New directions for the education of clinical psychologists: The primary care setting,the VA's PRIME program,and the in-depth generalist model

As part of this special issue on psychology in primary care settings, we describe the Department of Veterans Affairs' (VA's) new approach to education for practice in the primary care setting and we concurrently address some general issues related to the education of clinical psychologists for practice in this setting. In this article we argue that the primary care psychologist, in parallel with the generalist in medicine, must have a strong generic background in clinical psychology in order to gain the broad range of clinical skills necessary to function effectively as an in-depth generalist (IDG) who is capable of addressing the variety of psychological issues that emerge in the primary care setting. The IDG model of professional practice, which we believe is best suited for primary care/managed care settings, requires extensive training in generic clinical skills and increased time devoted to its implementation at both the predoctoral and the postdoctoral levels.     

The detection and management of mental health disorders in pediatric primary care

We reviewed the literature on the detection and management of mental health disorders within the context of pediatric primary care. Pediatricians have displayed a low sensitivity and high specificity in research investigating the detection of mental health impairment in children. Active management efforts characterize approaches to identified cases with more recently trained primary care pediatricians displaying a wider range of skills in managing mental health disorders. Few efforts have been made by pediatric psychologists to develop strategies for enhancing detection rates and management or to empirically evaluate the integration of pediatric psychology services into the primary care context. A conceptual model of factors influencing detection rates and ongoing management of mental health disorders within pediatric primary care is presented. Recommendations are made for more direct involvement of pediatric psychologists within the primary care context.     

Primary and secondary reflection in existential family therapy

The author uses Gabriel Marcel's topology of primary and secondary thought to clarify and outline the process of reflection in Existential Family Therapy. Clinical material is used to illustrate the differences between primary and secondary reflection during the practice of Existential Family Therapy.     

Cultural specificity of support sources,correlates and contexts: Three studies of African-American and Caucasian youth

Levels and correlates of parental support, peer support, partner support, and/or spiritual support among African American and Caucasian youth were examined in three contexts: adolescent pregnancy (Study 1), first year of college (Study 2), and adolescence and young adulthood (ages 15–29; Study 3). Partially consistent with a cultural specificity perspective, in different contexts different support sources were higher in level and/or more strongly related to adjustment for one ethnic group than the other. Among pregnant adolescents, levels of spiritual support were higher for African Americans than Caucasians; additionally, peer support was positively related to well-being only for African Americans whereas partner support was positively related to well-being only for Caucasians. Among college freshmen, family support was more strongly related to institutional and goal commitment for African Americans than Caucasians; conversely, peer support was more strongly related to institutional and goal commitment among Caucasians. Among 15 to 29-year-olds, levels of parental support and spiritual support were higher among African Americans than Caucasians; additionally, spiritual support was positively related to self-esteem for African Americans but not for Caucasians. Implications and limitations of the research are discussed. The third study was supported by National Institute of Mental Health Grant RO1 MH40963. We thank Monica Greene, Shea Lyda, Wendy Stevenson, and the many undergraduate students who contributed to the three research projects. We also acknowledge the very thoughtful and helpful comments of the anonymous reviewers and the editor, Edison Trickett.     

A biopsychosocial therapeutic approach in a private outpatient clinic in Portugal

Patients with chronic stress and ambiguous symptoms are likely to be more frequent in primary care. Somatizers represent 75.8% of the patients in this study and executives 56% of the sample. Job stressors were present in 78.3% of executive men. This scenario suggests that the primary care physician has to be academically better prepared to fully understand and deal with stress problems in daily clinical practice. The physician must have skills to deal with stress at a curative and preventive level, extending those skills to the workplace.     

Psychopathy and structure of primary mental abilities

The Comprehensive Ability Battery (CAB) was used to assess 18 primary mental abilities in 53 white, male prison inmates for whom highly reliable ratings of psychopathy were available. None of the correlations between ratings of psychopathy and scores on the CAB tests was significant, and the overall pattern or structure of abilities was the same for inmates with low and high ratings of psychopathy. The possibility is raised that the personality characteristics of psychopaths make them appear to be brighter and more creative than they actually are. Compared with norms for male high school students, the inmates as a group generally performed well, falling near the 50th percentile on 11 of the tests. The inmates performed significantly better than the normative sample on tests of verbal ability, esthetic judgment, aiming, and representational drawing, and significantly worse on tests of ideational fluency, spontaneous flexibility, and word fluency.This research was supported by Grant MT-4511 from the Medical Research Council of Canada.     

Peer tutoring among elementary students: educational benefits to the tutor

To determine whether tutoring might be academically beneficial to the tutor, this study investigated the acquisition of spelling words by three elementary students in a peer tutoring program. The experimental design allowed a simultaneous comparison of each child's gain in performance on comparable word lists on which the child tutored another child, was tutored by another child, or neither gave nor received tutoring. The children's spelling improved nearly an equivalent amount on those words on which they tutored another child as on the words on which they were tutored; no such change was noted on the words on which they neither gave nor received tutoring. These findings, that peer tutoring is profitable for the tutor as well as the tutee, provide a basis for recommending peer tutoring as one method of individualizing education.     

THE EFFECTS OF A GOOD-BEHAVIOR CONTRACT ON THE CLASSROOM BEHAVIORS OF SIXTH-GRADE STUDENTS1

The effects of a good-behavior contract on the on-task behavior, disruptive behavior, daily assignment completion, and weekly grades of four sixth-grade students were examined in a public school classroom. The contract consisted of presenting the students with a list of good conduct and assignment completion goals and a list of disruptive behaviors coupled with a list of rewards and penalties that could be earned. The rewards and penalties made use of existing facilities and classroom privileges. At the beginning of each morning work period, the teacher negotiated the good-behavior contract with each experimental subject. During the negotiations, the teacher emphasized student self-management and encouraged each student to earn a reward by achieving the good-conduct goals and completing the contract assignments. An isolated work area was provided to allow students the opportunity to remove themselves from their desks for a fixed period of 15 min. At the end of the work period, the teacher determined whether each student earned a choice of reward or penalty dependent on assignment completion and whether the teacher had observed disruptive behaviors. Thus, the contract permitted the student to negotiate the goal behaviors and contingencies with the teacher. Throughout the study, the students were in agreement with the teacher on whether a choice of reward or penalty had been earned. The contract was introduced for different children at different times, constituting a multiple-baseline analysis. On-task behavior and daily assignment completion increased, weekly grades were higher, and disruptive behavior decreased when the contract was in effect. Three contrast subjects were selected from the class as model students who consistently produced acceptable assignments and who did not engage in high rates of disruptive and/or off-task behaviors. When the contract was in effect for the experimental subjects, their performance compared favorably with the contrast subjects, who never received the daily contract. The results demonstrated that the contract was effective within the confines of the facilities and contingencies readily available in a public school classroom setting.     

Who drops-out? Do measures of risk to self and to others predict unplanned endings in primary care counselling?

Aims: Unplanned endings, where clients unilaterally end therapy, are of concern for psychological therapy services generally as they raise questions about the appropriateness of the treatment and it's delivery for some clients. Limited available data indicates that those who drop-out often have more severe symptoms at entry, and have poorer clinical outcomes. This raises further questions about risk to self and others for those clients who leave therapy prematurely and how these clients might be identified and kept engaged. Method: This paper uses a large dataset of CORE data collected routinely in a primary care counselling service between 2000 and 2003. Logistic regression was utilised to consider different measures of risk and other client characteristics recorded at assessment to predict drop-out from the service. Results: These indicate that younger age, greater psychological distress at assessment, an addiction problem and greater risk to others, are associated with an unplanned ending. However, no reliable logistic regression model could be produced. This may be partly due to data quality issues or important characteristics not being available in the data. Implications for practice: The paper concludes that counsellors should actively seek to minimise unplanned endings, as amongst them may be represented the more distressed and risky clients referred to primary care counselling.     

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.