Linda Berg-Cross, PhD, Denee Thomas Mwendwa, PhD, Stacey L. Crump, MS, and Richard Griffith, MS
There are many definitions emerging to define a primary care psychologist. McDaniel, Hargrove, Belar, Schroeder, & Freeman (2003) succinctly and aptly state “a psychologist who works in primary care is a general practitioner of common health problems experienced by patients and families throughout the lifespan” (p.66). Training for primary care practice is happening at all career levels.
Seasoned practitioners take fellowships, self-study, and continuing education to retool for this new professional opportunity. There are postdoctoral settings now devoted to primary care practice, including the University of Mississippi Family Medical Center and the Bethesda Family Practice Residency Program in Cincinnati (Talen, Fraser, and Cauley, 2002). Many pre-doctoral internships are developing a rotation in primary care, including Wright State University and Yeshiva University (Talen et al., 2002 and Zweig et al., 2005). At the doctoral level, Howard University strives to give interested students a strong academic foundation and appropriate practicum experiences to shape their identity as primary care psychologists.
In the following article we discuss: a) the evolution of our primary care practicum through the 5W exercise, b) the competencies required of a primary care psychologist, and c) the experiences of practicum students at the sites, with an emphasis on the relational dimension, collaboration, and ethical issues.
THE EVOLUTION OF HOWARD’S PRIMARY CARE PRACTICUM
Howard University’s clinical psychology program, with support from the Department of Health and Human Services HRSA grant #4D40HP00004-04-02, developed a doctoral behavioral health practicum located in an ambulatory primary health care facility. The People’s Community Wellness Center (TPCWC), in conjunction with The People’s Community Baptist Church and the Montgomery County government, founded an ambulatory healthcare facility to provide low-income uninsured residents with primary health care service. The center utilizes a multidisciplinary approach to provide medical prevention and treatment services to underserved populations in efforts to address the growing health care disparities within the county. Howard University students are integrated into this system of care to deliver critical psychological and behavioral health services to patients presenting a multitude of health-related problems. The behavioral interventions vary from lifestyle modifications to cognitive behavioral therapy to helping individuals’ access job searches on the Internet. Consultations range from treating stress-related medical problems, such as hypertension and gastrointestinal disorders, to medication adherence or apprehension about treatment regimens.
Howard’s program is not the only doctoral program training graduate students to work in primary care settings. Howard has chosen to focus on the management of chronic illness, medication adherence, and previously undiagnosed mental health problems.
When developing a primary care psychology model for our graduate students, we had to answer the five basic questions: who, what, where, why and when.
WHY DO WE WANT TO TRAIN STUDENTS TO WORK IN A PRIMARY CARE SETTING?
Behavioral health services are desperately needed in primary care settings. After all, 60% of primary care visits involve some behavioral health need (Cummings, Cummings and Johnson, 1997). Chronic illnesses constitute the overwhelming number of cases seen in primary care. Proper management of chronic care involves mobilizing patients to change their life styles, maintain positive social networks, and learn effective coping skills (e.g. to deal with pain, disability, and loss). Primary care settings allow psychology students to intervene in patient-physician and patient-family relationships, which are critical to the overall care of patients. Talen and colleagues (2002) note the importance of practica trainees acquiring the skills to identify relationship dynamics and the impact of these relationships on treatment outcomes. Doctoral students assist other practitioners with patient treatment adherence. Psychosocial factors often contribute to patients’ reluctance to adhere to a treatment regimen. Practicum trainees offer recommendations to physicians and patients to ensure better treatment compliance. In addition, doctoral students use psychological interventions to help minimize the negative impact of the illness and prevent co-morbid conditions from developing, such as depression and anxiety.
Indeed, depression and anxiety are the most common unrecognized and untreated mental health conditions seen by primary care practitioners. Studies in primary care settings indicate many patients who meet the criteria for affective or anxiety disorders are never identified and/or treated (Beck, 2001; Coyne, Thompson, Klinkman, and Nease, 2002). When considering anxiety and other psychological disorders, the percentage of undiagnosed and untreated patients in a given year is nearly 28 percent according to epidemiological research studies (Narrow, Reiger, Rae, Manderscheid, Locke, & Goodwin et al., 1993).
In cases where primary care physicians correctly diagnose their patients with psychiatric conditions, many are unaware of the most effective psychological interventions or do not have the time or expertise to deliver such interventions. Therefore, psychologists situated in primary care settings help fill this treatment gap. APA (1998) has strongly endorsed the training of psychologists for primary care noting, “Given the nature of problems presented in primary care, psychologists need to be an essential part of that inter-professional primary healthcare team (APA, 1998, p 5)”.
WHO DO WE WANT TO SERVE IN PRIMARY CARE SETTINGS?
Howard’s program is dedicated to training psychology health care service providers committed to treating African Americans and other racial and ethnic groups who historically have been denied equal access to quality health care. They are less likely to receive proper diagnoses and effective treatment for mental disorders as compared to Caucasian Americans (Satcher, 1999). This can be attributed to a myriad of factors. First, there is an under-representation of ethnic minority psychologists as practitioners. For example, only 2% of psychologists are African American (Holzer, Goldsmith, & Ciarlo, 1998), although African Americans constitute 12% of the US population (U.S. Census Bureau, 2002). Second, a lack of multi-cultural training has interfered with psychologists’ ability to form successful therapeutic relationships and working alliances with ethnic minority clients. This has led to the development of cultural biases by clinicians and contributed to ethnic minority clients being misdiagnosed and receiving inadequate treatment (Delbello, 2002). Finally, cultural mistrust and concerns about stigma has often interfered with ethnic minorities seeking and participating in mental health treatment (Satcher, 1999).
Ethnic minorities are more likely to suffer from health disparities (DHHS, 2000; CDC, 2002). Disparities exist for each of the top ten risk factors derived by Healthy Peoples’ 2010 nationwide disease prevention and health promotion initiative (DHHS, 2000). The leading health indicators are physical inactivity, overweight and obesity, tobacco use, substance abuse, responsible sexual behavior, mental illness, injury and violence, poor environmental quality, lack of immunizations, and inability to access health care.
Therefore, we needed to form an alliance with a non-profit medical clinic that provided ambulatory services to the uninsured. By doing so, we hoped we would have a greater chance of capturing ethnic minorities in need of behavioral health services, who otherwise may have been reluctant to receive mental health treatment in more traditional settings.
WHAT MODELS EXIST FOR TRAINING IN PRIMARY CARE SETTINGS? AND WHAT COMPETENCIES DO WE WANT TRAINEES TO LEARN?
There are currently three major models for how to integrate behavioral health care into primary care settings: the co-location model; the integrated care model, and the consultant model. The co-location model involves a psychologist sharing the physical space with a primary care clinic and perhaps sharing the receptionist and billing personnel. The proximity leads to increased opportunity for referrals and easy communication about how to help particular clients. Psychologists in this capacity provide more traditional mental health services and function as separate entities within the same space (Garcia-Shelton, L., 2006; O’Donohue, Byrd, Cummings, & Henderson, 2005). This model of care is not conducive to a practicum setting since opportunities for students to interact with the other clinic professionals would be severely limited due to the pace of office practices in today’s world.
In the integrated care model, the psychologist is part of the treatment team and may see the patient with the doctor or facilitate family sessions or patient groups. The integrated care model might be a very attractive model for practicum placements, since one of the limitations of this model is that with so many professionals in the room, only the PCP gets to bill for their time. Usually, the integrated care model has salaried psychologists that function like the receptionist and nurse, helping the doctor deliver services effectively and efficiently. This model would work best at large clinics with multiple primary care physicians so that there would be enough appropriate cases to offer the integrated care recommended at the times the students were on site.
The consultant model involves having the psychologist conduct evaluations of patients with the goal of informing the physician of the patient’s mental health status and lifestyle issues. This model of primary care psychology evolved from psychologists’ involvement with patients seeking medical treatment in the U.S. military and Veteran’s Administration Hospitals (Garcia-Shelton, 2006). Referred to as the behavioral health consultant, psychologists incorporate clinical techniques into patients’ medical treatment without use of traditional long-term psychological interventions (Rowan & Runyan, 2005). Psychologists support primary care providers with decisions about effective treatments, create brief psychological interventions, educate practitioners on mental health issues, and work collaboratively with patients to educate them about self management skills. Sessions are most often shorter than the traditional 50 minutes (more often like 20 minutes) and co-occur at the time of the appointment with the PCP. Here, the psychologist offers brief interventions and typically will see a client 1-6 times.
The Howard University model is a hybrid of the co-location model and consultation model. We refer to it as a consultation and liaison model. This model adequately describes how our students work collaboratively with medical personnel at TPCWC to address patients’ health care needs in nontraditional as well as traditional ways. For instance, students see patients on a regular basis for 50-minute sessions. In addition, they consult with healthcare practitioners to provide clinical insights into the biopsychosocial variables that affect the treatment of patients with chronic illnesses. Less experienced doctoral students follow the co-location model. They sharpen their skills, concentrating on diagnosis and treatment, medical consults, and crisis intervention. They hone in on more behavioral health skills that tackle the prevention and treatment of chronic illnesses while collaborating with medical professionals and patients. More advanced students focus on the consultation portion, where there is a shift toward a “hybrid of the psychotherapy hour and the 15-min weekly medical office visit” (Talen et al., 2005, p. 140).
WHERE SHOULD STUDENTS INTERESTED IN A PRIMARY CARE PLACEMENT BE PLACED?
We originally contacted the Primary Care Coalition, an umbrella organization that co-ordinates all not for profit primary care clinics in the county. With their help, we identified The People’s Community Wellness Center as having a population in need. Geographically, the center was accessible to major highways and within a 30-minute drive from campus. Most importantly, they had evening hours. This allowed us the greatest flexibility in placing appropriate students, since we didn’t have to worry about class conflicts. The TPCWC had only been open for two years and was still in its infancy. It was open to having psychology students.
Our HRSA training grant was critical in making this site viable. We were only able to place students here because we had the training funds available to hire external supervisors who were seasoned healthcare psychologists. While on site, the administrative supervisor for the students was the Director of the Clinic, their patient care supervisor was the nurse practitioner on site and their psychopharmacology supervisor was a psychiatrist. This actually fostered more inter-disciplinary contact than if the supervising psychologist had been on site, since the students eagerly sought out team supervisors, and team supervisors were both protective and nurturing towards the students. As we enter the third year of operation, medical practitioners are now eagerly seeking out the students for their help and input. We have created a strong collaborative team.
However, the most essential feature for our success with TPCWC is that the Director is an innovative, enthusiastic advocate of interdisciplinary care willing to allow the collaboration to grow by consistently including students in all aspects of the clinic operation (from greeting patients in the waiting room, to helping out during health screenings, to being introduced by the nurse practitioner during an examination). Individuals or programs seeking should look to the top management to see if they are ready for the inclusion of behavioral health services and willing to experiment with different models to see what works best with the particular patient population being served at that clinic.
WHEN SHOULD STUDENTS BE INTRODUCED TO PRIMARY CARE SETTINGS?
Our original plan was to place only master’s level students at TPCWC. We looked for students who would be able to culturally relate to the wide range of patients seen at the clinic. We chose well. Our first students are still working at the clinic. However, this year, we placed a second year student at the site with the more experienced students serving as mentors. By using a classic laddered training model described by Dobmeyer, Rowan, Etherage, & Wilson (2003), the second year student has a traditional case load but shadows the more experienced student until sufficient modeling has occurred and the younger trainee feels confident to act as a consultant. At that point, the external supervisor feels confident the student has gained the competencies to be effective.
COMPETENCIES, SKILLS, AND PROBLEMS IN TRAINING
The growing consensus is that there are three sets of knowledge and skills needed to provide effective behavioral health interventions in the primary care setting. These are: a) knowledge of the DSM-IV disorders and the evidence-based treatment practices ; b) health psychology, inluding the bio-psycho-social spiritual factors; and c) effective interdisciplinary functioning. We try to expose students to all three areas. Their general knowledge in psychological treatment is drawn from the core clinical curriculum as well as through their individual supervisor. We require all third-year adult-track students to take a course in health psychology, psychopharmacology, and neuropsychology so they will have the necessary background to function in a primary care setting. The supervisors on site provide the training and supervision in interdisciplinary teamwork. Of course, without an onsite licensed clinical psychologist it is possible that a host of problems could emerge for the students in this area. Yet, we have not had one major problem – to the contrary, the insights and leadership the interdisciplinary professionals offer has been invaluable to the students. Perhaps this harmonious relationship exists because our students are the only students at the clinic. There are no competing nursing students, social work students, or interns to vie for the attention of the professional staff.
Expert supervision is also key to ensuring trainees obtain the skills to be effective in a primary care setting. Supervisors need to have knowledge in community-based systems and understand the inner workings of a multidisciplinary team. They also need to be expert in the prevention strategies and intervention skills used in primary care (Talen et al., 2005). Our psychology supervisors are responsible, in large part, for helping students understand the health system and training them to treat chronic disease problems with their co-morbid psychological disorders. Supervisors also help students resolve ethical issues unique to this setting. The ethical issues that confront the students each day are: a) closely monitoring the scope of practice to insure that they are only engaged in activities appropriate to their training; and b) maintaining confidentiality, as notes in a primary care clinic are routinely open to all staff and the psychologist usually has information about the client unknown to the primary care physician.
Dobmeyer and colleagues (2003) report a series of common problems trainees experienced at their pre-doctoral primary care internship at Malcolm Grow Medical Center at Andrews Air Force Base. Our students have had many of these problems and we are planning on incorporating this problem list into our evaluation and supervision process. The most common problems relevant to our site, as discussed by Dobmeyer et al (2003) included:
- Time management
- Attempts to do traditional psychological interventions instead of requested consultative activities
- Over-reliance on relationship building strategies
- Lack of individualized assessments and interventions
- Complex recommendations
- Premature or rushed recommendations
- Inappropriate level of care determinations; referring unnecessarily for more intensive mental health interventions
- Over-documentation of patient information
- Lengthy verbal feedback to primary care physician
- Hesitantancy to recommend modification in primary care physicians’ behavior
EXPERIENCES OF GRADUATE TRAINEES AT TPCWC
As clinical psychology externs, we provide individual psychotherapy to low income, racial and ethnic minority patients who do not have traditional access to health care. This is a great learning opportunity due to the broad exposure externs have with clients from diverse national, cultural, and ethnic backgrounds. Through this multicultural experience, externs examine how culture affects health and chronic illness. In addition, these experiences consistently highlight the cultural distrust of ethnic minorities, struggling with various illnesses, as well as, the challenges involved with dismantling them.
As members of the treatment team, we address a host of behavioral health problems (e.g., medication compliance, hypertension and diabetes management) that interfere with patients’ primary care. Our role is important in (1) providing consultations on coping with medical conditions, (2) improving psycho-education to support preventive health behaviors, and (3) providing differential diagnosis for patients presenting with medical symptoms of unknown etiology. This is beneficial to the medical staff, freeing their time to focus on the diagnosis and treatment of medical symptomatology, while the externs focus on the psychosocial aspects relates to patients’ medical conditions.
The following case studies illustrate what have become typical cultural-sensitive interventions that occur on a weekly basis.
CASE STUDY #1
A 40-year old Middle Eastern woman was referred for depression surrounding a work-related injury that left her unemployed. As a result of the injury, the client suffered from excruciating physical pain and had been placed on temporary disability. Her pain interfered with her daily routine, where the execution of small tasks required considerable effort. A variety of health specialists had seen her and provided her with various treatments (e.g., nerve blockers, cortisone injections, physical therapy). Yet, these methods along with prescription medications proved to be ineffective, and some had even exacerbated her pain.
The therapy goal was more effective pain management. During the first meeting, she was taught deep breathing techniques to help her cope with anxiety. In the follow-up session, the client was given a daily pain management chart to (1) identify the level of pain she experienced throughout the day, (2) determine whether her pain changed with any activities, (3) monitor the effects of pain relief strategies, and (4) identify any negative thoughts associated with pain. After working with the client for four sessions, the client was able to accept her current diagnosis of chronic pain, understand the mind’s role in the body’s expression of pain, become an active participant in her care, and identify triggers and pain relief methods that exacerbated or provided relief from her pain. The team members were all aware of the interventions and supported her self help strategies. The patient became an active participant in her care, reported much less distress, and had greatly increased self-esteem because she “knew what it was all about.”
A 40-year-old North African, Muslim man was referred for symptoms of depression. The patient’s physical condition was alarming because of his 6’6 frame and low body weight. The patient’s physical health was suffering and he had no strength in his legs. He also had difficulty sleeping at night. Having no health insurance, the patient could not afford his anti-depressant medication. In addition, because of his deteriorated physical condition, he was only able to work two days a week. This was problematic for him as he viewed his unemployment as a sign of failure and weakness.
Following a thorough assessment with a multidisciplinary treatment team, we determined that his presenting symptoms were biologically-based but were complicated by psychosocial factors. His reluctance to disclose to his medical team was deeply entwined with his cultural beliefs about manhood and his notion of what it means to be successful in this country. The psychology extern consulted with the team about the patient’s ambivalence about treatment and discussed ways the staff could help reframe the meanings associated with medical care and social services. The team reframed masculine competency as being an active advocate and co-coordinator of one’s own care. They stressed that strength and independence were needed to work collaboratively with the medical staff. Another goal of therapy was to improve the patient’s interpersonal skills. Traditional interpersonal therapy was partnered with staff encouragement towards developing healthy social relationships in his community. This opened up new employment opportunities and new avenues of social support that has directly supported the patient’s improved health status.
A FINAL NOTE
In closing, please note that psychologists are not the only specialty pushing for collaborative care. All of the helping professions realize that primary health care needs to be a basic basket of services. There are even training program for family practice residents to learn how to do collaborative care with psychologists (Blount, De-Girolamo, & Mariani, 2006). The Worcester Family Medicine Residency Program involves team supervision (where the team observes the physician behind a one way mirror). The biological, psychological and social insights can be integrated after the interview. They also have a dual interview rotation requirement where a fellow in primary care psychology works in the exam room with a family practice physician.
Examples are increasing and will need to, if the multifaceted health problems faced by a diverse society is to be addressed systematically, successfully and economically.
Linda Berg-Cross received her PhD from Teachers College/Columbia University and is a Professor of Psychology at Howard University. Dr. Berg-Cross is a member of the National Register Board of Directors.
Denée T. Mwendwa, PhD, is an Assistant Professor in Clinical Psychology at Howard University.
Her research interests are in the area of hypertension and treatment adherence in minority populations. Dr. Mwendwa currently works with Howard graduate students and the staff at TPCWC to provide behavioral health services to diverse underserved populations.
Stacey Crump, M. S., is a doctoral candidate in clinical psychology at Howard University. Ms. Crump currently serves as an extern at TPCWC and provides counseling. Her research interests include the psychosocial aspects of health and illness, as well as mental health/health policy and program implementation.
Richard L. Griffith, M. S., is a doctoral candidate in clinical psychology at Howard University. Mr. Griffith currently serves as an clinical psychology fellow at Friendship Public Charter Schools and conducts assessments and therapy to students at the school. His research interests include the psychophysiological aspects of depression on cardiovascular functioning. More specifically, he is interested in the relationship between an individual's style of appraisal, and subsequent cardiovascular regulation.
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