An Unexpected Journey: Or, How I first got introduced to primary care behavioral health integration and PCBH

My first exposure to integrated behavioral healthcare was at my university medical clinic during graduate school in South Moonpietown. At the time I was in my second year of my doctoral program, in my first practicum placement, and under a lot of stress. I was experiencing significant anxiety and had experienced an episode of syncope while on campus walking between the library and the psychology building. After discharge from the emergency department, I scheduled a visit with my primary care provider (PCP) at the on-campus medical clinic. My PCP suggested that I might benefit from meeting with a therapist to work on managing my stress and anxiety and told me that they had therapists who could see me right in the clinic. I scheduled a visit with the therapist for the next appointment in a few weeks.

On the day of my appointment, I checked in as usual at the medical clinic front desk. The therapist called me from the waiting room and we went to an exam room. This was a bit unexpected—I was used to the therapy rooms we had in the psychology building. I sat in a chair against the wall, he on a stool next to an exam table. He had a manila folder in his hand—which as different than the green charts we used in the psychology clinic—and different than my PCP who always charted at the computer. He introduced himself as a psychology intern, and told me that the clinic was trying a new model that involved integrating care into medical settings.

I was surprised when he asked me a few questions and then made some suggestions for self-care activities, and he wrapped up the visit in about 30 minutes. I didn’t say anything, but was confused because from my perspective he hadn’t completed a biopsychosocial assessment, and how could he be done in less than 50 minutes, and why was he giving me homework at the first visit?

I scheduled another appointment a week later, went home, and tried some of the ideas the therapist had suggested. We had a couple more visits—they were always so short!–and I told him I was doing better, my stress and anxiety were better controlled, and we stopped following up. It seemed an odd way to do therapy, but it worked for me, and I soon forgot about my experience.

I continued my training in clinics focused on substance use disorders and long-term trauma treatment. When it was time for me to apply for internship, I applied to substance use and trauma-focused sites. I was applying to internships during the height of the APPIC Match imbalance when 22% of Match applicants did not match .

As I was applying to internship sites, I started running a search each Friday for all sites that were closing the coming week—and then looking at those sites to see if there was any overlap with my skills. During one of these searches, I discovered an integrated site that talked about working in a primary care medical setting. I realized that substance use and trauma were likely very common in primary care settings, so I started applying to similar sites as I found them. I didn’t know anything about integrated behavioral health models and had only had a brief introduction to health psychology, although I had done some work treating insomnia and helping people with lifestyle change.

My first real introduction to Primary Care Behavioral Health (PCBH) was on internship interview day at a Federally Qualified Health Center (FQHC) in Washington—one of those sites I had found that talked about working in a medical setting in their site description. When I interviewed, applicants spent the morning shadowing a current intern, and then the afternoon learning about the model of care and being interviewed. I was struck during the shadowing when the current intern called a patient back from the exam room, took them into an exam room, and charted on the computer during the 30-minute visit. After the visit, I commented that it seemed like she was doing Solution Focused Therapy, something I had some training in, and it seemed like she was able to just get right to point to get it all done so quickly. Despite the time limit, this seemed like something I could do—work with people on their mood and substance use concerns using brief interventions.

After the shadowing was done, I drove to the administrative offices for the program presentation and interviews. I don’t remember much about the presentation except people were talking about their experiences in health psychology settings, how much they enjoyed reading “The Book” , and asking questions about how the agency determined the cutoff between pre-diabetes and diabetes. Was it based on A1c levels or something else? I realized that I was very poorly prepared for this interview.

I also remember two other things—I remember Jeff Reiter giving a presentation on Primary Care Behavioral Health, which the FQHC had been doing for 10 years at that point, and the then-CEO coming in to talk about the importance of the Behavioral Health program to the organization’s patient and providers. The CEO also talked about how we were expected to treat every patient who came in—regardless of how much money they did or didn’t have, whether they were insure or not—like they were the most important person in the world in that moment and make sure they got the very best care, and the very best experience. He drew a parallel to Nordstrom’s (which is headquartered in Seattle) customer service mythology . I was sold!

I went into my interview—and Dr. Reiter was on my interview panel. And boy did I do poorly! I was nervous and kept getting tripped up, and in retrospect, it must have been clear that I knew nothing about this model of care. After I got to the hotel that night, I called my wife and told her that I loved the site, I was going to rank them very high, but I was certain I didn’t have a chance to match there.

I remember I was back in South Moonpietown on February 24^th, 2012 when I got the email—I had matched. To that FQHC in Washington. “Well,” I told myself, “I can do anything for a year!” I was scared about moving, scared about this model of care I didn’t know, scared about this setting that was so intimidating, and excited for what was coming…

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