Quilts, Cars and Integrated Care

By: David Baker, LPC
Clinical Director
Georgia HOPE

NOTE: You may have noticed that this blog seems to mostly be addressed to people who are providing helping services rather than on the people who receive the help. There are a couple reasons for that. The first reason is that I am a “helper” (in my case a licensed professional counselor) so in part that is the point of view I see the world from. As a clinical director for our company it is also my job to help helpers become better helpers.

The second reason my blog posts are focused the way they are is because I think it’s important for the professional process of helping people to be transparent. There shouldn’t really be secrets between those who help and those who are being helped about the process of helping.

So with that being said I do intend to address both the helper and helped points of view and I think this next post is sort of addressed to both helpers and the helped.


Here at Georgia HOPE we have really adopted the integrated care approach to providing mental health services because we believe that addressing the needs of the whole person is the best way to provide quality care.

We believe so strongly in this approach that, in 2016, we became certified as a “Patient Centered Specialty Care Practice” for Behavioral Health by the National Committee for Quality Assurance. We are very proud of this certification.

But what does it mean to be a provider of “integrated care?” Or, for that matter, what does it mean to be a client or patient receiving integrated care? I did a Google search on the term “behavioral health integrated care” and I came up with 1,930,000 + results. Clearly there’s a lot that’s been said about what integrated care means and there are a lot of different points of view on the “what” and the “how” of providing this type of care.

If you are like me, the wealth of information gets a little overwhelming. What sometimes works for me is to have a metaphor for what a complicated idea like this. So there are a couple pictures I’ve been thinking about that help me visualize what it means to integrate mental health help with other kinds of help. Maybe they’ll make sense to you also.

THE QUILT METAPHOR

A few years ago a friend gave my wife and me a video and a book about a group of women who make quilts in a place called Gee’s Bend in Alabama. (If you’re interested in their story, you can go here.) The amazing thing about how these quilts are constructed is that most of them took more than one person to make. That is because quilts require a variety of different skills to produce.

You need to have an eye for how colors and patterns work.
You need to know how to cut out the pieces of the quilt so that they will look right when they are all sewed together.
You need to have sewing skills
You need to know how to join the quilt together
You need someone who finds the materials out of which to make the quilt.

And I’m sure there are other skills I’m not aware of. The point is making a thing of beauty is not a simple process. While there are people who may possess all the skills needed for making a quilt, it’s often the case that a quilt is produced by a group rather than by a single person.

In similar fashion, the integrated care approach to providing help for a whole person builds on this idea that producing beautiful and satisfying help relies on more than just one set of skills. If I’m only good at cutting out the pieces of the quilt and not at the sewing together or quilting of those pieces, then the quilt I come up with on my own is not going to be very complete or satisfying. Integrated care recognizes the importance of making sure that all the right people with the right skills are present and working together so that the resulting help that is provided is complete and has as satisfying a result as possible.


THE CAR METAPHOR

For those who are more mechanically than artistically minded, think about integrated care in terms of maintaining a car in good working order. Like quilts, cars are not all that simple. There are a variety of different systems that all need to be working well together to make sure that a car gets us from here to there. If the engine is working well but the transmission isn’t, being able to get where you need to be is not going to be possible. Or if everything is working but the braking system, you may be able to get where you’re going but you won’t be able to stop once you’re there. As with quilt makers there are mechanics with special skills that specialize in different areas of car maintenance and repair. You probably wouldn’t take your car to the brake specialist to get your transmission fixed or to the oil change place to get new tires.  And if the care of any of those systems is neglected, you may have a car that runs but it may not run well and it may not run safely. And it may not be able to stop…

Again, the point is that as in car repair and maintenance, integrated care requires a variety of different skills sets to make sure that the right help is provided to address all the different parts of who a person is. If I am currently experiencing high blood pressure, can’t sleep at night and have depression and anxiety, I am not really going to get well unless I work on all those issues together. If I go to see my therapist and they only want to talk about my depression, then, while my depression may decrease, my overall health may limit how well I maintain my progress in resolving my depression. Or if my primary care doctor just wants to give me medication for my blood pressure and to help me sleep, then I am probably still going to have depression. And my depression will probably keep me from being as physically healthy as I can be. And if therapy would be helpful to me but I cannot get there because I don’t have gas for my car, then I am going to need help that gets me to therapy to have success in resolving my depression. Helping a whole person usually means that my therapist and my doctor and probably others may have to work together to help me be as well as I can be and continue to stay well.

Integrated care is about looking at the whole quilt and ensuring that all the skills and materials are there to make it beautiful. It is about making sure that all the systems are running smoothly so that the whole car gets where it needs to go safely and on time.

For helpers, this means that we need to make sure that we’re not only looking at the colors we’ve selected, but are also looking at how the colors are arranged and sewed together to make a whole quilt. It means that we need to make sure that in addition to having gas in the engine that the transmission will shift out of park into drive. We don’t have to have all the skills to provide all the help that’s needed, but we need to be aware that needs are connected and the best progress is made when all needs are addressed by the right kind of helpers who are working together.

It also means that we shouldn’t forget that there are more ways to approach a need than just those on which we usually rely. Therapy is proven to help relieve depression, but so is physical exercise because the mind and the body are connected systems which rely on each other to keep both working well. So just because I am a therapist, that doesn’t mean that every need should be addressed with therapy.

If you are being helped but the help you are getting only focuses on one part of your life and not all aspects of your well-being, then tell your helper(s)!

As humans, we are all made up of physical, spiritual, emotional, intellectual aspects.  The goal of integrated care is to support our overall well-being in all areas of our lives. The goal of integrated care is not just a quilt that looks beautiful, but one that also keeps us warm. The goal of integrated care isn’t just a car that stops, but one that also goes and gets us where we are going. And sometimes it takes more than one kind of specialist working together with other specialists to make sure that happens. That’s integrated care.


 

We’re Not Gonna Take It Anymore

Or, Why We Need to Stop Calling Clients

“Non-Compliant”

By: David Baker, LPC
Clinical Director
Georgia HOPE

I know it’s probably dangerous to quote the title of a song recorded in 1984 by a band called Twisted Sister in a blog about mental health related topics because 1) it certainly dates me a bit (though I promise you I wasn’t really a Twisted Sister fan in my youth) and 2) as a protest song (and I know you’ve probably heard it and maybe even sung along with it) it makes some pretty strong statements. But I think the title and the sentiment behind the lyrics of the song make a pretty good point about not trying to force people to fit into a box they don’t belong in.

I can already hear you asking “So what does that have to do with non-compliant clients?” My response is: “A lot!” Let me explain. Most of the time when we identify a client as “non-compliant” what we are saying is “They aren’t doing what I or someone else thinks they should be doing.”

For example:

  • “They aren’t keeping appointments”
  • “They aren’t taking their medicine”
  • “They aren’t returning my calls”
  • “They aren’t using the skills I’m teaching them”
  • “They aren’t getting anything out of the therapy I’m providing”
  • Or you fill in the blank

Usually “non-compliance” has more to do with what I think my client’s unmet needs are than with what my client thinks their unmet needs are.

At the risk of giving Twisted Sister more credit than they might deserve for brilliant therapeutic insights, think about these lines in the context of the clients you work with who you think of as “non-compliant”:

“We’ve got the right to choose it/There ain’t no way we’ll lose it/This is our life, this is our song”

and

“We’ll fight the powers that be just/Don’t pick our destiny ’cause/You don’t know us, you don’t belong”

While these sentiments may be somewhat overstated (and I’m probably stretching these lyrics way beyond their intended purpose…), I think these lines make the point that people have the right to choose their destiny and when this is challenged or disregarded the response is usually to fight or flee from whoever is trying to force us to do something we didn’t choose.

So when your client is “non-compliant” maybe what they’re telling you is there’s something about the help they are getting that they don’t want to “take.” If we are accurately reflecting in treatment the unmet needs our clients have asked us to help them to address, than “non-compliance” is a non-issue as a client can’t be non-compliant with themselves.

I think these lines make the point that people have the right to choose their destiny and when this is challenged or disregarded the response is usually to fight or flee from whoever is trying to force us to do something we didn’t choose.

So, what do we as therapeutic helpers do when we our clients become disengaged from treatment? I think the first and best thing we can do is to listen. Sometimes the listening is easy because our clients are singing as loud as Twisted Sister letting us know that they don’t want what they’re being offered by us – “We’re  not gonna take it!” More often than not though the listening requires a little more skill because the communication isn’t so “in your face.”

In an article on addressing resistance in therapy the following statement was included: “…resistance is a signal that the client views the situation differently.  This requires that [staff] understand the client’s perspective.  This is usually a signal for [staff] to change direction or to listen more carefully” (http://rssw705.tripod.com/id15.html).

The point is in order to better align treatment with the client’s unmet needs we need to make sure we understand our client’s unmet needs. For our clients to stay involved in treatment we need to create the positive motivation for them to stay involved in treatment. If we haven’t asked them why they aren’t engaged, we need to. If we haven’t given them the freedom to have a different point of view than ours and express that point of view, than we need to give it. If we haven’t put ourselves in our client’s shoes as best we can and tried to understand the challenges they are facing from their point of view, than we need to. And we need to be willing to acknowledge that while we may have a lot of experience and education in providing help to other people, our clients are still the experts on their own unmet needs even if they don’t always know it. So we need to make sure that we are developing the skills to hear in all the various ways our clients are expressing those unmet needs and then help our clients tell us how we can assist them to most effectively and positively meet those unmet needs.

And we need to be willing to acknowledge that while we may have a lot of experience and education in providing help to other people, our clients are still the experts on their own unmet needs even if they don’t always know it.

Finally, there will be times when our clients continue to tell us straight up “We’re not gonna take it anymore!” and our response will have to be “OK” because our clients have the right to make that choice. It’s their treatment. Hopefully that will be after we have made every effort we can to listen and have exhausted every possible avenue for creating motivation to access the help we have been trained and want to provide.

Oh and if you’re feeling lost without the word “non-compliance” in your vocabulary, I guarantee you if you put yourself in your client’s shoes and try to see things through their eyes you’ll probably come up with something more positive to use.

 


 

Dr. Seuss and the Individual Recovery Plan:
Oh the Places You’ll Go!
By: David Baker, LPC
Clinical Director
Georgia HOPE

When I graduated from graduate school a friend of mine gave me the Dr. Seuss book “Oh the Places You’ll Go.”  Some of you may be familiar with this book. The book is about a character who is at the beginning of a journey and it emphasizes the destinations on that journey he will reach and the experiences he will have along the way. The story is all about moving forward even if there are experiences like the “slump” and the “lurch” or places like The Waiting Place and The Alone Place that create problems or slow our hero down. The point of the story is that the character is moving forward toward a positive (and even exciting!) destination. The story ends with the promised excitement of what you’ll see when you make it to the top of the mountain you’ve chosen to climb.

Our job in working with clients is to help them identify the destinations they want to reach – the “mountains” they want to climb. Think of a time when you were planning a vacation or trip to somewhere. Usually when we do this we are thinking about the destination we want to reach – Bora Bora, Destin, the Smokey Mountains. Usually we aren’t just thinking about what we are getting away from. Ok, sometimes we are thinking “I just want to get away from it all” – work pressures, family pressure or some other discomfort. But we usually have a picture in mind of where we want to be instead – walking on a beach in Maui, sitting on your deck with a cool breeze blowing, curled up on the couch reading a great book, climbing a mountain with a Dr. Seuss character.

The role we can play with our clients is to help them identify those mountain summits they want to reach in life.

The role we can play with our clients is to help them identify those mountain summits they want to reach in life. They’re not usually physical mountains. Sometimes the “summit” is being able to get to the end of the day and say I’m proud of something or many things I did today. Sometimes it’s being able to say when I felt myself getting anxious today I knew what to do to return to my chosen sense of calm and peace. Sometimes it’s being able to say when I thought about the loved one I lost I was able to remember something positive about them and smile instead of breaking into tears. So while it may be very important for little Johnny to stop having temper tantrums at school or Sally to stop injuring herself when she feels afraid or anxious, it’s also just as important to help Sally and Johnny identify what they want instead. Maybe Johnny’s and Sally’s mountain to climb is developing a comprehensive sense of safety that they can call on when times are difficult.

Some mountains may seem big and some may seem small, but the thrill of getting to the top is usually the same and you almost always have a better view. Sometimes getting to the top of a small mountain gives a view of the next mountain you want to tackle. Not everyone wants to reach the same mountain top and not everyone climbs the same mountain the same way. So as tempting as it is for helpers like ourselves to think “I know the way to go and I’ll tell you how to get there” it’s probably more helpful for us to help our clients decide where they want to go and then help them decide what way there works best for them. Then our job is to simply cheer them along the way to the places they want to go.

So as tempting as it is for helpers like ourselves to think “I know the way to go and I’ll tell you how to get there” it’s probably more helpful for us to help our clients decide where they want to go and then help them decide what way there works best for them.

So the next time you look at or write an Individualized Recovery Plan see if it passes the Dr. Seuss test. Is it about “Oh the Places you’ll Go”? Do the “mountains” it identifies for climbing look exciting and positive? Or is it only about staying out of the “slump” or avoiding The Alone Place? And does it sound like something that your client thinks would be a good place to get to instead of the “slump” or The Alone Place? If it doesn’t pass the Dr. Seuss test, than have your client help you change it! As important as it is to prepare for the “slumps” and to know what to do about the “Alone Place”, it’s equally important to decide where you want to be once you get beyond those places. Our job as helpers is to keep that phrase in the back of our minds and to keep reminding our clients of it – “Oh the places you’ll go!”