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Not Feeling Well? Sometimes It's All In Your Head

One of the aims of the Affordable Care Act is to tear down the walls that separate doctors from psychologists, dentists from doctors and so on.

The thought is that by bringing the various disciplines together, patients will get better — and perhaps less expensive — care. 

Kristian Foden-Vencil visited a doctor’s office in Bend that has brought psychologists on site, to see how it works.

Doctors deal with physical problems, like rashes and broken bones. But sometimes, patients turn up with physical symptoms that stem from mental health problems.

Dr. Robin Henderson

Dr. Robin Henderson

Kristian Foden-Vencil/OPB

That, says Dr. Robin Henderson of the St. Charles Health System in Bend, is where psychologists come in.

But, there’s a problem.

“It’s pretty scary when you walk into your medical professional’s office and they say, ‘You know I really think you ought to go see a therapist. Here’s a number for someone.’ You call them. And guess what? People don’t follow up,” Henderson says.

She says patients don’t want the stigma of going to see a psychologist, so they procrastinate, they minimize their problem, and they get sicker.

So, instead of sending patients out to psychologists’ offices, St. Charles has been running a pilot project to put psychologists into doctor offices.

“You’re sitting on the table, in comes your psychologist to sit next to you. It changes the stigma dynamic. Now we’re saying: ‘It’s okay for my mind to be involved with my body. Because I’m in my doctor’s office.’ “

Take the case of 17-year-old Tyson Engel.

Back in the spring of 2011, he was snowboarding on Mt. Bachelor when he fell so hard, he cracked his helmet.

Dave, Tyson, and Jennifer Engel

Dave, Tyson, and Jennifer Engel

Kristian Foden-Vencil/OPB

His mom Jennifer Engel says she soon began to notice some pretty dramatic changes in his character.

“Tyson talked about headaches for a while. He could not sleep at night and had difficulty regulating his activities. He was always on the run, not eating very much, not sleeping very much,” Engel says.

Over a period of several months, she took him to the ER five times. There was even a three-day hospital stay.  But the symptoms weren’t improving.

That’s when she found the Mosaic Medical clinic, where the pediatrician and psychologist work together.

Tyson had a problem with impulse control. His mom says she’d be taking him to an important appointment and he’d suddenly run across the street to see a shiny new bike.

Dr. Kristi Nix

Dr. Kristi Nix

Kristian Foden-Vencil/OPB

Tyson’s psychologist Sandra Marshall says she worked to identify the problem and to give him the tools to deal with it.

She was able to make suggestions to his parents about how they should talk with him.

“Sometimes there would be too much talk. And they would talk and talk and talk and he would get frustrated, and too fast. And it was ‘Okay, you guys have to stop talking too much.’ And we have to have come up with: ‘Is this the right time or the wrong time? Is this a big deal or a little deal? Do you need it now, or can you wait?’ And that’s all that was left. And then it gave him time and space, there wasn’t so much language to process and then he could respond to that,” Marshall says.

Tyson says those choices were clear enough that he could use them — as opposed to trying to recall some long, in-depth family conversation.

“I would want to go see a bike. I would think to myself: ‘Is now the right time, is now the wrong time? How badly do I want to see the bike? Is it that important, is it not important?’ And just by asking myself questions, I’d get better at the certain situations I was into,” Tyson says.

Tyson’s case is complex.

Dr. Henderson says more common examples where a psychologist is helpful involve children who are getting stomach aches because they’re being bullied, or the parents are getting a divorce.

Dr. Sandra Marshall

Dr. Sandra Marshall

Kristian Foden-Vencil/OPB

“These are short, brief interventional strategies designed to help parents and the practitioners and the children themselves. Deal with the things that they’re coming into a pediatrician’s office for, that aren’t necessarily treatable with an antibiotic,” Henderson says.

Dr. Kristi Nix is the pediatrician that worked with Tyson’s psychologist at the Mosaic Medical Clinic, she says, “I’m so thankful to have another perspective.

“It’s hard I mean it’s not satisfying as a physician to say, ‘I don’t know what’s wrong with you. Get out of my office.’ Right. That’s not okay and it’s not good healthcare.”

Tyson’s mom, Jennifer, says having Dr. Nix confer with a psychologist, worked wonders. “I think it’s huge because they both know Tyson personally, they know our children. They know the extended family at this point. We didn’t fall through the cracks in any way.”

But the idea of having a psychologist drop in to talk to a patient for 20 minutes, instead of setting up a schedule of weekly visits, is a substantial change.

Dr. Robin Henderson says St. Charles initially had problems hiring psychologists to do the job.

“Some of them, it’s not worked for some of them. Initially, especially when we were first starting out, we had a couple of folks who just couldn’t manage the model. It takes a different type of personality, and we find the folks coming right out of school, fresh, who’ve been trained in health psychology models.  You have to have that type of personality that wants to engage in team-based care. You know it in the interview,” Henderson says.

The American Psychological Association is supportive of integrating psychologists into doctors offices. According to the APA website, research shows the strategy is effective in reducing depression.

In Tyson Engel’s case, the family hasn’t needed to return to the ER, or have him stay in a hospital. So that has saved money.

On a larger scale, Dr. Henderson says St. Charles looked at about two years of data from the Medicaid population visiting Mosaic.

“We were only able to look at about 400 patients. And the average was a drop of about $860 over the course of a year in the patient’s medical costs. Now that included a minor increase in their pharmacy costs, but even with that increase, the total medical spend was going down.”

St. Charles Medical Center in Bend

St. Charles Medical Center in Bend

Kristian Foden-Vencil/OPB

St. Charles is doing a much longer study.

But meanwhile, Benjamin Miller at the University of Colorado School of Medicine says, going from a small project to broad adoption may not be easy — for several reasons. There needs to be a payment mechanism that recognizes the input of both the doctor and the psychologist; the electronic health records of doctor offices and psychologists offices also need to work together; and students of the two disciplines need to be taught to work together.

“You know they are raised almost in this culture of indifference to the other providers. Where they are taught, you as a mental health provider are going out there and do mental health work. You as physical health provider are going to go out and do physical health work. Wherein do the two meet? It’s not in training,” Miller says.

The American Hospital Association wrote to President Barack Obama highlighting St. Charles’ project this summer. The President had asked for help to raise awareness about dealing with mental health in the nation’s communities.

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