The Future of Psychology in Family Medicine

Psychology has been integral to the field of family medicine since its inception as a medical specialty in the 1960s. Psychologists and other behavioral scientists contribute to family medicine in teaching clinical skills, in defining research questions, in developing research methodology, and in creating integrated physical/mental health care delivery systems. Future developments in the field of psychology in family medicine are likely to emphasize development and evaluation of screening measures which identify mental health problems in primary care, development of early intervention for those mental health problems, and more precise measurement of process and quality of care and health outcomes. Psychologists have an important role to fulfill in educating physicians on alternatives to pharmacologic and medical interventions for common presenting problems in primary care. However, current economic forces shaping the practice of medicine may work against further enhancing the efficacy of the physician in dealing with psychosocial issues. The future role of psychology in family medicine is not yet delineated, and while the move toward parity of reimbursement for mental and physical health care delivery may enhance this collaboration, there is a need to continue to evaluate how the psychological well-being of patients is influenced in the evolution of new models of care delivery.     

Performance of Mental Health Counselors in Integrated Primary and Behavioral Health Care

Integrated primary and behavioral health care (IPBH) is becoming a preferred mode of service delivery in the United States. Integrated care includes the participation of medical and mental health professionals, such as mental health counselors. The clinical outcomes of these professionals need to be studied to determine their effectiveness in such settings. We examined the performance of 10 mental health counselors on the clinical outcome of 1,747 clients treated in an IPBH center. Analyses using growth curve modeling and pre‐post test design revealed that mental health counselors were effective overall, but they differed in client dropout rates and efficiency in reducing clients' initial symptoms. We used the analyses to rank order counselors based on their effectiveness. Counselors who were the most effective varied in their efficiency but demonstrated the lowest client dropout rates. Implications for future research and counseling practice were discussed.     

Implementing a Primary Mental Health Service for Children: Administrator and Provider Perspectives

The Child Mental Health Service (CMHS) is an Australian primary care program introduced in July 2010 to provide mental healthcare to children who have, or are at risk of, developing psychological disorders. The Australian Government provided supports (e.g., training for mental health professionals), resources (e.g., funding for positions devoted to fostering inter-agency linkages or partnerships) and various flexibilities in service delivery. This study aimed to explore the processes used in the implementation of the CMHS in order to achieve its objectives of delivering a high quality standard of service, and forging linkages and support networks with other relevant health and non-health agencies. Structured interviews were conducted with 20 program administrators, six referring professionals and eight mental health professionals. Interviews were recorded, transcribed and analysed for themes using NVivo. The CMHS appears to have made good progress towards achieving its objectives by implementing processes that facilitated the delivery of a high quality service (e.g., engaging appropriately qualified, and encouraging additional training and clinical support for, mental health professionals; employing quality assurance mechanisms and clinical governance arrangements) and establishment of inter-agency linkages (e.g., devoting a professional role—Coordination and Liaison—to this purpose). Provider perspectives suggest that the CMHS has had a positive impact on children and their families. Comparable countries implementing primary mental health programs for children may benefit from considering similar additional supports (e.g., training for mental health professionals), resources (e.g., funding positions devoted to fostering service inter-agency linkages) and service delivery flexibilities as those available in the CMHS.     

Psychology Internships in the Treatment of Severe Mental Illness: Implications for Training in Academic Medical Centers

Despite an increasing focus over the past 2 decades by federal and state governments on the care of persons with severe mental illness, psychologists remain underrepresented among behavioral health professionals working with this population. Within the discipline there is growing concern about the need to adequately train, recruit, and retain psychologists in this specialty. This is a particular concern in academic medical settings where the overall severity of illness among those receiving psychiatric services continues to increase. The purpose of this qualitative research study was to intensively examine the experience of predoctoral interns engaged in treating individuals with severe mental illness in an academic medical center in order to identify the professional developmental experiences and training needs of those learning to care for this population. This analysis, conducted with semistructured interviews at four points during the internship year, yielded a series of recommendations for improving internship training and recruiting psychologists to this specialty.     

Confidentiality and Mental Health/Chaplaincy Collaboration

Confidentiality can both facilitate and inhibit working relationships of chaplains and mental health professionals addressing the needs of service members and veterans in the United States. Researchers conducted this study to examine opportunities for improving integration of care within the Department of Defense (DoD) and Department of Veterans Affairs (VA). Interviews were conducted with 198 chaplains and 201 mental health professionals in 33 DoD and VA facilities. Using a blended qualitative research approach, researchers identified several themes from the interviews, including recognition that integration can improve services; chaplaincy confidentiality can facilitate help seeking behavior; and mental health and chaplain confidentiality can inhibit information sharing and active participation on interdisciplinary teams. Cross-disciplinary training on confidentiality requirements and developing policies for sharing information across disciplines is recommended to address barriers to integrated service delivery.     

Training needs among nonmental health professionals working with service members: A qualitative investigation

Though many service members will not directly seek mental health care due to stigma and other factors, they may interact with the healthcare system in other ways including contact with first responders, nurses, and allied health care professionals. However, little attention has been spent in this regard on the educational needs of these professionals whose contact with service members and Veterans may provide the opportunity to assist Veterans in need with overcoming barriers to accessing mental health care. This qualitative study investigates the educational training needs of first responders and health care professionals in contact with military families and trauma survivors to determine whether, and what type, of additional training is needed. A sample of 42 first responders and health care professionals including emergency medical technicians, police officers, fire fighters, speech language pathologists, occupational therapists, physical therapists, and nurses were recruited to participate in 1 of 6 focus groups. Sessions were audiotaped and transcribed verbatim. Data analysis was guided by a thematic analysis approach. Thematic analyses suggest there is a significant knowledge gap with unmet educational needs of these professionals such as information on the invisible wounds of war, military culture, and screening and referring patients who present symptoms falling outside professionals’ scope of practice. Findings point to a need and desire for more robust education for first responders and health care providers around mental health concerns of military populations, including topics such as trauma, military culture, and screening tools. Efforts to develop curricula addressing these concerns are warranted.     

From Constraints to Opportunities? Provision of Psychosocial Support in Portuguese Oncogenetic Counseling Services

Although available guidelines for familial cancer risk counseling clearly state the need to provide adequate psychosocial assessments and support, this feature of care is only available in part for individuals and families in oncogenetic counseling protocols in Portugal. The purpose of this study was to examine the psychosocial aspects of oncogenetic counseling provided by a sample of Portuguese genetics professionals. We sought to ascertain perceived need for the provision of psychosocial services and ways to enhance the psychosocial focus in service delivery. A qualitative study was designed; semi-structured focus groups and individual interviews were performed with 30 professionals from Portuguese healthcare institutions where oncogenetic counseling is offered. Findings suggest: current practice is aligned with the teaching model, with a mainly information-based focus; use of psychosocial counseling techniques and psychosocial support is limited throughout the genetic counseling timeline; there is a limited workforce of adequately trained psychosocial professionals, who are disadvantaged by structural and organizational constraints. These factors are considered to be serious barriers for psychosocial delivery. Development of multidisciplinary teams working in oncogenetics, and need for further counselling skills and training for genetics healthcare professionals were identified as priorities. Implications for practice and policy are discussed. Portuguese genetic counselors who have recently completed their training, may therefore contribute to enhanced psychosocial services delivery.     

Physician-assisted suicide: the role of mental health professionals

A review of the literature was conducted to better understand the (potential) role of mental health professionals in physician-assisted suicide. Numerous studies indicate that depression is one of the most commonly encountered psychiatric illnesses in primary care settings. Yet, depression consistently goes undetected and undiagnosed by nonpsychiatrically trained primary care physicians. Noting the well-studied link between depression and suicide, it is necessary to question giving sole responsibility of assisting patients in making end-of-life treatment decisions to these physicians. Unfortunately, the use of mental health consultation by these physicians is not a common occurrence. Greater involvement of mental health professionals in this emerging and debated area is advocated. Beyond describing mental health professionals' role in the assessment of patient competency or decision making capacity, other areas of potential involvement are described. A discussion of ethical principles relevant to this area follows, along with comments on the training necessary to adequately serve patient needs.     

Education and Training of Children's Mental Health Professionals: The Existing and Potential Role of Schools of Public Health

Since the early 1980s, increasing attention has been devoted in the literature to the conceptualization, development, and implementation of integrated and comprehensive mental health systems of care for children and adolescents. In establishing this new children's mental health paradigm of community-based systems of care, there are presently very few well-trained professionals and leaders focused on collaborative (including interagency) initiatives in the delivery of children's mental health services. Nevertheless, the field of public health offers an interdisciplinary setting for the education and training of individuals in children's mental health services. This national survey of all 27 accredited schools of public health in the United States and Puerto Rico examined the existing capacity for and potential to expand educational and training opportunities in the organization, financing, and delivery of children's mental health services.     

School Psychology: Training Individuals for One of the Best Kept Secrets in Professional Psychology

Abstract

School psychology training at the doctoral level is discussed. Given the increasing diversity in the schools as well as the varied education and mental health needs of the population, school psychology training is necessarily broad, involving traditional skills such as assessment, intervention, consultation, and counseling, all of which are taught within a context of a changing school population with changing needs. Because there is compulsory education, school psychologists’ interface with a broad cross-section of individual children, their parents, and their teachers. Moreover, school psychological practice is not limited to schools, as doctoral school psychologists are health service providers; many of these individuals work in other settings for which they are trained to provide services. The complexities and challenges of training school psychologists within this broad agenda effectively across domains are discussed.     

The next wave of change for psychology and mental health services in the health care revolution

Recent national changes in the de facto system of health and mental health care are described. Although the percentage of people without health insurance (always or sometimes) has not decreased, the organization of insured care has changed dramatically. Of the insured population, 75% are under some form of managed care. For 88% of the managed care population, mental health care has not been integrated with health care: the so-called carve-out. The author argues that system integration (carve-ins), for a variety of reasons, will begin soon and will occur very rapidly. A tilt toward carve-ins will have substantial impact on psychologists' training, service delivery, and research.     

Primary Care Behavioral Health Provider Training: Systematic Development and Implementation in a Large Medical System

The expansion of integrated, collaborative, behavioral health services in primary care requires a trained behavioral health workforce with specific competencies to deliver effective, evidence-informed, team-based care. Most behavioral health providers do not have training or experience working as primary care behavioral health consultants (BHCs), and require structured training to function effectively in this role. This article discusses one such training program developed to meet the needs of a large healthcare system initiating widespread implementation of the primary care behavioral health model of service delivery. It details the Department of Defense’s experience in developing its extensive BHC training program, including challenges of addressing personnel selection and hiring issues, selecting a model for training, developing and implementing a phased training curriculum, and improving the training over time to address identified gaps. Future directions for training improvements and lessons learned in a large healthcare system are discussed.     

The Woodlawn school mental health training program: A community-based university graduate course

The observance of traditional jurisdictional boundaries in the training of human service professionals has contributed heavily to the general failure of these professions to provide adequate and effective services. This article describes the rationale, design, and development of a community-based school mental health training program that seeks to establish constructive collaboration between those principals most influential in the mental health of young school children-educators, mental health professionals, parents, and the children themselves. A single curriculum for both professionals and parents and the diversity of professional disciplines involved are two of the unique aspects of this training program.     

Predictors of Recent Mental Health Service Use in a Medical Population: Implications for Integrated Care

This study investigated the relationship between physical and mental health and psychosocial variables and recent (within the last 12 months) mental health service use among 240 medical patients recruited from general and specialty outpatient clinics at an academic medical center. Results indicated 43.3% of the participants had recently received mental health services in the form of psychotropic medication (75%), psychotherapy (2%), or a combination of these treatments (20.2%). Among patients with moderate to severe symptoms of anxiety or depression, approximately two-thirds were receiving mental health treatment. Moreover, four variables (healthcare provider referral for mental health services, perceived need for mental health services, prior use of mental health services, and frequency of medical appointments) were significant unique predictors of recent mental health service use. This suggests collaborative/integrated medical care may increase needed mental health service use.     

Interdivisional Healthcare Committee: Speaking with One Voice on Cross-Cutting Issues in Health Care Psychology

One of the greatest challenges facing psychology in health settings today is the need for unification on critical issues of client access, workforce oversupply, education and training, and outcomes evalutions. Health care psychology specialty areas can no longer afford to operate in parallel. A unified vision is needed to overcome threats to the viability of the profession and to maximize the potential for achieving common goals. The current paper describes the formation of the Interdivisional Healthcare Committee (IHC), whose purpose is to establish a common agenda for promoting the professional, educational, and scientific goals of health care psychology. The IHC's initiative to develop new CPT codes for increasing access to psychologists' services in health care settings is outlined.     

Training Bartenders as Helpers on a College Campus

Student bartenders working in a college rathskeller are portrayed as “gatekeepers”: individuals at a strategic point of contact between mental health professionals and people in need of such service. This article describes a training program that sought to enhance the skills necessary to perform a variety of gatekeeping functions. The program, which took the form of a one-day workshop, included six major segments. The authors suggest that such a workshop is a potentially useful preventive mental health program for a college campus.     

An ecological approach to child and family clinical and counseling psychology

The ecological model of child and family clinical and counseling psychology considers mental health service delivery within a health maintenance framework, approaching the complexity of children's behavior in a systematic and organized fashion using science-based intervention practices. The service delivery framework integrates assessment, intervention, and motivation at all phases of an intervention. Assessments enhance the participants' and professionals' appraisal, which in turn impact motivation to change. Interventions are sensitive to assessment-based targets and participant motivation. A menu of interventions range from assessment, feedback, and brief interventions to more extensive mental health services, potentially integrated with other community agencies and school settings. The ecological model suggests revisions in the conceptualization of child and adolescent psychopathology, training for mental health professionals, and strategies for the design and testing of interventions. In general, a reformulation of mental heath services for children and families within an ecological framework enhances the potential for integrating science and practice.     

Research in Adolescent Suicide: Implications for Training,Service Delivery,and Public Policy

Four domains of research in adolescent suicide are reviewed: (1) the role of psychopathology, (2) family history of psychopathology, (3) mental health treatments, and (4) firearms in the home. Based on the extant literature, recommendations are made for changes in training, service delivery, and public policy. Among the recommendations for training professionals are: an emphasis on diagnostic proficiency, skill and attentiveness in the assessment of the entire family unit, and assessment of the availability of firearms in the home. With respect to changes in service delivery, we recommend treatment of the entire family system, and treatment of psychiatric and substance abuse problems in the same setting, and we show the need for a continuum of intensity of care from inpatient to outpatient. With respect to policy changes, we recommended parity of mental and physical health insurance coverage, screening for psychiatrically at-risk youngsters in schools and physicians' offices, providing funding to support a continuum of care between inpatient and outpatient, and gun control laws to restrict access to handguns. We believe that these changes can result in a substantial reduction in the adolescent suicide rate.     

The Development and Evaluation of a Parent Empowerment Program for Family Peer Advocates

Family-to-family services are emerging as an important adjunctive service to traditional mental health care and a vehicle for improving parent engagement and service use in children’s mental health services. In New York State, a growing workforce of Family Peer Advocates (FPA) is delivering family-to-family services. We describe the development and evaluation of a professional program to enhance Family Peer Advocate professional skills, called the Parent Engagement and Empowerment Program (PEP). We detail the history and content of PEP and provide data from a pre/post and 6-month follow up evaluation of 58 FPA who participated in the first Statewide regional training effort. Self-efficacy, empowerment, and skills development were assessed at 3 time points: baseline, post-training, and 6-month follow-up. The largest changes were in self-efficacy and empowerment. Regional differences suggest differences in Family Peer Advocate workforce across areas of the state. This evaluation also provides the first systematic documentation of Family Peer Advocate activities over a six-month period. Consistent with peer specialists within the adult health care field, FPA in the children’s mental health field primarily focused on providing emotional support and service access issues. Implications for expanding family-to-family services and integrating it more broadly into provider organizations are described.