General practice, primary care, and health service psychology: concepts, competencies, and the Combined-Integrated model

The profession of psychology is being impacted profoundly by broader changes within the national system of health care, as mental and behavioral health services are being recognized as essential components of a comprehensive, preventive, and cost-efficient primary care system. To fully define and embrace this role, the discipline of professional psychology must develop a shared disciplinary identity of health service psychology and a generalized competency-based model for doctoral education and training. This very framework has been adopted by Combined-Integrated (C-I) doctoral programs in professional psychology, which train across the practice areas (clinical, counseling, and school psychology) to provide a general and integrative foundation for their students. Because C-I programs produce general practitioners who are competent to function within a variety of health service settings, this innovative training approach has great potential to educate and train psychologists for a changing health care marketplace.     

Better access to psychological treatments through Medicare: Rejoinder to Carey,Rickwood and Baker

The inclusion of evidence‐based psychological interventions within Medicare through Better Access addresses an inequity within the Australian health system against people with mental disorders. The question of “Who is qualified to provide these services” is the overriding focus of many commentaries on Better Access within psychology. Carey et al. (2009) argue for examination of the Medicare data to answer this question. We show that Carey et al. (2009) fail to clarify if and how the Medicare data could be used to answer the questions they put and that the reasons for the current eligibility requirements within the Medicare Benefits Schedule are transparent, justifiable and responsible. The preoccupation with within‐profession distinctions is counterproductive because it distracts from a proper examination of the impact of Better Access on mental health care in Australia. Research dollars need to be directed to questions that most directly affect the quality of care, such as how can interventions under Better Access be delivered appropriately according to best practice, improve access and equity for everyone and be most cost efficient? Given the current policy agenda in primary care favouring integrated, multidisciplinary models of care, these questions are the critical ones for the future direction of Better Access.     

The genesis,implementation and impact of the Better Access mental health initiative introducing Medicare‐funded psychology services

The Australian Government's Better Access to Mental Health Care initiative introduced mental health reforms that included the availability of Medicare‐funded psychology services. The mental health initiative has resulted in a huge uptake of these services, demonstrating the strong community demand for psychological treatment. The initiative has also had a substantial impact on the profile of the psychology profession. After a full year of implementation, analysis of the impact of the availability of funded psychology services identified a number of issues and challenges. However, it is evident that the inclusion of these services under Medicare has been a most important advance for the psychology profession and the mental health of the Australian community.     

Meeting the Mental Health Needs of Older Adults in Primary Care: How Do We Get the Job Done?

Most elderly persons in the United States with mental health problems such as depression receive no attention or care. Those who receive treatment generally do so in primary care settings, where disorders like depression have a hard time competing with other common and chronic medical problems. Typically, mental illnesses are under-recognized and under-treated in elderly persons attending primary care clinics. The experience of the PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) study is briefly described, indicating that depression, for example, can be treated successfully in primary care elderly using the type of multidisciplinary collaborative care model advocated by Speer and Schneider (2003 ; this issue). The challenge now facing all of us is to create a consumer- and family-driven demand for good mental health services in geriatric clinics and a political consensus to reimburse such services fairly. Recent improvement in Medicare reimbursement for mental health services to victims of Alzheimer's dementia provides a basis for hope.     

Providing Interdisciplinary Geriatric Team Care: What Does It Really Take?

We concur with Speer and Schneider's arguments (2003 ; this issue) that more psychologists should offer mental health services to older adults and that the primary care system is a good focus of such efforts. Three issues deserve more prominence in their review. First, their argument that older adults are averse to mental health services seems incorrect, given research indicating that older adults prefer psychotherapy to medication for treatment of depression. Second, psychologists working in primary care need to be aware of new Current Procedural Terminology (CPT) codes that allow documentation of psychological work in medical settings. Third, Speer and Schneider allude to interdisciplinary team functioning, but provide little information about models of team care or issues in developing a well-functioning interdisciplinary team; this commentary expands on those topics.     

Assessment in Clinical Psychology: A Perspective on the Past, Present Challenges, and Future Prospects

Assessment emerged during the early twentieth century with the development of tests for assessing characteristics such as intelligence, personality, and suitability for employment. The long, interwoven relationship between clinical psychology and assessment began to change during the 1970s when many clinical psychologists became more involved in behavioral therapy and moved away from psychological testing and with the expanding role of managed care in the mental health services. Clinical assessment broadened into forensic, medical, and personnel applications with psychologists expanding professional roles. The status of assessment was reviewed and some challenges were highlighted. The potential for assessment to contribute to the understanding of mental health problems through collaborative cross-cultural study of psychopathology was suggested with the growing development of clinical psychology internationally.     

The increased needs of patients in nursing homes and patients receiving home health care

To evaluate the effects of Medicare's prospective payment system and Medicaid's preadmission regulations on long-term care, we constructed clinical profiles in 1982 and 1986 of about 500 randomly selected patients from each of three types of facilities: nursing homes with relatively high proportions of Medicare patients (high-Medicare nursing homes; n = 23), traditional nursing homes (n = 19), and home health agencies (n = 18). Data were obtained directly from the care givers on the medical problems, problems requiring skilled nursing, and functional problems of these representative patients from 12 states. For Medicare patients in high-Medicare nursing homes, the prevalence of medical problems and problems requiring skilled nursing increased substantially, whereas the prevalence of functional problems remained relatively unchanged. For example, from 1982 to 1986 there was a marked increase in the frequency of tube feedings (21 to 29 percent), oxygen use (6 to 14 percent), urinary tract infection (7 to 13 percent), and diastolic hypertension (1 to 10 percent), but not difficulty in eating (48 to 51 percent) or speaking (28 to 29 percent). In contrast, in traditional nursing homes there was an increase in the prevalence of functional disability, but virtually no change in that of problems requiring medical and skilled nursing care. In home health care the functional care needs of Medicare patients increased significantly, and there was a slight increase in the prevalence of problems requiring medical and skilled nursing care. We conclude that from 1982 to 1986 the needs of patients in long-term care increased substantially. This trend appears to result from Medicare's prospective payment system, which encourages earlier hospital discharge to long-term care settings, and from Medicaid's policy of de-institutionalization. Meeting this greater need for care will be costly. We require a better system of reimbursing for long-term care and ensuring its quality.     

Integrating spirituality and psychotherapy: ethical issues and principles to consider

Professional and scientific psychology appears to have rediscovered spirituality and religion during recent years, with a large number of conferences, seminars, workshops, books, and special issues in major professional journals on spirituality and psychology integration. The purpose of this commentary is to highlight some of the more compelling ethical principles and issues to consider in spirituality and psychology integration with a focus on psychotherapy. This commentary will use the American Psychological Association's (2002) Ethics Code and more specifically, the RRICC model of ethics that readily applies to various mental health ethics codes across the world. The RRICC model highlights the ethical values of respect, responsibility, integrity, competence, and concern. Being thoughtful about ethical principles and possible dilemmas as well as getting appropriate training and ongoing consultation can greatly help the professional better navigate these challenging waters.     

Urban bioethics: adapting bioethics to the urban context.

Urban bioethics is an area of inquiry within the discipline of bioethics that focuses on ethical issues, problems, and conflicts relating to medicine, science, health care, and the environment that typically arise in urban settings. Urban bioethics challenges traditional bioethics (1) to examine value concerns in a multicultural context, including issues related to equity and disparity, and public health concerns that may highlight conflict between individual rights and the public good, and (2) to broaden its primary focus on individual self-determination and respect for autonomy to include examination of the interests of family, community, and society. Three features associated with urban life-density, diversity, and disparity-affect the health of urban populations and provide the substrate for identifying ethical concerns and value conflicts and creating interventions to affect population health outcomes. The field of urban bioethics can be helpful in creating ethical foundations and principles for public health practice, developing strategies to respect diversity in health policy in a pluralistic society, and fostering collaborative work among educators, social scientists, and others to eliminate bias among health professionals and health care institutions to enhance patients' satisfaction with their care and ultimately affect health outcomes. Educational programs at all levels and encompassing all health professions are needed as a first step to address the perplexing and important problem of eliminating health disparities. Urban bioethics is both contributing to the social science literature in this area and helping educators to craft interventions to affect professional attitudes and behaviors.     

Increasing mental health awareness and appropriate service use in older Chinese Americans: A pilot intervention

Objective

This study evaluated the effectiveness of a community intervention in increasing awareness of mental health issues and available resources among elderly Chinese Americans.

Methods

Twenty-seven members of a community church received a 1-h didactic presentation, in English and Mandarin, and completed surveys regarding their help-seeking preferences before and after the intervention. Results were analyzed using a series of Wilcoxon matched-pair signed rank tests and comparing pre- and post-test scores.

Results

Findings indicated an increase (p < .05) in intention to consult a mental health professional for psychiatric symptoms at post-test. A significant increase also was found in preference for consulting a physician for physical symptoms.

Conclusion

The pilot educational intervention increased awareness of mental health and treatment issues and the role of mental health professionals, lending support to evaluate the intervention on a larger scale.

Practice implications

Greater awareness of mental health among Chinese Americans can be promoted via education forums provided through faith-based organizations. Stigma of mental illness leads many Chinese individuals to seek help for psychiatric problems from primary care physicians. Integrating mental health practitioners in primary care settings may help decrease stigma and encourage appropriate help-seeking behavior.     

Trends Influencing Future Delivery of Mental Health Services in Large Healthcare Systems

The delivery of mental health services, particularly psychotherapy and other psychosocial care, is being increasingly limited by financial constraints. We briefly review three trends that will play an increasingly important role in the delivery of mental health services in large organizations such as health maintenance organizations. These are (a) an increasing role for self-help and bibliotherapy interventions, both in traditional and electronic formats; (b) mental health services being offered in settings other than mental health specialty clinics; and (c) an increased emphasis on mechanisms for improving the quality and type of services offered, including quality improvement methods and pay-for-performance.     

Community mental health in rural schools: A demonstration project

A pilot program was initiated by a rural community mental health center in which staff went into the local junior and senior high schools to provide personal-problem-oriented counseling services to students. Results of the program suggest that students perceived their problems as serious, that they found counseling interventions helpful, that they favorably perceived referral to a mental health professional, and that students desired the availability of such services within the school environment on a regular basis. Conceptual and service-delivery issues are discussed within the context of a preliminary model for mental health-public school collaboration in the delivery of counseling services to students in rural areas. Suggestions for future research are noted.     

Unified professional psychology: implications for the Combined-Integrated model of doctoral training

The authors outline a new identity for the professional psychologist termed Unified Professional Psychology (UPP). UPP combines recent movements toward a unified psychological science, an independent professional psychology, and Combined-Integrated (C-I) doctoral training programs in psychology. The value in the synthesis of these ideas is that they (a) provide a comprehensive system of thought that defines the science and practice of psychology in a commensurable manner, (b) offer a clear identity for the professional psychologist, and (c) set the stage for a training model that develops competencies that will prepare graduates to serve as leaders and advocates in a wide array of health settings. Issues pertaining to why a new view is needed and how UPP specifies the science-practice relationship are addressed in detail.     

Prescribing non-psychopharmacological agents: a new potential role for psychologists in primary care settings and specialty clinics

At least 10 years have passed since the Department of Defense Psychopharmacology Demonstration Project graduated its first class of psychologists. All graduates of that program were credentialed to prescribe and the program received promising external reviews and audits. The profession has since moved well beyond the initial question, “Can and should psychologists prescribe?” posed over two decades ago. A number of professional schools and training institutions have implemented postdoctoral psychopharmacology training programs and over 20 states are actively pursuing legislative agendas. Given recent initiatives to provide health psychology services within the primary care arena, the authors introduce a new role in the scope of psychology's prescribing activities. They propose that psychopharmacological agents are not the only medications psychologists should be trained to prescribe and psychopharmacology training should include course work and supervision related to treatment within a primary care patient setting in addition to a traditional psychiatric one. The authors provide the rationale for primary care clinical health psychology training as the appropriate mechanism for psychopharmacology education and practice. Public health needs and epidemiological data provide the rationale for health psychologists additionally prescribing non‐psychopharmacological agents. © 2006 Wiley Periodicals, Inc. J Clin Psychol 62: 1213–1220, 2006.     

Privacy in the Digital Age: Implications for Clinical Practice

In 2012, privacy breaches exposed the confidential health data of 22.5 million U.S. citizens. Ensuring clients’ privacy is essential in clinical psychology, and a task that has become increasingly complex as technology has evolved. Many current professional guidelines for clinical practice do not consider issues pertaining to potential privacy breaches from sources such as human error, malicious acts, metadata, and surveillance (e.g., APA, 2007, http://www.apa.org/practice/guidelines/record-keeping.pdf ; APS, 2013, http://www.psychology.org.au/Assets/Files/2013-APS-psychological-services-framework-for-public-sector-NGO%20.pdf ; BPS, 2011, http://www.bps.org.uk/sites/default/files/documents/electronic_health_records_final.pdf ). We review potential sources of privacy breaches arising from electronic storage and communications use. We conclude with best practice recommendations regarding electronic storage and communication, software choices, and spyware removal designed to minimize privacy risk in mental health care. These recommendations need to be regularly reviewed to continue to minimize the risk of privacy‐related breaches in the context of ongoing technological development.     

The Consensus Conference and Combined-Integrated model of doctoral training in professional psychology--overview of part 1: nature and scope of the Combined-Integrated model

This special series of articles on the Consensus Conference and Combined-Integrated (C-I) model of doctoral training in professional psychology consists of 13 articles in two successive volumes of the Journal of Clinical Psychology. Six articles are presented in Part 1 (Vol. 60, Issue 9), which collectively describe the "nature and scope" of the C-I model (e.g., historic and definitional issues; the potential advantages of this model; implications for the profession). In Part 2 of this special series (Vol. 60, Issue 10), articles 7 through 12 address the broader implications and potential applications of the C-I model within a range of professional and societal contexts (e.g., for interprofessional collaboration; the health care field; development of a global curriculum; the unified psychology movement; issues of assessment and professional identity; and higher education); article 13 provides a summary of the series as well as a discussion of future directions. As an overview, this paper provides the abstract for each of the articles in Part 1, and describes the various topics of the articles in Part 2. Taken together, the articles in this special series are designed to provide a coherent account of how and why the C-I model is timely and relevant, and therefore warrants serious consideration by the larger education and training community in professional psychology.     

A new approach to medicare: implications for health care reform and for medical education.

Medicare Parts A and B engender a system of payment and delivery at odds with that of health maintenance organizations (HMOs). Most evident in the conflicting incentives and requirements levied on primary care physicians participating today in both traditional Medicare and HMOs, the dichotomy has vitiated the promise of managed care and constitutes a significant factor in both the rising cost inflation in health care and the growing dissatisfaction of patients, physicians, payers, and insurers. The resulting impact affects the robustness and quality of medical education as well as the character and quality of health care delivery. An innovative incentive-based system of payment and delivery is proposed as an alternative option for Medicare, with expectation that the system, which the authors title Medicare-New, or Part N, could trigger a more effective approach to health care reform for Medicare, foster more rational support for medical education and the care of the indigent, and benefit private insurance programs as well. Positive changes in both public and private sectors would strengthen both medical education and the access to and quality of health care throughout the nation.     

Adapting empirically supported treatments in the era of integrated care: A roadmap for success

The emerging era of integrated care represents a major opportunity for clinical psychology to migrate empirically supported treatments (ESTs) into the mainstream of public health. To succeed will require us to modify current ESTs to make them brief, cost‐effective, patient‐centered and acceptable to and easily learned by both the mental health and health‐care professionals that will deliver them. Changes to the recently modified standards for designating ESTs are proposed that will facilitate adoption of a population health model of treatment development and testing, designed to promote rapid dissemination of empirically supported interventions that are a “good fit” for integrated settings. Defining characteristics of the “new look” for ESTs are examined.