In one of my favorite movies, “Eat, Pray, Love,” the main character reflects on a story told by her friend, who is a therapist, about counseling Cambodian refugees who recently immigrated to escape a humanitarian crisis where they experienced unimaginable threats to their safety and stability. The young therapist, who had no experience in providing crisis intervention to refugees, felt daunted by the task and wondered if she had the skill set to address the complex concerns of her new clients. To her great surprise, she realized that their concerns were very similar to those of her American clients. They wanted to talk about their relationships, love lives, and personal hopes and aspirations. It was not the major traumas that troubled them, but their relational and emotional experiences. In response to this, Julia Roberts’s character opines, “This is how we are” — we want to discuss relationships. Regardless of how troubling our circumstances may be, it is the “who we are” and “who we love” that matters most to us.
As a psychologist who has worked for over 20 years in long term care settings, I can attest to the truth of this Hollywood illustration. The clients I have worked with over the years focus on their personal stories of love, loss, hurt, joy, disappointment and pride of accomplishment. Seldom have I heard clients discuss their “deficit in ambulation” or their “nutritional status” as a primary concern. It is not that physical health and functional changes don’t matter to them, but rather the medical realities of aging and functional loss serve as the backdrop. The focus that lies at center stage in their stories is relationships and how they impact their sense of personal identity and wellbeing. This is how we are.
Those of us committed to culture change and person centered care know this. Listening to the stories of each individual and weaving their personal priorities into individualized care is the way to ensure that life continues to be worth living, even against the backdrop of significant health problems and functional losses. However, mental health professionals, who are uniquely positioned to serve as trained listeners, translators of human experience, and experts in communication, are all too often missing from our interdisciplinary care teams-even in the settings where these realities are recognized and honored.
In our book, “Transforming Long Term Care: Expanded Roles for Mental Health Professionals” (Carney and Norris, 2017), Margie Norris and I review the history of mental health issues and services in long term care and argue for an expanded role for mental health professionals. Mental health clinicians have the potential to serve as catalysts, facilitators and partners in culture change and person centered care. The very tools of our profession are listening and understanding what is most important to each person. Our clinical expertise lies in interpreting stories within a framework of knowledge directed at supporting relationships and personal identity, and coping and thriving within difficult circumstances. We are communication experts, able to translate verbal and nonverbal expressions into coherent explanations that allow others to understand each individual’s story better. As trained group facilitators we can lead interdisciplinary care planning in a way that puts the story of the individual at center stage, while also appreciating the medical and functional backdrop for each person. As trained educators we can share psychological knowledge with others, fostering their ability to listen to and appreciate each person’s story.
Skeptical about the course I am suggesting? Thinking you don’t have the time to engage in training and team meetings with a mental health professional? Worried about the additional cost of such services, or justifiably concerned about access to mental health providers? Yes, there are challenges in creating truly integrated care that appreciates the psychosocial aspects of care in equal measure to medical care. Change is difficult — it always is. However, just because a thing is difficult to do should not alter the understanding that it is the right thing to do. Research literature tells us that integration of mental health and medical approaches improves clinical outcomes and reduces medical costs. And while there may be costs in time and money involved in fully engaging mental health professionals, the improved clinical outcomes, medical costs offset and enhanced quality of care make the investment worthwhile. What you invest on the front end, you will reap on the back end. And finally, while it is true that there are fewer mental health clinicians than required to meet the needs of older adults across the county, there are creative alternatives to address this challenge. Accessing county mental health supports, partnering with local academic institutions for assistance, utilizing telehealth services (reimbursed under Medicare in designated rural areas) and connecting with national resources are all options to explore. In reality, the workforce deficits in geriatric mental health are similar to those in other geriatric healthcare specialties and creativity is needed in all areas to ensure adequate access to professional resources. In sum, fully integrating expanded mental health services into long term care is the right thing to do and it can be done with great success by those with the will and a bit of creativity. Pioneer Network members understand the power of grit and innovation to improve quality of care better than most.
The new CMS conditions of participation includes regulations on Behavioral Health (§483.40), compelling us to identify ways to integrate mental health professionals into our interdisciplinary care teams. Pioneer Network members are just the folks to take the lead on this path to improving care, just as we have in so many other areas.