There are many good reasons for the strain and experience of burnout among healthcare professionals at-large and primary care teams specifically, but there may be a hidden factor affecting your integrated behavioral health staff that you may not have yet considered: role diffusion.
The shorthand version for this phenomenon is, “your staff is trying to do too much.” In our experience providing technical assistance over the last two years, primary care behavioral health programs (PCBH) have drifted towards colocated psychotherapy as a “response” to the increased distress in the population. What this does is promote role diffusion and in fact role confusion for behavioral health consultants (BHCs). Some patient consults feel like the “old” primary care consults and some begin to feel more like full-fledged psychotherapy, stretching the behavioral health consultant to fill these two roles at once while trying to fit into the operational structure of the PCBH model. The end result is that the behavioral health consultant will feel stretched, confused as to what limits and boundaries to follow in their work, and often times ineffective at both the old-school consultation consults and the psychotherapy they are providing. And of course, wait times grow, warm handoffs diminish, team communication suffers and the behavioral health consultant becomes more and more isolated under a mountain of demand and expectation.
Basically some programs have become high productivity specialty therapy programs with shorter slot times and little to no warm handoffs.
The irony of the response is that the more adaptive response to the need in the population should not have been a move to creating more of an access issue by defaulting to a specialty psychotherapy approach (which by nature provides more resources to fewer individuals in the population) but rather to work to adapt the colocated telehealth approach to the population health goals of PCBH. Instead what happened is that colocated telehealth presented a path of least resistance that included spending more time with patients on average and inviting them back to be seen at shorter intervals than what we would have likely chosen if we were in clinic. Then as we filtered back into clinics we found it difficult to undo some of these practice changes.
Again, the rationale for all of this was the need of the population and the crisis of the pandemic, and while this is admirable, the truth is that the same or similar mental health crisis existed before the pandemic. In other words, we can’t really pretend that access to mental health care was somehow robust before the pandemic and then only became a problem after the pandemic hit. In retrospect (because as I write I also acknowledge that I had the same response) I think many of us were responding to our own transference and counter transference. In other words, I think because we were feeling so affected by the pandemic and we saw our patients experience the same thing we found it harder to set limits and to think strategically with patients around how often to see them and for how long. That challenge has always been there in my 20+ year career in PCBH. I have always practiced in settings that had limited to no realistic access to mental health support for the patients that I see in primary care. I have always practiced in settings where the demand was greater than the resources and in fact this is what inspired me to practice in the PCBH model and to adhere to its targeted approach based on population health principles. In truth while the pandemic certainly made that situation worse the only difference I can discern is that I too was going through what my patients were going through.
So what we have been doing here at the Collaborative Family Healthcare Association (CFHA) in our consultation work has been to encourage teams to define their roles once again. It is so important in good PCBH practice to have at the forefront of your mind the job that you are there to do and to understand that you are there not to act as a specialist who is in charge soup to nuts for all of the mental health needs of your patients but rather that you are there as part of a team providing support across the lifespan of the patient that is targeted, empowering and focused on improving their health and well-being in a functional manner. You are not there to provide psychotherapy in the traditional sense. You are not there to be their friend or support network. You are not there to be their only coping resource. You are there to empower and help engage the patient/ family, the captain(s) of the care team, and to similarly empower and engage your teammates. Our hypothesis is that if you’re able to move your team back to that vision you will see less burn out because your team members will be operating with a more refined and singular purpose.
I’m an N of one, but that certainly helped me in my clinical practice a few months into the pandemic once I caught the practice drift I was experiencing. I started by simply tracking how often I was bringing patients back and found that with a few adjustments I was able to create more room in my schedule as I spaced patients more appropriate to a primary care style. Then I went back to basics. I started working on my introduction to patients, reinforcing my role as part of the team and the consultative nature of my work with them and my colleagues. And I started working on my own transference. Yes, I am affected by this pandemic too. Yes, it feels bad, really bad at times. No, I can’t let my pandemic response impact how I strategically target care for my patients. That’s my stuff, my needs.
Now, not everyone is burning out due to the above. Like I said, there are lots of good reasons for this phenomenon these days, particularly the organizational dysfunction that rears its head in systems that already had issues before the pandemic. However, this may be one of the things to check in on with your teams. We can’t be all things to all people. We need well functioning PCBH and we need well functioning specialty mental health (and BTW – this phenomenon may also impact CoCM programs). We just can’t be both in the same person or the same service.