Integrated Behavioral Health Manual

For a long time, it has been universally recognized that mental illness and substance use have significant impacts on one’s overall health and wellness. However, over the last decade, integrated, person-centered, care approaches that treat the full spectrum of one’s health needs, including mental health and substance use issues, have become increasingly popular. There is an abundance of research demonstrating integrated care’s positive effects on clinical outcomes, patient experience, and healthcare costs. It reduces the stigma of receiving behavioral health services for individuals who would not normally have sought treatment outside of the primary care setting, simultaneously addresses co-occurring behavioral and physical health disorders, and saves organizations and health plans money. In this sense, integrating behavioral health services and primary care is no longer thought of as a new or innovative model, but instead, considered to be a standard of care.

While some form of integration has been happening in health centers since the 1960s, the last 12 years have seen a significant acceleration in the field. In 2006, the California Endowment and the Tides Foundation launched the Integrated Behavioral Health Project (IBHP), the first statewide effort in California to advance integrated care. Since that time there have been numerous federal, state, and philanthropic grants aimed at advancing integration in the safety net, primarily funding “bi-directional” integration that integrates primary care into traditionally mental health and/or substance abuse organizations. However, the most robust integration continues to occur in community clinics. This manual is written, specifically, with this (and clinicians practicing in this setting) in mind.

Still, it is important to note that integrating behavioral health and primary care poses many challenges. Beyond issues with funding, systemic or organizational change, and healthcare policy, working within the culture of a traditional primary care setting can feel alienating for behavioral health providers because behavioral health practices are founded on principles that sometimes seem to be at odds with the culture of primary care. Primary care can at times appear to be a system that supports overwork, lacks person-centered care, or has an absence of empathy as a primary component of treatment. Some behavioral health providers fear that integration in these settings can threaten to subsume the behavioral health culture and leave them feeling chronically overwhelmed and concerned about the quality of care they are providing. However, integration should not be avoided for these reasons. Instead these points should only point to the importance of consciously integrating behavioral health AND primary care, as opposed to integrating behavioral health INTO primary care. This manual hopes to support practicing behavioral health clinicians providing services in an integrated setting. In addition, it aims to serve as a comprehensive overview of the philosophical, clinical, administrative, and operational characteristics of an effective integrated care model.

Some of the writings here come from my own 12 years of experience working as a clinician in primary care settings, some from being a Director of Behavioral Health in an integrate setting for a decade, and much comes from the experiences shared with me by my many wise integrated behavioral health colleagues. This manual was composed to reflect a “point in time” in the field of integrated behavioral health, as it is one that is dynamic and constantly changing and evolving. In this spirit, I would invite readers to provide suggestions and feedback to any parts of this manual. Lastly, it is my hope that this manual is not interpreted as directive in any sense, only supportive and reflective of the complex work we are all engaged in.