At 7:45 AM, Dr. Gather phones Trish, Dr. Ames’s patient who went to the hospital ER over the weekend asking for a narcotic pain medication. Trish is new to the clinic’s pathway program for patients who are receiving narcotic medication long term for chronic pain. It is called the “Pain and Quality of Life” Pathway. Dr. Gather knows her from a pathway orientation visit five weeks ago and from her attendance at the monthly “Quality of Life Class” that is part of the pathway. Both the orientation visit and class attendance are required for patients enrolled in the pathway, and Trish attended her first class three weeks ago. Trish confirms that she did receive pain medication at the ER and explains that she was having a flare in pain but denies knowing this was in violation of her medication agreement. Dr. Gather asks her to come for a visit to talk further about her medication agreement and to identify any barriers to her following its requirements. She agrees to come in for a visit on Tuesday with Dr. Gather, explaining that she “can get a ride on Tuesday, but not today.”

May’s follow-up visit with Dr. Gather today is her first contact with the clinic in seven weeks. She is anticipating the anniversary of the unexpected death of her father five years ago; she is experiencing more dizziness, upset stomach, and head pain. She’s been leaving work early and her supervisor recently expressed concern about her keeping up with her work. May’s father died of a brain aneurysm, and while Dr. Town has reassured her about her health, she worries that she too will have an aneurysm. She’s been trying the breathing techniques at work but feels minimal benefit because, “I’m so wound up.”

Dr. Gather reviews acceptance strategies with May, and they practice a mindfulness exercise together, involving trying to hold onto a thought and then trying to push it away while at the same time trying to be aware of their immediate surroundings. They pick a neutral thought and work with it a few minutes and then they try the experiment with a frightening thought, not May’s thought about an aneurysm, but another stress-provoking thought (e.g., “I didn’t set the brake on the car; it could roll away.”). May observes that the thoughts hang around more when she struggles with them, particularly the frightening thought, and that she has trouble staying in the present where she can observe her surroundings when she is trying to control her thinking. Dr. Gather also reviews a breathing technique May used previously with benefit, and they take a walk around the outside perimeter of the clinic together with an intention of paying attention to two things: breathing (saying “here” on the inhale and “now” on the exhale) and surroundings (while allowing the mind to do whatever it does). This seems helpful to May and she agrees to daily morning and lunch walks to practice this skill. Dr. Gather also expresses compassion concerning the loss of her father and they plan for May to follow up with Dr. Town in four weeks. As a last thought, Dr. Gather offers a phone call check-in in one week, and May agrees that it would be helpful. They set a 7:45 AM phone check-in in one week; the focus will be on her rate of engaging in the walks.

Raymond is 27 months old and was identified during a 24-month well-child visit as in need of a warm handoff to Dr. Gather. His parents had self-identified a positive screen for autism (see Figure 11.3 for the clinic’s Neurodevelopmental Disorders Pathway). With no patient previously scheduled in his 8:30 AM appointment slot, Dr. Gather was easily able to accommodate the warm handoff. During the visit, Raymond has no eye contact with his parents, nor Dr. Gather. He is very active and explores the room from the floor up. Both parents are concerned but tend to see him as making progress and probably “just being a boy.” Raymond’s parents are older and this is their first child. Their primary concerns are his lack of language, his tendency to put all kinds of objects in his mouth, and his restricted dietary preferences.

When Dr. Gather asked the parents to prioritize their three primary behavioral concerns about Raymond, they decided that language was their priority. They said, “We want to communicate more with him.” Raymond’s mother had already started exploring sign language as a way to communicate with Raymond and he was responding somewhat positively. She was using a website to learn a few words and then trying to teach them to Raymond by standing in front of a mirror, as he seemed to have better attention to a reflected image of himself and his mother.

With Dr. Gather’s encouragement, the father agreed to support this direction and they brainstormed a list of ten words that they would try to teach Raymond to sign over the next 2–3 weeks. Dr. Gather also suggested that the parents look online for safe mouth toys that Raymond might use to satisfy his needs for oral stimulation, explaining that some children are more oral than others. Finally, Dr. Gather talked about the challenges of being parents of a child with developmental differences and asked if they might be interested in attending a workshop to get a few new ideas about how to address these successfully. Both indicated an interest, so Dr. Gather put them on the contact list for an initial offering of a workshop he planned to offer in the next 1–2 months. He also talked with Raymond’s parents about community resources and prepared a letter for the PCP to use when referring Raymond for services from the public schools and additional community resources.

Dr. Reese referred this 66-year-old married mother of two adult children for a consultation concerning diabetes and atherosclerotic vascular disease three months prior to today’s BHC visit. This is her third BHC contact. At the time of initial referral, Dr. Reese had explained that Janet’s diabetes was not well controlled, even though Janet insisted that she was “pretty much doing okay” with her diabetes. Dr. Reese hoped that Dr. Gather could help Janet with some of her psychosocial concerns and her motivation for better self-management.

In her initial BHC consult, Janet explained that her 75-year-old husband had chronic obstructive pulmonary disease (COPD) and was in poor health. They were both worried about two of their children, one of whom had lost her job and the other who had problems with alcohol. Their son was serving time in Montana for a driving under the influence conviction. She missed him terribly and asked if Dr. Gather would write a letter to prison officials requesting that he be moved to a local facility. Janet indicated that she was testing her blood sugar on a regular basis but did not exercise and found it hard to make dietary changes. She reported that she was taking all medications as prescribed including an SSRI that she had taken off and on for years. Dr. Gather wrote a short letter to prison officials during the visit and gave it to Janet to mail. The homework plan resulting from the initial visit was that Janet would take daily walks with her husband and ask for his support in making dietary changes. Janet also agreed to initiate brief daily phone calls with her daughter who lived nearby. She left with an agreement to follow up with Dr. Gather in one or two weeks.

Janet had returned 16 days later for a second follow-up visit. She indicated that she and her husband were walking together for about 10 minutes every day and that she had started checking her feet daily. Both she and her husband were also eating better. She had talked with her daughter almost daily, and they were considering buying a used treadmill together, as the daughter was now reemployed. She had sent the letter to the prison officials, and her son had sent her a Mother’s Day card.

In today’s visit, Janet seems pleased to see Dr. Gather and report her progress. Figure 11.4 is a graph of Janet’s Duke Health Profile scores, as Dr. Gather views them today in the EHR. The light gray column represents her scores at her initial visit and the darker gray scores are today’s. As can be seen, physical, mental (zero at the initial visit), and social health scores have improved. Janet is pleased to see the graph when Dr. Gather shows it to her, and she reports that she is now walking six or seven times per day for 5–6 minutes on the treadmill that she and her daughter did end up purchasing together. She is socializing more and enjoying outings with her daughter. She is eating more vegetables, and she was concerned about her morning blood sugars, which have been high for several days. She is seeing Dr. Reese later in the morning. Dr. Gather did not schedule a follow-up visit with Janet, but did recommend that she attend the clinic’s drop-in “Living It Up! Lifestyle Class.” The class teaches a variety of skills related to healthy living (including values identification, value-informed goal setting in multiple areas, making strong behavior change plans, etc.). Additionally, Dr. Gather recommended in his chart note that Dr. Reese encourage Janet’s efforts to socialize more, use exercise to reduce stress, and ask for help when needed.

Marie is a 31-year-old single mother of two young children. She has a diagnosis of schizophrenia and has worked with her PCP (Dr. Town) and Dr. Gather for several years. She does not have citizenship and is not eligible for community MH services. She doesn’t want to go there anyway and she has problems with transportation as well. Today, she comes to the clinic because she got a ride and because she is “hearing voices again and can’t sleep.” She was not able to get an appointment with Dr. Town, but the front desk did add her to Dr. Gather’s schedule in the 9:30 AM slot, which was initially empty. She updates Dr. Gather, explaining that she moved away from the area for a few months with her previous boyfriend who has been violent toward her in the past. She is now back and living with a family from a church where she recently sought help. She needs medications and encouragement.

Dr. Gather first worked with Dr. Town to obtain a medication refill for Marie. Because of their long-standing relationship with Marie, Dr. Town knew which medications helped her and was willing to refill them given Dr. Gather’s assistance. Marie also agreed to a follow-up with Dr. Town in two weeks. Dr. Gather then encouraged Marie to use a skill discussed in a previous visit concerning working with hallucinations. This skill involves Marie taking a different perspective on her hallucinations, as well as her thoughts and feelings; the perspective is that of a passive observer, as opposed to a participant. In previous visits, Dr. Gather used a metaphor to help Marie develop this skill. The metaphor involved having Marie consider three perspectives on a roller coaster ride: a person taking the ride, sitting in the front seat (participant perspective), a person taking the ride experiencing the thrills but sitting back away and observing others on the ride (participant observer), and a person standing back from the ride and watching the big picture of the roller coaster and the people on it (passive observer). Dr. Gather reminded Marie to practice taking on the role of the passive observer in order to observe her hallucinations, instead of engaging them. This passive observer skill development exercise is an empirically supported ACT technique described in Strosahl and Robinson (2014). Dr. Gather also briefly reviews possible changes to improve sleep hygiene and encourages increased physical activity, printing all of this out for her in a written plan that she can take with her.

The following day is when Dr. Gather regularly offers his “Pain and Quality of Life Class.” While looking at his schedule for the next day, he sees it already looks quite busy, so he takes advantage of 15 minutes of free time to develop a simple handout for the class. Over the weekend, he’d come across a good article about using progressive muscle relaxation for patients with chronic pain, and he decided he would teach this in tomorrow’s class. Thus, he uses this time to make a handout summarizing the article’s main points and makes copies for the entire class.

This is Juan’s third visit with Dr. Gather. He is a 14-year-old, referred two months ago by Dr. Goldberg for a consultation concerning weight gain, fatigue, and sad mood. At the initial visit, Juan indicated he was following Dr. Goldberg’s advice, making changes to his diet and exercising more. Dr. Gather had completed a functional analysis at that visit and found that emotional triggers were an important part of Juan’s weight gain over the past year. His parents had separated after a period of high conflict and his father had attempted suicide when he and his sister requested permission to live with their mother. He was passing in school and wanted to grow up to be an artist. The results of the initial functional analysis suggested that emotional distress, a low rate of activity, and a lack of relaxation skills (other than watching television) contributed to Juan’s problems with weight gain, fatigue, and sadness. Specifically, Juan tended to anticipate stressful interactions with his father during his weekend visits with him and to protect himself by overeating and watching television.