Primary Care Behavioral health

Elisa A. Escalante/ LCSW/ 08-24-2025

We are no longer in a debate of ‘nature vs nurture’. It is nature and nurture combined, working together, every single day. Around the clock. Causing confusion. As everyone hopes that there will be one direct cause, and one specific cure. And a prognosis, with an end in sight. Ultimately, we just want to stop suffering. -EaE

In January of 2022, I walked into the Naval hospital of 29 Palms with excitement, as it was my first day as an LCSW in a new full time position for the DoD. I met at my reporting station and was quickly escorted to the Primary Care clinic. The department head was a wonderful young Doctor, happy and eager to see me. As she explained my new role to me, I felt confused, but my facial expression was stoic. (My military training prepared me well). I thought that I was going to be a social worker that evaluated troops with post deployment screenings. But the primary care manager (PCM) was describing a completely different type of role: Behavioral health consultant (BHC) for primary care. (WTF is that??!) I quickly learned that it was formerly known (during my Air Force days) as a BHOP (Behavioral health optimization program).

I was nervous. Why? I was out of my territory. As a former military member and VA provider, I was used to working with military members, veterans and PTSD all day everyday. I learned that my new population would be majority; military spouses, military child dependents; kid’s & teens. She also quickly informed me that they receive a ton of post partum depression and anxiety patients. Gasp! (I’ve never had children and was unfamiliar with how to treat this population) But, I would need to learn. Time to adapt and overcome. I acted completely calm about my position despite being blind sided. The fact is, I needed to work full time again and move out of my Dad’s house.

Training to become a BHC/ Behavioral health consultant for Primary Care (3 months of training was required before I could talk to a patient)

• We are no longer ‘therapists’, we are consultants
• We are generalists not specialists; we can see any person, any age, any problem
• They are patients, not clients, as we must adopt the primary care language
• We are an extension of the doctor’s services, we serve both the patient and doctors needs. (Every doctor has knocked on my door with a concern about their patient at some point)
• We serve many patients in brief spurts that are not seen otherwise, because many people will never go to a mental health clinic
• We are easily accessible versus a mental health specialist that would require extra referrals or a different process to establish care
• It’s better that many people get some care, versus many people get no care at all
• We must approach patients with a holistic model in the primary care world. We use the Biopsychosocial approach. The patients biology, psychology, and social environment are all equally important

My patients. (PTSD, depression and anxiety are still very common in primary care. And many patients suffer from comorbidities; medical and mental health concerns combined)

Post partum mood disturbance: My average patient is a young Mom (early twenties) that got married, moved to 29 Palms Mojave desert; far from her family support system, and had a newborn. Her life is a blur and as the dust settles sometimes she asks herself: “What the heck did I do with my life???” Her husband is working all of the time, she is single parenting, her family is too far to help, the desert is rural and far from resources and family friendly activities. If either her or the baby needs medical specialists, that’s a long drive. My first solid year of working with post partum patients, my main focus was to listen. I took it all in. All of the concerns, medical symptoms, mental symptoms, pregnancy and post partum scares/ traumas. I built interventions tailored to post partum depression, anxiety, anger, & PTSD. Goals for post partum Mom’s look different. In creating goals I must respect their time limitations as the newborn is the priority; the newborns entire livelihood is dependent on their Mom’s body and emotional attunement. I have so much concern, respect and admiration for Post partum Mom’s. I do everything in my power to help them feel heard and validated. It’s important as a society that we do not compete over ‘who has it harder’ but instead give credit where credit is due. Parents of newborns are in the trenches. Parenting is around the clock work with little to no appreciation. I also refer to outside specialists if needed; Family workshops, couples counseling, new parent support program on base, baby boot camps etc.

Chronic Pain: Pain affects mood during the day, and sleep at night. And if someone cannot get sleep due to their pain condition, the sleep deprivation will also impact their mood into the next day. This is a cyclical and reoccurring issue with most chronic pain patients. Back, knees, hips, shoulders, migraines, pelvic floor, ankles, feet etc. A chronic pain condition is also just as invisible as a mental illness, to a third party perspective outside of a hospital. People believe they are embellishing it. Their family and friends might continue to try to push them to do things their body will not let them do. They might feel more angry and tempted to socially isolate due to this. Their own mind wants to do what they did when they were younger and before their injury was severe, but their body no longer lets them. There is an actual grief process that chronic pain patients go through. Grieving a younger version of themselves that was more able bodied. Then they have the battle of accepting their new lifestyle with new limitations. They need regular reminders to attend their medical visits; pain specialists and physical therapy. Movement is still essential as they are still human. But they must move differently, with modifications and pacing interventions, as to not exacerbate the pain condition.

Auto Immune conditions: The important thing to remember even if you do not know a lot about auto immune conditions: Their bodies immune system is attacking healthy cells, making it difficult for the body to fight against invaders. Their body is prone to a lot more illnesses and symptoms versus a person without an auto immune condition. It’s not enough for me to write down the name of their condition. I ask every patient with an auto immune condition: “What symptoms does this cause on a regular basis?” And “Which symptoms are the most difficult to deal with?” I’ve worked with patients that have Arthritis, gastritis, vitiligo, Type 1 diabetes, multiple sclerosis, lupus, Graves, IBD, hashimotos, psoriasis, and fibromyalgia. Because auto immune conditions have many invisible symptoms, they are also important to validate. Many patients that have suffered from these conditions were dismissed once upon a time. Made to believe they were being ‘dramatic’ or ‘making it up’ until they were medically tested enough to finally receive the proper diagnosis. I must take any/ all symptoms into consideration when helping the patient create behavioral health goals.

Health Anxiety: Health anxiety is a perpetual condition in which there is a medical scare that causes anxiety, and the anxiety causes more medical symptoms, and more medical symptoms causes more anxiety. Do you see the pattern? It is very real and not ‘just in their head’. The physical symptoms are not their imagination, and the fear about what their body is doing to them is valid. The fear of what the medical symptoms could cause them later in life is valid. They do not want to feel anxiety, as they learn that anxiety causes more symptoms, but their mind and body are perpetually going through fight, flight freeze responses. It’s living in a body that you do not trust and various symptoms that cause you to panic. It’s also going to hospitals more than the average person and sometimes developing a fear of hospitals and the next diagnosis, or the next dismissive/ judgmental provider. It’s them googling their conditions, symptoms, causes and treatments in a hope to resolve the issue but sometimes perpetuating more anxiety because of the ‘worst case scenarios they read about. People with health anxiety need answers and ongoing treatment; for their physical and mental health.

ADHD: ADHD has been a more common presenting concern in primary care versus mental health clinics. It’s tricky, because when people present with concerns about their memory and focus, there are many things that could be causing that. Trauma, depression, anxiety, and brain injuries could also cause focus/ memory issues for a variety of different reasons. But ADHD is different because it is neuro developmental. Meaning the brain developed in a way that differs from what society considers a ‘healthy functional’ brain. There are parts of the brain that are smaller in ADHD patients: The prefrontal cortex, the frontal lobes, amygdala, hippocampus, the cerebellum and the basal ganglia. These brain areas affect decision making, impulse control, focus, self regulation, memory, motivation, coordination, balance and motor control. I’ve learned that ADHD ought to be medicated before prescribing behavioral interventions, as it disrupts the patients ability to engage in relaxation goals, behavioral activation, or cognitive work. If they do not want medication, then we take it slow. I will be the reminder of what they said they want to focus on, in every single follow up.

Sexual health concerns: Plenty of patients come with a presenting concern that involves decreased libido or the inability to perform sexually or climax. Ten times out of ten, there are underlying issues impacting their sexual health. Such as a busy tired Mom taking care of kid’s all day, too drained to feel sexually excited. Or a working Mom that is both providing and doing the majority of the chores. Or, a man that is working long hours, stressed at both work and at home; they cannot live in peace if their boss and their spouse keep making demands without gratitude. Couples in which the trust was broken due to infidelity, secrets, lies etc. Because intimacy between two people requires trust first. Underlying concerns include depression, anxiety, self esteem/ confidence issues, medical conditions etc. Though the presenting concern involves sexual health, I will be working with the patients on the root cause. When they work on their symptoms that impact their sexual health, naturally their libido and sexual energy will get healthier. And sometimes, a break up/ divorce can be one of the best solutions to a healthier lifestyle and sex life.

Kids/ Teens behavioral problems: My most common referral for kids/ teens involve ‘behavioral problems’. Parents are very busy, and the behavioral issues are a disruption to the routine. They get phone calls from the school on the regular. They are pushed to either medicate their kid’s at younger ages and/ or home school them. Kid’s with behavioral issues are rarely ‘bad kid’s’. It’s a symptom of a deeper problem. They might be getting bullied, they might have self esteem issues, they might be getting abused at home, they might be modeling their parents compulsive behaviors. And sometimes, they might be doing very normal things and getting in trouble for it. Such as getting excited and talking too much to their friends in class while ignoring a very boring lecture. Or doing silly pranks to entertain themselves or their class mates through a very boring lecture. Kid’s were not supposed to sit still indoors for six hours a day, just as adults are not supposed to sit still for 8+ hours a day. People around us, from our macro level social norms to our peers/ family create our behavioral issues. There is no such thing as a child that has ‘spontaneous’ behavior issues out of no where. As I get to know the child through the psychosocial assessment and follow up appointments, everything they did that was ‘labeled as bad’, just makes sense. But I will help them explore the consequences and divert toward healthier coping activities. This will promote healthier dynamics at school and at home.

Conclusion: I have now been a behavioral health consultant for primary care for 3 years and 7 months. Having access to my patients medical charts and the ability to send messages on their behalf to their medical providers/ medication prescribers gives me an added ability to advocate for them; help them meet their needs. I really take pride in what I do in this position. It’s funny how an accidental job ended up being a great fit for me in the long run. I also love the requirement that I help the patient create SMART goals by the end of the first appointment. This empowers the patients to take their health into their own hands from the start. Yes, they have medical and mental health conditions, but they are still able to do things. As a social worker, I am a big fan of a strength based approach. Exploring mental health and medical concerns is not meant to victimize or infantilize people. It is meant to search for the truth, and tailor a treatment plan according to their reality.