Referring to mental health in integrative practice

Photo Cred: Toa Heftiba/Unsplash

By Julie Luzarraga

Mental illnesses can have a negative impact on a person’s physical health and often require a referral to a licensed mental health professional for further assessment and treatment.  Integrative medicine recognizes the benefit of collaborative models in treating patients who live with both physical and mental health conditions. Understanding the primary interventions and therapies used in integrative mental health settings will the help the provider in making effective referrals for integrated patient care.

According to the National Alliance on Mental Illness, 19.1 percent of adults in the United States experienced a mental health illness in 2018. While there are a wide array of therapies and techniques used by mental health providers, there are a few that lend themselves most to integrative models of practice. 

Most mental health providers will use a combination of techniques in working with patients.  Furthermore, treatment is always guided by the patient’s unique experience. In a shift from the western model of developing a treatment plan around the disease, integrative mental health providers will look to the patient as well as the presenting symptoms for determining which techniques will be most beneficial. Some of the most commonly used evidence-based practices are cognitive behavioral therapy (CBT), cognitive behavioral therapy for insomnia (CBT-I), and mindfulness-based therapies. 

Cognitive behavioral therapy is based on the understanding that negative thought patterns influence or mood, which in turn influences our behaviors. A mental health provider using CBT will work with patients on identifying the negative thought patterns and patterns of behaving in order to develop new patterns. CBT has been found to be effective with depression, anxiety, substance abuse, and other mental health disorders. It can also be an effective approach to creating health behavior change. CBT can be used in individual, family, and group settings.

Insomnia is a common complaint for many patients. According to an analysis done by Maurice Ohayon, MD, 85 to 90 percent of the time insomnia is comorbid with psychiatric disorders, medical disorders, or circadian rhythm disorders. Many patients are not getting enough sleep and healthy sleep is imperative to both physical and mental healing and resilience. 

Cognitive behavioral therapy for insomnia or CBT-I is the recommended first line of treatment for insomnia. This therapy uses the foundation of cognitive behavioral therapy to teach patients to shift their automatic thoughts about their ability to sleep. Therapists who are trained in CBT-I may also use sleep restriction, stimulus control therapy, and relaxation techniques. A 2012 review of research on CBT-I found it to be a more effective treatment compared with pharmaceutical approaches. CBT-I can be used with individuals and in a group setting.

Mindfulness-based therapy integrates mindfulness skills into the therapy. CBT principles are often a part of mindfulness-based therapies and therapists who provide this type of treatment should have their own dedicated mindfulness practice. Mindfulness-based therapies are particularly helpful in integrative care settings, as mindfulness practices have been shown to have a positive impact on both mental and physical conditions such as chronic pain, anxiety, depression, hypertension, and other stress-related health conditions. These therapies may use guided imagery, relaxation techniques, and meditation to help patients alleviate symptoms.  Other mindfulness-based interventions are dialectical behavior therapy, mindfulness-based stress reduction, and acceptance and commitment therapy.

The primary benefit of referring patients to mental health providers is to establish the correct diagnosis. It is difficult for patients to paint a clear picture of their emotional health, especially when there are additional chronic health issues or chronic stress. There are many diagnoses that are difficult to tease out. For example, adult attention-deficit/hyperactivity disorder is often misdiagnosed as anxiety or depression. Survivors of trauma may present with an array of symptoms and can look very different during different stages of healing.

With the plethora of information available, it is not unusual for patients to come in with a self-diagnosed condition. New patients often arrive at our clinic for their first assessment and have noted on their paperwork that they carry a diagnosis of bipolar or obsessive-compulsive disorder. These diagnostic terms get used lightly in common conversation and oftentimes patients do not meet the criteria for these conditions, though they have labeled themselves.  Our clinic has found it best to refer to mental health providers for a diagnosis unless it has already been established by a mental health provider. 

When diagnoses are more complicated, we want to make sure we also recommend psychological testing. Psychological testing can be done by a licensed clinical psychologist specifically trained in administering assessments. Testing may include cognitive, emotional, behavioral, and executive functioning. After gathering information, a clinical psychologist will administer the tests. This typically occurs over multiple sessions before the clinical psychologist can score and interpret the results. It can be helpful for differential diagnoses as well as investigating new or otherwise unexplained symptoms. The results will help guide the treatment plan as well as the need for any further referrals.

Regardless of the approach used in therapy, the therapeutic relationship between patient and provider continues to be shown as a primary curative factor. Having working relationships with the mental health providers you refer to helps inform who you refer to. Mental health providers tend to specialize in different areas, age groups, and other demographics. We have mental health providers who specialize in trauma or grief as well as those who work primarily with chronic health conditions or geriatrics. When you know who you are referring to, it also lays the groundwork for establishing the therapeutic relationship. When I see a new patient who has been referred to therapy by one of our other providers, they typically comment on how good it feels to know that the referring provider they have a relationship with trusts us with their mental healthcare. That is a solid foundation to start with.

One of the many upsides of practicing integrative healthcare is that we are not siloed or practicing on an island. We have the benefit of sharing the care of our patients, which only enhances their treatment and experience. With the high rate of mental health disorders, stress, and trauma in our communities today, it is invaluable to know more about referring to mental health. 

References

Mitchell, M.D., Gerhrman, P., Pelis, M., and Umscheid, C.A. (2012).  Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review. BMC Family Practice.  Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3481424/

National Alliance on Mental Illness. (2018) Mental health by the numbers. Retrieved from: https://www.nami.org/Learn-More/Mental-Health-By-the-Numbers 

Ohayon, M.M. (2002). Epidemiology of insomnia: What we know and what we still need to learn. Sleep Medicine Reviews. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/12531146