Many patients who have mental health conditions need talk therapy in addition to the treatment you provide as the pediatric primary care provider (PCP). If you practice in an area where therapists are available, we hope you have developed referral relationships, as you learned in your REACH training. You may also see patients who are already working with a therapist.
In either case, the communication between you and the therapist makes a huge difference in the quality of care the two of you provide.
To learn how PCPs and therapists can collaborate to improve the mental health of children and adolescents, we talked with clinical psychologist Kevin Stark, PhD, a founder of The REACH Institute’s CATIE program, and pediatrician Hilary Bowers, MD, director of behavioral and mental health services at Children’s Primary Care Medical Group, a large pediatric practice in San Diego and Riverside counties in California.
Both noted that collaboration is easiest in an integrated or co-located practice. They described what Dr. Bowers called a “warm hand-off,” in which the PCP walks with the patient and family down the hall to the therapist—thereby overcoming an important barrier to treatment. HIPAA compliance and shared documentation are other advantages.
If you and the therapist are not in the same practice, you may have more paperwork and fewer secure communication options.
But the more important aspects of PCP-therapist collaboration are essentially the same whether you are in the same building or across town in a separate practice.
“When I get a referral from a physician,” said Dr. Stark, “I ask, ‘What’s the best way to communicate with you? If I leave you a message that I’m seeing your patient, can I call you at lunchtime or the end of the day?’ I tell them when I’m generally available. The key is to structure it so it doesn’t become phone tag.”
When your patient is already seeing a therapist or when you’re evaluating whether to establish a referral relationship, you want to know whether the therapist is using evidence-based practices. Dr. Bowers asks, among other questions, “Is there homework?” A therapist who is implementing cognitive behavioral therapy for depression, for example, or parent-child interaction therapy for behavior issues will assign tasks for patients to practice between sessions.
Talk with the therapist regularly to find out what they are working on. Then, when you see the patient and family, you can reinforce the therapeutic goals, for example, “How are you doing with getting outside most days?”
Patients’ and families’ perceptions of how things are going with the therapist are important. But their perceptions of what therapists expect or have recommended may be skewed. Dr. Bowers told the story of a teen who was attending an intensive outpatient program (IOP) for an eating disorder. Both the teen and her caregiver said the program was going great. Only by talking to the IOP therapist did Dr. Bowers learn that the caregiver had never shown up for family sessions. Dr. Bowers talked with the caregiver alone to emphasize the importance of participating in the teen’s care.
“Parents often don’t have a clue what’s going on in their child’s therapy,” said Dr. Bowers. Although therapists can’t tell parents what their child talks about in therapy (unless the child’s safety is at risk), they can share the treatment goals and homework. Caregivers, in turn, may impart valuable information about what’s going on at home or school.
With the family’s permission, reach out to the therapist at the child’s school, if there is one. School therapists can help set up plans for educational accommodation (IEPs or 504 plans), if needed. They also have access to accurate information about the patient’s ability to function at school.
“I see a fair number of patients with chronic disease,” said Dr. Stark, “but they have rarely been referred by their physicians.” Dr. Stark pointed out that a chronic disease like diabetes affects patients’ mental health: “They feel like they’re different, even broken. It’s critical to have that integration of psychology and medicine.” Besides supporting patients’ emotional health, therapists can work with patients to improve their compliance with treatment plans.
Noting that time spent in collaboration is billable at a lower rate than many other services, Dr. Stark emphasized, “Finally, it’s a matter of how dedicated the PCP and the therapist are to providing quality care. They have to be committed to making it happen for their patient.”
Dr. Stark suggested these articles on integrating psychology with pediatrics:
· Burt, J. D., Garbacz, S. A., Kupzyk, K. A., Frerichs, L., & Gathje, R. (2014). Examining the utility of behavioral health integration in well-child visits: Implications for rural settings. Families, Systems and Health, 32(1), 20. https://doi.org/10.1037/a0035121
· Gatchel, R. J., & Oordt, M. S. (2003). Clinical health psychology in the primary care setting: An overview. In Gatchel, R. J., Oordt, M. S. (Eds), Clinical health psychology and primary care: Practical advice and clinical guidance for successful collaboration. American Psychological Association. https://doi.org/10.1037/10592-001
· McDaniel, S. H., Grus, C. L., Cubic, B. A., Hunter, C. L., Kearney, L. K., Schuman, C. C., Karel, M. J., Kessler, R. S., Larkin, K. T., McCutcheon, S., & Miller, B. F. (2014). Competencies for psychology practice in primary care. American Psychologist, 69(4), 409. https://doi.org/10.1037/a0036072
· Shafran, R., Bennett, S. D., & Smith, M. M. (2017). Interventions to support integrated psychological care and holistic health outcomes in paediatrics. Healthcare, 5(3), 44. https://doi.org/10.3390/healthcare5030044
“The training provided an interactive learning experience for a highly salient topic with limited community resources. The specific tools provided (for screening, treatment, and follow-up) and the network of providers are so valuable for sustaining this in practice.”