Behavioral Health

Integrating Individual and Family Interventions in the Treatment of Medical Conditions

Len Sperry

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136192975
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

In this age of accountability, and irrespective of whether they work in health-care settings or conventional mental health settings, all therapists will be increasingly expected to provide effective psychosocial treatment to individuals and families who face co-morbid medical conditions. Statistics these conditions are daunting: 75 percent of adults over age 65 and 50 percent of Americans constantly experience chronic medical symptoms, and prevalence rates of chronic medical conditions that are more than three times higher than mental illness. While it can be helpful to conceptualize treatment in terms of individual dynamics and utilize cognitive behavioral strategies, it can be much more effective to conceptualize family as well as individual dynamics and to utilize systemic interventions when indicated. Effective Treatment of Individuals and Families Facing Medical Conditions addresses the need for these types of interventions. It provides background information on 12 common medical conditions, and includes discussions of family dynamics as well as medical and psychosocial treatments. While recognizing the role of personality, culture, and illness dynamics, it emphasizes the centrality of family dynamics in conceptualizing and implementing interventions.

Part I

Integrated Behavioral Health

Basic Considerations

1

Integrated Behavioral Health

An Overview¹

Traditionally, most health care has been provided in primary care settings by physicians trained in the biomedical model. Not surprisingly, the treatment they provide consists largely of medications, medical procedures, and advice. Since more than half of medical patients have comorbid psychological issues, it is quite common for their psychological issues to exacerbate, complicate, or masquerade as physical symptoms. Sometimes, these patients have been referred for psychological treatment by psychologists and mental health counselors. Occasionally, this psychological help has been effective. Often, however, that treatment has not been effective or patients have refused it. The result was and is overutilization of medical services and rising health care costs. Initiatives like the Affordable Care Act—also called Obamacare—are efforts to reduce cost and increase the effectiveness and efficiency of health and mental health care. Implementing the Affordable Care Act will require a gradual shift from the traditional to a more integrative form of health. In broad designs, psychological or behavioral health interventions would be integrated with medical interventions. This is quite different from from the way in which psychological services or behavioral health is currently “carved out” and separate from medical care. Instead, integrated behavioral health is colocated—provided in the same location as primary care—and collaborative, with the behavioral health provider working as an integral member of the treatment team.

Integrated medical care will require more than just “integrating” mental health or behavioral health clinicians into the existing health care team of physician, nurse practitioner, nurse, physical therapist, and nutritionist. It will require “integrated behavioral health,” meaning that behavioral health clinicians will provide “integrated” services that combine and integrate individual and family dynamics and individual and family or systemic interventions.

This chapter begins with a description of the need and justification for integrated behavioral health services, including the “medical offset effect.” Next, models and their anticipated role in health care settings and the importance of cultural competence in behavioral health care are described. Then, emerging trends in mental health practice are noted. Finally, implications of integrated behavioral health for the practice of individual and family therapy are discussed.

Integrated Behavioral Health: Need, Models, Roles, Culture, and Clinical Trends

Need

The need for behavioral health is important because about 50% of all patients in primary care present with psychological comorbidities, and 60% of psychological or psychiatric disorders are treated in primary care settings (Pirl, Beck, Safren, & Kim, 2001). Furthermore, the need for integrating behavioral health care has been obvious to many for some time. Simply stated, most physicians cannot provide the psychological care needed by the increasing numbers of medical patients. However, it was not until the financial justification for integrating it was made that behavioral health care became a reality. There have been several efforts to integrate behavioral health into medical practice since the 1960s. These include Kaiser Permanente, Health Care Partners, Group Health Cooperative of the Puget Sound, Kaiser Group Health of Minnesota, Duke University Medical Center, and more recently, the Veterans Administration (Cummings, O’Donohue, Hays, & Follette, 2001). All of these efforts have consistently demonstrated significant cost savings, which are referred to as medical cost offset.

A major meta-analysis of 91 studies published between 1967 and 1997 provided evidence for what the researchers called the “medical cost-offset effect.” Behavioral health interventions that included various forms of psychotherapy were provided to medical patients with a history of overutilization as well as to patients being treated only for psychological disorders such as substance abuse. Average savings resulting from implementing psychological interventions were estimated to be about 20% (Chiles, Lambert, & Hatch, 1999). In short, the medical cost offset effect occurs when emotionally distressed medical patients receive appropriate behavioral health treatment. As a result of this treatment they tend to reduce their utilization of all forms of medical care. Even though there is a cost associated with behavioral health treatment, the overall cost savings is considerable.

A second area of medical cost savings is workplace wellness programs. A meta-analysis of the literature on costs and savings associated with such programs found that medical costs fall by about $3.27 for every $1 spent on wellness programs. It also found that costs attributed to absenteeism fall by about $2.73 for every $1 spent (Baicker, Cutler, & Song, 2010). Since more than 130 million Americans are in the workforce, wellness programs are increasingly important in containing health care costs. Presumably, mental health and family counselors can have a central role in both medical settings and wellness program settings.

Models

As already noted, most physicians operate from the biomedical model in which they were trained. The biopsychosocial model is an extension of the biomedical model (Sperry, 2006a) that incorporates the psychological and sociocultural dimensions with the biomedical dimension. The biopsychosocial model fosters integrative care and is the operative model in the practice of behavioral health.

Roles

Currently, behavioral health providers are most likely to be trained as psychologists, social workers, mental health counselors, or family counselors. They work side-by-side with the rest of the health care team—physicians, nurses, and other allied health providers—to enhance preventive and clinical care for psychological problems that typically were treated solely by physicians. The role of behavioral health providers is to collaborate with the health care team to develop integrative treatment plans, monitor patient progress, and provide direct behavioral health care to patients.

Cultural Competence

Rapidly changing demographics in the United States will increasingly require that cultural competence be incorporated into the delivery of behavioral health services. Hunter, Goodie, Oordt, and Dobmeyer (2009) propose a patient-centered, culturally competent approach to behavioral health care that is sensitive to the patient’s explanatory model of health and illness, various social and environmental factors affecting treatment adherence, as well as fears and concerns about medication and side effects. With such an approach, behavioral health counselors can effectively assist primary care providers in meeting the medical, psychological, and cultural needs of patients and their families.

Trends in Clinical Practice

The following are some predictions about trends in clinical and psychotherapy practice. First, assuming current reimbursement trends, psychotherapy will be less frequently carried out by psychologists and more often by social workers and mental health counselors. It is predicted that most psychotherapy will occur in integrative medical settings. In contrast, only a small number of clients will pay out-of-pocket to the few therapists who will be able to make a living serving only self-pay clients. Currently only 5 to 7% of patients with insurance benefits will forgo those benefits and pay out-of-pocket for psychotherapy (Cummings & O’Donohue, 2008).

Second, the mode of psychotherapy practice is predicted to change: “Only 25% of the psychotherapy of the future will be individual. Another 25% will be group psychotherapy, while at least 50% will be psychoeducational programs” (Thomas & Cummings, 2000, p. 399). Third, mental health and substance abuse treatment currently constitutes a mere 5% of the health care budget in the United States. In the future, mental health providers will increasingly provide psychologically oriented services to the other 95% because “that’s where the money is” (Cummings & O’Donohue, 2008, p. 83). Presumably, this will occur in integrated primary care settings by behavioral health providers or behavioral care professionals (BCP), the designation coined by Nick Cummings (Cummings & Cummings, 2013). Instead of practicing in a location different from the primary care site, BCPs are able to work more effectively when they are colocated within the primary care site. The rationale for colocation is clear: when the behavioral health provider is off-site about 10% of patients follow through with a physician referral for outpatient mental health treatment. This contrasts with a 90% follow-up rate when the BCP is colocated (Cummings & Cummings, 2013).

Fourth, it is predicted that psychotherapy will become briefer and more focused. Third-party payers will increasingly require that psychotherapy be as brief as possible, and not scheduled simply based on tradition or the convenience of the therapist. Reimbursed treatment will increasingly require that therapy be “medically necessary,” rather than being aimed at problems of living, improving self-esteem, pursuing self-actualization, or other nonspecific goals. This emphasis on treating only specific and at least moderately severe disorders means that psychotherapy in the future will look more medical or clinical than it does today. The 50-minute hour will be replaced by the 15-minute hour wherein the therapist will diagnose patients and begin treatment in 15 minutes, just as physicians do (Cummings & O’Donohue, 2008).

Fifth, in addition to becoming briefer, it is predicted that psychotherapy will become more standardized, with sessions being spaced further apart rather than occurring weekly. Psychotherapy and other behavioral health services will be provided on an as needed basis, rather than on a continuing basis as is currently the case (Cummings et al., 2001). Evidence-based and focused interventions will become the expected standard of practice, in sharp contrast to the way psychotherapy is practiced today (Thomason, 2010). Inevitably, psychotherapy will become a behavioral health intervention rather than a stand-alone profession.

While some of these predictions may seem extreme and far-fetched, mental health and family counselors cannot afford to be complacent, given the economic challenges facing Americans (Thomason, 2010). In the next few years the plausibility of these predictions will become evident as the Affordable Care Act, with its integrative health care vision, is further implemented.

Clinical Implications of Integrated Behavioral Health

The emerging integrated health care philosophy is that integrated behavioral health care will utilize behavioral interventions for a wide range of health and mental health concerns. The primary focus will be on resolving problems within the primary care setting, as well as on engaging in health promotion and compliance enhancement for “at risk” patients. The goal of health care integration is to position the behavioral health counselor to support the physician or other primary care provider and bring more specialized knowledge to problems that require additional help.

Accordingly, the behavioral health counselor’s role will be to identify the problem, target treatment, and manage medical patients with psychological problems using a behavioral approach. They will help patients to replace maladaptive behaviors with more adaptive ones. In addition, they will use psychoeducation and client education strategies to provide skill training.

More specifically, the behavioral health counselor will be expected to provide expertise in dealing with undermotivated, noncompliant, or otherwise resistant patients. They will utilize motivational interviewing with individual patients (Rollnick, Miller, & Butler, 2008) and with patients’ families (Sperry, 2012) to increase readiness for change. They will also utilize focused cognitive behavioral strategies to increase compliance with treatment regimens, reduce symptoms, and increase their acceptance of chronic and life-threatening illnesses (Sperry, 2006a; Sperry, 2009).

Increasing Readiness for Change and Treatment Compliance with Family Interventions

Failure to follow treatment regimens or advice is called treatment non-compliance or nonadherence. It is a significant problem. Research indicates that 40 to 50% of patients in the United States do not comply with the health care plan for treatment, such as taking medication as directed, while nearly double that number fail to comply with dietary restrictions, exercise, or other health-compromising behaviors (DiMatteo, Giordani, Lepper, & Croghan, 2002). Typically, health educati...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Series Editor’s Foreword
• Foreword
• Preface
• Acknowledgments
• Part I: Integrated Behavioral Health: Basic Considerations
• Part II: Integrated Behavioral Health: Treatment of Common Medical Conditions
• Part III: Integrated Behavioral Health: Competence and Training
• Index