Comparison of Prolonged Exposure (PE) Coach to Treatment as Usual: A Case Series With Two Active Duty Soldiers

PE Coach is a mobile application (app) designed as a treatment companion to support patient and provider work during prolonged exposure (PE), a first-line treatment for posttraumatic stress disorder. Little research exists about patients’ and providers’ reactions to mobile apps in the context of psychotherapy. The present study examined PE Coach with 2 soldiers to assess usability and satisfaction with the app. Soldiers completed 8 sessions of PE and used PE Coach during 4 of those sessions. Soldiers rated the PE Coach positively and reported higher levels of satisfaction during PE with PE Coach as compared with PE alone. Authors discuss their clinical observations from using PE Coach. The soldier and provider experiences demonstrate the potential value of PE Coach in enhancing treatment engagement and support the value of future research exploring mobile computing platforms to support evidence-based treatments, in general.     

Ethical and Legal Issues Addressing the Use of Mobile Health (mHealth) as an Adjunct to Psychotherapy

mHealth refers to the rapidly evolving use of mobile devices for health care treatment purposes, particularly the use of apps and texting as adjuncts to psychotherapy. Although there is currently an extensive literature on issues related to telehealth, to date little guidance has been developed to help professionals function ethically in the rapidly emerging area of mHealth. This article identifies the major ethical considerations that need attention and proposes several recommendations to address mHealth use as an adjunct to psychotherapy, including the pressing need for relevant American Psychological Association practice guidelines to assist mental health providers in the ethical implementation of mHealth.     

Internal health locus of control predicts willingness to track health behaviors online and with smartphone applications

Given rising technology use across all demographic groups, digital interventions offer a potential strategy for increasing access to health information and care. Research is lacking on identifying individual differences that impact willingness to use digital interventions, which may affect patient engagement. Health locus of control, the amount of control an individual believes they have over their own health, may predict willingness to use mobile health (mHealth) applications (‘apps’) and online trackers. A cross-sectional study (n = 276) was conducted to assess college students’ health locus of control beliefs and willingness to use health apps and online trackers. Internal and powerful other health locus of control beliefs predicted willingness to use health apps and online trackers while chance health locus of control beliefs did not. Individuals with internal and powerful other health locus of control beliefs are more willing than those with chance health locus of control beliefs to utilize a form of technology to monitor or change health behaviors. Health locus of control is an easy-to-assess patient characteristic providers can measure to identify which patients are more likely to utilize mHealth apps and online trackers.     

From self-reliers to expert-dependents: identifying classes based on health-related need for autonomy and need for external control among mobile users

ABSTRACT

Mobile health apps are seen as promising tools to support autonomous consumers in their quest for better health. However, individual differences in the need for autonomy and need for external control may impact the degree to which individuals perceive mobile health apps to be useful in their daily life. Using data from a representative sample of the Dutch population (N = 1,027), we applied latent class analysis to identify subtypes among mobile users based on their need for autonomy and need for external control, and to examine differences among these subtypes. We identified four subgroups: the self-reliers, confirmation-seekers, expert-dependents, and indifferents. Next to demographic differences, self-reliers and confirmation-seekers were generally more e-health literate and expressed more privacy concerns than the expert-dependents and indifferents. Our findings demonstrate that subgroups of people express different degrees of health-related need for autonomy and need for external control, which should be taken into account in online and mobile health communication efforts.     

Competencies of Process: Toward a Relational Framework for Integrated Care

As integrated care (IC) has gained more traction within both the psychosocial and medical fields, the need to train medical family therapy students and established professionals in this care typology has increased in tandem. To address this stated need, there is a large body of literature pertaining to models of care, typologies of intervention, clinical and financial effectiveness, and now a burgeoning discussion related to the academic and practice-based competencies necessary for IC practice. While the ability of the medical family therapist as behavioral health provider (MedFT/BHP) to practice in integrated settings may rely on an understanding of population-based medicine, disease etiology, medication and psychopharmacology, as well as augmentations to patient conceptualization and practice, all of the specifics related to that care are ultimately leveraged on the relationships formed by the MedFT/BHP with their healthcare colleagues. What this means is while we have attempted to distill the gestalt of integrated care into its major practice-based parts (e.g., model development and implementation, competencies, financial viability, efficacy/effectiveness, mechanisms of activation, and marketing), we have not adequately described the competencies necessary to set the stage for these types of close working relationships: relationships that make integration, of any kind, a possibility. The following paper was written to discuss three competencies related to the relational process of integration: (a) conceptual flexibility, (b) understanding and acceptance, and (c) acknowledgment and appreciation, as well as how these competencies provide the backdrop against which integrated care, as a practice, can emerge.     

Expansion of Genetic Services Utilizing a General Genetic Counseling Clinic

We established a general genetic counseling clinic (GCC) to help reduce long wait times for new patient appointments and to enhance services for a subset of patients. Genetic counselors, who are licensed in Tennessee, were the primary providers and MD geneticists served as medical advisors. This article describes the clinic referral sources, reasons for referral and patient dispositions following their GCC visit(s). We obtained patients by triaging referrals made to our medical genetics division. Over 24 months, our GCC provided timely visits for 321 patients, allowing the MD geneticists to focus on patients needing a clinical exam and/or complex medical management. Following their GCC visit(s), over 80 % of patients did not need additional appointments with an MD geneticist. The GCC allowed the genetic counselor to spend more time with patients than is possible in our traditional medical genetics clinic. Patient satisfaction surveys (n?=?30) were very positive overall concerning the care provided. Added benefits for the genetic counselors were increased professional responsibility, autonomy and visibility as health care providers. We conclude that genetic counselors are accepted as health care providers by patients and referring providers for a subset of clinical genetics cases. A GCC can expand genetic services, complement more traditional genetic clinic models and utilize the strengths of the genetic counselor health care provider.     

A Two-Session Hierarchy for Shaping Successive Approximations of Speech in Selective Mutism: Pilot Study of Mobile Apps and Mechanisms of Behavior Change

Selective mutism (SM) is an anxiety disorder marked by withdrawal of speech in particular social situations. Treatment is often difficult, requiring attention to several characteristics particular to the disorder. Therapeutic tools and activities such as games and mobile applications (apps) may be particularly advantageous to behavioral therapy for SM. A 2-session hierarchy for shaping successive approximations of speech in SM was piloted with 15 children, 5 to 17 years old, who were randomly assigned to shaping while using mobile apps, other therapeutic tools/activities, and reinforcement alone. Very strong treatment gains were observed: 13 of 15 (88.7%) children completed the hierarchy during the first session and 14 (93.3%) did so during the second session, with the final child completing all but the final step (i.e., to ask and respond to at least 5 open-ended questions). Moreover, all 15 children spoke to the clinician within 59 minutes of treatment (M = 17 minutes), and 14 (93.3%) children held five, 5-minute conversations with additional unknown adults during the second session. This occurred regardless of the inclusion of therapeutic tools/activities, although preliminary patterns of responding were observed such that children shaped while using mobile apps tended to show less self-reported and physiologically measured anxious distress. The utility of therapeutic activities and mobile apps when treating SM is discussed as well as areas for future research.     

Family,friend, and neighbour child care providers and maternal well‐being in low‐income systems: An ecological social perspective

Integrating theory from the family ecological systems and social support literatures with findings from child care research, in this study we develop and test a model relating family, friend, and neighbour (FFN) child care provider characteristics to perceived child care quality (provider reports of caregiving behaviours, mother‐provider caregiving relationship) and maternal well‐being (work‐family conflict, depressive symptoms). Results from phone interviews with 187 FFN providers receiving public subsidies indicated that even after controlling for familial status or household income, caregiver perceptions of higher quality care were associated with higher education levels, greater attachment to child care as a job; and lower provider depressive symptoms. After controlling for familial status, data analysed from a subset of 51 mother‐provider pairs, indicated that mothers using care from providers who reported higher quality parent‐caregiver social relationships reported lower work‐family conflict and depressive symptoms. This study suggests mothers who have providers with whom they have good caregiving interactions may experience positive social support and psychological crossover dynamics associated with mother well‐being.     

Capitalizing on the potential of mobile health applications as behavioral interventions: A research agenda for calorie-tracking and activity-tracking applications

Mobile health applications (mHealth apps) are widely used tools that provide support for people seeking help managing their health in a particular behavioral domain (e.g., physical activity). Despite their popularity, evidence for the effectiveness of mHealth apps as stand-alone behavioral interventions is limited. Psychological and behavioral scientists can play a critical role in addressing this gap by pursuing programs of research that leverage basic behavioral science principles to test links between key features of mHealth apps (e.g., goal setting, feedback) and behavior change. To demonstrate this approach to evaluating mHealth apps, we systematically examine five key features of popular calorie-tracking and activity-tracking apps, explain how these features align with established behavior change techniques, discuss the evidence base for the effectiveness of these techniques within each behavioral domain, and situate predictions about how individual app features may promote behavior change in a conceptual model. Through this work, researchers can guide the design of mHealth apps and optimize them for facilitating sustained health behavior change.     

Child Sexual Abuse

Summary

Children who are recent victims of sexual abuse may initially present to their primary care health provider. Often, the outward manifestations of sexual abuse are somatic complaints or nonspecific behavioral changes. Retrospective reports of adults suggest that about 20-30% of women were sexually abused as children, with figures for men ranging from 10-15%. Interview guidelines for children and adolescents emphasize the need for sensitivity to cognitive development and emotional issues while simultaneously being focused on eliciting specific behavioral data. The use of anatomically detailed dolls, in the context of a comprehensive assessment, is discussed. Health care providers are mandated reporters and must disclose suspected child sexual abuse to the state's child protective service department. Guidelines for reporting as well as addressing this issue with parents are discussed.     

Healthcare at Your Fingertips: The Professional Ethics of Smartphone Health-Monitoring Applications

Health professionals are inundated by the surfeit of health apps while lacking guidance to help them critically evaluate whether a particular health-monitoring app is safe, likely to lead to clinical benefit, and not introduce additional liability. Our objective is not to argue for or against the use of mobile health-monitoring apps but to illuminate the associated ethical issues and provide recommendations to guide the ethical decision-making process for clinicians who are considering the use of a mobile health-monitoring app. To this end, the Canadian Code of Ethics for Psychologists is used as a framework to situate recommendations.     

Supporting Transgender and Sex Reassignment Issues

SUMMARY

For the care provider unfamiliar with supporting transsexual and transgender persons, as well as their partners, it becomes an imperative to be able to identify this population's unique needs, transition concerns and relationship dynamics. New challenges arise as transgender clients become more prevalent within the GLBT community and contact community clinical resources. These include distinguishing between sexual orientation and the complexities of gender identity; differentiating actual transgender issues and ordinary relationship concerns; and recognizing characteristics of strong relationships versus those doomed to fail when one or both partner's needs can no longer get met.

This article reviews an abundance of stereotypes adversely affecting transgender individuals, relationships and which can taint the treatment environment. At a core level, there exists the need for care providers to recognize when having a transgender identity stops being a disorder, such as when the client is no longer gender dysphoric, and where the care provider needs to advocate the individual's right of self-determination. This includes recognizing when situational depression or anxiety and social discrimination are the actual root of ongoing individual and relationship concerns. With basic transgender knowledge, effectively supporting transgender persons and their relationships is possible for cross-specialty providers, and is recommended.     

Reflective Capacity: An Antidote to Structural Racism Cultivated Through Mental Health Consultation

Effecting a paradigm shift from “reproductive health” to “reproductive justice” within the perinatal field requires changes simultaneously at the levels of the individual healthcare provider and the system of care. The Infant-Parent Program at the University of California, San Francisco (UCSF) has extended its pioneering infant and early childhood mental health consultation to perinatal service systems applying an infant mental health approach to programs caring for expecting and new parents. In partnership with two nursing programs, UCSF consultants direct their efforts at supporting reflective practice capacities and use-of-self in patient–provider relationships. Both nursing programs serve vulnerable groups of expectant and new parents who grapple with challenges to health and well-being stemming from structural racism. As reflective capacities are supported within the consultation case conferences, providers spontaneously identify the need for tools to effectively address issues of race, class, and culture and to combat structural racism throughout the healthcare system. Policies and procedures that uphold structural racism cease to be tolerable to providers who bring their full selves to the work that they are trained to do. Using these nurse consultation partnerships as organizational case studies, this article describes a range of challenges that arise for providers and delineates steps to effective engagement toward reproductive justice.     

Succeeding in Rural Mental Health Practice: Being Sensitive to Culture by Fitting in and Collaborating

Sustainable solutions to the access to mental health care problems are complex and must address both the availability of mental health care resources and the acceptability of those resources to consumers. The purpose of this study was to determine how to address the acceptability problem by learning from medical and mental health care providers what mental health therapists need to know to be successful in providing care in rural communities. Using a qualitative design, focus groups were conducted in three rural communities (<2,500) with medical and mental health care providers practicing in these communities. Data were analyzed using inductive qualitative methods. Results indicate that in addition to sound clinical skill, mental health therapists should (A) be sensitive to the culture of the rural community in which they are working and (B) practice in a way that accommodates to the care culture of the community. The latter includes spending time with patients commensurate with what is expected by other providers, engaging in generalist practice, and collaborating with local providers in patient care. An important implication of these results is that mental health care must be acceptable to both the residents of the community and the gatekeepers to health care.     

The Challenge of Integrated Care for Mental Health: Leaving the 50 minute hour and Other Sacred Things

A growing body of research has demonstrated the effectiveness of integrating mental/behavioral healthcare with primary care in improving health outcomes. Despite this rich literature, such demonstration programs have proven difficult to maintain once research funding ends. Much of the discussion regarding maintenance of integrated care has been focused on lack of reimbursement. However, provider factors may be just as important, because integrated care systems require providers to adopt a very different role and operate very differently from traditional mental health practice. There is also great variability in definition and operationalization of integrated care. Provider concerns tend to focus on several factors, including a perceived loss of autonomy, discomfort with the hierarchical nature of medical care and primary care settings, and enduring beliefs about what constitutes “good” treatment. Providers may view integrated care models as delivering substandard care and passively or actively resist them. Dissemination of available data regarding effectiveness of these models is essential (e.g. timeliness of treatment, client satisfaction). Increasing exposure and training in these models, while maintaining the necessary training in traditional mental health care is a challenge for training at all levels, yet the challenge clearly opens new opportunities for psychology and psychiatry.     

Digital Mental Health Interventions for Child and Adolescent Anxiety

Anxiety disorders are the most common mental health conditions in children, with approximately 13% of kids struggling with excessive anxiety. The vast majority do not have access to effective treatments and there continues to be a disjunction between treatments that are empirically supported and those that are available in the community. Digital mental health interventions (DMHI) can increase efficiency, reach, and standardization as well as reduce costs of providing of mental health care. Here we review the extant research on DMHI, including web- or cloud-based programs, mobile applications (apps), virtual reality (VR), and digital assessment methods such as ecological momentary assessment (EMA) for the delivery and/or support of evidence-based care in child anxiety. Preliminary research is promising for these tools to improve access and efficiency of evidence-based practice. However, ethics and practice guidelines are needed and questions remain regarding what level and quality of therapeutic involvement is needed to maximize treatment completion and outcomes in youth and whether DMHIs are contraindicated for certain populations or whether they are similarly effective with those with comorbid conditions is unclear.     

The Use of a Family History Risk Assessment Tool within a Community Health Care System: Views of Primary Care Providers

Primary care providers (PCPs) offered input regarding the incorporation of a family health history (FHH) risk assessment tool into a community health care system (CHCS). Sixteen PCPs participated in one of three focus groups. Perceived impediments included the lack of standard screening guidelines, effective screening tests, genetic counseling resources, and services for high-risk patients. The PCPs were concerned about their level of expertise, the cost of preventive health care, and genetic discrimination. They also were concerned about the use of a FHH tool by oncologists within the CHCS because of communication gaps between oncologists and PCPs, lack of clarity regarding follow-up and legal liability, and reimbursement issues. To integrate a FHH tool into a CHCS, PCPs will need consultation and referral services, evidence-based recommendations, and "just-in-time" educational resources. Oncologists who use the tool will need to develop a streamlined communication system with PCPs, establish clearly defined roles, and ensure patient follow-up.     

Experiences of the health care delivery system in a rural South African setting

This exploratory study aimed to examine health care provider work-related experiences in a rural South African context. Participants were a convenient sample of 12 medical practitioners (private sector = 55%). The practitioners responded to an open-ended question on their health care delivery-related experiences. Thematic analysis of the data revealed that the medical officers experienced both care provider fatigue and satisfaction from their work roles. Experiences of care provider fatigue were characterised by stress, anxiety, hopelessness, depression, burnout, frustration, and anger. Care provider satisfaction was associated with happiness, ability to cope, security, conscience, and commitment. Job retention and satisfaction of the health care providers were dependent on material and manpower resourcing of health services.     

Prevalence and predictors of expulsion in home-based child care settings

This study explored the prevalence of expulsion in home-based child care (HBCC) settings using a nationally representative sample of HBCC providers from the National Survey of Early Care and Education. In addition to prevalence, enrollment and provider characteristics that predicted expulsion were examined. Although there is increasing awareness of the prevalence of early childhood suspension and expulsion in early care and education settings and the negative effects it has on children's development, few studies have included or focused on HBCC, where many children receive care. This study highlights that many home-based providers, especially listed providers, report that they expelled at least one child within the last year. Significant predictors of expulsion emerged, including enrollment characteristics such as caring for children with disabilities, enrolling more children, and caring for children unrelated to the provider. Provider characteristics, including years of experience, provider education, and provider age, also predicted provider report of expulsion. These results provide insight as to possible strategies that may be effective in reducing expulsion rates in this caregiving context.