For me, the term holistic encompasses an integrative process rather than the opposite, a state of compartmentalization that has become prevalent in the provision of health care services. Integration is the process of connecting the differentiated parts of the system leading to the coordination and balance of the flow of energy and information. Primary care providers are in a position to be integrative, meaningfully uniting and synthesizing information consisting of differentiated findings from specialists and making the most appropriate decisions for the patient in a holistic way, being in the role of “the captain of the ship” navigating it to the safe harbor. Instead, they have been in the role of gatekeepers, referral managers, check box clickers, and prescription distributors. In this way, the whole system has been skewed toward disease management, rather than providing patient-centered and life-enhancing care.
Healthcare reform underway
When I decided to work at the Veterans Administration Health Care System, I was pleasantly surprised to come at transformational times when integrative processes were underway on multiple levels. The headquarter was in Washington, D.C. directing the work of 23 distinct regions, called Veterans Integrated Services Networks (VISNs). Our 23 VISN, the so-called VA Midwest Health Care Network, provided services to almost half a million enrolled Veterans residing in the states of Iowa, Minnesota, Nebraska, North Dakota, and South Dakota. Health care was delivered through an integrated system of nine hospitals, sixty-three community-based outpatient or outreach clinics, eight community living centers, and four domiciliary residential rehabilitation treatment programs.
I was even more surprised to find out that at the location where I was physically present there were complementary and integrative treatments used to promote wellness, improve mental health, and pain management. Natural products and special diets, deep breathing, meditation, yoga, tai chi, healing touch, aromatherapy, chiropractor, acupuncture and acupressure, stress management, creative arts, and music therapy were used in conjunction with traditional medical treatments.
Primary care was organized through Patient Aligned Care Teams (PACT). PAC teams provided accessible, patient-centered care managed by physicians with the active involvement of other clinical and non-clinical staff. General care included health evaluation and counseling, disease prevention, nutrition counseling, weight control, smoking cessation, and substance abuse counseling and treatment. Integration of primary and mental health services was underway when I arrived. Mental health professionals consisting of a psychologist, social worker, psychiatric nurse, and psychiatrist were embedded into PAC teams.
Mental health services lead the way
These team-based, recovery and prevention-oriented integrative approaches were visible at every turn, especially when I entered the space on the 4th floor of the main building where the majority of the mental health service providers were located. Skill-based, support, and educational groups were offered on a daily basis. Access to care was a priority, with the mission of providing necessary treatments at the right time, at the right place, and with the right person. The health behavior coordinator (psychologist) was promoting healthy lifestyle changes by enhancing motivation in the individual or group setting. Patients were being instructed on how to quit smoking, lose weight, eat healthy, exercise, better manage physical health conditions, improve sleep, etc.
There was a recovery coordinator (another psychologist) whose role was to facilitate the implementation of the main principles of the recovery model throughout the system. The development of a sense of hope, and the building of a support system with peers, family, friends, and mental health professionals was a priority. In addition, the application of self-help strategies that included identifying symptoms and taking actions to counteract them, reading and learning about an illness and its treatment, and applying coping skills were considered empowerment-based activities. Finally, meaningful employment and other work-oriented activities were an opportunity to gain a positive identity, including a sense of purpose and value. As might be evident from the above, this model emphasized respect, strength-based patient support and empowerment, and a person-centered, self-directed, responsibility-infused approach, which was very different from the business model I left behind in the private sector.
Other important coordinators were the suicide prevention (social worker) who implemented a program with the purpose of saving lives through the use of crisis lines, training about risk assessment, safety planning, enhanced clinical care, public awareness, and bereavement counseling for survivors of suicide loss. Another coordinator’s role (nurse) was to ensure that each patient had established continuity of care throughout the course of their mental health treatment, especially during the transition from one level of care to another.
The spirituality-based program was implemented using chaplain services. The spiritual assessment was provided to patients who expressed a desire to see the chaplain. Pastoral care and counseling were effective ways to help these patients and relieve them from the burden of guilt, address moral injury, and initiate the process of self-forgiveness. Having an opportunity to safely reflect on the spiritual dimension of life and search for meaning and purpose was a service available to all veterans. When requested, the chaplain was able to perform religion-specific ceremonies or services, such as meditation, prayer, reading holy texts, and observing holy days.
The captain of the ship
I liked the “ship” I was boarded on. As soon as I became “the captain of the ship” I started to facilitate and grow the lines of connection and blur the lines of division. This was not always easy because the VA organization was a strange mixture of innovation and rigidity imposed by the “rules of engagement,” the bureaucracy at its best and its worst. But despite this interesting paradox, there were “sweet spots” where individual action was allowed and mattered. For me, one of these “sweet spots” was initiating the mental health service line newsletter. With this monthly “project,” I was gradually recruiting more and more “players in the orchestra” consisting of contributors who harmonized and created the “music” written on the pages of glamorously designed newsletters with the beauty pleasing to the eyes and vibrations that inspire and inform, rise the “octave” of the working environment to the new level.
There were regular features that gradually expanded to include the word from the leader, an administrative officer column, a person of the month, a healthy living message, discipline updates, staff recognition, new staff introduction, book review, bridging mental health service line and chaplain service, program updates, the value of the month, theme of the month, and many others. The newsletter contained an abundance of material spread over up to 15 pages. The readership of the newsletter gradually expanded from our own mental health service line to Fargo’s VA Medical Center and the whole region (VISN 23). From time to time, I invited guests to contribute and, in this manner, expanded the scope and the reach of the newsletter.
This is what I wrote on the occasion of the celebration of the first anniversary of the publication in July 2014.
This issue of the newsletter celebrates its first anniversary. The newsletter has been published monthly in the fourth week of the month. The stated purpose of the newsletter is to be informational and relevant to our work as well as encourage participation from its readers. Many of you have contributed to its content and quality. In this regard, I am grateful for your contributions. I have received positive feedback from many of you in our service line and from other individuals who had an opportunity to read the newsletter. Despite all of this, I still wanted to make sure that we are on the right path; so I have asked many of you to write your reflections about the newsletter’s relevance to you personally and to our service line, columns and articles you liked and ones you would rather see gone, wish list and new ideas that you would like to see featured. I read them carefully and will take your reflections, suggestions and objections into consideration when planning future issues of the newsletter. Your responses are included on the pages that follow. I wish us a happy first anniversary and a bright future. Enjoy and stay engaged. As a small recognition for this occasion I wrote a poem:
A year ago to this day
The newsletter came to be
Inspiration for the crowd
Information that is loud.
It came in a monthly cycle
Equipped with a flashy title
Looking good on the screen
Office-based desktop machine.
With a few skilled clicks
We are led to a variety mix
Editor’s esthetic presentation
And meticulous organization.
Page after page is read
As if it is our daily bread
To nourish a hungry mind
And make it so refined.
Most of the reflections and feedback from the readers were positive and complimentary. I share here some of them.
“What I find relevant and helpful are the references to mindful awareness. Not only does mindfulness apply to the work we do with veterans, but it also applies to one’s own personal self-care. In the last few years, I have been making a conscious effort to practice mindfulness as a way of life to address my own mental health needs. Like any endeavor, it takes work and commitment. The reminders I find in the newsletter are one of the many tools out there that help me to stay the course.”
“I have enjoyed the newsletter. It has been beneficial for learning the latest news and updates within the service line. I particularly like the reminders of mindfulness and taking care of ourselves. I appreciate the positive insights and the book reviews. I think your personal invitations have been great for getting everyone involved—I’ve enjoyed seeing input from lots of people who would not normally speak up. Another great idea was to have new people and people leaving contribute a paragraph, so we are aware of the comings and goings.”
“Regarding my reflections on our newsletter, I must say that form of communication within our department is quite new to me, as I have not seen it in other hospitals. For that reason, I did not have particular expectations but found it helpful. It is good to get an overview of our department and the structure of our service line with important administrative updates, as well as specific information about what each of us does in our department. Personally, I found helpful information regarding different options for outpatient care that exists in our outpatient clinic, with specific treatment modalities and therapies that are available in our department. This has been quite helpful to me as a hospital-based psychiatrist and in our discussions on the inpatient unit when it comes to referrals for outpatient care after discharge. I particularly like the evidence-based psychotherapy updates, which provide succinct information on specific treatment modalities. This is helpful as it refreshes my memory on that topic and also brings new knowledge regarding those treatment modalities, used in the specific population that we service.”
The self-care is the best care
One important emphasis in the newsletter was self-care. Providers of care to others frequently live unbalanced life in regard to taking good care of themselves. Many providers of mental health care are empaths, sensitive people who deeply feel the pain and suffering of others they come in contact with. This is a great quality but at the same time potential risk for their own health, hence the need (or better said a must) for them to spend enough time in self-care activities. As was evident from the reflections from readers, many of them appreciated the reminders for self-care activities. In the newsletter, there were extensive contributions about burnout syndrome, personal coping skills for a balanced living, healthy lifestyle, gratitude-based mode of existing, recognition of the symptoms and signs of stress and how to address them, and many others. I specifically emphasized the importance of self-care when I said:
I take seriously the meaning of the expressions “Train the trainer” and “Heal the healer” because I believe we are the primary therapeutic tool in the process of accomplishing the mission of our agency in providing exceptional health care that improves the health and well-being of veterans. As mental health professionals, we ought to “walk the walk” and “practice what we preach.” For these reasons, you have been reminded of a healthy lifestyle, nutritional and mind-body-spirit practices, particularly related to self-compassion. Our mind has a tendency toward negativity and self-criticism. The best way to get away from this mind propensity is to store positive experiences and make them as vivid as possible over an extended period of time. You can start by focusing on the good things, deciding to let yourself feel pleasure and be happy, choosing things deliberately to create a good time, and letting your attention linger toward positive sensations and emotions. Experiment with this strategy and you will notice signs of lowered stress response in your body, lifting your mood and shifting toward an optimistic (glass half full) attitude.
Whole Health
The future of the newsletter was firmly established. After several years of being its guiding post, I released this task and responsibility to the editorial board consisting of the representatives of each discipline within the mental health service line and turned my attention to other “holistic” avenues. I became more intimately involved in the further development of the model of Whole Health Care, which was based in Washington, D.C. in the Central Office under the guidance of the Patient-Centered Care and Cultural Transformation Office. Its task was to oversee cultural transformation in the philosophy and process for healthcare delivery which was never before undertaken by an organized healthcare system.
The main two elements of patient-centered care are the experience of health care and the practice of whole health. The most important component is the whole health. This component indicates the importance of the relationship and partnership between patients and the community of providers. The focus is on empowering the self-healing mechanisms within the person while co-creating a personalized, proactive, patient-driven experience. This approach is informed by evidence and makes use of all appropriate therapeutic approaches, healthcare professionals, and disciplines to achieve optimal health and well-being.
The whole health is visually represented by 3 circles with the patient being like a sun surrounded by the three inner planets of the solar system. The outer circle represents community, the middle circle is related to prevention and treatment approaches to care by both conventional and complementary methods, and the inner circle, one the closest to the patient (sun) consists of three components of the personal health inventory: physical well-being, mental/emotional well-being, and day-to-day life. The goal is to create a personal health plan.
Personal health plan
A personal health plan is based on personal health assessment. The patient starts this process by filling out the personal health inventory indicating what really matters to him and what brings a sense of joy and happiness. On a scale from one to five, the patient assesses where he is at the present time and where he would like to be in the future by reporting on different components of health such as working with the body through movement and other physical activities. On the same scale, he reports rest, relaxation, and sleep quality. Then he relays where he is in regard to healthy eating habits, consisting of balanced meals with plenty of fruits and vegetables and enough water. In the area of personal development, the patient is revealing his learning and growing experiences, abilities and talents. In the relationship section of the inventory, the patient is assessing the quality of communication with family, friends, and people he works with. Next, the patient indicates whether he feels connected to something larger than himself that provides strength to him in difficult times. In the end, he evaluates the power of his mind to help him heal and cope using mind-body techniques such as relaxation, breathing, and guided imagery.
After he has completed the personal health inventory, the patient is now ready to develop a personal health plan. It is uniquely built upon personal values, conditions, needs, and circumstances and the use of the most appropriate interventions and strategies. It addresses the skills and support needed for the management of the disease, and to regain and maintain optimal health and well-being. The main components of the personal health plan are the personal mission, shared goals, self-care, professional care, skill building, consults and referrals, as well as the timeline and follow-up visits. It is clear that the whole health approach to care is not defined merely by the absence of disease, but by the addition of confidence, skills, knowledge, and connection necessary for a joyful, and meaningful life.
Whole health and holistic health hold the same set of values. They are in pursuit of the highest level of functioning and well-being regardless of the presence or absence of disease. They view people as the unity of body, mind, spirit, and the systems in which they live. A holistic approach is not a disease management healthcare system even though it doesn’t disregard symptoms that are troubling to the person who comes for help. The emphasis is placed on modifying contributing factors and enhancing innate powers of healing in bodies, minds, and spirits to optimize well-being. This approach is rooted in nurturing the quality of the relationship by building trust, compassion, autonomy, and empowerment. Radical acceptance of all life experiences as learning opportunities is pointed out through the process of mindful awareness. Holistic psychiatrists apply the principles and practices of whole health in their own lives and teach others by example.
Wellness manifesto
One way how I tried to practice what I preach was by undergoing assessment and treatment by integrated health and wellness coach who was trained at the Andrew Weil Center for Integrative Medicine. * I worked on developing vision, purpose, and aspirations related to my health. I identified areas that would support it and focused on goals and action steps that were necessary to facilitate the development of these areas. The brief summary or manifesto about my own state of wellness and holistic approach to self-care is outlined below.
I love to be physically healthy, mentally sharp, compassionate, authentic, honest, and open. I love the place where I live, the job I do, and my free time spent reading, learning, writing, and connecting with my wife, family, friends, and nature. My purpose is to develop all my capacities to the fullest degree, to get to know myself, to do good to others, and to transmit knowledge and experience. I practice stress-protective activities utilizing humor, relaxation, positive affirmations, and healthy coping skills to stay grounded, flexible, curious, present, and able to emotionally self-regulate. I seek and give support through guidance and advice, reassurance, shared interest, emotional closeness, and reliable help. I predominantly eat whole non-processed nutritious organic plant-based food. I am physically active on a daily basis. I honor the role of spirituality in overall health and growth. I value healthy socializing and building relationships with others. I realize that I need to improve my sleep to get the most benefits from all healthy practices. I emphasize the importance of enhancing awareness of the present. By closing my eyes I anchor myself to the present moment, moving intention and energy to a place beyond time and thought into the realm of “open focus” or “free-floating attention.” In this way I allow my mind and my body to work together, becoming more balanced and integrated. By breaking the habit of being predominantly oriented toward the outside world, I can initiate a new healthier and more productive physical and emotional reality. It is a wonderful stress reliever and a way to open myself to new and unexpected possibilities. In a recent book I read **, there is a basic premise that we have an incredible ability to heal ourselves based on our mental state. By enhancing the inner “life force” we become our own healers following the wisdom embedded in our higher selves. I embrace this way.
* https://integrativemedicine.arizona.edu/
** You Are the Placebo: Making Your Mind Matter, by Joe Dispenza, Hay House, 2014
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