Integrated Behavioral Health – Podcast

Nicholette Leanza:

Hello, everyone, And welcome to Convos from the Couch by LifeStance Health. I’m Nikki Leanza, and on this episode, I’m really delighted to talk with Emily Mohr, one are Senior Clinical Directors on the topic of integrated behavioral healthcare. So Emily, so good to talk with you today.

Emily Mohr:

Thanks for having me, Nikki.

Nicholette Leanza:

Tell us a little bit about yourself.

Emily Mohr:

Well, I’m a psychologist by profession. I have been working in integrated behavioral health for are almost the last decade. My family and I moved out to Illinois in 2020, and I started in 2021, beginning of 2021, in my current role as Senior Clinical Director. But prior to that, I was in Massachusetts, and I was our Regional Director of Integrated Care. So my responsibilities out there were both providing services in an integrated behavioral health capacity; I was actually situated within a primary care practice, where I saw patients from the primary care practice, did behavioral health with them, and helped them build and establish their integrated behavioral health offerings to the community, which was really fun. And that’s what led me to the place that I’m at right now, the role that I’m in right now, which is helping LifeStance to build its integrated behavioral health programs in a larger, more national scale.

Nicholette Leanza:

So to jump in, tell us a little bit more about what is integrated healthcare.

Emily Mohr:

So, integrated healthcare basically means when you bring professionals from different disciplines together to really collaborate and work together for the best treatment outcomes for a patient. And it includes also the patients; so it’s patient-centered care, but different disciplines coming together to be informed by one another in how they work with and for the patient. So, it could be primary care working with orthopedics, or it could be dermatology and podiatry coming together. But I’m a psychologist, so for me, integrated care means bringing behavioral health into other spheres of healthcare; and usually primary care, but not always.

Nicholette Leanza:

So what does that look like, to integrate behavioral health into those other aspects of healthcare?

Emily Mohr:

Oh, gosh. It can look a lot of different ways. We could have a very long conversation about all the different models of innovative behavioral healthcare; the ones that are most central to the work that I have done are something called the Primary Care Behavioral Health Model. I’ll tell you a little bit about that.

Nicholette Leanza:

Yeah.

Emily Mohr:

There’s also something that’s similar, that’s called the Collaborative Care Model; similar, but very different. But basically, what it means is that first of all, a little bit of background.

Nicholette Leanza:

Yeah.

Emily Mohr:

When people go and see their doctors, their primary care doctors, about 60, 70% it’s probably more like 70% of the time, what they’re going in with actually has some behavioral component to it; whether it is stress related or lifestyle behaviors: smoking, diet, things like that, there’s a component of what they’re going to their doctor for that has a behavioral, emotional, cognitive component to it.

Emily Mohr:

And primary care doctors are not usually the most well-trained to cope with those things. So, the idea would be, if we actually bring some behavioral health services into the setting where people go when they have a behavioral health need; most people, if they’re feeling depressed or anxious, the first person they talk to is their family doctor. Right?

Nicholette Leanza:

Right.

Emily Mohr:

Their doctor.

Nicholette Leanza:

Right.

Emily Mohr:

So, if you bring behavioral health to those doctors, and thus make behavioral health a part of the team of people that’s just always available to help those patients, it really does help, number one, the patient get the care that they really do need, and what they’re looking for. It helps the provider, the doctor, feel like, “Oh my gosh, there’s somebody on my team who can help me deal with this,” rather than, “I’ve got this person in my exam room crying. I’m getting behind.” Right?

Nicholette Leanza:

I got you. Right.

Emily Mohr:

So what we do when we bring behavioral… In the Primary Care Behavioral Health Model, the therapist or the behavioral health specialist is just another member of the primary care team, who can get brought in on any primary care visit, like, “Hey. Dr. Mohr, can you step in here? Sally Jones was just telling me that she was feeling really anxious. It’s giving her some stomach upset. And so, I was thinking maybe you could help her with some strategies to manage that.” So actually, the intervention for the problem that the patient comes in for to see their doctor, is a behavioral health intervention, and we can step in and provide that.

Nicholette Leanza:

That’s great. It sounds like to me, it’s the missing piece that’s been missing all along for really even looking at merging physical health and mental health together, as it’s all important.

Emily Mohr:

Yeah.

Nicholette Leanza:

I think it is-

Emily Mohr:

Exactly. We like to say, “It goes all the way back to Descartes. Right? You’ve got the Cartesian Dualism: mind/body split.

Nicholette Leanza:

Exactly.

Emily Mohr:

And it’s funny, because a lot of primary… Some primary care doctors really get it, and they are very holistic. And then, there are some primary care doctors who we joke, I and my colleagues will joke, “Oh, the patient was leaking from the eyes. I don’t know what to do with that bodily fluid.” It’s like the… If it happens from here up, they’re aren’t quite sure what to do. That’s not entirely true, but yes, definitely, we help to make healthcare more holistic. It’s the entire person: mind, body, emotion, spirit, all in one package. So, yeah. I agree. I feel like in that way, it’s a very noble branch of behavioral health work.

Nicholette Leanza:

For sure. For sure. You might mentioned another model too, for behavioral health integration.

Emily Mohr:

Mm-hmm (affirmative).

Nicholette Leanza:

Can you tell us more about that model, too?

Emily Mohr:

Yeah. So, the Collaborative Care Model is similar in some ways to what I just described and also different. It’s a very research-based model. You can look it up from the University of Washington, the AIMS Model, A-I-M-S. And basically, what it is, is they identify patients who fit a certain criteria; oftentimes, it’s depression. So they’ll get screened; a PHQ-9 is frequently the tool that they’ll use to screen.

Emily Mohr:

And if a patient screens positive on that, they’ll be asked if they’d like to participate in the Collaborative Care Model Program. If they want to participate, they’re put on a registry where they’re tracked. So then they are… They meet with, or have conversations with someone who’s identified as a care manager. Sometimes that person is a nurse, sometimes that person is a therapist; but that care manager sort of helps the patient do some kind of behavioral health interventions. Maybe we’ll do some behavioral activation; it really helps them sort of identify things they can do to get better.

Emily Mohr:

But they keep re-screening them, and they keep identifying, “Okay. Are they getting better? Do we need to change their treatment plan?” And they’re doing that in service of helping the primary care provider measure how well is a medication working? So, I’m going to give this patient a medication; how well is it working? Are they getting better? Are they not getting better? And then, the therapist will, or the care manager will also work with a consulting psychiatrist. So it’s kind of this triangle model where the PCP, the care manager, the consulting psychiatrist, and then the patient in the middle, are all working together to make sure that the meds are in exactly the right spot, to make sure that the treatment intervention is at the right level. And the PCP doesn’t have to do it alone; they’ve got these other people who are really helping to watch how the scores are changing, to watch how the patient’s functioning is changing, with the goal of getting them back to baseline functioning. Right? We want to get you back to where you were, and get you on your way.

Nicholette Leanza:

Right. And I like that it’s a team approach, while previously, I think it was probably the primary care physician as the sole island of providing all the delivery of services. So definitely, to look at it as a team approach wrapped around that patient, I think even as a patient, that would feel more warm and fuzzy that, “My different kind of team members all are communicating with one another.”

Emily Mohr:

Yeah. I agree. I think that patients who have participated in Integrated Behavioral Health Model really do feel that. They really feel like, “These are humans who really care about me, and they’re talking to one another. There’s relationships that these providers have with one another that are all about just helping me feel better.” And so, it really does feel like, “I’ve got a whole team trying to help lift me up.” And it also makes it more challenging for people to say to one doctor, “Well, I’m struggling with substances, but please don’t tell my doctor.”

Nicholette Leanza:

Oh yeah.

Emily Mohr:

“Oh, okay.”

Nicholette Leanza:

Oh, right. Right.

Emily Mohr:

So there are ways in which it can be challenging. But ultimately, it really is in service of the patient getting far better care, more holistic care, and having a team of people on their side.

Nicholette Leanza:

So, I know one of the many jobs you do here at LifeStance is to lead this charge of how to help LifeStance, as a whole, to move in this direction for probably all us clinicians to be more integrated with the care, the medical care, and melding together that mental health care. Can you give me an example of how you specifically do that in your own work, or in the region where you’re working out of, which I believe is Chicago, out of Illinois. Do you guys have a set program that you are currently doing that?

Emily Mohr:

Yeah. So, I’m not working with programs that are currently running in Illinois. Actually, I physically live here.

Nicholette Leanza:

Okay.

Emily Mohr:

But my focus is on some programs that we have running in California.

Nicholette Leanza:

Oh, okay.

Emily Mohr:

And also one that we have running in Texas and Florida.

Nicholette Leanza:

Ah, got you.

Emily Mohr:

Yeah. So really, what we’re doing is trying to, well, not trying, we are; we’ve built these relationships with some pretty large medical practices. One of the programs I’m working with is with a renal care program, so it’s actually a specialty group, not primary care. And the other program I’m working with is primary care, and we are… We’ve built a team of behavioral health providers who are specifically spending time creating access for these patients. Right? So, patients are coming either from the primary care setting, or they’re coming from the renal care setting, and we have a team of folks who are ready to see those patients, who will do what we call a behavioral health consultation. So they bring them in; they do a very focused evaluation. “Hey, your doctor said you’re struggling with this. Let’s look at what’s going on for you.”

Emily Mohr:

So they find out what kind of symptoms a patient has, how those symptoms are impairing their functioning, like “I’m not doing as well with my relationships as I was. I’m not doing as well with keeping up with my healthcare as I was.” Whatever. And really then identifying, “Okay. Let’s find a treatment plan. Let’s find out what specific things we can do to move the needle on those symptoms that are bringing you in.”

Emily Mohr:

What ends up happening, is that we create a treatment plan that’s meant to be briefer in nature. It’s really meant to be… If you think about your primary care doctor is the person who is there when, “Take two pills and call me in the morning.” Like, “Okay, here’s the problem. I’m going to help you solve it. I’m going to help support you in being as well as possible.” But it’s sort of like keeping the smaller problems at bay.

Nicholette Leanza:

Oh, yeah.

Emily Mohr:

“Let’s make sure that we keep things rolling along, keeping the smaller problems at bay. If there’s something big that comes up, your primary care doc is going to send you to a specialist.” Right? Like, “Ooh, that rash, isn’t getting better. I’m going to send you to the dermatologist.”

Emily Mohr:

Think of integrated care clinicians as being like the primary care doctors of behavioral health. So we focus on, “What’s the problem that it’s bringing you in? Let’s identify a targeted treatment to help you with that problem. We’re going to help you change how you’re approaching this with your behaviors. We’re going to help you address cognitions. We’re going to… All those good things that we as therapists do, but in a very targeted, brief way. And if what you need is something bigger, no problem. We’ll get you connected with people who do specialty mental health, which is LifeStance.”

Nicholette Leanza:

I got you.

Emily Mohr:

We call it LifeStance bread and butter.

Nicholette Leanza:

Right.

Emily Mohr:

Right? Everybody else in LifeStance. So, we are sort of that first step to really capture these patients, help them get a good first line intervention, and then triage. If they need more, we get them connected to more.

Nicholette Leanza:

Got you. Let’s jump back to, you did mention how really working with the entire person, that mind and body. Can you tell me more about that? Why is that so crucial in working with individuals?

Emily Mohr:

Gosh, because people come to you with their entire self. Right?

Nicholette Leanza:

Right.

Emily Mohr:

Nobody walks into their doctor’s office or their doctor’s exam room, and leaves their mind and their emotions and their… That just doesn’t… That isn’t real. It’s silly to even think about it that way. And yet, that’s how medicine has been treated in a lot of respects.

Nicholette Leanza:

Yeah.

Emily Mohr:

So the same is true in reverse. I think if you go back and think about your training; I think about my training. I don’t know that I was really taught to think about things like, “This person is waking up in the middle of the night, and they’re having panic attacks. They’re waking up in the middle of the night, and they feel like they’re smothering, and they’re panicking.”

Nicholette Leanza:

Right.

Emily Mohr:

And no one ever said to me, “Emily, make sure you check for sleep apnea; because that might be what’s happening here.” Or, depression, going off of the sleep apnea one, depression oftentimes is caused by, or the symptoms over lap strongly, with sleep apnea; somebody is really exhausted.

Nicholette Leanza:

Ah, interesting. Okay.

Emily Mohr:

Yeah. Yeah. So, we aren’t really taught in our silos, to think about the whole person. But when we do, we get… Number one, we get a much more complete picture. And number two, we actually are so much more helpful to the patient.

Nicholette Leanza:

Good point.

Emily Mohr:

So I could… The number of times I have caught sleep apnea, that somebody came to me, and the doctor said, “Oh, they’re having panic attacks,” or the doctor said, “They’re really depressed.” And I go back and I say, “Actually, can we treat their sleep apnea? Let’s get them tested. I think they need a sleep test. And then, let’s treat it if it shows up.” That happens all the time. Also, people who are experiencing a lot of GI distress, I get this one a lot, too.

Nicholette Leanza:

Yeah.

Emily Mohr:

What they need is to treat unrecognized trauma. They need to treat… They need stress management skills. They need emotional regulation skills. And then, oh my goodness, their GI issues start to feel better. They start to have fewer episodes and fewer flare ups. So we just can treat people so much better.

Nicholette Leanza:

Yeah.

Emily Mohr:

If you just consider the entire person.

Nicholette Leanza:

I see your passion as you’re speaking about this. What was it that initially kick-started this passion into integrated behavioral healthcare? Was there one thing or a series of things? What… I love this passion you have. So what kick-started it?

Emily Mohr:

Yeah. We joke, the people on my team and I, we joke all the time. I have zero poker face. It’s written all over me. And you’re right; I love this. So, that’s a great question. When I was just out of my predoctoral internship, throughout my training, my doctoral training, I studied women’s body image. That was… My master’s thesis was on that. My doctoral dissertation was on that. My internship, I got some training on eating disorder work. So in my postdoc, I worked at an eating disorder treatment facility. And that really was the thing that shifted me to this real recognition of how much your physical state is impacted by your mental state, and vice versa. And so much so, that we would talk about how, “This individual has some pretty severe anxiety and also some pretty severe depression, but the medication isn’t going to work until we get some weight on them.”

Nicholette Leanza:

Yeah.

Emily Mohr:

And we don’t even know what the symptom picture is going to look like until we get some weight on them. And so it was that just real clear link between your physical state and your mental health that I learned working at the eating disorder clinic. And it just stuck; just learning to look at things through that lens, and then going into other spheres, just regular out patient work, looking at people who had pain, chronic pain, and what that would do to them, or anxiety and how that manifested in their body. It just was always fascinating to me. And when I looked at people through that lens, I just felt like I could get, number one, a much richer picture and a more complete picture.

Nicholette Leanza:

Yeah. Yeah. For sure. You mentioned chronic pain. And that is something that if there should be any integrated platform, it really should just be this full approach of integrated behavioral healthcare. When have you found this helpful when you’re working with patients who have chronic pain? How has that whole platform improved their symptoms?

Emily Mohr:

Oh, wow. Oh, wow. So much. Okay. So, I really did quite a bit of learning about behavioral health treatments for chronic pain when I was a little further along on my pathway. I went through my first postdoc. I got licensed. I was doing outpatient work. And then, I decided, “I really want to pursue this integrated care thing full-time.” So then, I went back and I did another postdoc.

Nicholette Leanza:

Wow.

Emily Mohr:

At the VA, where-

Nicholette Leanza:

Oh, wow.

Emily Mohr:

Where I learned… They have a great program in training people in this. But part of the program that I got to experience at the Bedford VA; big shout-out to the Bedford VA in Bedford, Massachusetts, they’re phenomenal, was about chronic pain. So what we got to learn there was, number one, how just training people in stress management, when you can decrease the autonomic arousal in your body, how that… If you know anything about Gate Theory with pain. Right? Closing down those gates… because when you’re distressed, those gates are wide open, and the pain signals are infiltrating your brain loud.

Nicholette Leanza:

Right. Right.

Emily Mohr:

So if you can quiet down, close those gates a little bit, by quieting down the autonomic arousal, so what is that? That’s stress management skills. That’s breathing. That’s mindfulness skills. Right?

Nicholette Leanza:

Yeah.

Emily Mohr:

So there’s just a lot of behavioral, cognitive behavioral strategies that can really help people to actually experience less pain-

Nicholette Leanza:

Wow.

Emily Mohr:

… by calming and soothing themselves. And that was just a game changer, in terms of that mind/body connection. Plus, we got to use biofeedback.

Nicholette Leanza:

Oh, great.

Emily Mohr:

So, we were actually using computers and other technology, to gather data from people about, “What impact are you having on your body as you do this calming strategy or doing this mindfulness strategy?” And the way that people were able to change their experience of pain was dramatic.

Nicholette Leanza:

Can you talk a little bit more about the biofeedback and how that works, to help people understand why that is such a great platform to use?

Emily Mohr:

Yeah. So, it really goes squarely back to this idea of, “What can consciously do to down-regulate your autonomic arousal?” Right?

Nicholette Leanza:

I got you.

Emily Mohr:

“What can you do to bring the stress response down in your body?” And I think people get very freaked out at times about biofeedback. And patients, they feel like, “What are you doing to me? I don’t want that…”

Nicholette Leanza:

Yeah.

Emily Mohr:

“It’s nothing that we’re doing to you. It’s just like getting a blood pressure. Well, blood pressure is actually an example of biofeedback. We’re looking for data from your body. That’s all.”

Nicholette Leanza:

Yeah. Yeah.

Emily Mohr:

So one thing that people will do for chronic pain management is actually temperature regulations; so you can hold a little… You’ve probably seen them, these little mini alcohol thermometers; hold a little mini alcohol thermometer in your hands, and you can do a visualization and a relaxation exercise, where you’re imagining your hands warming, like warming by a fire.

Nicholette Leanza:

Oh, I love that, Emily. I love that.

Emily Mohr:

It’s so cool.

Nicholette Leanza:

Oh.

Emily Mohr:

And you literally can watch the thermometer rise as you raise the temperature in extremities; because you’re relaxing, your blood vessels dilate, the blood flow goes into your fingertips, and you get that immediate feedback. “It’s working. I’m relaxing myself.” And that’s rewarding. It teaches you, “What is the right thing to do to make it happen?” It’s so effective. There’s lots of other biofeedback, but that’s just one.

Nicholette Leanza:

No. But thank you for sharing just that one; because I do think patients get intimidated by, “What is this?”

Emily Mohr:

Yeah.

Nicholette Leanza:

And so, I think you just gave a really great example of a very simple thing, and how that is that biofeedback there. So thank you for sharing that.

Emily Mohr:

Absolutely.

Nicholette Leanza:

Yeah. Any other takeaways you’d like us to know about integrated behavioral healthcare?

Emily Mohr:

What I think I would really love for people to know, is that it is a really fun and exciting way to provide behavioral health services.

Nicholette Leanza:

Yeah.

Emily Mohr:

The reason that people do this, the reason that this is a thing, is because of what we call the Quadruple Aim; which is, we are trying to provide right treatment to patients. Right? Really focusing on, “What is the treatment that’s really going to work for what they need, at the right cost, so we don’t need to throw a full episode of care in outpatient mental health, when just this brief model will work.” That preserves access. Right? So the people who really need longer term care, we all know right now; everywhere across LifeStance, waiting less, wait less, like crazy. So access is a real issue. If we can provide the right care at the right cost, so this more minimal kind of form of treatment, we can create more access. It creates a better experience for patients. So, to provide for the satisfaction of patients, and also the satisfaction of providers. It makes the primary care doctor’s job more fun. It really is very fun for the behavioral health provider, too.

Emily Mohr:

And I would just encourage people to consider whether or not this could be something that would maybe enrich their experience as a provider, and what kind of benefits they might see for their clients. Or even for patients, what kind of benefit you might see for yourself, if you were to include behavioral health into the medical-

Nicholette Leanza:

Yeah.

Emily Mohr:

… care. It’s really enriching. It’s really fun. And wow, does it work.

Nicholette Leanza:

Emily, your passion and excitement for this is like, it’s tangible. I would say-

Emily Mohr:

You want to do it now, don’t you?

Nicholette Leanza:

Yeah. Yeah. I’m totally down for this. It’s like, “Yes, this is what I want to do.” It’s great stuff. And I appreciate you sharing everything about this, so to help our listeners and our viewers to understand it more, and how, it sounds like LifeStance, we’re at the forefront of really feebly trying to integrate this into our society. And it’s so important that we do. So, bringing it all together-

Emily Mohr:

That’s right.

Nicholette Leanza:

… that mind and body into the whole individual; so important to change.

Emily Mohr:

You got it. You got it. Yeah.

Nicholette Leanza:

So thank you for your time today. And I’d love to have you back out and talk more about this, for sure.

Emily Mohr:

Wonderful. I’d love to. Thanks, Nikki.

Nicholette Leanza:

Thank you.