare professionals will be reviewed, including how collaboration can facilitate referral network development.   Other healthcare professionals’ and patients’ perspectives on collaborative care will be illustrated via their comments regarding experiences with such care.


After discussing the benefits of a paradigm shift towards shared care, the focus will shift to “how to” collaborate.  This portion of the program will outline pragmatic, time efficient strategies to initiate contact with medical professionals and collaborative techniques to make collaboration a routine part of clinical care.  The goal is to help psychotherapists integrate collaboration with other healthcare professionals into all clinical care, not just care of patients with specific health issues.  The program will offer practice management strategies such as forms, collaboration tracking systems, and communication tools to streamline communication and collaboration.  Emphasis will be placed on the importance of whole person assessment in psychological practice, and the knowledge and skills that all psychotherapists need to understand the interplay of physical and mental health.   Case examples will illustrate routine collaboration.


The next section will focus on intensive collaborative strategies and skills for use with patients with complex medical and psychological issues, including patients with poorly managed chronic medical illness, somatization and personality disorder.  The program will discuss the literature regarding the medical profession’s struggle with challenging clinical encounters, and how these struggles often result in frustration for the medical professional and poor outcomes for patients.   It will outline specific techniques psychotherapists can employ to help medical professionals increase their success and satisfaction in these encounters.  These techniques are culled from various theoretical orientations, including cognitive behavioral techniques, family therapy techniques, and mind/body strategies.  They also include collaboration strategies to improve care and enhance support for both medical and mental health professionals.  Case examples will illustrate the use of these strategies. 


Learning Objectives


Describe three reasons that mental health professionals should collaborate with primary care professionals.


Explain three practice strategies that facilitate collaboration with primary care professionals.


Discuss how to identify patients in need of intensive collaboration.


Explain two consultation or psychotherapy strategies to optimize care for complex patients. 


Primary Care Behavioral Health


What is Primary Care?


Primary Care is made up of three disciplines:  Internal Medicine, Pediatrics, and Family Medicine.  Internal Medicine providers treat only adults, pediatric providers treat only children and adolescents, and Family Medicine providers treat all ages, including well woman care and obstetrics.  Some consider Obstetrics and Gynecology as part of primary care, as well, since many women get most all of their care from their OB/GYN.  It should be noted that the word “providers” is used, rather than “physician.”  “Midlevel providers,” such as nurse practitioners and physician assistants, work in collaborative relationships with physicians providing this critical front line care. 


The term “primary care” connotes much more than just “who” provides the care.  The primary care setting is the first place most people turn when they have a troubling symptom, be it physical or psychological.  Primary care providers often know patients very well from working with them over many years.  They often provide care to more than one family member, helping them put the patient into context. 


Primary care is intended to be comprehensive and preventative medical care.  Its goals include helping patients find the right care and coordinating all of the patient’s health care providers to optimize health (Ruddy, Borresen & Gunn, 2008).  In this role, primary care providers assess and treat to the best of their abilities.  When they are unsure of the correct diagnosis or treatment, or the treatment falls outside their expertise, they refer the patient to a specialist.  They may help the patient to select the right specialist, and to understand their treatment options based on the specialist’s recommendations.  When patients must work with multiple specialists, primary care providers often help the patient understand his or her condition and help the patient make treatment decisions.  Unfortunately, specialists do not always agree on the best course of action, in part because they focus primarily on the part of the body or organ system in which they specialize.  In these cases, the primary care provider may play a critical role to help the patient synthesize the information and make treatment decisions.


Primary care providers play this central role for patients with mental health issues, as well.  They try to help patients to the best of their ability, and refer to mental health professionals when they do not feel they can optimally care for the patient.  From the primary care providers’ perspective, psychotherapists are essentially a type of “specialist.”  The following vignette illustrates a typical primary care encounter that has a mental health substrate:



Case Example



When Sandra made an appointment with Dr. Kingston, her primary care doctor, she told the receptionist she was having dizziness.  Sandra usually came to the doctor once or twice a year with upper respiratory infections, so Dr. Kingston entered the appointment anticipating a similar situation.  However, she did not complain of congestion, only periodic dizziness that interfered with her ability to get through her day.  She told Dr. Kingston that the only thing she had found that relieved the dizziness was to stay in a dark room for a few hours and rest.  “Dizzy” symptoms are vexing to doctors, because there are so many potential causes, some of them quite serious.  Dr. Kingston felt his heart sink when he realized that this was not going to be a simple upper respiratory infection that needed 10 minutes of his time.  He tried to regroup and think about how to approach Sandra’s concerns in a time efficient, yet comprehensive and empathic way.  As Dr. Kingston conducted his “review of systems” he asked Sandra specifically about stress.  Sandra became tearful and told Dr. Kingston that she had recently learned her husband was having an affair.  When Sandra confronted her husband he told her he was in love with the other woman and wanted a divorce.  Sandra readily acknowledged that the dizziness started with this stress, and that she believed the dizziness was primarily stress induced, but that part of her worried that there was something very wrong.  Dr. Kingston provided Sandra with reassurance that the dizziness was most likely benign.  However, he also ordered tests that would rule out any serious medical causes of her dizziness.  He acknowledged that extreme stress such as her marital situation could cause these types of symptoms, but also reassured her that the tests he was ordering would help them rule out treatable medical conditions and hopefully reassure her that she was physically healthy.  He asked Sandra if she was willing to see a mental health professional.  She declined a referral, but agreed to see Dr. Kingston in a week to check on the dizziness and talk more.  Before ending the appointment, Dr. Kingston asked Sandra about her social support and learned that she had not talked to anyone about her husband’s affair because she was so humiliated. He asked her to think about who she could talk to, and reminded her she hadn’t done anything wrong.  He also helped her recognize that people who cared about her would want to be there for her, and that keeping her situation secret did not serve any purpose.  She agreed to think about who she might confide in, and said she felt better for having told someone what she was experiencing.  She denied any intention of hurting herself or anyone else, and said she felt she would be able to manage until the next appointment.  Dr. Kingston reiterated that he was available to Sandra, and that she could call any time to talk to someone.  He encouraged her to make an appointment earlier than a week if she felt she needed it. 



This vignette is typical in a number of ways.  First, the patient’s presenting concern was a somatic symptom commonly associated with stress.  Second, the patient did not disclose life stressors until specifically asked about them.  Third, the patient had little to no interest in seeing a mental health professional.  Fourth, the physician experienced some internal struggle about delving into psychosocial issues for fear of what he would find and then feel compelled to deal with.  Yet, he knew he would not be doing his job if he didn’t “go there” to assess and address underlying psychosocial issues.  Fifth, the physician realized he couldn’t “fix” her problem.  Rather he focused on giving her some reassurance and some concrete things she could do to help herself cope (seeking support).  Sixth, the physician used continuity of care – a follow up appointment in a week, to manage Sandra’s concerns without spending an enormous amount of time that was not allotted in his schedule on this day.  Seventh, he ruled out suicidality and homocidality.  Finally, he attempted to support Sandra by emphasizing his availability. 


Not all primary care providers are as astute and skilled as Dr. Kingston.  There are many who would have simply ordered the tests, provided some reassurance but not delved into her psychosocial situation.  There are many reasons for this – lack of training, time, and interest for some.  One of the biggest reasons primary care providers avoid psychosocial issues is the reality that they do not feel able to help patients with stress themselves, AND feel unable to easily connect the patient to a mental health specialist.  Because the process of referring patients for mental health care tends to be more difficult than referrals to medical specialists, primary care providers do not have the same level of “back up” on complex psychosocial issues that they do on complex medical issues.  Also, the post-referral communication between mental health professionals and primary care providers tends to be problematic.  The sources of these difficulties will be discussed in more detail later.


Patient Centered Medical Home and Mental Health Care


Over the last two decades the concept of the “patient centered medical home” has gained prominence.  Some mental health professionals take umbrage at the term, preferring “health care home.”  We will use the “medical home” term because it has been in use since 1967 (American Academy of Pediatrics, 1967), and because the term has gained traction in the health care reform debate in a way that “healthcare home” has not.  The concept was defined by the American Academy of Pediatrics, American Association for Family Practice, the American College of Physicians and American Osteopathic Association in 2007 to include the following elements:


An ongoing relationship with a personal physician who provides continuous and comprehensive care.


Multi-disciplinary care teams that share responsibility for patient’s ongoing needs.


Whole person health care


Coordination and/or integration of care across all levels of healthcare provision (e.g. inpatient, outpatient, specialty care, primary care)


Use of practice management systems such as patient registries, electronic health records, and health information exchanges to improve access to care and care provision. 


How is this relevant to mental health professionals?  Basically, to be successful, a medical home must integrate behavioral health into primary care practice.  In some settings this entails having mental health professionals on site to provide services as part of a care team.  However, this level of integration is not feasible in all settings, and current reimbursement structures preclude true integration in most private healthcare settings (Bachman, Pincus, Houtsinger, 2006; Goldberg, 1999, Kausch, Mauch, & Smith, 2008).  However, even in settings where integration is not currently feasible, the medical home still advances the centrality of behavioral health issues in medical care.  Medical professionals who strive to meet the standards of care outlined in the medical home concept will need assistance from mental health professionals because the behavioral health needs far outstrip their expertise and time.  But, mental health professionals must learn to work in a way that enhances care, and begin to work as part of a larger care team.


The Prevalence of Mental Health Issues in Primary Care


Most mental health professionals are not aware that the vast majority of mental health care occurs in primary care.  In 1978, Regier, Goldberg & Taube declared that “Primary care is the de facto mental health system.”  Their work indicated that most people who needed help with emotional issues never darkened the doorstep of a mental health professional. Little has changed in the decades since; consider the findings summarized in Table 1.



Table 1. Primary Care and Mental Health Treatment



Primary care medical professionals prescribe 60 – 70% of the psychotropic medications prescribed in the United States (Lewis, Marcus, Olfson, Druss, & Pincus, 2004; Miranda, Hohnmann, & Attikisson,  1994)


68% of people with a diagnosable mental health condition seek assistance in primary care, while only 28% of these patients seek assistance from a mental health professional (Miranda et al 1994).


Among people who evidenced mental health and/or substance abuse issues via structured diagnostic interview, only 41.1% received any treatment for their difficulty in the past 12 months.  12.3% were treated by a psychiatrist, 16% were treated by a non-psychiatrist mental health provider, while 22.8% were treated by a general medical provider (treatment could be from multiple sources) (Wang, Lane, Olfson, Pincus, Wells, Kessler, 2005).


A National Mental Health Association survey indicated that 32% of healthy respondents would approach a primary care provider if they experienced a mental health issue, while only 4% would seek help from a mental health professional (NMHA, 2000).


89% of primary care patients diagnosed with depression desire counseling from their primary care provider, but only 11% desire a referral to a mental health professional (Brody, Khaliq & Thompson, 1997). 


80% of patients with a diagnosable mental health condition will visit a primary care provider at least once a year (Narrow et al).


50% of all behavioral health disorders are treated in primary care (Kessler, Demler, Frank, Olfson, Pincus, Walters, Wang, Wells, & Zaslavsky, 2005).   



These data points show that primary care is the “entrance” to the health care system for both physical and psychic distress.  Further, many people, regardless of their current mental health status, do not view the mental health treatment system as a resource they would access. 


Mental health issues and treatment are important in primary care not only because they are common.  There are four other factors that highlight the centrality of mental health issues in primary care and these are highlighted in Table 2.



Table 2. Mental Health Issues in Primary Care



There is a documented relationship between chronic illness and mental health.  Chronically ill people are more likely to suffer from emotional distress (Kato, Sullivan, Evengard, & Pederson, 2006).  Further, chronically ill patients who evidence mental health issues have poorer outcomes (Blount, 2003). 


People with depression have higher healthcare costs than patients who do not have mental health issues (Welch, Czerwinski, Chimire, Bertisimas, 2009).  It is estimated that 30% of primary care visits are for psychosocial issues (Kessler et al 2005; Robins & Regier, 1991). 


Primary care providers cannot find organic etiology for symptoms in 25 – 50% of all visits (Khan, Khan, Harezlade, Tu, & Kroenke, 2002), with rates of 80 – 90% for some presentations (Bleijenberg & Fennis, 1989; Kroenke & Mangelsdorff, 1989).  In the absence of organic etiology they know how to treat, primary care providers must try to either help the patient cope with the symptoms, or discern how stress and other psychological factors may play a role in the symptom profile.


Most of the causes of preventable death and poor health in the United States have behavioral precursors.  It is estimated that 40% of the Americans who die prematurely do so primarily because of behavioral issues (e.g., smoking, alcohol and drug use, etc.) (McGinnis & Foege, 1993; MokdaD, Marks, Stroup, & Gerberding, 2000). 



The Costs of Untreated Mental Health Disorders


The cost of untreated and undertreated mental health disorders goes far beyond the direct health implications.  Aside from the cost of treating these disorders, one must consider the disability costs, impact on productivity, and impact on the productivity of family members affected by a loved one’s mental illness or addiction.  The following statistics are from Hertz & Baker 2002, Loeppke, Taitel, Haufle, Parry, Kessler & Jinnett, 2009, and Edington & Burton, 2003. 


As noted earlier, chronically ill patients with co-morbid depression tend to seek more, and costlier, treatment.  It has been estimated that untreated mental disorders in medical patients with chronic illness cost commercial and Medicare purchasers alone between $130 billion and $350 billion annually in additional health related, mostly general medical, expenses.  This is in addition to the direct care costs of mental health and substance abuse treatment costs.  Direct care costs totaled $104 billion in 2001, representing 7.6% of total healthcare spending in the United States.


Unlike other medical conditions, the indirect costs associated with mental illness and substance abuse disorders commonly meet or exceed the direct treatment costs. Approximately 217 million days of work are lost annually due to productivity decline related to mental illness and substance abuse disorders, costing US employers $17 billion each year. 


Mental illness and substance abuse disorders are represented in the top five causes of disability among people age 15-44 in the United States and Canada. Combined as a group, mental illness and substance abuse disorders are the fifth leading cause of short-term disability and the third leading cause of long-term disability for employers in the United States. Employees on disability for mental health issues have 44% more lost time than employees who had no depression treatment during their disability leave.  On average, a disability leave for depression costs employers $3,408 more per case than other sources of disability. 


The Case for Collaboration and Integrated Services


The Status Quo – and the Problems it Causes


People who need psychotherapy and mental health treatment are often very ambivalent about initiating treatment.  In the primary care setting, patients often present their distress in a somatic symptom, and may or may not have insight that emotional issues or stress are causing or exacerbating their symptoms (Goldberg & Bridges, 1988).  These situations are a tall order for a primary care provider.  In order to successfully treat the patient the primary care provider must address issues outlined in Table 3.   



Table 3. Tasks for the Primary Care Provider



·         discern that stress or emotional issues are present

·         make a link between the stress and the patient’s symptoms

·         carefully investigate the patient’s level of insight and acceptance of a role for stress in their presentation

·         ensure that all biomedical causes are treated appropriately

·         help the patient consider treatment options for their emotional distress. 



Given that the typical primary care encounter is 15 minutes or less, it is a small miracle that these issues are ever dealt with in any way.  In fact, a 2005 study by Wang, Bergland, & Olfson indicated that the latency between onset of symptoms and initiation of treatment averages 6-8 years for depressive disorders and 9-23 years for anxiety disorders.  Further, research indicates that such issues often receive suboptimal treatment in the primary care setting (Katzelnick, Kobak, Greist, Jefferson, & Henk, 1997; Simon, VonKorff, Wagner & Barlow, 1993).  Clearly, the detection and treatment or referral of these issues from primary care is problematic.


Unfortunately, the problems don’t stop there.  Even when a primary care medical provider detects emotional issues and has a successful dialogue with the patient about referral, patients often do not want to seek psychotherapy (Brody et al., 1997).  Primary care providers often must expend a great deal of time and effort just to get the patient to agree to seek psychotherapy. Once the patient does agree to seek psychotherapy they often encounter numerous systemic access to care barriers as summarized in Table 4.



Table 4. Barriers to Mental Health Referral



Challenges finding a mental health provider who takes their insurance


Challenges finding a mental health provider who is available in a timely fashion


Difficulty affording typical mental health treatment co-pays


Long waiting lists in public mental health care settings


Lack of knowledge regarding how to find a therapist appropriately trained to help with their specific type of problem


Lack of knowledge about what to expect from psychotherapy and appropriate expectations for progress in psychotherapy



These very real barriers, coupled with the ambivalence that many patients feel about entering psychotherapy, and the reality that patients suffering from depression or anxiety may find the task of overcoming these barriers daunting, result in poor follow through rates for psychotherapy referrals.  This is a source of great frustration to primary care providers, who then must do their best to manage the situation alone. 


The problems with the status quo don’t stop once a patient has managed to follow through on the referral to a mental health professional.  Many mental health professionals do not communicate, or communicate only minimally, with primary care professionals (Chantal, Brazeau, Rovi, Vick & Johnson, 2005).  This is in stark contrast with communication by other specialists.  Typically, when a primary care provider sends a patient for specialist consultation, the specialist responds with a summary of the consultation, including diagnostic impressions and treatment recommendations.  Depending on the situation, the specialist may provide ongoing care to the patient, may begin treatment to be followed by the primary care provider, or may make recommendations for the primary care provider to implement.  In essence, there is a general sense that the primary care provider should at least be informed, if not centrally involved, in the care the patient receives post consultation.  Primary care providers are very frustrated when they don’t get this level of information from mental health professionals, referring to mental health as a “vacuum” into which their patients simply disappear. 


It is not difficult to imagine why this lack of communication between mental health and primary care providers is problematic.  The primary care provider continues to care for the patient without the input of the mental health provider.  They are “left in the dark” about the patient’s mental health diagnosis, treatment plan, treatment progress, and even if the patient has followed through on the referral and/or continues in treatment.  By not communicating, mental health professionals essentially separate the mind from the body – exactly what many accuse the medical community of doing. 


This lack of communication becomes even more problematic when the patient is taking psychotropic medications prescribed by the primary care provider, has a chronic disease, or whose health is affected by their psychological functioning.  While one could argue the last group includes everyone, it is particularly true for patients who have suffered trauma (Brown, Schrag, & Trimble, 2005; Green & Kimmerling, 2004), patients in domestic violence situations (McCauley, Kern, Kolodner, Dill, Schroeder, DeChant, Ryden, Bass & Derogatis, 1995), and patients who tend to express psychological distress somatically.  The following case example illustrates a typical referral process, and how the lack of communication can be problematic.



Case Example



Brenda was a 35 year old bank executive who presented to her primary care physician with headaches.  Although she believed her headaches were secondary to stress, she wanted to “get checked out” to make sure that there wasn’t anything else wrong.  Her primary care provider, Dr. Hyden, reassured her that her description of her headaches was consistent with stress induced headaches.  However, he could tell that she wasn’t completely reassured.  They negotiated that he would order a few tests to rule out her fear that she had a brain tumor, and that he would see her back.  Two weeks later, Brenda returned to the office to review her test results.  Her tests were normal.  Dr. Hyden probed more about Brenda’s stress level.  During this conversation, Brenda disclosed that she was stressed at work because she had a new boss who she felt didn’t like her.  The bank was likely to lay people off in the next few months, and Brenda felt certain she would be let go.  Initially she claimed this was really the main stressor in her life.  However, after Dr. Hyden probed about her home situation, Brenda shared that the relationship between she and her husband was becoming strained because he wanted to start a family and she did not feel ready.  They had tried to have a baby for many years with no success.  About one year prior, Brenda had started infertility treatment, conceived, but then miscarried the baby.  The disagreement had adversely affected their sex life, which had been basically non-existent for the past six months. Dr. Hyden expressed his condolences, and asked Brenda if she would like to talk more about the situation.  Brenda agreed to come back to see Dr. Hyden to talk about her situation.  Dr. Hyden did offer a psychotherapy referral, but Brenda did not want to see a therapist.


Dr. Hyden saw Brenda four times over the next three months, in part to follow up on her headache status, and in part to offer her supportive care.  Brenda was laid off from her job.  The stress between Brenda and her husband increased because of the financial pressure, and because her husband hoped she would recommit to the infertility process now that she didn’t have work commitments.  Brenda did not know how to tell her husband that she wasn’t sure she would ever go through infertility treatment again.  Dr. Hyden recognized that Brenda was becoming increasingly depressed.  She acknowledged that she couldn’t sleep, couldn’t concentrate, didn’t enjoy anything, wanted to socially isolate herself, and often felt tearful.  Brenda’s headache frequency and intensity increased during this time, and she kept asking Dr. Hyden if she was sure that she didn’t have a brain tumor.  Dr. Hyden started Brenda on an antidepressant, and pressed the issue of psychotherapy because she felt that Brenda’s concerns were beyond the type of supportive psychoeducation she could offer.  Brenda did not want to see a therapist, as she didn’t see the point and was worried about the co-pay after her loss of salary.  Dr. Hyden negotiated with Brenda that they would meet every week for six weeks.  This would give the anti-depressants time to begin working.  If Brenda didn’t feel better after those six weeks, she would seek a therapist.


Six weeks later Brenda was feeling worse.  While she was sleeping (thanks to the anti-depressant) she was feeling more desperate and depressed than before.  She had withdrawn from her husband, who had called Dr. Hyden greatly concerned about her.  She had not felt able to seek new employment, convinced it was hopeless.  She had started to spend a great deal of time thinking about what a failure she was – she couldn’t keep a job, couldn’t get pregnant, and was a terrible wife.  Her headaches occurred daily and were debilitating.  She dealt with her headaches by taking an over the counter pain reliever and laying in bed in a darkened room for hours each day.  She acknowledged that she sometimes wished she could just “go to sleep and not wake up” but denied that she would ever hurt herself because of her religious beliefs.


Dr. Hyden finally convinced Brenda to see a psychotherapist.  He recommended a psychologist that other patients had found helpful, but the psychologist did not take Brenda’s insurance.  Brenda called the customer service number for mental health care on her insurance card, and was given the names of three providers in her area.  Dr. Hyden did not know any of them.  She called all three providers.  One never called her back.  One called back and said that she was currently full, but could seek Brenda in about one month.  The third agreed to see Brenda in two weeks.  Brenda made the appointment.


Brenda attended her first appointment with the therapist, Dr. Jenkins, and felt a decent connection.  She explained that Dr. Hyden had been a great support to her, and described the care he had offered.  During the initial consultation Brenda disclosed that Dr. Hyden was prescribing an anti-depressant for her, but that she did not feel it was helping her, and she believed it was making her gain weight.  The therapist asked about Brenda’s general health, and Brenda told Dr. Jenkins that she had very bad headaches.  Dr. Jenkins did not seek further information about these, and did not focus on them in the treatment. 


Dr. Jenkins and Brenda met weekly for about three months.  During this time Brenda met with Dr. Hyden monthly about her headaches.  Although Brenda made some progress in therapy around her negative thoughts about herself and in understanding how her job and marital issues were relevant to her depression, the therapist never really talked to her about the headaches.  Dr. Jenkins did elicit the history of infertility treatment and miscarriage.  She felt that the loss of the pregnancy was a big factor in Brenda’s depression, and did a fair amount of grief work around this loss.  They also talked about Brenda’s frustration with the weight gain she attributed to the anti-depressants.  Dr. Jenkins encouraged Brenda to talk to Dr. Hyden about these concerns, but Brenda never did because she worried that Dr. Hyden would think she was being critical or unappreciative of the help Dr. Hyden had given her.  Ultimately, Brenda simply stopped taking the anti-depressants because she wasn’t sure they helped and didn’t want to gain weight.


Brenda felt that psychotherapy had been of some help, but she decided to stop attending therapy because she could no longer afford the co-pay.  Dr. Jenkins had helped her deal with her marital situation more directly, and talk to her husband about her fears of going through further infertility treatments. Her headaches were somewhat less frequent and less intense, but they still were an issue in her life.  She was afraid she wouldn’t be able to hold down a job because of the headaches.  Yet, she felt that she would just have to learn to cope with them.  Dr. Hyden was unaware that Brenda had stopped psychotherapy until about two months later when she inquired about therapy progress as part of an encounter focused on the headaches.  Brenda felt that she was no better or worse than when she had been in psychotherapy and therefore was unwilling to return to Dr. Jenkins or try another therapist.



This case is typical in many ways.  Brenda sought help in primary care when she was in distress.  She initially used a somatic “ticket in the door” to address her distress, but had some insight as to the role of stress in her headaches.  Yet, she worried that the headaches might be due to something more serious, and was only somewhat reassured by the benign test results.  These worries ultimately became more troubling as she grew more depressed and ruminative.


Brenda’s primary care provider attempted to provide biopsychosocial care.  Dr. Hyden was able to see her regularly because she had a physical symptom to “justify” the visits.  She provided Brenda with support and information, while attempting to set the stage for a referral to a mental health professional if needed.  She gave Brenda psychotropic medication when she felt Brenda’s condition was worsening, in part because she didn’t know what else to do.


Brenda was reluctant to seek psychotherapy.  Yet, when her primary care provider communicated that she felt it best that Brenda seek psychotherapy, Brenda did follow through.  She met road blocks in this process, which might have completely stopped another patient.  If anything, Brenda’s entrance to the mental health system in this scenario may have been optimistic if not unrealistic.


Brenda found a therapist that she felt good about on the first try, and had an initial consultation only a few weeks after starting the search for a therapist.  Dr. Jenkins did ask about her general health, but did not focus on the headaches, per se.  Dr. Jenkins did not communicate with the primary care provider, even when Brenda had indicated that Dr. Hyden had been the source of the referral and had treated her for the depression.  Also, as is often the case, Dr. Jenkins put the responsibility for communicating with Dr. Hyden on Brenda’s shoulders.  She coached Brenda to talk to Dr. Hyden about the weight gain, but did not initiate contact herself.  Finally, while her focus on the infertility and miscarriage was helpful, it illustrates how many mental health professionals only will talk about health matters that have obvious mental health implications (e.g., miscarriage).  Many mental health professionals tend to underestimate how much medical conditions (such as headaches) affect mental health.


How might Brenda’s care have been improved by collaboration and communication between Dr. Hyden and Dr. Jenkins?  First, Brenda most likely would have been comforted to know that the two people she was relying on to care for her were working together as a team.  Second, Dr. Jenkins likely would have better understood the central role of the headaches and might have focused on them more directly.  Third, Dr. Hyden would have learned that Brenda felt only a mild improvement from the antidepressants, and that Brenda felt that the negative side effect of weight gain was greater than the benefit she was obtaining.  Dr. Hyden could have tried a trial of another antidepressant, or referred Brenda to a psychiatrist for consultation.  If Dr. Jenkins had told Dr. Hyden that Brenda had terminated psychotherapy prematurely, Dr. Hyden could have used her influence to encourage Brenda to continue, or could have further explored why she had stopped attending sessions.  At the very least, Dr. Hyden could have monitored Brenda’s situation more closely from that point.  This basic, “run of the mill” case might have had a much improved outcome, if only the two professionals had taken the time to communicate. 


The Benefits of Collaboration


Brenda’s case illustrates many ways that collaborative care can improve treatment.  These benefits to clinical care include, but are not limited to elements listed in Table 5.



Table 5. Treatment Benefits of Collaboration



Primary care professionals are often the source of the referral and have important information regarding the history of the presenting problem that may help the mental health professional prioritize issues and facilitate history gathering.


Primary care professionals often have a long-standing, significant relationship with patients they refer.  They can use this relationship to support the psychotherapy. 


When primary care and mental health professionals communicate with each other, they can ensure that the patient is getting similar messages from both types of professionals, strengthening the messages.


Mental health treatment focus and progress has implications for medical treatment and vice versa.  Collaboration allows professionals to synergize each other’s care.  It allows each professional to understand the patient from multiple perspectives, and to be aware of how their care in the other setting might affect the care in their own setting.  A lack of collaboration can be problematic when there is overlap or cross over in the two treatments that are at cross purposes, or when there is not information sharing on relevant issues.


When the primary care provider is prescribing psychotropic medication, it is very helpful for them to have input from the mental health professional regarding the success of this treatment and patient experiences of side effects.  Often, patients themselves do not recognize when they are improving, while the mental health professional can share observations regarding the impact of medication care.


In a parallel fashion, the patient’s medical care and functioning has direct impact on their psychological wellness.  It can be very helpful, if not critical, that the mental health professional understand that patient’s overall health status. 


Adherence with treatment is a common issue.  Mental health professionals can help primary care providers understand the psychology behind non-adherence with medical regimens, and suggest ways to help the patient become more successful in self-management of medical issues.  The adherence issues themselves can become a focus of psychotherapy, when appropriate.


Collaboration helps professionals avoid “splitting” where the patient pits one professional against another, or complains about one provider to another.  The professionals can work together to avoid this situation via direct communication with one another.  Sometimes, patients do have a “bad match” with their primary care or mental health provider.  In a collaborative situation, direct experience with the other provider will reveal this “bad match.”  Ideally, the collaboration will include a direct discussion of the issue and an agreement that the patient seek care from another provider to improve the care.



Collaboration creates teamwork between healthcare professionals that can be very reassuring to patients.  Collaboration can also be helpful to mental health and primary care providers themselves.  These benefits are summarized in Table 6.



Table 6.  Professional Benefits of Collaboration



Collaboration can help professionals avoid burn-out with especially difficult patients or situations.  Burn-out often results from feeling overwhelmed by a situation, or feeling unable to help.  Established collaborative relationships give the providers themselves a built in “support” in the other provider.  In addition, it gives each provider a resource – another person who knows the situation, has a relationship with the patient and may provide perspective when things get frustrating.  Providers can bounce ideas and perspectives off of one another to think through options and facilitate comprehensive care.  Finally, it can be very helpful to have another professional with whom to review the situation when patients are in crisis and may need a more intensive level of care. 


Collaboration can reduce the sense of isolation mental health professionals’ experience, especially those in independent, solo practice.  The sense of “shared care” can be reassuring to the professionals as well as to the patient.


Collaboration can help primary care providers’ link patients with mental health professionals.  A psychotherapy referral has been likened to a “blind date.”  The primary care provider has to convince the patient to seek care, that they’ll “like” the mental health professional.  This is much easier for them to do if they have an established relationship with a specific psychotherapist and can reassure the patient that other patients who have worked with this specific mental health professional have met with success.  This facilitates the referral, and may help the patient and mental health professional establish a therapeutic alliance, which has been linked to improved outcomes in psychotherapy (Gabbard, Beck & Holmes, 2007).


Establishing collaborative relationships can help mental health professionals establish a referral network and build their practice.  As noted earlier, primary care providers see a lot of patients each day, a high proportion of whom have mental health concerns.  Because collaboration is not the norm in many areas, a mental health professional who does collaborate will “stand out from the crowd.”  Primary care providers want follow up information about their patients who seek mental health care.  If one mental health professional communicates with them and another does not, one can guess which person they’ll recommend to patients seeking mental health care in the future.  Communication between specialists and primary care providers who share patients is the norm in the medical care – collaboration between mental health professionals and primary care providers is simply an extension of this norm. 



Barriers to Collaboration


Even though most patients want their mental health professional and primary care provider to collaborate, this does not occur commonly.  So why isn’t collaboration the norm in mental health?  There are many reasons, most of them based in how mental health and medicine traditionally have had separate training, separate treatment and research systems, separate reimbursement structures, and very different cultures (Seaburn, Lorenz, Gunn, Gawinski, & Mauksch, 1996).  The three most commonly cited barriers are concerns about confidentiality, time constraints, and a perception that medical professionals do not value mental health input (APA survey, 2006).    


Confidentiality:  Many mental health professionals fear that patients themselves will be offended or put off by the request for a release of information to the primary care provider.  Confidentiality is a cornerstone of mental health treatment and culture.  Mental health professionals fear that patients will not feel comfortable disclosing sensitive information if that information might be shared with others.  Others express concern as to how mental health information will be used in medical settings, secondary to perceptions that medical professionals are less sensitive about privacy concerns or may use the information in an insensitive manner.  These provider beliefs continue, despite research that shows that team care results in improved outcomes, particularly in chronic disease management (Wagner, 2000).


Time Constraints:  Busy schedules are both a perceived and real barrier, particularly in light of the reality that neither party receives reimbursement for time spent collaborating.  Unfortunately, busy medical and mental health professionals can be very difficult to reach, expanding the time it takes to make collaboration happen.  Yet, those professionals who take the time to develop an ongoing relationship report that they feel the time is well spent.  A 5 – 10 minute consultation can save enormous time and frustration in patient care encounters, providing much needed contextual factors in treatment and ensuring that both providers are on the same page. 


Devaluation of mental health input by medical professionals:  Mental health professionals also express concern that their input is not valued by medical professionals.  In the 2006 APA survey, one respondent expressed this common concern by stating, “Most physicians seem very impatient when they are contacted by phone, even though I keep the contact short, organized and try to speak their language.” (Ruddy, Borresen & Gunn, p. 33).  Clearly, medical professionals fall along a continuum of interest in the interplay of mental health and physical health, and in the level of respect they have towards mental health professionals.  Yet, many mental health providers would be surprised to learn that a survey of family physicians indicated that 13.5% already have mental health professionals providing services in their office, and an additional 60.2% indicated they value collaborative care to the point they would consider having an in house mental health professional (Chantal, Brazeau, Rovi, Yick, & Johnson, 2005).   A significant percentage of primary care providers so value mental health input they either have, or are interested in having, a mental health professional as part of their team.

Overcoming Barriers to Collaboration


Routine Collaboration Practice and Clinical Strategies


Establishing professional relationships with specific primary care professionals greatly mitigates most of the barriers to collaboration.   It is easier for a mental health professional to trust that sensitive information will be managed appropriately when they know the medical provider from previous collaboration.  Established collaborators know the best methods and times to reach one another for consultation, reducing the time barriers.  Finally, a medical professional who engages in an ongoing collaborative relationship obviously values the input of the mental health professional, and likely will encourage patients to seek services from the mental health professional(s) who they know.


So, how does a mental health professional go about contacting primary care professionals to set the stage for collaboration?  This section reviews specific strategies for creating and maintaining collaborative relationships.  A more specific review of these strategies, including forms that facilitate collaboration, can be found in The Collaborative Psychotherapist (Ruddy et al., 2008).


Initiating Collaboration:  Creating Opportunities


The easiest way to begin to establish collaborative relationships is to reach out to the primary care providers of current and recent patients.  Phone contact may seem the most direct, but calls can be frustrating because it can be so hard to connect.  Also, in many primary care offices, front desk staff view themselves as “protectors” of the providers’ time and may make direct contact a challenge. Unfortunately, this combination can make even the most motivated mental health professional throw up their hands, or at least feel highly unwelcome. 


The first time you attempt to contact a potential partner in collaboration, send a letter of introduction that very briefly reviews information about the patient you share including diagnosis, length and course of treatment and the anticipated termination date.  Indicate a desire to collaborate, and that you will contact the provider by phone in short order.  Ask them to notify the front desk that you will be calling so they can put the call through.  Also, ask that they leave you a voice mail if there is a specific time or alternate phone number (e.g., the office’s “private line”) that would facilitate connecting.  It is critical that the letter is no more than one page. 


A few days after the provider would have received the letter, place a phone call.  Do not take it personally if the provider is not anticipating your call or does not remember your letter.  While all incoming patient care documentation is reviewed by a provider before it is filed, the incoming documentation in a primary care office is voluminous.  Each primary care provider has primary responsibility for literally hundreds (and in very busy practices, thousands) of patients.  It is not realistic to expect the provider to remember every paper they review.  So, why bother with a letter?  It increases the likelihood that the call will be productive.  If the patient regularly visits the provider, or if the provider had concerns about the patient or initiated the referral, they are much more likely to remember the specifics.


Just getting through to the primary care provider can be a struggle.  There are a few strategies that can help and these can be seen in Table 7. 



Table 7. Establishing Contact with the Primary Care Provider



When you call the office, introduce yourself, using “Doctor” if appropriate.  The front staff can seem like guards at a gate, but they are trained to process calls from other doctors quickly.  If the phone message has a “if this is a doctor calling” option, choose this option, even if your title is not doctor.  This is appropriate because this option is intended to facilitate communication from other providers who share care with the primary care provider. 


When a front desk person answers the phone say, “This is X, and I see Dr. Y’s patient, Z.  I would like to talk with Dr. Y about Z.  Is he/she available?”  If you are told that Dr. Y is with a patient you can either leave a message or ask that Dr Y be interrupted.  This is a judgment call, based on how urgent it is that you speak with the primary care professional, and on how difficult it has been to reach him or her.  If you do interrupt the patient care session, explain that you need to talk with him or her soon, or that you have had a very difficult time reaching him or her. 


Offer to arrange a time to speak later, unless the call is emergent.  Don’t be surprised if the primary care professional is willing to speak to you briefly, because interrupting patient care sessions for brief consultation calls from other professionals is commonplace in primary care. 


When you reach the primary care provider, ask them if they have a few minutes.  If they cannot spare more than a few moments, briefly state that you want to collaborate on this patient and ask to arrange another time to talk.  If they have a few minutes, briefly share your sense of the patient’s diagnosis and treatment plan.  Take no more than a few minutes to do this, and don’t go into any great detail. 


Ask if the primary care provider has any specific concerns, and if they want to talk more than they have time for at this moment.  The response you get will depend both on the patient situation and the primary care provider. 


If the patient has been challenging to the provider, they prescribe psychotropic medications, or have a poorly managed chronic condition, the medical provider will likely want to talk more.  If not, they may end the call quickly, as there is no immediate pragmatic value to talking more.  Again, don’t take this personally.  First, many primary care professionals are very surprised when they hear from a mental health professional because it happens so rarely.  Second, because collaboration is not the norm, they may not know what they need from you.  Third, there is such intense time pressure in primary care that providers typically try to keep interactions focused and pragmatic.  Once the conversation has served its purpose the primary care provider has to move on to the next task or risk running behind all day. 


Before ending the conversation, ask how they want to collaborate on this particular patient going forward.  The options range from being informed when treatment ends (very little collaboration) to regular updates regarding the patients progress.  Also, ask if they would prefer these updates be via a phone conversation or in writing.  Again, because many primary care professionals have little experience collaborating with mental health professionals it may be helpful to present this range of options. 



Follow up the phone call with a brief note thanking the medical professional for their time, documenting the patient information that was discussed in the call, and reviewing the level of collaboration that will follow.  Again, include business cards with this letter to facilitate further referrals. 


It is imperative that you follow up with the primary care professional in the way that was discussed during the call.  For many clinical presentations, a letter at termination is sufficient.  This is true for situational stressors (e.g., divorce, job loss, etc) and when the patient does not have any ongoing health concerns or does not take psychotropic medication.   Regular updates should occur for patients who obtain psychotropic medications from the primary care professional, or who have chronic health concerns.  When and how more intensive collaboration occurs will be reviewed in a later section.


Establishing a Collaborative Relationship


Simply collaborating on one patient is unlikely to establish a collaborative relationship, particularly when little follow up is needed. There are a number of strategies you can use to assess the medical professional’s interest in collaboration, and to create other opportunities for establishing an ongoing relationship with them.  These can be summarized as follows in Table 8 and are discussed in more detail subsequently.



Table 8. Overview of Strategies to Develop Collaborative Relationships


Get a sense of the medical professional’s interest in establishing a referral relationship.


Try to focus on medical professionals who regularly refer for mental health services, appear to value and focus on mental health and psychosocial concerns in their practice, and want to collaborate


When you have identified a primary care professional who seems interested in collaborating, ask if they would like to meet in person to discuss working together more in the future


During this meeting ask the providers if they have any other challenging patients they would like to discuss


Anticipate expending effort and time to initiate contact and determine the medical provider’s interest in collaboration. 


As you seek potential partners in collaboration, take into account geography.  Seek out professionals near your practice.


If you have an area of specialty that might be of interest to medical providers, contact their local or county professional organization and offer to present on the topic. 



First, try to get a sense of how interested the medical professional is in establishing a relationship.  If they never refer to you again and want only notification of termination, they may not be terribly psychosocially oriented, or may already have a mental health professional to whom they refer.  Use your sense of how receptive they were to the initial call to gage interest in collaboration.  If you see that you get more referrals from that provider, the sharing of multiple patients creates the opportunity for greater collaboration.  Also, if you share a particularly challenging patient situation and communicate often it is likely a relationship will develop.


Try to focus on medical professionals who regularly refer for mental health services, appear to value and focus on mental health and psychosocial concerns in their practice, and want to collaborate.   All three of these characteristic fall on a continuum, and the trick is to assess these characteristics and adapt your collaboration style to the needs of the primary care provider.  Some primary care providers don’t like managing mental health issues, but recognize they are important.  These providers tend to make a lot of referrals (rather than trying to manage the situation themselves), but may not want to collaborate extensively.  Connect with these providers by emphasizing your availability and willingness to inform them of the care and involve them directly only when necessary.  Some primary care providers enjoy psychosocial aspects of care, and may have even chosen primary care because of the centrality of psychosocial issues.  They may make a lot of referrals, or may try to manage situations on their own.  These providers sometimes struggle to “let go” of patients whose needs exceed their training, and may realize the problem too late.  Connect with these providers by offering to provide pre-referral consultation to help them manage situations and to determine when a referral is necessary.  Also, they are likely to want more information from you regarding the mental health care, and may want more direct involvement.  Some of these providers even specialize in helping very complex, challenging patients.  It can work very well to establish a relationship with such a primary care professional by providing intensive collaboration such as that described in the “intense collaboration” section to follow.  At the other end of the continuum there are primary care providers who basically choose to ignore psychosocial issues.  These providers are simply not good candidates for establishing a collaborative relationship.  They are unlikely to generate referrals or to want to collaborate.  To be fair, the mental health professional who largely ignores health issues and collaboration with medical professionals is far more common than the primary care professional who ignores psychosocial issues and collaboration with mental health professionals!


When you have identified a primary care professional who seems interested in collaborating, ask if they would like to meet in person to discuss working together more in the future.  Offer to bring lunch to their office.  Depending on the size of the office consider bringing lunch for all of the providers and support staff, since it is an opportunity to network with all of them.  Recognize that support staff often facilitates referrals and having a personal connection with them may be beneficial.  It is common sense that providers are going to be more comfortable referring to a mental health provider they’ve met, especially given the reality that personality and social skills are so much of what facilitates a connection in the early stages of psychotherapy. 


During this meeting ask the providers if they have any other challenging patients they would like to discuss.  With both providers and support providers describe your practice (focus, philosophy, hours, insurances etc.).  Don’t be surprised if the support staff suggests patients to discuss because they are often aware of which patients wreak havoc in the office.  Also, expect that people will come in and out at their leisure while you’re there.  Primary care offices tend to be very fluid places, even chaotic compared to mental health settings.  So, while you may bring lunch at noon, the support staff may come in shortly thereafter, with providers coming in around 12:30 as they finish their morning session.  Some people may come in, grab food and leave, others will spend some time.  Clearly you will spend time with the provider with whom you’ve shared patients.  They may be able to encourage their colleagues to give you some time, also.  Within a given practice different providers may have very different styles regarding psychosocial issues and collaboration, so don’t be surprised when the practice partner of a great collaboration partner won’t give you the time of day.  However, because most primary care professionals do try to provide biopsychosocial care, it is unlikely that all of the providers in an office will be disinterested.


Building a collaboration network via shared patient contacts takes time.  Anticipate spending about thirty minutes per new patient to initiate contact and determine the medical provider’s interest in collaboration.  Following through from that point can take very little time, if collaboration is part of your routine.  However, each new referral is an opportunity to find a partner in collaboration.  The thirty minute investment is a small price to pay to slowly build a cadre of teammates in clinical care who will refer to you, and work in tandem with you to provide optimal care for shared patients.


Other Strategies for Building a Collaboration Network


Another factor to consider as you seek potential partners in collaboration is simple geography.  If you are in an office park look at the directories of all of the buildings for both primary care and specialists who might need to refer patients.  Make a list of all of the primary care offices in a ten mile radius of your office (more in rural areas).  Patients generally want to seek care close to home, so the geography matters.  Again, start with a letter of introduction and follow up with a phone call.  When you don’t share any patients with any medical providers in a given practice it might be more productive to call the office manager rather than one of the providers.  The office manager has a sense of the providers in the practice and may be able to advise you if the providers are likely to be interested in establishing a relationship with a mental health professional.  Emphasize that your office is close by, which insurances you take, and your willingness to collaborate.  Non-primary care specialties most likely to need to collaborate with mental health professionals are endocrinology (diabetes), cardiology (post cardiac care depression, anxiety disorders and lifestyle modifications), infertility centers (depression and marital stress), pain centers (depression and pain management) and pediatric chronic disease specialists (cystic fibrosis, etc.).  Often, cancer centers, infertility centers and pediatric chronic disease centers have mental health professionals on staff, but this is not always the case.  If the office manager or medical professional seems interested, offer to visit the office to discuss opportunities for further collaboration.  Keep in mind that specialists fall along the same continuums as primary care providers in their interest level and skill in dealing with psychosocial issues and collaboration.  Assess these factors and adapt your approach to specialists in the same way as you would for a primary care provider. 


If you have an area of specialty that might be of interest to medical providers, contact their local or county professional organization and offer to present on the topic.  The topic does not necessarily need to be “health psychology” topics.  For example, you might make a presentation to pediatricians focused on attention deficit disorder or learning disabilities.  Depression and anxiety management might be appropriate to a family medicine or internal medicine audience.  Of course, the presentation should be catered to a medical audience and ideally be very interactive rather than didactic.  Co-presenting with a medical colleague with whom you already collaborate is ideal because it creates the opportunity to discuss how sharing care has been beneficial to the medical provider and his or her patients.


If you are actively involved in your own professional organization, reach out to medical providers in your area who might be willing to present on a topic of interest to your mental health colleagues.  Any kind of “cross pollinization” between mental health and medical professionals has the potential to create greater collaboration.  At the very least it creates opportunities for medical and mental health people to interact. 


Making Collaboration Part of Routine Practice 


Collaboration starts during clinical consultation with patients.  The first step is to integrate questions regarding health, medical care, and personal and family medical history to create a full-person assessment.  This is a significant expansion of the interview focus for many mental health professionals.  Some mental health professionals may be uncomfortable asking questions about health, fearing that the patient will think they are trying to practice medicine without a license.  However, simply gathering a personal and family health history is in no way diagnosing or treating medical conditions.  This information is important to set the stage for integrated, holistic care from the very beginning of care.  Questions about health assess not only if the person seeking care may have health issues, but also assess if familial health issues are relevant to the presenting concern (e.g., caregiver stress).  Basic health information such as chronic medical conditions, troubling physical symptoms, and a medication list can help the mental health professional determine the degree to which health concerns should be a focus.  Patients should be asked when they last saw a medical provider, and the date of their most recent comprehensive physical.  If they have not had a general physical exam in the last 12 – 24 months they should be encouraged to schedule one.   Overall, the goal is both to help patients recognize the interplay between their mental health and overall physical wellness, and to ensure that the mental health professional is aware of all relevant health concerns. 


Intake forms should include information about the patient’s medical providers, including the name and number of their primary care provider.  Some patients will indicate they do not have a primary care medical provider, and this should be discussed. 


Obviously, mental health professionals must obtain consent from patients before contacting medical professionals.  When patients have an established, comfortable relationship with a primary care professional this is rarely a problem.  Preface the request for the release of information with an explanation of the reasons collaboration can enhance care, and clarification about what information will and will not be shared.  Explore any concerns the patient may have, while ensuring that the patient does not feel pressured in any way to agree to the release.  Again, this dialogue serves multiple functions.  It is helpful for a mental health professional to know the patient’s prior experiences with helping professionals.  Have they found these interactions helpful or unhelpful?  Have there been any critical incidents or breaches of trust that might affect the development of a therapeutic alliance between the mental health professional and the patient?  Patients who balk at a request to release information to their primary care provider may have had negative experiences that could be relevant to the development of a working relationship with the therapist.   Additionally, this dialogue serves to clarify to the patient what will and will not be shared with the medical professional.  All information exchange should occur on a “need to know” basis.  In other words, sensitive information irrelevant to the patient’s medical care should not be communicated.  When patients express concern about the type of information that will be shared, the mental health professional can reassure them that they will share only that information the patient has approved. 


One way to clarify information exchange is to specifically discuss collaboration communications during clinical encounters.  For written communication, co-create letters during clinical encounters to reassure an anxious patient regarding the information exchange.  This exercise serves a therapeutic purpose as well, because it creates an opportunity to discuss the focus of therapy and review the patient’s progress.  Co-creation of a letter might occur something like this (See Table 9):



Table 9. Developing a Co-Created Letter  



Therapist:  As you know, I have agreed to send Dr. Young a letter after every third session to update him on our progress.  In the letter I update him on your progress and on the focus of our work.  It is time to send that letter, and I’m wondering what you think it should include.


Patient:  Well, I think I’m sleeping better.  The medication really helped with that.  But, I still just don’t function very well during the day.  I just can’t concentrate and I feel tearful a lot.  I’m still really afraid I’m going to get fired.


Therapist:  OK, so in the letter I should say that the medication has helped with sleep, but not with concentration and tearfulness?


Patient:  Yes.


Therapist:  That isn’t exactly an optimal response to the medication.  Do you think that you and Dr. Young should talk about your dosage or a medication change to see if something else might help you more?


Patient:  Yes.  I thought it was helping at first, but lately I kind of feel like I’m backslipping and I really don’t think the medication is helping all that much anymore.


Therapist:  Do you think you should have an appointment with Dr. Young to talk about this?


Patient:  Yes.  I have an appointment with him next week, so I can talk to him about it then.


Therapist:  OK, and we’ve been talking a lot about how your mother’s death last year and your husband’s embezzlement case have contributed to the stress and your depression.  What does Dr. Young already know about this?


Patient:  He knows that my mom died, but I haven’t told him about the lawsuit.  I’m just too embarrassed, and we’re hoping that my husband can come to terms without the situation being made public.  I don’t want Dr. Young to know about that.


Therapist:  I won’t include that in the letter, but it is ok if I tell him that we’ve been doing some grief work around your mother’s death and discussing other major stressors in your life?


Patient:  OK. 


Therapist:  How have you been doing with your diet and your diabetes? 

Patient:  Not too good.  I know that I should be avoiding sugar, but I just crave it and I feel like I don’t have any willpower.  Food is one of the few things I still enjoy and it is just a comfort thing.


Therapist:  I think it is important for Dr. Young to understand that, both so he can have realistic expectations and also try and help you make better choices.


Patient:  OK. 


Therapist:  Are you taking both your diabetes and depression medications as prescribed?


Patient:  Yes


Therapist:  Good, glad to hear that.  That is really important.  Is there anything else that you think Dr. Young needs to know?


Patient:  No, I think that’s it.  Just please make it clear that I really am trying to manage my diabetes better but it’s really hard.  Sometimes I feel like he gets frustrated with me, or thinks I don’t try or understand how important it is.  I know it’s important – my mom died from diabetes complications.  But I just can’t always do what I know I should.


Therapist:  I know it’s really hard, and I think Dr. Young understands that, too.  We will work as a team, you, him, and I, to try to get you back on the right track with all of this.  I know you also wanted to talk to your husband about starting to exercise together because you’re worried about him, and you know it would be good for you.  I really support this idea, because exercise is also a natural antidepressant.  Can I tell Dr. Young that your husband is going to come to a session so we can talk about this?


Patient:  That’s fine as long as you don’t tell him about his legal problems. 



The resulting letter might be something like that seen in Table 10.



Table 10. Example Letter to Referring Physician



Dear Dr. Young,


Thank you for your referral of Kristine Franks (DOB: 11/19/64).  As you know, she has been struggling with depression for approximately six months after the loss of her mother and other life stressors.  You are currently prescribing Prozac for her.


Ms. Frank has attended six psychotherapy sessions since her referral two months ago, most recently on 3/6, 3/20, and 4/7.  Ms. Frank reports that the medication has helped her sleep, but had little impact on her ability to concentrate and function during the day, particularly at work.  Ms. Frank reports that the medication does not seem as helpful, and has scheduled an appointment to discuss this further with you.


Unfortunately, Ms. Frank has found it difficult to implement dietary changes to improve her diabetes.  She has stated that she feels too overwhelmed to make these changes now, although she realizes these are very important. We will continue to discuss how healthy lifestyle will improve both her diabetes and depression.  Her husband is coming to our next session to discuss how they can work together to begin an exercise routine and help each other become more healthy.


Ms. Frank currently attends appointments every two weeks.  I anticipate that she will continue to do this over the next few months.  As per our agreement, I will send you another update after three more sessions.  However, if you would like to discuss her situation before then you are always welcome to call to request more information or arrange a time to talk.


Again, thank you for this referral and I look forward to working with you to help Ms. Frank and any other patients you feel may benefit.  I have enclosed my business card for your convenience.



Using in-session time can significantly reduce the amount of time such a letter takes to create.  In ongoing cases, or very simple presentations, a form letter can be used.  Creation of such form letters further saves time and streamlines communication.  The information found in Table 11 is critical to include in letters.  Brevity is the key; only exceed one page in very complicated situations.



Table 11. Example Outline of Referral Letter



Patient name and date of birth:  Primary care practices are large enough that they often have more than one patient with the same name.  Including the date of birth ensures that the letter will be put in the right patient’s chart.


Referral issue: A very brief description of the referral issue


Treatment issues:  Length of treatment to date and most recent appointments


Brief review of symptoms:  This can be done in a checklist format, which can be helpful to include in a form letter.  You indicate which symptoms are present, if they have improved, worsened or stayed the same since the last communication, and which symptoms are most troubling to the patient.  Medication impact should be specifically addressed, and any medication side effects should be reviewed, especially if they are troubling to the patient to the point that the patient is considering discontinuing the medication.


Brief review of health related information:  If the patient takes medication or has a health regime specifically ask the patient if they are following their treatment plan.  If they are not it is important to convey this information to their medical professional.


Treatment plan:  A brief review of psychotherapy treatment plan, including frequently of anticipated appointments, should be included.  When possible, include an estimate of the length of overall treatment.  If termination is nearing, include this information.


Working together.  Review the collaboration agreement, and indicate when the medical professional can anticipate further communication.  Include your business card to facilitate communication. 



Communication can occur via letters, scheduled phone consultations, or e-mail, with the appropriate HIPPA protections in place.  As electronic health records become more commonplace, they may well facilitate communication and information sharing (Richards, 2009).


Even in the most basic of presentations it is critical that you tell patient’s medical professionals when treatment has terminated.  The medical professional needs to know that care has stopped.  When the termination is not mutually agreed upon, letting the medical professional know the patient has stopped treatment allows him or her to reach out to the patient and try to understand why they have decided to discontinue therapy.  Depending on the situation, they may encourage the patient to return to see you, or another provider.  If the patient does not want to continue therapy, or cannot for financial or others reasons, the medical professional can ensure that the patient has some kind of regular follow up and support to help them maintain therapeutic gains.  This example of a letter regarding an unplanned termination can be found in Table 12.



Table 12.  Example Letter Regarding Unplanned Termination



Dear Dr. Michaels,


As you know, I have been seeing your patient, John Simpson (DOB:  12/27/60) in psychotherapy since January.  Mr. Johnson did not come to a scheduled appointment on March 21, and has not responded to two phone messages regarding rescheduling.  I am not sure why he is not continuing in psychotherapy, but I felt it was important for you to know.  I would welcome Mr. Simpson back into my practice if he feels I can be of further assistance, and of course will understand if he seeks treatment with another provider.  When I last saw Mr. Simpson he was not having any critical symptoms such as suicidality, so there is not great urgency to contact him.  Again, I hope I can be of further assistance and welcome any feedback you might have for me regarding Mr. Simpson’s care. 



When the termination is agreed upon, the medical professional can offer to see the patient some time after therapy has ended to ensure that they feel comfortable with the support of psychotherapy.  Also, they can be alerted of “early warning signs” that the patient is having difficulties again.  The letter should briefly review the referral issues, length of therapy, primary focus (including any health related issues), status at termination, and “warning signs” of relapse.  Table 13 shows a sample letter for a planned termination.



Table 13. Example Letter Regarding Planned Termination



Dear Dr. Michaels,


Thank you for referring John Simpson (DOB: 12/27/60) to my practice in January.  At that time Mr. Simpson had visited the emergency room for chest pain six times in one year with no evidence of cardiac problems.  Both you and he felt that he had difficulties with anxiety and possibly panic attacks. 


Mr. Simpson attended 12 appointments over six months.  During this time we focused on helping Mr. Simpson make a connection between his physical symptoms and anxiety.  He readily acknowledged that his chest pain often followed stressful events, and that his extensive medical tests revealed no cardiac problems.  We then moved on to develop anxiety management strategies including relaxation techniques and cognitive behavioral strategies to manage his fears of a heart attack.  It was very helpful when you talked to him about differentiating a fast heart beat associated with anxiety from a heart attack, and this seemed to be a turning point for him. He began to use the anxiety management techniques daily to reduce his baseline anxiety, thus reducing the frequency and intensity of his panic episodes. Mr. Simpson only visited the emergency department once during the last six months, with his last visit in February after a fight with his wife.   Over the last six weeks of treatment Mr. Simpson reported no panic episodes, and an overall improved sense of well being.  He felt that he did not need further assistance, but agreed to return to psychotherapy if he began to experience more anxiety or any panic attacks. 


I hope you will meet with him in the near future to monitor his status, and encourage him to return to psychotherapy if his symptoms return.  Obviously, if Mr. Simpson begins to present in the emergency department with chest pain symptoms it would be prudent to re-refer him, if he is willing.  It was a pleasure working with you to help Mr. Simpson.  Please do not hesitate to contact me if you feel that I may be of further assistance with Mr. Simpson or any of your other patients. 



Making collaboration routine helps you develop and maintain collaborative relationships with medical professionals in a time efficient and effective manner.  Most mental health professionals find that these types of letters and communications take very little time but have great benefit.  It simply makes sense that patients benefit when their medical and mental health professionals are on the same page, and are aware of what the other is doing for the patient’s benefit.  Each of the examples here are pretty typical mental health presentations – and each letter illustrates how simple information exchange can improve care.  Ms.  Frank was worried that her doctor would be mad at her because she wasn’t effectively managing her diabetes, and the therapist’s letter gave her a way to express her concern indirectly to her doctor.  Mr. Simpson had a very frightening physical symptom secondary to anxiety – the teamwork between his therapist and medical professional helped him differentiate palpitations from a heart attack, and helped him commit to more proactively managing his anxiety.  While cost reduction benefit research is a bit murky, Mr. Simpson’s case is the kind of anecdotal evidence that mental health professionals cite as how collaboration may reduce overall healthcare costs.  Six psychotherapy sessions are much cheaper than multiple trips to the emergency department and the ensuing workups.  Further, if Mr. Simpson’s anxiety difficulties return, referral back to the therapist should be relatively easy.


Intensive Collaboration

Occasionally, letters simply don’t allow for the kind of give and take discussion and sharing of ideas that facilitate optimal care in complex clinical situations.  This section reviews the types of presentations that necessitate more intensive collaboration, and strategies and techniques for collaboration and consultation in these complex situations. 


­Clinical Presentations that Need Intensive Collaboration 


There is hefty medical literature outlining the various characteristics of “challenging” patients (Krutitzky, 1996; Murtagh, 1991; Nyman, 1991).  More recently, literature has focused on “patient complexity” and attempts to create a vocabulary and set of strategies for providing complex patients with optimal primary care (Peek, Baird, & Coleman, 2009).  Unfortunately, medical professionals get little training in strategies to help them be more effective with patients with complex problems who don’t respond well to typical care.  They are trained to interview a patient, create a differential diagnosis, order tests or treatments that will help them rule out or rule in various diagnoses, convey this plan to the patient who will then enact the plan and get better.  At least, that is how it is supposed to work.  This model breaks down in any number of situations.  The following is not an exhaustive list, but gives the reader the general sense of the types of situations and patients that stymie medical professionals (See Table 14).



Table 14. Difficult Patients for Primary Care Providers



Patients who are “poor reporters”:  Many people have a difficult time conveying their illness story in any cohesive, meaningful way.  Some are tangential, some have memory issues, some lie, some manipulate, some are simply so overwhelmed by their experience that they can’t put all the pieces together, and some have illness stories that are so complex they are almost impossible to convey.  Any of these situations make it difficult for the medical professional to use one of their most powerful diagnostic tools:  the medical interview.


Patients who have a long problem list:  Many problems presented in one visit overwhelm both medical professional and patient.  Medical professionals are trained to elicit one or two chief complaints, and to try to get the patient to choose at most three symptoms to be addressed in a typical primary care encounter (Coulehan & Block, 2005; McDaniel, Campbell, Hepworth & Lorenz, 2005).  This is made more challenging when the medical professional and patient have very different priorities (e.g., the patient wants to focus on toe pain while the doctor is a little concerned about that chest pain and difficulty breathing).  Also, patients sometimes do not share complaints until the end of the visit when the medical professional is trying to end the encounter.  Any of these situations often result in the patient being labeled “difficult” by the medical professional (Marvel, Epstein, Flowers, & Beckman, 1999).


Patients with vague, difficult to diagnose problems:  These difficulties are vexing for medical professionals and patients.  For the medical professional, symptoms that don’t fit easily into a diagnostic category are frustrating and a bit frightening – medical professionals fear “missing something.”  This may result in a flurry of test ordering in search of an elusive diagnosis.  When all of the results are normal, or don’t explain the symptoms, medical professionals get frustrated and some may even blame the patient or doubt the symptoms are “real.”  In parallel, the patient may be very frightened that there is something wrong with them that the medical professionals are missing.  They don’t have a diagnosis, treatment plan, or prognosis to help them cope or feel any modicum of control.  They may feel that medical professionals don’t “believe” them about the symptoms, which can result in an escalation in symptoms as the patient attempts to establish credibility that their illness is “real.”  It isn’t difficult to imagine the potential destructive pattern that can result as the medical professional orders more tests, resulting in more anxiety, the tests are “normal” but not reassuring to the patient, who then seeks more medical opinions in the search for an answer.


Medically non-adherent patients:  Some patients simply don’t follow through on agreed upon treatment plans.  They don’t fill prescriptions, don’t take medications, don’t make lifestyle modifications, don’t record symptoms, don’t get ordered tests, and don’t follow up on referrals.  Sometimes, the patient recognizes their own behavior complicates treatment and takes some responsibility for ongoing problems.  Sometimes patients have no insight as to how their choices are adversely affecting their health, and may even blame the medical professional for poor outcomes. 


Chronically ill patients:  While chronic illness management is a very large part of the patient care provided in primary care, not all primary care professionals enjoy working with patients who don’t get well.  There is a continuum of situations, depending upon the patient’s diagnosis, type of illness, illness pattern, necessary lifestyle changes adherence to treatment, etc. that affect how difficult these situations can be.  An excellent review of these issues and how they affect individuals and families can be found in Medical Family Therapy (McDaniel, Hepworth & Doherty, 1992) and Families Illness and Disability (Rolland, 1994).  Managing the emotional impact and necessary lifestyle changes inherent in most chronic medical conditions is a challenge to primary care medical professionals.  Chronic disease has a strong correlation with mental health issues, especially depression (Kato, Sullivan, Evengard, & Pederson, 2006).  Some chronic diseases may be more likely in people with depression and other mental health concerns (Lett, Blumenthal, Babyak, Sherwood, Strauman, Robins, & Newman, 2004).  Further, patients with mental health issues are less likely to manage their illness proactively and therefore have a poorer prognosis (Cross, March, Lapsley, Byrne, & Brooks, 2006; Dec, 2006; Hamilton, Karoly & Zuatra, 2005; Merikangas, Ames, & Cui, 2007; Kessler, Ormel, & Demler, 2003; Van de Putte, Engelbert, Kuis, Sinnema, Kimpen, & Uiterwaal, 2005).  Taken together, all of these factors contribute to the need for mental health and medical professionals to collaborate to optimize care for patients with chronic disease.


Patients with Chronic Pain:  This subset of chronically ill patients tends to be especially difficult for primary care medical professionals (AAFP, 2010).  Most primary care medical professionals try to co-manage these patients with a pain management specialist, but this is not always possible.  It can be difficult to balance concerns about addiction and dependence on narcotic medications with appropriate pain management.  Again, depression is a common comorbidity (Elliott, Renier, & Palcher, 2003). 


Patients with Personality Issues:  Patients with most types of personality pathology, by definition, have difficulties maintaining healthy relationships with others.  These difficulties often affect the medical professional/patient relationship.  Patients who are perceived as manipulative, entitled, emotionally labile or overly dependent are difficult for primary care medical professionals to manage.  Medical professionals have little training in recognizing and managing patients with personality disorders.  Many therefore do not understand the patient’s behavior, or realize the importance of appropriate limit setting and managing their own internal reactions (Ward 2004). 



While this is not an exhaustive list, it does encompass most of the types of patients that are frustrating for primary care professionals.  Of course, a review of the list reveals that these are the same patients that are frustrating to mental health professionals.  Their complexity, chronicity, and the high level of skill necessary for optimal care make them a challenge under the best of circumstances.  A team approach to these patients lessens the burden for any one person, creates an ally in providing care, and can create a genuine bond between providers as they help each other help someone truly in need. 


Intensive Collaboration:  Strategies and Techniques


How does intensive collaboration differ from routine collaboration?  In short, intensive collaboration necessitates a team approach, where the medical and mental health professional consult each other as they plan and implement care to ensure not only that the other knows what they are doing, but also that the approaches being used complement each other.  In contrast, in routine collaboration most of the communication is simply to inform the other party what has occurred in treatment.  Obviously there is a continuum of collaboration, but this sense of shared, team care is the critical difference between the two approaches. 


Pre-referral Collaboration:  In an established collaborative relationship the medical professional may occasionally ask for assistance before they make a mental health referral.  This is common when the patient can’t or won’t seek psychotherapy, or when the medical professional is attempting to determine if a psychotherapy referral is appropriate.  Sometimes medical professionals struggle with a patient and simply need the input of a professional who understands behavior, relationship patterns, and behavior change strategies.  In these consultations try to clarify the exact consultation question.  Recognize that medical professionals sometimes just want empathy for the difficulties of caring for a particularly difficult patient and acknowledgement that they are doing a good job.  Unsolicited suggestions can be perceived as criticism, so tread carefully.  These dialogues illustrate these challenges as displayed in Table 15.



Table 15. Example Dialogues with the Primary Care Physician



Dr. Jenkins is a family doctor and Dr. Howe is a mental health professional.  Dr. Jenkins has referred a number of patients to Dr. Howe, and is calling him about a prospective referral.



Dialogue 1: The first approach.



Dr. Jenkins:  Hi, Paul.  I’m calling because I think I may have another one for you.  She is a 49 year old woman with lots of complaints.  I swear it’s a different one every time I see her.  I’ve been seeing her for about a year and she is making me crazy.  Even though I have a regularly scheduled appointment with her every two months she calls almost every week demanding an immediate appointment for some minor complaint.  Last week she had my receptionist almost ready to quit.  I’ve told her I think she needs a therapist, but she isn’t biting.  I’m hoping I can get her to call you after our next meeting so I just wanted to give you a heads up because she’s a doozy.


Dr. Howe:  She sounds tough.  But, you know, she just may not be ready to start psychotherapy.  It really should be something the patient at least kind of wants.  I wonder if you set more limits with her around how she treats the staff and schedule her even more often if maybe things would settle down.  Right now you’re always in “crisis du jour” mode in her care and I think that makes it hard to get to the real issues.


Dr. Jenkins:  She is my “crisis du jour.”  Every time I see her name on the list I just want to cry.  I’ve sent her for lots of tests and referrals just to make sure I’m not missing something but every time the tests are normal.  By the time I see her again she’s moved on to some other symptom anyway so sometimes I don’t think it matters what I do.


Dr. Howe:  Like I said, you need to see her more often – that’s what she is trying to tell you.


Dr. Jenkins:  Well, I’ll talk to her about seeing you because I think that she really needs a therapist.  She is so needy there is no way I can fill that black hole.  I’ll let you know if I can get her to call. 


Dr. Howe:  I’ll keep an eye out for her.  Good luck.



Dialogue 2:  The same call, different approach by a different mental health professional.



Dr. Jenkins:  Hi, Chris.  I’m calling because I think I may have another one for you.  She is a 49 year old woman with lots of complaints.  I swear it’s a different one every time I see her.  I’ve been seeing her for about a year and she is making me crazy.  Even though I have a regularly scheduled appointment with her every two months she calls almost every week demanding an immediate appointment for some minor complaint.  Last week she had my receptionist almost ready to quit.  I’ve told her I think she needs a therapist, but she isn’t biting.  I’m hoping I can get her to call you after our next meeting so I just wanted to give you a heads up because she’s a doozy.


Dr. Ryan:  She sounds really frustrating – she really disrupts your office!


Dr. Jenkins:  You got that right.  Every time I see her name on the list I just want to cry.  I’ve sent her for lots of tests and referrals just to make sure I’m not missing something but every time the tests are normal.  By the time I see her again she’s moved on to some other symptom anyway so sometimes I don’t think it matters what I do.


Dr. Ryan:  Yeah, needy patients like this can make you feel like you’re spitting in the ocean.  Do you want to tell me more about your appointments with her to see if I have any ideas?


Dr. Jenkins:  Sure, you never know.  Well, once I’ve steeled myself to see her I walk in and just try to withstand the onslaught.  Honestly, I know I tune out pretty quickly but I just can’t help it.  I try to get her to pick one or two things to focus on but she jumps all over the place.  I usually just pick whichever symptom I haven’t already worked up a bunch of times, or something I haven’t checked out yet.  I order a referral or a test and see her back in two months. 


Dr. Ryan:  Do the test results reassure her?


Dr. Jenkins:  No, not really.


Dr. Ryan:  So the pattern is she overwhelms you with complaints, you kind of check out because she is making you crazy, you order a test or referral to appease her, she leaves and then returns all too soon to start the pattern over again and whatever test result you have from last time is kind of irrelevant.


Dr. Jenkins:  Yeah, that’s pretty much it. 


Dr. Ryan:  I do have a couple ideas – nothing magic, but some things that might help.


Dr Jenkins:  I’m listening


Dr. Ryan:  Well, I wonder if you need to see her more.  I know that is the last thing you want to do, but maybe if she knows she is going to see you noncontingent of having a symptom she’ll calm down a little.  If she’s coming in every week any way, you might as well schedule her that way so you have some control over the situation.


Dr. Jenkins:  I can try it.  I’ve done that with other patients and sometimes it does calm things down. 


Dr. Ryan:  Does she have any support people that could come with her? 


Dr. Jenkins:  I had her husband come in once – he’s a saint.  Can’t imagine being married to her.  Think I should have him come back?


Dr. Ryan:  Might be helpful to hear his perspective, having him there might structure her a little bit and help you set some goals to focus things.


Dr. Jenkins:  I want her to come see you.


Dr. Ryan:  I totally agree with you that she needs a therapist, but I’m not sure I’m hearing that she is ready or going to follow through anytime soon.  Do you think she would be more willing to come if you framed the referral focus as helping her cope with her symptoms rather than because she is depressed and anxious?  Also I wonder if it is presented this way in front of her husband if he can kind of nudge her to call, too.


Dr. Jenkins:  I can try – that’s a good idea.  She won’t admit that she is depressed and anxious, but she does say that being sick all the time stresses her out.  I’ll try it and let you know if I think she is going to call.


Dr. Ryan:  For what it is worth I give you a lot of credit for sticking with her.  I hope she’ll follow through and call me – she definitely needs both of us!  Even if she doesn’t seem like she is going to come see me feel free to call so we can strategize – sometimes these cases take a long time to work through – she’s probably been functioning like this for a long time so it isn’t going to get better overnight.  Good luck, and let me know if I can be helpful. 


Dr. Jenkins:  Thanks.



In the first dialogue the Dr. Howe offers some empathy, but quickly addresses the likelihood the psychotherapy referral is going to fail.  Since this is the reason for Dr. Jenkins’ call, this statement (although likely true) puts Dr. Jenkins a bit on the defensive and questions the very reason for the call.  Also, Dr. Howe jumps into offering strategy without hearing more about the patient.   Again, this could make Dr. Jenkins feel defensive or criticized.  Finally, Dr. Howe doesn’t seem to want to continue to dialogue when it is clear that the phone call is not going to yield a referral in the near future.  Dr. Jenkins could interpret this to mean that Dr. Howe only wants to help him when he can get a referral out of the situation. 


In contrast, Dr. Ryan offers multiple empathic statements about how frustrating and disruptive this patient can be.  He seeks more information about the medical professional/patient interaction to see if he can discern a pattern.  Then, he non-judgmentally describes the pattern.  This review of the pattern both establishes that he understands the situation, and that the situation is a two-sided interaction in which Dr. Jenkins has a role.  He asks if Dr. Jenkins is seeking ideas and strategies before he offers them, and clarifies that he may not have an easy solution.  Both strategies are paired with a rationale, and empathy for how challenging it can be to break a pattern.  Dr. Ryan then addresses the desire for a referral, and the reality that this patient is probably not going to follow through right now.  He emphasizes his willingness to provide further consultation, even in the absence of a referral, and offers a strategy that might facilitate the referral.  This dialogue illustrates a few “cardinal rules” of pre-referral collaboration as can be seen in Table 16.



Table 16.  Rules of Pre-Referral Collaboration



Empathize before you jump into “fix” mode


Gather information about the pattern of interactions between the medical patient and the physician.  Distancer-pursuer patterns and triangulation are common patterns with challenging, complex patients (Ruddy, Borresen & Gunn, 2008).


Help the medical professional assess the patient’s readiness to change and devise strategies consistent with the readiness stage (Prochaska, Velicer, Rossi, Goldstein, Marcus, Rakowski, 1994; Zimmerman, Olsen, & Bosworth, 2000).  The behavior in question might be treatment adherence issues, lifestyle modification, or, as in the dialogue above, readiness to seek mental health treatment.  Some primary care medical professionals have some familiarity with “readiness to change” and “motivational interviewing” usually in the context of smoking cessation.  They often can implement cognitive behavioral strategies that are presented within this context.  The reader who is not familiar with motivational interviewing is referred to:  MINT, 2010


Convey your willingness to be helpful, even if it won’t result in a referral.  This is crucial to building a collaboration relationship and network.  A medical professional will not forget that you were helpful to them when they felt “stuck” with a difficult, complex patient situation. 


When appropriate, offer to meet with the medical professional and patient together.  The purpose of this meeting is to allow the patient to meet you, and hopefully facilitate a referral.  Also, a consultation session can be helpful if the medical professional has mental health diagnostic questions or feels they are unable to structure the patient.  Some mental health professionals are willing to occasionally have such sessions without reimbursement, while others will do this only if the patient is willing to pay out of pocket or has insurance that would cover such a visit.  If the patient has a chronic illness that is adversely affected by behavioral or mental health issues, you may be able to bill using Health and Behavior Codes, especially if the patient has public insurance (Medicare). 



Post-Referral Intensive Collaboration Strategies


The need for intensive collaboration may not be obvious at the time of referral, or you may not have an established relationship with the patient’s provider before you begin to work with them.  This is one reason that some level of collaboration with all patients from the very beginning of care is a good idea.  It allows you to get the primary care professional’s perspective, which may indicate that the patient has complex issues.  Also, it sets the precedent for ongoing collaboration as your normal practice, so the patient does not interpret the collaboration as something outside the norm.  Primary care professionals are likely to welcome collaboration regarding their challenging patients.  They may not know exactly how you will be able to be helpful, but they likely are seeking assistance. 


Just as with routine collaboration, begin by talking with the patient’s medical professional to determine the frequency and methodology of communication.  If you sense that the patient will need intensive collaboration but the medical professional does not engage at the outset, use your judgment as to how much to push the medical professional.  In the context of an established relationship you can explain why you anticipate that regular communication will be helpful.  Without an established relationship it is likely best to mention that you have needed to communicate more for patients like this in the past, but take a “wait and see” attitude.  Primary care medical providers tend to be very pragmatic, so will accept greater communication when it becomes clear to them how it can help them provide better care and more optimally manage a challenging patient.


Since intensive collaboration entails extensive communication it helps to have multiple means of contacting one another.  E-mail can be very helpful in this regard as it is more conducive to idea sharing and dialogue than letters and does not require that both providers be available at the same time as with a phone call.   Ensure that your e-mail settings are consistent with HIPPA regulations. 


Often the focus of the collaborative contacts is similar to routine collaboration.  The focus may include symptom profile (psychological, psychiatric and medical), adherence to medical care, and impact of issues on functioning and relationships.  When appropriate, explore the relationship between the medical professional and the patient.  This helps you assess if there are medical professional/patient interaction problems and if the medical professional is open to discussing how to improve the relationship or work with the patient differently.  You must tread carefully here to ensure that the medical professional doesn’t feel criticized or blamed for problems.  Again, starting with empathy for the challenges of caring for complex patients, and recognition of the effort and skill the medical professional has used to this point reduces the likelihood that the medical professional will feel criticized. 


Patients often complain to mental health professionals about the medical care they receive.  Be aware they often complain about the mental health care system and mental health professionals to medical professionals, as well.  Be particularly careful about triangulation during intensive collaboration, especially if there is tension or frustration between the medical professional and the patient.  If the patient has personality issues they may try to “split” providers.  Regular dialogues with the medical professional will help you gage their level of frustration and the degree to which they’re willing to alter how they interact with the patient.   These opportunities for a “reality check” on the patient’s reports of their medical encounters also can help steer a dialogue with the patient about their own role in any difficulties, and how they might work with the medical provider differently in the future. 


Occasionally it becomes clear that the medical professional is burned out working with a particular patient or that there is a poor working alliance between the medical professional and patient.  These circumstances are difficult if you don’t have an established relationship with the medical professional, because they may not be open to discussing the problem and potential solutions.  However, when you do have an established relationship you may be able to serve a critical role in either improving the relationship or helping the medical professional and patient realize it is time for a transfer of care to a new medical professional.  The latter is rare, but it does occur.  Usually, the medical professional and patient are relieved when their conflict or tension is confronted and they can agree to work together differently or part ways.  Given the continuum of skill sets medical professionals have regarding complex patients you may encounter situations where the medical professional is “in over their heads.”  Gently probe to assess the medical professional’s level of awareness of the problem and their level of commitment to working with this patient.  Medical professionals usually are aware when things are not going well and welcome suggestions.  Often, if a transfer of care is warranted, both the medical professional and patient want to end their working relationship.   


The situation is a bit more difficult when the medical professional is burned out on the patient, but the patient has little to no insight regarding the situation.   Even very skilled, compassionate medical professionals can reach a point that they just feel unable to continue working with a particular patient.  Also, some offices have specific rules about patient behavior towards staff that may result in a patient with emotional regulation or anger management issues to be dismissed from the practice.  Most primary care offices have very specific protocols for patients for whom they prescribe narcotic medications and dismiss patients who do not follow the protocol.  When a patient needs to change medical providers because their current provider is unwilling to continue to work with them, therapy can both support the patient through this loss and/or perceived rejection, and help them prepare to work with a new provider more effectively.  The medical professional/patient relationship is likely a microcosm of the patient’s relationships with others.  As such it can serve as a catalyst for discussion of the patient’s relationship difficulties in other arenas.  Although these situations are challenging they highlight how much collaboration can help complex patients, and how a lack of collaboration could be problematic.


Finally, consider scheduling a joint appointment with the medical professional and patient.  While these appointments can be difficult logistically, the upfront time and effort can save enormous time and frustration.  Joint appointments can focus on critical relationship issues between the patient and medical professional, new diagnostic information, treatment decisions and planning, information dissemination to the patient and family, adherence to treatment plan, lifestyle modification, or simply “check-ins” during protracted mental health treatment.  Before suggesting a joint appointment to the patient, discuss the idea with the medical professional to ensure he or she is interested in having a joint appointment and to determine what the focus of the appointment should be.  Then, suggest the appointment to the patient to see if they are willing.  Patients generally welcome the opportunity to meet with their “team” together.  Help the patient determine their desired focus for the session, and who they want to include in the meeting.  Try to overtly dovetail each participant’s agendas to ensure that all will be addressed during the appointment.  Schedule the session as the first appointment during an office session for the medical professional, to ensure that they are able to start on time.  Realistically, these sessions almost always occur in the medical setting.  Ideally, spend a few minutes alone with the medical professional before the meeting to review the focus of the meeting.  Agree on who will “run” the meeting (usually the mental health professional).  During the meeting be very mindful of time, and ensure that all tasks that emanate from the meeting are assigned specifically to one person.  Document the meeting closely and review your documentation with both the patient and medical professional. 


Collaboration at the Larger System Level


Integration of Mental Health Services into Primary Care


It is becoming more common, especially within the public health system and military, for mental health professionals to serve an integral role in primary care (Robinson & Reiter, 2007).  Definitions and implementation of “integration” vary widely and fall along a continuum ranging from basic co-location of providers, to very structured protocols for team based care (Doherty, McDaniel, & Baird, 1996; Wulsin, Sollner, & Pincus, 2009; Veterans Administration Healthcare Network, 2005).  A growing outcome literature examining different models of integration with various populations shows positive trends for integrated care (AHRQ, 2008; Blount, Schoenbaum, Kathol, Rollman, O’Donohue, & Peek, 2007).  However, a description of integrated primary care is beyond the scope of this document.  The interested reader is referred to Behavioral Consultation and Primary Care:  A Guide to Integrating Services (Robinson & Reiter, 2007) and Integrated Behavioral Health in Primary Care: Step-by-Step Guidance for Assessment and Intervention (Hunter, Goodie, Oordt, & Dobmeyer, 2009). 



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