Psychologists in Academic Health Centers: Reflections on Traditions and Innovations in Education,Science, and Practice

In 2007, the Association of Psychologists in Academic Health Centers (APAHC), formerly known as Association of Medical School Psychologists (AMSP), held its first national conference since 1997. At the latter conference, the author of this article [Sheridan (1999) Journal of Clinical Psychology in Medical Settings, 6, 211–218] was asked to present some of the issues that would be important to health care psychologists in the next decade. These issues included the role of psychology in academic health centers, interventions psychologists offer, reimbursements for such treatments, education and training models, and research. This article examines those observations, offers new data, and explores the current challenges and opportunities for psychologists in academic health centers. The presentation also addresses aspirations of psychologists as well as resistances within the profession. Parts of this paper were delivered at the 3rd Conference of the Association of Academic Health Center Psychologists in Minneapolis, Minnesota in 2007.     

Women,Mental Health,and Managed Care

Abstract

Managed care has changed the way that mental health care is provided. These insurers manage such factors as length and type of therapy made available, access to therapy, and level of payment for therapy. Women, as the majority of those insured by managed care and as consumers of mental healthcare, are differentially affected by these changes.     

How Managed Care Can Help Couples Cope

ABSTRACT

This article traces how managed care became a quick fix to curb out-of-control healthcare costs rather than a real effective approach to managing care. To date, the impact has been not only a negative experience, but impediment to treating couples facing relationship and related problems. The author is optimistic about how managed care will evolve to recognize the importance of couples and family treatment as we enter the future with integrated systems of healthcare. ? The future will also require significant shifts in the thinking and practice patterns of providers and an emphasis on quality and outcomes.     

We are not a Healthcare Business: Our Inadvertent Vow of Poverty

Psychology has been fractionated from mainstream healthcare delivery and this schism has resulted in huge costs to psychologists and our intended customers. Psychology has also been naïve economically. The authors suggest three revolutions: (1) for clinical psychology to be better integrated into the healthcare delivery system; (2) for psychologists to better understand healthcare economics and business; and (3) for psychologists to become more entrepreneurial, i.e., see needs in healthcare (such as those of the elderly, obesity, improved access and value through ehealth) and systematically fill these. We note high quality businesses help many individuals (customers, family members, employees) not typically recognized by anti-business psychologists.     

Sleep locus of control and computerized cognitive-behavioral therapy (cCBT)

This study investigated the relationship between sleep locus of control and sleep in a secondary data analysis. Participants were 100 adults with chronic insomnia previously involved in a randomized controlled trial of 5 weeks of computerized cognitive-behavioral therapy (cCBT). Additionally, a sample of 46 completers of an in-person group for insomnia were utilized as a comparison group. At pre-treatment, participants completed the Sleep Locus of Control Scale, the Insomnia Severity Index, the Pre-Sleep Arousal Scale, 7 days of sleep diaries, and participated in structured interviews to assess for psychiatric and medical conditions. Measures were re-administered at post-treatment and at a 4 week follow-up. Results showed that sleep locus of control mediated the impact of cCBT on insomnia severity at follow-up. cCBT more than waiting list control or a convenience sample of individuals treated with in-person CBT, enhanced an internal sleep locus of control. Implications are that sleep locus of control may be an important variable to assess in the internet context and that internet programs for insomnia may want to consider amplifying or giving priority to interventions which enhance an internal sleep locus.     

Behavioral Health Consultation and Primary Care: Lessons Learned

This article provides an overview of 20 years of professional experiences with developing and implementing a model for integrating behavioral health services into primary care. The Primary Care Behavioral Health (PCBH) model is designed to provide immediate access to behavioral care for a large number of primary care patients by positioning a behavioral health consultant in the exam room area to function as a core member of the primary care team. In an initial era of discovery, the authors were directly involved in developing and testing a variety of new approaches to providing behavioral health services in general medicine. In a second era focused on feasibility, the authors worked with Kaiser Permanente, the United States Air Force and Navy, the Veteran’s Administration, and the Bureau of Primary Care to system test this innovative model of integrated care. Now in an era devoted to dissemination, the authors review the various roles formal research, system level quality improvement initiatives and stakeholder analysis play in promoting integrated care. The authors also describe current efforts to (1) create a tool that helps systems develop integration targets and (2) use the PCBH model as a platform for teaching medical residents and behavioral health providers to work together in a redesigned primary care team model.     

Integrating Care for Persons, Not Only Diseases

Integrated care is geared toward enhancing usual care and decision-making for common combinations of medical and mental health conditions, including the behavioral health and behavioral change aspects. Yet even with comprehensive and well-integrated care for health conditions and well-coordinated teamwork in place, some patients do not engage or respond to care in the way clinicians would like or predict. This troubles patients and clinicians alike and may be chalked up informally to things like medical complexity (multiple co-existing conditions), mental health conditions (that complicate care), or simply the case being considered complex or difficult. It also raises the question of how to address person-specific factors that interfere with care of whatever conditions the patient may have, and invites behavioral health clinicians in medical settings to look beyond care of conditions to the care of persons, and to look beyond disease-specific care management protocols to master generic practices of care management across whatever conditions the person may have. This person-centered emphasis is intrinsic to the concept of the “patient-centered medical home” which has burst into animated discussion and demonstration among providers, health plans, government plans, employer purchasers, and professional associations across public and private entities. This represents an opportunity for collaborative care clinicians to help shape the national state of the art in medical home and includes a range of person-oriented (rather than disease-oriented) practices for care management, including working systematically with complex patients and difficult patient–clinician relationships.     

Comment

ABSTRACT

Comments on the role of greed at all levels of the managed care system, from individual patients to corporations. It is suggested that couples therapists not seek inclusion as “health care providers.”     

Targeting the probability versus cost of feared outcomes in public speaking anxiety

Cognitive-behavioral theory suggests that social phobia is maintained, in part, by overestimates of the probability and cost of negative social events. Indeed, empirically supported cognitive-behavioral treatments directly target these cognitive biases through the use of in vivo exposure or behavioral experiments. While cognitive-behavioral theories and treatment protocols emphasize the importance of targeting probability and cost biases in the reduction of social anxiety, few studies have examined specific techniques for reducing probability and cost bias, and thus the relative efficacy of exposure to the probability versus cost of negative social events is unknown. In the present study, 37 undergraduates with high public speaking anxiety were randomly assigned to a single-session intervention designed to reduce either the perceived probability or the perceived cost of negative outcomes associated with public speaking. Compared to participants in the probability treatment condition, those in the cost treatment condition demonstrated significantly greater improvement on measures of public speaking anxiety and cost estimates for negative social events. The superior efficacy of the cost treatment condition was mediated by greater treatment-related changes in social cost estimates. The clinical implications of these findings are discussed.     

Delivery of internet treatment for compulsive hoarding (D.I.T.C.H.)

This study tested the effectiveness of an existing private online CBT-based group intervention designed to help people with hoarding. Web-group participants were hypothesized to show more improvement in hoarding symptoms over time compared to those placed on a naturalistic waitlist. This web-based self-help group (N = 106 members, N = 155 waitlisted) includes a formal application process and requires that participants post action steps and progress at least once monthly. Members have access to educational resources on hoarding, cognitive strategies, and a chat-group. Potential research participants were invited to complete an anonymous web-based survey about their hoarding behaviors and clinical improvement on five occasions (3 months apart). The sample was mainly middle-aged, female and White. Regression analyses show that Recent members reported greater improvement and less clutter at 6 months (than Waitlist). Long-term members reported milder hoarding symptoms than Recent ones, suggesting benefits from group participation over time. All members showed reductions in clutter and hoarding symptoms over 15 months. Less posting activity was associated with greater hoarding severity. Online CBT-based self-help for hoarding appears to be a promising intervention strategy that may extend access to treatment. Evaluating the benefits of internet self-help groups is critical given growing popularity of and demand for web-based interventions.     

In Search of Intimate Autonomy

Cases were analyzed and discussed in which couples had autonomy but not intimacy, pseudointimacy but not autonomy, and both intimacy and autonomy. Guidelines for establishing intimate autonomy were proffered, and psychotherapeutic intervention for couples dysfunctional for intimate autonomy was discussed. The guidelines included having mutual respect for the partner's individuality, mutual areas of interest, basic philosophical agreement, desire to share with the partner, wanting the ultimate good for the partner, and accepting what is unchangeable in the self and the partner. The myth and reality of intimate autonomy are examined.     

Task-shifting to improve the reach of mental health interventions for trauma patients: findings from a pilot study of trauma nurse training in patient-centered activity scheduling for PTSD and depression

ABSTRACT

Despite high rates of posttraumatic stress disorder (PTSD) and depression among traumatically injured patients, engagement in session-based psychotherapy early after trauma is limited due to various service utilization and readiness barriers. Task-shifting brief mental health interventions to routine trauma center providers is an understudied but potentially critical part of the continuum of care. This pilot study assessed the feasibility of training trauma nurses to engage patients in patient-centered activity scheduling based on a Behavioral Activation paradigm, which is designed to counteract dysfunctional avoidance/withdrawal behavior common among patients after injury. Nurses (N = 4) and patients (N = 40) were recruited from two level II trauma centers. A portion of a one day in-person workshop included didactics, demonstrations, and experiential activities to teach brief intervention delivery. Nurses completed pre- and posttraining standardized patient role-plays prior to and two months after training, which were coded for adherence to the intervention. Nurses also completed exit interviews to assess their perspectives on the training and addressing patient mental health concerns. Findings support the feasibility of training trauma nurses in a brief mental health intervention. Task-shifting brief interventions holds promise for reaching more of the population in need of posttrauma mental health care.     

Narcissistic Vulnerability in Marriage

Many couples who seek therapy with issues around money, work, sex or children are actually dealing at a deeper level with problems of narcissistic entitlement, vulnerability to emotional injury, or defenses that protect against perceived attacks upon a fragile self. This paper considers the concept of narcissism as it relates to marriage and family issues and suggests some important ingredients in treating a narcissistically vulnerable relationship.     

The efficacy of cognitive-behavioral interventions for reducing anxiety sensitivity: a meta-analytic review

The present study meta-analytically reviewed the efficacy of cognitive-behavioral therapy (CBT) vs. control conditions in the reduction of anxiety sensitivity. A computerized search was conducted to indentify CBT outcome studies that included the Anxiety Sensitivity Index as a dependent variable. Of the 989 studies that were identified, 24 randomized-controlled trials with a total of 1851 participants met inclusion criteria and were included in the analysis. Data were extracted separately for treatment-seeking (16 studies) and at-risk (eight studies) samples. Results indicated large effect sizes for treatment-seeking samples, Hedges' g=1.40, SE=0.21, 95% CI: 1.00-1.81, p<0.001, and moderate to large effect sizes for at risk samples Hedges' g=0.74, SE=0.18, 95% CI: 0.39-1.08, p<0.001. Additionally, both the amount of therapist contact and control modality (waitlist vs. psychological control) moderated the effect sizes for treatment-seeking samples. Our review indicates that CBT is efficacious in reducing anxiety sensitivity. However, more research is needed to determine the mechanisms by which CBT exert its effects on anxiety sensitivity.     

The Unmanageability of Characterologic Couples in Managed Care

ABSTRACT

This article explores the issues associated with treating characterologic couples in the managed care environment. The article focuses on the definition of the characterologic couple and the specific issues that emerge when the characterologic couple is attempting brief treatment in the managed care environment. Attention is focused on the difficulties in the two-stage approach to character treatment, the potential for hurting the non-characterologic member of the couple, and the problems that emerge when the character is identified, but not worked with.     

Existential Marital Psychotherapy and the Experience of Managed Care

ABSTRACT

In this article the experience of managed care is over-viewed from the perspective of existential marital therapy. It is concluded that managed care disrupts the experiential nature of participation between couple and therapist, dilutes the authentic nature of the treatment relationship, decreases the importance of subjectivity, disturbs the discovery of meaning and purpose in marital life and deters existential communication.     

Maintenance of weight loss after obesity treatment: is continuous support necessary?

OBJECTIVE: This study examined outcome differences of 109 obese subjects, who participated in a 10-week cognitive-behavioral inpatient treatment followed by either a weight maintenance program or a follow-up period without professional support. METHODS: Self-rated weight loss, eating behaviors, and general psychopathology were assessed several months before treatment, when subjects were admitted, at discharge, and at the 6-, 12-, and 18-month follow-ups. Structured interviews for mental disorders and eating pathology were conducted additionally. RESULTS: The mean weight of the sample at baseline was 127 kg. Weight loss of the total sample amounted to 8.0 kg (6.3%) and was completely maintained during the follow-up period. Significant reductions of eating and general psychopathology were observed at the 18-month follow-up. The outcome in the maintenance condition did not significantly differ from the outcome in the control condition. CONCLUSIONS: Weight regain after obesity treatment is not inevitable, but continuous patient-therapist contacts do not distinctly improve treatment effects.     

Cognitive-Behavioral Therapy for Offender Hopelessness: Lessons from Treatment of Forensic Inpatients

Patients remanded to forensic hospitals often experience a marked situational depression once initial psychotic symptoms subside and the reality of their legal situation becomes evident. Individual psychotherapy is not often used with this population due to a generally high level of impairment. It is suggested, that with modifications, the cognitive-behavioral therapy manual by Michael Thase (in: VanHasselt, Hersen (eds) Sourcebook of psychological treatment manuals for adult disorders, 1996) designed to treat depression in psychiatric inpatients can be used to treat situational depression in forensic inpatients. Modifications include the use of increased behavioral techniques, the addition of a group component, and lengthening of time limits for each treatment phase. Case examples from a first attempt to implement the new treatment program are presented.