Practicing psychology in the era of managed care. Implications for practice and training

Beginning with the HMO Act of 1973, managed care, a system for controlling health care costs, rapidly expanded and gained influence as the main vehicle for health care delivery in the United States. Implementation of managed care principles in the mental health arena has generated much debate, particularly with respect to issues of quality of care. The authors briefly trace the development of managed care and evaluate its impact on the practice of psychology. The extant literature is reviewed with specific attention to issues of quality of care, confidentiality of patient information, and shifting practice patterns of clinicians. Finally, the future of professional psychology within the context of managed care is examined, and the implications of newly created mental health roles for practitioners, training programs, and organized psychology are discussed.     

Cognitive behavioral therapy for suicide prevention (CBT‐SP): Implications for meeting standard of care expectations with suicidal patients

Accumulating evidence supports the efficacy of cognitive behavioral therapy for suicide prevention (CBT‐SP) as an empirically supported treatment approach for suicidal patients. In light of these findings, several procedures pulled from CBT‐SP have been recommended for standard care with suicidal patients. The present article provides an overview of the procedures used in CBT‐SP and discusses how these procedures meet, or even exceed, standard of care expectations for outpatient mental healthcare clinicians. Finally, the relevance of clinician fidelity to the CBT‐SP model when evaluating standard of care expectations is discussed.     

Predicting Response to an Internet-Delivered Parenting Program for Anxiety in Early Childhood

Previous research has identified factors related to outcome in child anxiety treatment and parent training programs for child behavior problems. However, it is unclear what factors predict outcomes in interventions delivered online to parents of young children at risk of anxiety. This study investigated predictors of child anxiety outcomes among 433 families with young children (3–6 years) who participated in a randomized controlled trial of Cool Little Kids Online, an eight-module early intervention program for child anxiety based on cognitive-behavioral therapy (CBT). Potential predictors included baseline demographic factors, child and parent mental health factors, and indicators of program use, including number of online modules completed and frequency of homework practice. Results showed that only access to a printer moderated intervention effectiveness. Printer access predicted lower child anxiety in the Cool Little Kids Online group, but had no effect on outcomes in the wait-list group. In both groups, higher levels of child anxiety symptoms, child-inhibited temperament, and poorer parent mental health at baseline predicted higher levels of child anxiety symptoms at 6-month follow-up. The amount of online program use was not related to improvements in child anxiety symptoms. However, parents who reported practicing the program skills more frequently showed greater reductions in child anxiety, and access to a printer was related to frequency of program skills practice. These findings provide empirical support for the important role of skills practice in online CBT interventions, and suggest that practicing program skills may be more important than completing the online modules.     

Clinician competencies: Strengths and limitations for work with transgender and gender non-conforming (TGNC) clients

Individuals who identify as transgender or gender nonconforming (TGNC) face a number of health disparities compared to individuals who identify as cisgender (those who self-identify with the sex they were assigned at birth). For example, TGNC individuals experience heightened rates of clinical depression, anxiety, general psychological distress, suicidal ideation, and suicide attempts. Despite these troubling disparities, many TGNC individuals report hesitance to seek mental health services due to concerns regarding culturally insensitive or even overtly discriminatory services from providers. In addition to decreasing service utilization among TGNC populations, discriminatory services impair intervention effectiveness even when TGNC individuals persist in seeking mental health services. The American Psychological Association (APA) and the World Professional Association for Transgender Health (WPATH) provide guidelines for culturally competent work with TGNC clients; however, research indicates a profound lack of TGNC-specific training and resources among mental health care providers. To address this gap, the present investigation utilized a mixed-method design to assess training experiences, understanding of terminology, and TGNC competence among mental health care providers at various training levels. Participants were current mental health clinicians across the United States. Implications for improving reported and demonstrated weaknesses are discussed.     

Integration of Cognitive-Behavioral and Interpersonal Therapies for Latinos: An Argument for Technical Eclecticism

The integration of psychotherapeutic techniques is a common practice among today's clinicians. However, most discussions on psychotherapy integration have focused on general theoretical issues without attention to special populations. Latinos now represent the largest ethnic minority population in the United States and the mental health needs of this population are increasing. Although there are few controlled outcome studies that focus on Latinos, basic research suggests that integrating components of interpersonal therapy (IPT) into cognitive-behavioral therapy (CBT) may be particularly effective with this population. Specific suggestions for integrating CBT and IPT techniques are presented, and ways in which this integration can be adapted in a culturally sensitive manner are reviewed. An ethical and culturally sensitive CBT-IPT integration for Latinos requires empirical verification. Future studies on CBT-IPT synthesis should demonstrate the effectiveness of such integration relative to CBT or IPT alone.     

Promoting Mental Health Equity: The Role of Integrated Care

People suffering from mental illness experience poor physical health outcomes, including an average life expectancy of 25 years less than the rest of the population. Stigma is a frequent barrier to accessing behavioral health services. Health equity refers to the opportunity for all people to experience optimal health; the social determinants of health can enable or impede health equity. Recommendations from the U.S. government and the World Health Organization support mental health promotion while recognizing barriers that preclude health equity. The United States Preventive Services Task Force recently recommended screening all adults for depression. The Satcher Health Leadership Institute at the Morehouse School of Medicine (SHLI/MSM) is committed to developing leaders who will help to reduce health disparities as the nation moves toward health equity. The SHLI/MSM Integrated Care Leadership Program (ICLP) provides clinical and administrative healthcare professionals with knowledge and training to develop culturally-sensitive integrated care practices. Integrating behavioral health and primary care improves quality of life and lowers health system costs.     

Integrating Advocacy for Marginalized Children and Families Into Evidence-Based Care During COVID-19: Clinical Vignettes

The novel coronavirus (COVID-19) has disproportionately impacted the health and socioeconomic outcomes for low-income populations, people of color, and immigrant children and families in the United States. As inequities in resources (i.e., food, internet, housing), health care, and education increased for marginalized families as a result of COVID-19, child-focused clinicians had to broaden their professional scope and implement new advocacy efforts. The current paper uses clinical vignettes taken from a New York State Office of Mental Health–licensed child and adolescent outpatient clinic in the Bronx, New York. The vignettes highlight the social inequities that impacted marginalized children and families during the pandemic, as well as the clinical team’s response through the integration of evidence-base practice and advocacy. Implications for practice with vulnerable populations as the COVID-19 pandemic persists are discussed.     

A model for evaluation in child custody disputes

Abstract

Over one million children in the United States were involved in child custody decisions in the past year (Glick, 1979). Mental health professionals have been increasingly employed in such decisions. In this paper, we will delineate a model for clinicians to use in evaluating the family with respect to custody and will describe the values which guide our methods and recommendations.     

Implementation of the Wolverine Mental Health Program,Part 2: Implementation Phase

To enhance mental health care for youth in a midwestern residential treatment facility, Wolverine Human Services partnered with the Beck Institute (an intermediary) and an implementation research team to implement cognitive-behavioral therapy (CBT). CBT has strong evidence supporting effectiveness for treating youth internalizing and externalizing problems, but it is a complex psychosocial intervention that demands a thoughtful implementation approach. This study outlines the implementation phase (2.5 years) of a 5-year collaborative effort. The implementation phase focused on (a) adapting CBT to fit the complex youth needs and the roles of the multidisciplinary team members resulting in a new comprehensive and coordinated care model, and (b) the strategies utilized to support its competent integration by all team members. Six blended implementation strategies were deployed in this phase: forging implementation teams, installing progress monitoring, adapting CBT, training, providing supervision and consultation, and training the trainers. A components-based approach to CBT yielded six core skills: active listening, problem solving, mood monitoring and intervention mapping, activity scheduling, distress tolerance, and cognitive restructuring. By the end of this phase, all staff had robust exposure to and experience with the adapted form of CBT. The work of our academic–community partnership has both research and clinical implications, with respect to integrating an adapted version of CBT for residential environments (CBT-RE).     

Health services and health care economics: the health psychology marketplace.

In an effort toward cost containment, the health care system in the United States has undergone radical changes in the last decade. These changes have influenced the delivery of clinical health psychology services. This article reviews several economic and marketing factors salient to the clinical health psychology marketplace. For example, these economic changes have placed greater emphasis on the need for cost-effectiveness and accountability in the health psychology field. Implications for education and training, collaboration with other health care specialties, new practice initiatives, and public relations are reviewed. Future challenges and opportunities for clinical health psychology are discussed.     

The role of computer‐aided psychotherapy within an NHS CBT specialist service

To date, the feasibility of computer‐aided psychotherapy as an intervention has only been recognised in primary care practice. The present study sought to evaluate the impact of ‘Beating the Blues’ (BtB), an established computerised cognitive behaviour therapy (CCBT) self‐help programme for the management of anxiety and depression, within an NHS CBT specialist healthcare centre. Of the 555 service users who used BtB as part of routine care, with follow‐up assessment at six to eight weeks, 71% completed all eight sessions. Statistically significant differences on the Beck Depression Inventory‐II (BDI‐II) and Beck Anxiety Inventory (BAI) were found in completer and intention‐to‐treat analyses; 50% of completers achieved reliable change on the BDI‐II and approximately 25% of completers achieved reliable and clinically significant change on both measures. Outcomes were benchmarked against outcomes in studies of routine face‐to‐face CBT. These findings provide evidence that BtB may be of value to service users in secondary mental healthcare centres, alleviating current burdens on public health and therapeutic resources. Future research directions should include examining which factors influence individuals’ decisions to try computer‐aided psychotherapy, which individuals are best suited to using these interventions, and why some users drop out prior to programme completion.     

Characteristics and Components of the TADS CBT Approach

In this paper, we describe the Acute phase of a cognitive-behavioral therapy (CBT) developed for and utilized in the Treatment for Adolescents with Depression Study (TADS). The Acute phase of TADS CBT consists of eight skills that were considered essential to any CBT intervention for adolescent depression (e.g., mood monitoring, increasing pleasant activities, identifying cognitive distortions and developing realistic counter-thoughts). In addition, five optional individual CBT skills (e.g., relaxation, affect regulation) can be incorporated into treatment, depending on the needs of the adolescent. We describe each of these individual skills by reviewing the rationale for their inclusion in the treatment protocol and describing the format that is used to teach the skill area. Recommendations are provided for dealing with common challenges that can occur in the teaching of each skill module. It is our hope that clinicians will find this a useful introduction to this particular form of treatment and a practical guide to dealing with clinical problems common to the delivery of any cognitive behavioral intervention with depressed teens.     

Enhancing CBT Consultation With Multicultural Counseling Principles

The use of multicultural principles to enhance cognitive behavioral therapy (CBT) for individuals of marginalized backgrounds has received increased attention in light of the heightened national awareness of systemic oppression and racialized violence directed towards Black, Indigenous, and People of Color. However, there has been less of a focus on applying such principles to consultation for skill development. If ethical guidelines are expected to influence the behavior of clinicians in session, guidance is needed to indicate how and where and when clinicians should receive training in implementing culturally responsive CBT. Individual reading and reflection are necessary but are not sufficient in acquiring new clinical skills. Consultation is recommended and strongly suggested when clinicians are working with new populations or delivering a new treatment, or even using a new modality. Consultation can also be useful when adopting a new approach or stance to therapy. For practicing clinicians who have not developed these skills, additional consultation can and should be used to address this gap. Moving forward, integration of cultural responsiveness into standard consultation will ensure that these skills are seen as a core competency, rather than an optional additional skill that may be (or not be) elected. This paper presents core experiences that may be integral to a CBT consultation model that aims to enhance providers’ ability to provide CBT in a way that is culturally responsive to their clients. These recommendations attend to both content and process within CBT consultation and reflect guiding assumptions for helping clinicians to develop the ability to practice CBT in a culturally responsive manner, including (a) normalizing discussions of cultural identity and oppression, (b) an emphasis on cultural self-awareness, (c) emphasizing culturally informed CBT case conceptualization, and (d) skill development in applying cultural elements to CBT interventions.     

Psychologists' role in family-centered approach to practice, training, and research with young children

Family-centered, community-based, coordinated care for children with special needs is presented as the best practice model for providing services to children and families. Psychologists must learn to play an active role in this frame-work that both integrates psychology with other health and education disciplines and uses the broad spectrum of psychological knowledge about families, development, community organization, and intervention strategies. Key principles of family-centered child psychology affect practice research and training. The psychologist becomes part of a team created to support families as the primary care-givers of their children. Training programs must reorganize the types of experiences both in the classroom and the field to train new psychologists within this model. As mandates for family-centered care affect policies at the state and federal levels, research will remain a critical factor in understanding the effects of these policy shifts on child and family functioning and the delivery of services.     

Parent Training for Childhood Anxiety Disorders: The SPACE Program

Anxiety disorders are the most prevalent disorders of childhood and adolescence. Cognitive behavioral therapy (CBT) for anxiety poses a challenge for clinicians as it requires active client participation, and many children either decline or do not adequately comply with treatment. In addition, even after treatment with CBT, up to 50% of children remain symptomatic, and many still meet diagnostic criteria. Parent-directed clinical work has been advocated as a potential enhancer of treatment outcomes, and exclusively parent-based interventions might replace child treatment when the child is reluctant. However, parent involvement has yet to be shown to significantly improve outcomes, relative to child-only therapy. Studies so far have focused mainly on including parents in children’s therapy, training parents as lay therapists, or teaching parenting skills. Parent training focused on parental behaviors specific to childhood anxiety, such as family accommodation, may be more effective. In this treatment development report we present the theoretical foundation, structure, and strategies of a novel parent-based intervention for childhood anxiety disorders. We will also present the results of an open trial of the treatment, with an emphasis on feasibility, acceptability, and initial outcomes. Participants in the trial were parents of 10 children, aged 9 to 13. Children had declined individual child treatment. Multiple excerpts from the treatment manual are included with the hope of “bringing the treatment to life” and conveying a rich sense of the therapeutic process. Parents participated in 10 weekly sessions. Significant improvement was reported in child anxiety and family accommodation as well as in the child’s motivation for individual treatment. No parents dropped out and satisfaction was high. The SPACE Program (Supportive Parenting for Anxious Childhood Emotions) is a novel, manualized parent-based intervention that is feasible and acceptable and may be effective in improving childhood anxiety.     

Children's mental health as a primary care and concern: a system for comprehensive support and service

In response to the serious crisis in mental health care for children in the United States, this article proposes as a priority for psychology a comprehensive approach that treats mental health as a primary issue in child health and welfare. Consistent with the principles of a system of care and applying epidemiological, risk-development, and intervention-research findings, this approach emphasizes 4 components: easy access to effective professional clinical services for children exhibiting disorders; further development and application of sound prevention principles for high-risk youths; support for and access to short-term intervention in primary care settings; and greater recognition and promotion of mental health issues in common developmental settings and other influential systems. Integral to this approach is the need to implement these components simultaneously and to incorporate family-focused, culturally competent, evidence-based, and developmentally appropriate services. This comprehensive, simultaneous, and integrated approach is needed to achieve real progress in children's mental health in this country.     

Health Care Reform: Preparing the Psychology Workforce

This article is based on the opening presentation by the author to the Association of Psychologists in Academic Health Centers’ 5th National Conference, “Preparing Psychologists for a Rapidly Changing Healthcare Environment” held in March, 2011. Reviewing the patient protection and affordable care act (ACA), that presentation was designed to set the stage for several days of symposia and discussions anticipating upcoming changes to the healthcare system. This article reviews the ACA; general trends that have impacted healthcare reform; the implications of the Act for psychology’s workforce including the growing focus on interprofessional education, training, and practice, challenges to address in order to prepare for psychology’s future; and recommendations for advocating for psychology’s future as a healthcare profession.