11 Jul 2017

Nancy Sidun Wants Psychology to Help Prevent Human Trafficking

Nancy Sidun Wants Psychology to Help Prevent Human Trafficking
Nancy Sidun
APA Fellow Nancy Sidun's clinical work has covered international relations and women's issues as well as working with the military.

What Nancy Sidun, PsyD, loves about being a psychologist is that she gets to help people attain a better life than they might otherwise have—her patients, her colleagues and the subjects of her research.

"It's hokey but true," Sidun says. As a girl, "I saw that movie, The Miracle Worker, and I was so taken by the fact that Annie Sullivan didn't give up on Helen Keller. I wanted to be like Annie Sullivan. I wanted to spend my life investing in people others thought were disposable. That's the great thing about clinical psychology. Your job is trying to empower people to be the best they can be." 

 In her own career, Sidun has followed that goal into some tough areas. In 2014, she co-chaired the APA's Task Force on Trafficking of Women and Girls after chairing a similar investigation for Division 52. "They were the ones who gave me voice" for pursuing the issue, Sidun says of the  APA’s Division of International Psychology, but "it became clear that we needed the support of the full APA" to effect any real change. She first got involved with the issue a decade ago, in part because she had adopted a daughter from China. "My God, what if her life had taken a different path?" Sidun says.

She's excited about the influence organized psychology may eventually bring to bear on human trafficking, which the task force report defines as the "economic exploitation of an individual through force, fraud or coercion."

The International Labor Organization has estimated that 12.3 million people worldwide are now living in some kind of forced servitude. Far and away, most victims are women. While many are forced into agricultural work and urban industries like sweat shops, nail salons and domestic service, the overwhelming majority are exploited sexually. In the United States, when women are trafficked for sex, the coercion is most likely psychological, a "grooming" process whereby a woman is lured into a seemingly caring relationship with a man who will put her to work for his benefit in the commercial sex trade, Sidun says.

"Psychology can do so much to help, but we're very late to the table. Every other discipline has been attending to trafficking," Sidun says.

Psychologists can help prevent trafficking by backing empowerment programs for vulnerable women, working to change the public's perceptions about the commercial sex trade to reduce demand, championing the rights of victimized women and identifying at-risk individuals in schools and other settings. Psychologists can also develop effective therapeutic interventions that will address the "extensive and complex" needs of women for whom the very concept of trust has been shredded, and evaluate governmental and nonprofit programs that have been set up to intervene.

One of the most important roles for psychologists is to educate the public and officials in the criminal justice system. People need to know how to recognize trafficking when they see it, and how to follow up with appropriate action that will lead to freeing the women and prosecuting the traffickers. When coercion is psychological, it's not always easy to understand the dynamic without some familiarity with research that has been done on the topic, which psychologists can make available and digestible. They can also testify in court.

U.S. citizens are among both the victims and the perpetrators in the trade, and American Indian women are the most disproportionately trafficked of any U.S. group, Sidun says.

Research on trafficking can be "challenging" to conduct, as there is "no typical case," according to the task force report. What traffickers have in common is their utter willingness to exploit the vulnerable. Any instability creates an opportunity for them, notably poverty, natural disasters and political conflict. Orphans are at particular risk. Only about 6 percent of individuals trafficked into the commercial sex trade in the United States are male.

Sidun says trafficking "runs the gamut from mom and pop operations to organized crime," from sophisticated international enterprises to teenaged boys pimping out their girlfriends. One study that looked at 25 pimps in Chicago found that they often have been "born and raised in an environment where people were exploited. Trafficking is safer and more lucrative than the drug trade, and [pimps] are less likely to get arrested. They often think of themselves as the good guys, protecting the girls. It's quite disturbing," Sidun says.

A New Jersey native, Sidun spent most of her adult life in Chicago, but 17 years ago moved to Hawaii. In Chicago, Sidun taught at a number of colleges, but Hawaii didn't offer the same opportunities. She worked for several years in administration and direct service with Kaiser Permanente, and then went into "telehealth." In a state with a large military presence, Sidun now treats "100 percent" of her clients remotely, via secure clinical video-teleconferencing (VTC) systems. "Most of my clients are in Korea," others are in Japan, Guam, American Samoa, Alaska, and the far-flung islands of Hawaii. Virtually all are military dependents or personnel on active duty she treats through the Pacific Regional Tele-Behavioral Health Hub at Tripler Army Medical Center in Honolulu, Sidun says.     

"For the younger generation, it's the normal way of communicating," she says. "And some of the service members are not as comfortable with emotions, so they don't mind being in an office by themselves during a session. In some ways, for them, that [remote aspect] can enhance treatments. I don't get to read the full body language, but I really like working this way."

She finds the "military culture fascinating. You have to be aware of the culture to be effective [with military clients], and I've enjoyed getting to know about that. I'll say one thing: If I give my military clients homework, it's going to get done!" she says.

In the past, some active-duty personnel may have been concerned their careers might stall if they sought help for such work-related conditions as post-traumatic stress disorder (PTSD), but Sidun thinks that now, "the military is trying to change that mindset. There are good treatments for PTSD," including prolonged exposure, cognitive processing therapy, and eye movement desensitization and reprocessing (EMDR). "They can help people," she says, adding that military officials definitely are beginning to recognize and encourage active-duty personnel to get the help they need.

Sidun is a past president of the Hawaii Psychological Association. She thinks activity in associations is "critical in protecting psychologists' interests. We watch bills in the legislature very closely, and advocate if we think we need to," she says.

Sidun also trains psychologists in self-care, and she's returning to using her early training in art therapy in this sideline. "We psychologists are bad at self-care," she says. "We take care of our patients, not so much of ourselves."

You could say Sidun is pursuing the role that led her into psychology, that of the dauntless teacher.

"I love supervision. I love training. It's my favorite thing," she says. "I think I'm a good clinician, but I have an opportunity to touch more people if I'm teaching."     

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27 Jun 2017

Coaching Adults, Students and Young Kids with ADHD

Coaching helps clients cope with attention-deficit/hyperactivity disorder while helping psychologists flourish without relying on insurers

Children, adolescents and adults with attention-deficit/hyperactivity disorder (ADHD) don't necessarily need psychotherapy, says psychologist Abigail Levrini, PhD. What they often do need is help getting themselves organized and reaching their goals—coaching, in short.

To fill that niche, Levrini founded an ADHD coaching business called Psych Ed Connections in 2008. Demand for her services has been so great that the company now has three offices in two states. And what's good for consumers with ADHD has also been good for Levrini by allowing her to fulfill her dream of building a practice independent of insurance companies.

"I had heard many unfortunate horror stories about psychologists not getting reimbursed for the clients they had seen and worked with," says Levrini. "Fortunately, I have never had to go that route and have been able to make it without it."

Whether ADHD coaching is a full-time business or just a small supplemental income stream, it's a real growth area, says Frances Prevatt, PhD, the Florida State University psychology professor who developed the evidence-based ADHD coaching intervention that forms the basis of former student Levrini's coaching practice. "More and more people are being diagnosed," says Prevatt. "And there aren't that many people who specialize in treating those with ADHD."

A specialized business

Prevatt developed the coaching intervention 14 years ago when she realized she had no place to send students she was diagnosing with ADHD as director of Florida State's Adult Learning and Evaluation Center. "Other than recommending medication and accommodations, we didn't really have anything good to offer them," says Prevatt.

Grounded in cognitive-­behavioral therapy principles, the intervention she developed is an eight-week program that matches clients with doctoral psychology students who serve as coaches as a practicum experience. Working one-on-one, the coaches and their clients identify two or three goals to tackle, such as improving time-­management strategies, managing long-term projects, passing a specific class or even learning to do laundry. Each week, the pair identifies intermediate steps and brainstorms how to overcome obstacles, with rewards and consequences built in to boost motivation. "We're not telling them what to do," says Prevatt. "We're teaching them the problem-solving process."

Levrini was one of Prevatt's coaches at Florida State and studied the intervention for her dissertation. Once she graduated and launched her own practice, she took that model, tweaked it and established it in Ponte Vedra, Florida; Alexandria, Virginia; and Ashburn, Virginia. One key difference is that the coaches are all licensed psychologists and other mental health professionals. Because the Florida office is located in an underserved area, it offers services beyond coaching, but coaching represents at least half its business.

Educating children and adults about the difference between coaching and therapy is a crucial first step, says Levrini, who often compares being an ADHD coach to being an athletic coach for kids. "You'd never expect to be able to just put on a uniform and go out onto a sports field and play effectively on your own, so why should people with ADHD expect that they should just be able to figure out ways to stay organized or manage their lives effectively without help?" she says. "A coach can help you learn the rules of the game, see where your strengths and weaknesses are and help you 'play' more effectively, in sports or in life."

Coaches and clients then meet each week to outline "baby step" actions and track progress on two to four overall goals. These goals must be specific, measurable, action-driven, realistic and time-sensitive, says Levrini. They should also focus on the process of achieving them as well as the outcomes, she adds. "A student with ADHD might procrastinate, stay up until 3 in the morning to work on a project and still get a good grade," she points out. "But doing so generates a lot of stress and anxiety in the process, so it's important not to encourage positive outcomes that are not a result of healthy processes." As in the Florida State program, Levrini's coaches also use external rewards and consequences to help clients who need an extra dose of motivation.

Another twist on the original program is that coaches and clients don't necessarily meet face to face, thanks to Psych Ed Connections's online coaching option. That expands the potential client base to include the entire country or even the whole world, says Levrini.

A helpful sideline

For psychologist Peter C. Thomas, PhD, of Atlanta, a small ADHD coaching sideline represents a way to help his clients while bringing in a little extra income.

In his practice, Thomas focuses on evaluating children for ADHD and learning disabilities and providing psychotherapy to children, adolescents and families. About 20 years ago, he realized his clients needed something more: ADHD coaching.

What people with ADHD need most is help structuring their time, says Thomas. "Having someone to check in with helps them stay focused on what they want to accomplish," he says, adding that his clients tend to be disorganized college students and adults. "Coaching can help them learn to develop the habits that they're having trouble developing on their own."

To get the training he needed to launch his coaching business, Thomas attended a three-day workshop conducted by child psychiatrist and ADHD expert Edward Hallowell, MD, EdD, founder of the Hallowell Centers, which offer ADHD treatment in Boston MetroWest, New York, San Francisco and Seattle. Conducted by Hallowell and other coaches, the workshop focused on the intervention as well as the business aspects of coaching.

As a result of that training, Thomas developed a simple coaching intervention he dubbed FOCUS (From Organized Coaching Ultimate Success). The process begins with coaches interviewing new clients—who come to the service via referrals from other psychologists, psychiatrists, word of mouth and Thomas's own practice—about their problems and goals.

Clients then call their coaches each morning during the work week to discuss the three main goals they want to accomplish that day. Together clients and their coaches discuss how to accomplish those goals and make a plan. The process takes from five to 10 minutes. Clients renew their contracts and prepay with credit cards every two weeks as long as they need, which may be several months or even years. As clients internalize these problem-­solving skills, the calls taper off. To help keep the service affordable, Thomas doesn't provide coaching himself. Instead, he trains psychology graduate students to offer coaching services and monitors their work on an ongoing basis. He then splits the proceeds from the coaching with his coaches.

"It's not a big money maker, but it's slow and steady," says Thomas, who estimates that ADHD coaching represents 1 percent of his income. "It brings a little extra into the revenue stream."

Additional reading

ADHD Coaching: A Guide for Mental Health Professionals
Prevatt, F., & Levrini, A. APA, 2015

ADHD Coaching With College Students: Exploring the Processes Involved in Motivation and Goal Completion
Prevatt, F., et al. Journal of College Student Psychotherapy, 2017

By Rebecca A. Clay


 This article was originally published in the March 2017 Monitor on Psychology

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27 Jun 2017

Work-life Balance Still a Struggle for Most Psychologists

Work-life Balance Still a Struggle for Most Psychologists

When Pamela Hays, PhD, began her psychology career, she tried to do it all: clinical work, writing, research and teaching. But she couldn't sustain it. After a decade of going full tilt, she developed neck problems and carpal tunnel syndrome so severe she had to start using a voice-activated computer system.

"I was driven," she says. "But I drove myself into health problems I couldn't ignore anymore."

Hays, now a clinical psychologist practicing in Soldotna, Alaska, might be an extreme case. Or maybe not. Work-life balance is something that many psychologists struggle with.

The unfortunate irony is that psychologists know better than anyone the importance of making time for self-care. "We talk about it a lot with patients, but we don't practice what we preach," says Chelsi Day, PsyD, a behavioral health provider at Windrose Health Network in Indianapolis.

Psychologists might even have a false sense of invulnerability, says John F. Christensen, PhD, a psychologist in Corbett, Oregon, and past co-chair of the APA Advisory Committee on Colleague Assistance (ACCA). "We study burnout and think that applies to the people we're trying to help," he says. "In fact, health is on a continuum, with well-being at one end and burnout at the other. And most of us, during a professional career, slide back and forth on that continuum depending on what's going on in our lives."

Finding balance, however, is easier said than done. "The sin of the early 21st century is being nonproductive," Christensen says. "We're conditioned by our culture to equate value with productivity."

Of course, as psychologists well know, no one is as productive as they can be when they are exhausted and overworked. Burnout is a legitimate phenomenon, marked by feelings of emotional exhaustion, depersonalization and a diminished sense of accomplishment. "When we move into burnout, we get impatient, we treat others as objects, and we start treating ourselves as task-processing machines," Christensen says. "Our empathy tank has run dry."

For psychologists in clinical practice, neglecting well-being can even impair professional competence, making the matter an ethical concern. As Erica H. Wise, PhD, a psychologist at the University of North Carolina at Chapel Hill and current co-chair of the ACCA, argues in a recent article, it's much harder to stay competent when you're burned out. "Competence … is an essential ethical obligation and provides a critical link between ethics and self-care," Wise and her colleagues conclude (Professional Psychology: Research and Practice, 2012).

Practical balance

Unfortunately, there's no one-size-fits-all strategy for achieving personal-professional equilibrium. Stressors and obligations are different for everyone, and they also change over the course of an individual's life. "It is important for psychologists to stay attuned to these issues throughout their professional life span, since personal and work-related stressors tend to shift over time," Wise says. "Work-life balance isn't a once-and-done thing."

Some people start by establishing a career with some balance built in. Day, a sport psychologist, recently decided not to pursue an opportunity that she described as a dream job — building a counseling and sport psychology center at a Big 10 school. Although the opportunity thrilled her, after she factored in the long commute, the fact that she'd be on call 24 hours a day and her desire for personal and family time, the job didn't sound quite so dreamy. "Work-life balance is important to me," she says. "I don't want to burn out in 10 years."

After working herself into physical health problems, Hays left academia and moved back to her home state of Alaska to start a clinical practice. She joined a yoga class and a book group, started spending more time with family, and wrote the 2014 book "Creating Well-Being: Four Steps to a Happier, Healthier Life."

But finding balance doesn't necessarily mean you have to change jobs (or move to Alaska). You can start by taking a critical look at your commitments.

Wise recommends doing either formal or informal self-care assessments, which can remind you of your goals and help you figure out which daily activities energize you — and which feel like a slog. "From that, you have critical information that you can factor into your choices about your personal and professional activities," she says.

Jim Davies, PhD, a faculty member at Carleton University in Ottawa, says that for him and many of his colleagues, a lot of work commitments are self-imposed. "They are projects we are passionate about and take on whether we have the time to commit to them or not," he says. "We're too busy because we're overcommitted, not because our jobs are too onerous."

Davies uses a rigid strategy to balance personal and professional time. Every morning, he fills in a detailed spreadsheet with activities for each half hour of his waking day. "Crucially, I also schedule in my breaks," he says — including lunch, coffee breaks and even daily naps. "For me, prioritizing life means putting it in the schedule like all the other important things."

Still, for many people, time management isn't really the problem, says Sandra Lewis, PsyD, a clinical psychologist at Montclair State University in New Jersey and founder of The Living Source, a company that helps clients improve well-being and achieve their goals. "People focus a lot on time management, but I think in terms of personal energy management. If you have enough energy, you make better use of your time," Lewis says. "In the same way we charge our cellphones, we need to charge ourselves."

Yet when we're overextended, even activities that energize us can feel like one more item on an endless to-do list. So Wise suggests taking advantage of smaller moments. You might not have an hour to go to the gym, but you could take a 10-minute lunchtime walk. If you can't fit in a yoga class, take five minutes between appointments to breathe or stretch or meditate. "Find self-care strategies that you can integrate in rather than add on," she says. "Honor the smaller things."

While such strategies are helpful, more needs to be done to change the culture of workplaces from the top down, says Christensen. Too many organizations value busyness and productivity at the expense of their employees' well-being, he says. "Often in this kind of professional workplace, when you're working with other smart, committed people, the way to excel is to overwork."

Christensen has been collaborating with health-care systems in Oregon to measure well-being among clinicians, including physicians and psychologists. He's optimistic that many such organizations are starting to realize that helping employees avoid burnout is not only good for employees, but also for patients and the financial bottom line. That kind of sea change is crucial for making work-life balance more attainable, he says. "The things we as individuals can do will take us only so far."

Meanwhile, Wise argues that instead of focusing only on reducing stress, the field of psychology should do more to promote and maintain well-being broadly. "We need a more positive vision," she says. "As a profession, whether we practice or do research, whether we're being mentors or treating patients, we need to be aware that keeping ourselves healthy is important."

Further reading

  • Hays, P. H. (2014). Creating well-being: Four steps to a happier, healthier life. Washington, DC: American Psychological Association.
  • Walsh, R. (2011). Lifestyle and mental health. American Psychologist, 66(7), 579–592. DOI: 10.1037/a0021769
  • Wise, E. H., Hersh, M. A., & Gibson, C. M. (2012). Ethics, self-care and well-being for psychologists: Reenvisioning the stress-distress continuum. Professional Psychology: Research and Practice, 43(5), 487–494. DOI: 10.1037/a0029446

By Kirsten Weir


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20 Jun 2017

Care and Legal Help for Patients in Need

Care and Legal Help for Patients in Need

Medical-legal partnerships are bringing lawyers and paralegals to health-care teams to improve the health and well-being of underserved populations

When Jack Tsai, PhD, treats veterans at the VA Connecticut Healthcare System, they often have problems that go beyond the scope of his work as a psychologist. Many have post-traumatic stress disorder or cognitive disabilities and are fighting for disability benefits. Others are embroiled in housing disputes, are facing eviction or have already become homeless.

While psychologists can treat their mental health concerns, these veterans need legal help, too. "A lot of these patients have never had anyone advocate for them in court," says Tsai, who has dual appointments at the VA and the Yale School of Medicine.

Enter the medical-legal partnership, or MLP, a model that embeds lawyers and paralegals into health-care teams to detect, address and prevent social conditions that harm health. Those legal experts typically work on-site in health-care settings, either part time or full time, where they can access patients' medical records and even sit in on clinical meetings. The legal services are offered at no charge to the patient. Programs are typically funded through a combination of philanthropy, law schools and civil legal aid agencies, with a handful of contributions from health-care partners.

Psychologists are obvious candidates for getting involved in MLPs, Tsai says. They already have long-term relationships with their clients and understand how their legal problems might be interfering with their mental health and well-being. Plus, psychologists are often accustomed to working on interdisciplinary teams.

Unlike sending patients to a legal aid clinic, Tsai adds, the process is streamlined when the legal team is located inside the hospital. "We can walk patients down the hall and do a warm handoff," he says.

Helping underserved populations

The current MLP model was developed at the Boston Medical Center in 1993 but didn't begin to catch on until the late 2000s when it was embraced by the American Medical Association and the American Academy of Pediatrics. To date, nearly 300 hospitals and health centers nationwide have developed MLPs, according to the National Center for Medical-Legal Partnership.

Adding a legal expert to the team helps underserved populations in a variety of ways: They can help patients apply for food stamps and disability benefits; press landlords to improve substandard housing; help tenants avoid eviction; advocate for special education services; fight employment discrimination; and assist with issues related to immigration, child custody and domestic violence—just some of the many factors that can undermine a patient's health.

"I can't imagine what things would be like without having the MLP, because they do so much," says Britt Nielsen, PsyD, an associate professor at Case Western Reserve University and clinical psychologist at MetroHealth Medical Center in Cleveland. In 2015, the MetroHealth MLP provided assistance to 839 people. Of those, 43 percent had mental health disorders.

MetroHealth began its MLP program 14 years ago in the pediatrics department, Nielsen says. Though it has since expanded to assist adult patients as well, advocating for kids is still a focus. "We do a lot of advocacy as psychologists, talking to teachers or writing letters to a patient's school," Nielsen says. "But MLPs have a great working knowledge of the law, and the things they're able to do go beyond what I can do in a phone call or a letter."

Often, families in underserved populations don't understand what rights they have when it comes to education, living arrangements or Supplemental Security Income, she adds. In addition to helping families directly with legal issues, she says, the MLP has also made physicians more aware of patients' rights, helping to ensure more patients get the services and support they need.

In some cases, MLPs highlight a bigger need that goes beyond a single patient. Nielsen points to a case where a local school district wasn't providing students with the special education services required by law. "The MLP was able to take the district to court and get restitution for those families," she says.

Need for data

While anecdotal evidence suggests MLPs are valuable, few studies have assessed their effectiveness. The National Center for Medical-Legal Partnership is developing metrics to systematically measure the effects of MLPs on patient well-being and health-care costs. Meanwhile, some smaller studies have found the partnerships provide benefits.

A study by Mary M. O'Sullivan, MD, at St. Luke's-Roosevelt Hospital Center in New York City, and colleagues found asthma patients had reductions in asthma medications and their hospital admissions and emergency room visits declined after an MLP was put into place (Journal of Asthma, 2012). And a pilot study of a Tucson-based MLP by Anne M. Ryan, JD, and colleagues at the University of Arizona found patients' perceived stress levels decreased and overall well-being increased after receiving help from an MLP (Journal of Health Care for the Poor and Underserved, 2012).

Evidence also suggests that MLPs make economic sense. In one example, Kerry J. Rodabaugh, MD, at the University of Nebraska Medical Center, and colleagues studied the benefits of an MLP for cancer patients and their health-care institution. Between April 2004 and December 2007, the program assisted terminal patients with legal issues such as guardianship, estate planning and benefits advocacy. During that period, the MLP helped overturn denials of insurance benefits for 17 patients, preventing economic hardship for patients while recovering $923,188 in reimbursements to the hospital (Journal of Palliative Medicine, 2010).

Tsai and his colleagues recently received a grant from the Bristol-Myers Squibb Foundation to evaluate whether the MLP model improves mental health and quality of life for patients at four VA sites in Connecticut and New York over the next two years. Aside from his study, however, little research has been done focusing on the mental health benefits of such programs, he says.

Those data are sorely needed, says Tsai, especially as many MLPs are struggling to find funding through grants and donations. "There's huge potential for mental health researchers to help these legal clinics collect data and evaluate outcomes," he says. "It's an area ripe for psychologists."

For more information on medical-legal partnerships, visit the National Center for Medical-Legal Partnership http://medical-legalpartnership.org.

To watch a video on how medical-legal partnerships work, go to www.youtube.com/watch?v=NdvE5wbumYw.

When Jack Tsai, PhD, treats veterans at the VA Connecticut Healthcare System, they often have problems that go beyond the scope of his work as a psychologist. Many have post-traumatic stress disorder or cognitive disabilities and are fighting for disability benefits. Others are embroiled in housing disputes, are facing eviction or have already become homeless.

While psychologists can treat their mental health concerns, these veterans need legal help, too. "A lot of these patients have never had anyone advocate for them in court," says Tsai, who has dual appointments at the VA and the Yale School of Medicine.

Enter the medical-legal partnership, or MLP, a model that embeds lawyers and paralegals into health-care teams to detect, address and prevent social conditions that harm health. Those legal experts typically work on-site in health-care settings, either part time or full time, where they can access patients' medical records and even sit in on clinical meetings. The legal services are offered at no charge to the patient. Programs are typically funded through a combination of philanthropy, law schools and civil legal aid agencies, with a handful of contributions from health-care partners.

Psychologists are obvious candidates for getting involved in MLPs, Tsai says. They already have long-term relationships with their clients and understand how their legal problems might be interfering with their mental health and well-being. Plus, psychologists are often accustomed to working on interdisciplinary teams.

Unlike sending patients to a legal aid clinic, Tsai adds, the process is streamlined when the legal team is located inside the hospital. "We can walk patients down the hall and do a warm handoff," he says.

Helping underserved populations

The current MLP model was developed at the Boston Medical Center in 1993 but didn't begin to catch on until the late 2000s when it was embraced by the American Medical Association and the American Academy of Pediatrics. To date, nearly 300 hospitals and health centers nationwide have developed MLPs, according to the National Center for Medical-Legal Partnership.

Adding a legal expert to the team helps underserved populations in a variety of ways: They can help patients apply for food stamps and disability benefits; press landlords to improve substandard housing; help tenants avoid eviction; advocate for special education services; fight employment discrimination; and assist with issues related to immigration, child custody and domestic violence—just some of the many factors that can undermine a patient's health.

"I can't imagine what things would be like without having the MLP, because they do so much," says Britt Nielsen, PsyD, an associate professor at Case Western Reserve University and clinical psychologist at MetroHealth Medical Center in Cleveland. In 2015, the MetroHealth MLP provided assistance to 839 people. Of those, 43 percent had mental health disorders.

MetroHealth began its MLP program 14 years ago in the pediatrics department, Nielsen says. Though it has since expanded to assist adult patients as well, advocating for kids is still a focus. "We do a lot of advocacy as psychologists, talking to teachers or writing letters to a patient's school," Nielsen says. "But MLPs have a great working knowledge of the law, and the things they're able to do go beyond what I can do in a phone call or a letter."

Often, families in underserved populations don't understand what rights they have when it comes to education, living arrangements or Supplemental Security Income, she adds. In addition to helping families directly with legal issues, she says, the MLP has also made physicians more aware of patients' rights, helping to ensure more patients get the services and support they need.

In some cases, MLPs highlight a bigger need that goes beyond a single patient. Nielsen points to a case where a local school district wasn't providing students with the special education services required by law. "The MLP was able to take the district to court and get restitution for those families," she says.

Need for data

While anecdotal evidence suggests MLPs are valuable, few studies have assessed their effectiveness. The National Center for Medical-Legal Partnership is developing metrics to systematically measure the effects of MLPs on patient well-being and health-care costs. Meanwhile, some smaller studies have found the partnerships provide benefits.

A study by Mary M. O'Sullivan, MD, at St. Luke's-Roosevelt Hospital Center in New York City, and colleagues found asthma patients had reductions in asthma medications and their hospital admissions and emergency room visits declined after an MLP was put into place (Journal of Asthma, 2012). And a pilot study of a Tucson-based MLP by Anne M. Ryan, JD, and colleagues at the University of Arizona found patients' perceived stress levels decreased and overall well-being increased after receiving help from an MLP (Journal of Health Care for the Poor and Underserved, 2012).

Evidence also suggests that MLPs make economic sense. In one example, Kerry J. Rodabaugh, MD, at the University of Nebraska Medical Center, and colleagues studied the benefits of an MLP for cancer patients and their health-care institution. Between April 2004 and December 2007, the program assisted terminal patients with legal issues such as guardianship, estate planning and benefits advocacy. During that period, the MLP helped overturn denials of insurance benefits for 17 patients, preventing economic hardship for patients while recovering $923,188 in reimbursements to the hospital (Journal of Palliative Medicine, 2010).

Tsai and his colleagues recently received a grant from the Bristol-Myers Squibb Foundation to evaluate whether the MLP model improves mental health and quality of life for patients at four VA sites in Connecticut and New York over the next two years. Aside from his study, however, little research has been done focusing on the mental health benefits of such programs, he says.

Those data are sorely needed, says Tsai, especially as many MLPs are struggling to find funding through grants and donations. "There's huge potential for mental health researchers to help these legal clinics collect data and evaluate outcomes," he says. "It's an area ripe for psychologists."

For more information on medical-legal partnerships, visit the National Center for Medical-Legal Partnership http://medical-legalpartnership.org.

To watch a video on how medical-legal partnerships work, go to www.youtube.com/watch?v=NdvE5wbumYw.

Additional reading

  • Medical-Legal Partnerships: Transforming Primary Care by Addressing the Legal Needs of Vulnerable Populations, Sandel, M., Hansen, M., Kahn, R., Lawton, E., Paul, E., Parker, V., Morton, S., and Zuckerman, B. Health Affairs, 2010
  • The State of the Medical-Legal Partnership Field: Findings from the 2015 National Center for Medical-Legal Partnership Surveys, Regenstein, M., Sharac, J., and Trott, J.

By Kirsten Weir 


This article was originally published in the November 2016 Monitor on Psychology

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06 Jun 2017

Reimbursing Interns, Increasing Care

Reimbursing Interns, Increasing Care

When Medicaid pays for psychology interns' services, more people get care

It is already hard for many psychology graduate students to find high-quality internships. The fact that training programs in 34 states cannot be reimbursed by Medicaid—the government insurance program for those with low incomes and limited resources—for the work of their highly skilled interns makes it even harder. The result? Less access to care for vulnerable patients who are already among the most underserved in the nation.

At least one North Carolina internship site, for example, has already closed partly because it couldn't get Medicaid reimbursement for the services its interns provided. In states that allow Medicaid reimbursement for interns, internship sites use that money to help finance their internship programs.

"My concern is that as there is more and more pressure on internship programs to support themselves, we could be in danger of losing more," says Sally Cameron, executive director of the North Carolina Psychological Association. Traditionally, she says, clinicians did not have to worry about billing enough services to cover their salaries. But with health-care institutions facing mounting financial pressures, that has changed—in a way that could be bad news for internship programs and Medicaid patients alike.

"Not being able to bill for a qualified service by a highly trained, supervised intern could result in further losses," says Cameron.

The lack of reimbursement for interns is also bad for consumers, because fewer internship slots mean fewer providers and thus gaps in mental health care for people who rely on Medicaid, Cameron points out. The 60 or so North Carolina internship slots at sites that now see Medicaid patients—the state's 20 other internship slots are in the federal prison system, where Medicaid reimbursement is not an issue—may not be allowed to see Medicaid patients because they cannot be reimbursed for their services. There is also a quality of care issue, adds Cameron, noting that the interns who see Medicaid patients are better equipped to serve Medicaid patients well once they become full-fledged psychologists.

The North Carolina Psychological Association is just one of many state, provincial and territorial psychological associations (SPTAs) working alongside APA to push for new legislation or regulatory fixes. "Our goal is full reimbursement for interns' services, without any strings attached," says Cameron. "We want interns to be full partners in providing services under supervision."

What is at stake is access to high-quality psychological services for the more than one in five Americans who rely on Medicaid for their health care. And with the Medicaid expansion in many states as a result of the Affordable Care Act, the demand for psychological services will only grow. "In some places, clients are already waiting weeks or months to be seen," says Eddy Ameen, PhD, who directs APA's Office on Early Career Psychologists.

Meeting a growing need

Because Medicaid is a joint federal/state program, each state runs its own program, within broad parameters set by the federal government. "Programs vary tremendously from state to state," says Shirley Ann Higuchi, JD, associate executive director for legal and regulatory affairs in APA's Practice Directorate. The managed-care companies that run many state Medicaid programs—and provide services to 80 percent of Medicaid beneficiaries—may also have their own reimbursement rules.

Only 16 states currently allow reimbursement for interns in some capacity; Nevada and Texas have rule changes pending that would allow for intern reimbursement. Of those 16 states, some limit intern reimbursement to certain settings or services. In Oregon, for instance, interns can be reimbursed only for services provided in coordinated care organizations. In Colorado, interns can bill for Medicaid services provided in residential facilities and a few other settings.

APA's Practice and Education Directorates are working to increase the number of states that allow Medicaid reimbursement for interns. APA is researching state programs to determine how they function and to identify barriers, investigating possible legislative or regulatory fixes and trying to come up with a national strategy that could be used as a template for advising state Medicaid agencies considering changes. APA is also tackling the problem of the six states, plus the District of Columbia, that don't even reimburse independently practicing psychologists for services provided to Medicaid patients—a situation that also limits patients' access to mental health care.

One significant barrier that has to be overcome is the concern among some state Medicaid agencies that interns aren't competent to provide services because they aren't yet licensed. "People outside the psychology training community assume that because doctoral psychology students take their licensing exams after their internship years, these unlicensed practitioners aren't as qualified as their licensed supervisors," says Caroline Bergner, JD, a policy and advocacy fellow in APA's Education Directorate. "But interns have so much experience by the time they start their internships—between 1,500 and 2,000 hours of patient care—that they're very well-equipped to provide psychotherapy and a host of other services."

Bergner and others encourage psychologists and trainees to reach out to APA for help if they're interested in fixing the intern reimbursement problem in their states. They should also collaborate with their SPTAs, training directors, state psychology licensing boards, students and others as they begin exploring legislative or regulatory possibilities. In states that have already won the fight, the psychology community should share that story and help those in other states achieve success, too. Says Ameen, "We need champions in more states."

For more information about Medicaid reimbursement, tips on how you can help and resources, check out the Advocacy Toolkit at www.apa.org/ed/graduate/about/reimbursement/index.aspx.

By Rebecca A. Clay


This article was originally published in the September 2016 Monitor on Psychology

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06 Jun 2017

Improving Care for Children with Cancer

Improving Care for Children with Cancer

New standards outline the psychosocial supports that all pediatric oncology sites should offer.

When 6-year-old Mattie Brown complained that his arm hurt, his parents assumed that he had injured himself at tennis camp. Then a routine trip to his pediatrician — plus X-rays and other diagnostic testing — revealed he had bone cancer.

For more than a year, Mattie endured chemotherapy and surgeries that left him in a wheelchair and fitted with prostheses. But his problems weren't just physical. Despite the efforts of his mother, who has a doctorate in counseling, he was also diagnosed with depression, anxiety and medical post-traumatic stress disorder. Just over a year after his initial diagnosis, he died.

Determined to keep the memory of their only child alive, Victoria Sardi-Brown, PhD, and her husband, Peter, created the Arlington, Virginia-based Mattie Miracle Cancer Foundation to push for improved psychosocial care for children like Mattie. Now the foundation has achieved a major goal: the publication of the first national standards for the psychosocial care of children with cancer and their families.

Led by social worker Lori Wiener, PhD, of the National Cancer Institute, plus psychologists Mary Jo Kupst, PhD, Andrea Farkas Patenaude, PhD, Robert B. Noll, PhD, and Anne E. Kazak, PhD — all five of them fellows of APA's Div. 54 (Society of Pediatric Psychology) — a multidisciplinary group of experts drew on the research to establish standards of care for psychosocial support in pediatric oncology (see sidebar).

The standards could do more than just improve care at hospitals around the country. They could also help convince Medicaid and other insurers of the need to reimburse psychologists and other licensed mental health professionals for the psychosocial care the standards recommend, according to Sardi-Brown.

"Unless psychosocial issues are dealt with, medical care can't be as effective as it should be," she says. "We're clearly behind the need for medical research and drug development, but that's going to take years. Psychosocial support is something that can be implemented today."

Compiling the evidence

Although extensive research documents the psychosocial risks children and their families face during and after cancer treatment, that research hasn't necessarily been incorporated into pediatric cancer care. As a result, whether patients and families receive adequate support often depends on what pediatric cancer facility they end up in or what insurance they have.

Sardi-Brown and her husband began working to solve that problem in 2012, when their foundation sponsored a congressional briefing. Five experts — Kazak, Noll, Patenaude, Wiener and psychologist Kenneth Tercyak, PhD — joined childhood cancer survivors and parents in stressing the need for support. But that wasn't enough, says Kupst, an emerita professor of pediatrics at the Medical College of Wisconsin and one of the lead authors of the standards.

"At the briefing, people were very nice as always but said, ‘We need more evidence,'" says Kupst. "That was the impetus for doing this in a way that hadn't been done before — to do a very rigorous evaluation of the research in this area and develop standards."

Kupst and a multidisciplinary group of more than seven dozen other health-care professionals — most of them psychologists — spent the last three years doing just that, with support from Mattie Miracle. After reviewing more than 1,200 studies, the group produced 15 evidence- and consensus-based standards for services that are essential for all children with cancer and their families.

The standards call for systematically assessing children's psychosocial needs, preparing them for invasive procedures, monitoring adherence to treatment and ensuring access to support and interventions throughout the disease's trajectory, for example. Children with brain tumors should receive monitoring for neuropsychological problems, the standards state, while long-term survivors should receive yearly screening for educational, social and psychological problems. There are also standards focused on family members, which call for ongoing monitoring of their mental health needs, supporting siblings and assessing families' risk of financial hardship.

The emotional aspects of dealing with cancer can fall through the cracks, says Patenaude, another lead author of the standards.

"Families are immediately quite overwhelmed just taking physical care of their children," says Patenaude, a psychologist at the Dana-Farber Cancer Center and an associate professor of psychology at Harvard Medical School. "And it's not just the child who's having the hard time. Parents, siblings, grandparents and other family members are all struggling with emotions they might not have encountered before."

Psychologists and other mental health professionals help families overcome trauma and increase resilience during what is typically the multiyear — even lifetime — process of dealing with cancer, says Patenaude. They also help families communicate effectively with medical staff. "When there's not much psychosocial support, a lot of emotion can get funneled toward staff, which makes relationships between families and staff challenging in ways they don't have to be," she says.

Psychosocial care shouldn't stop after a child's death, according to the standards. One standard calls for contacting families to assess their needs, check for problems and offer bereavement resources.

The experts behind the standards also hope that they will spur research. "My hope is that the standards not only improve clinical service but that people will look at the standards, see holes in the literature and decide, ‘This is a place where I could really move my career and answer some questions,'" says Noll, a professor of pediatrics, psychiatry and psychology at the University of Pittsburgh and another of the lead authors.

For example, says Noll, there is little research in the important area of how to help school-aged children with cancer ease back into school after their diagnosis and treatment. "People just haven't researched it," he says.

Putting recommendations into practice

The publication of the standards is only a first step. One next step will be to seek endorsements from key organizations in the pediatric oncology field. The Society of Pediatric Psychology has already given its endorsement.

The group will also be assessing what services pediatric cancer sites are already offering. "As a baseline, we want to find out what the psychosocial teams look like in all the centers, what they're doing and how close they are coming to the standards," says Kazak, co-director of the Nemours Center for Healthcare Delivery Science at the Nemours Children's Health System in Wilmington, Delaware, and another of the lead authors.

Once it's clear what people are already doing, the standards group could help sites put the recommendations into practice. The standards are intentionally non-specific, adds Kazak. "We didn't want them to be prescriptive, to say, ‘You must give measure x within y number of days,'" she says. Because there are many ways to meet each standard, she says, the group hopes to eventually help sites comply with the standards.

The project's ultimate goal is to improve care for children with cancer and their families through the provision of services that embody these standards, says Kupst. "We want to increase access by having some ‘teeth,'" she says. "If it's the standard of care, then [insurance companies] really need to provide reimbursement for it."

The group hopes the standards will convince Medicaid and private insurers to cover the services outlined in the standards. Another tactic could be to make achieving the standards a requirement for hospital accreditation.

For Mattie's parents, the effort is a way to find meaning in the loss of their child and to keep his memory alive.

"We always reflect on Mattie's experiences and use them as a guide and driving force to help other children and families in the future," says Sardi-Brown. "We feel strongly that the way we can do that is through psychosocial support."

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By Rebecca Clay


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05 Jun 2017

Research-Based Strategies for Better Balance

Research-Based Strategies for Better Balance

1. Practice mindfulness. Numerous studies have demonstrated that mindfulness has benefits for body and mind, reducing stress and depression and even boosting immune function. It can also be instrumental in maintaining work-life balance. In a study of working parents, psychologist Tammy D. Allen, PhD, found people with greater mindfulness reported better work-family balance, better sleep quality and greater vitality (Journal of Vocational Behavior, 2012). "Cultivating a habit of self-awareness is vital," says John Christensen, PhD, past co-chair of the APA Advisory Committee on Colleague Assistance. "One of the best things we can do is to develop a reflective habit of checking in with ourselves at least a couple times a day, taking note of the emotional ‘weather' without judgment."

2. Look for silver linings. H. Shellae Versey, PhD, a psychologist at Wesleyan University, found that when working adults looked for benefit in negative situations, they experienced fewer negative psychological effects from work-family conflict. The finding was especially strong for women. During stressful periods, for instance, it can help to think of work-family conflict as a temporary strain, and to focus on the payoffs, such as higher salaries and better opportunities. But lowering expectations and downgrading one's goals did not have that protective effect, she found (Developmental Psychology, 2015). The difference, she believes, is that positive reappraisal is a way of taking control, while downgrading goals can feel like giving up. "Lowering aspirations without having another goal or Plan B in mind could be detrimental," she says.

3. Draw from positive psychology. The principles of positive psychology can aid in psychologists' self-care, as Erica Wise, PhD, and colleagues described in an article on psychologist well-being (Professional Psychology: Research and Practice, 2012). Positive emotions can broaden cognitive, attentional and behavioral repertoires, she explains, which boosts resilience and facilitates well-being. One evidence-based way to boost positive emotions is to practice expressing gratitude on a regular basis.

4. Take advantage of social support. Seeking support from other people is critical to well-being. Geertje van Daalen, PhD, at Tilburg University in the Netherlands, and colleagues found that social support from spouses and colleagues can be especially important for reducing conflict from family obligations spilling over into the workday (Journal of Vocational Behavior, 2006). Connecting with professional colleagues can be especially important for psychologists, Christensen adds. "Many psychologists work in their own silos and have little contact with professional peers," he says. "That isolation can be a risk factor for burnout."

5. Seek out good supervisors. Unsurprisingly, sympathetic bosses can also be helpful — something to keep in mind if you're on the hunt for a new job. David Almeida, PhD, at Penn State University, and colleagues found people had more negative emotions and greater stress on days when work obligations interfered with family responsibilities. But those negative effects were buffered by supportive supervisors (Journal of Marriage and Family, 2016).

6. Get moving. A robust body of research has shown that exercise can boost mood in the short term, and in the long term can improve symptoms of depression, anxiety, addictive disorders and cognitive decline.

7. Go outside. Spending time in nature has been linked to improved cognition, attention, mood and subjective well-being. It also appears to reduce symptoms of stress and depression, as Roger Walsh, PhD, a psychologist at the University of California, Irvine, described in a review of lifestyle changes and mental health (American Psychologist, 2011).

8. Make your life meaningful. In his American Psychologist article, Walsh also described the benefits of seeking meaning — whether through religion, spirituality or volunteer service. "We do our best work and live our best lives when we have a sense of meaning — a feeling that what we do extends beyond us and brings good to others," says clinical psychologist Sandra Lewis, PsyD.


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05 Jun 2017

Expanding Opportunities in Women’s Specialty Care

Meet three practitioners who work hand-in-hand with medical professionals to keep new mothers, military veterans and other women healthy

The expectant mothers at Denver's Presbyterian/St. Luke's Hospital—a regional center for high-risk pregnancies—often have such high blood pressure that both they and their babies are at risk of complications or even death. On bed rest at the hospital for weeks or even months, they have little to do but worry—which can send their blood pressure soaring even higher.

That's where consulting psychologist Jennifer Harned Adams, PhD, comes in. She teaches the women visualization, breathing exercises, progressive muscle relaxation and other strategies they can use while they're stuck in bed. She'll also help them find relaxation apps on their cellphones or tablets so they can use the techniques whenever they need them.

"These moms are facing all these potentially scary outcomes for themselves and their babies, but can't do a whole lot physically to manage that anxiety," says Adams. "Being a part of the team is great so we can think about these moms in a more holistic fashion."

Adams's work with pregnant women is just one example of how psychologists are working with physicians and other medical providers to improve women's overall health. Adams and other psychologists are helping women transition to motherhood, overcome chronic pain, heal from sexual assault and explore their gender identities.

The Monitor spoke to Adams and two other psychologists working in integrated settings focused on women's health.

Jennifer Harned Adams is assisting new mothers

Dr. Jennifer Harned Adams specializes in treating pregnant women on hospital bed rest. Presbyterian/St. Luke's and the affiliated Rocky Mountain Hospital for Children brought Adams on two years ago, and she spends a quarter of her time consulting with patients at the hospitals. "They were seeing the need for greater support for families," says Adams, who spends the rest of her work week at her private practice. "They saw how having a psychologist would help improve the quality of the hospital stay and the transition into parenthood."

Her training prepared her well. After earning her doctorate in clinical psychology from the University of Houston in 2003 and doing an internship at the University of Texas-Houston Health Sciences Center, she had three years of postdoctoral training in reproductive health and psychosocial oncology at The University of Texas-MD Anderson Cancer Center.

On the antenatal side, Adams now spends most of her time helping women cope with extended bed rest. In addition to boredom, they're facing worries about their babies, the work they're missing and their families back home. They may be mourning past miscarriages or—in the case of multiple babies—the death of a twin or triplet. "Of course, they're also bringing in whatever was going on with their lives to begin with—relationship or financial difficulties or previous histories of depression, anxiety or substance abuse," says Adams.

And since patients come from as far away as Wyoming and Nebraska, many are also isolated. Adams helps the women problem-solve and helps prepare them and their families for potentially bad outcomes. If their stay is long enough, she might even delve into more traditional psychotherapy.

Adams also works with mothers and other family members in the neonatal intensive care unit. For many patients, ending up in the unit is a traumatic surprise following an unexpectedly premature birth or delivery complication. "Women and families can be overwhelmed," says Adams. "It can be very unsettling to feel out of control." Adams helps them find a sense of control where they can, settle into a routine and work through the trauma.

The work is fluid and fast-paced, says Adams. "I love being able to walk down a hall and have a nurse tell me she's feeling worried about a mom and being able to troubleshoot or help make a plan," she says, adding that rounds and case planning meetings offer more formal collaboration opportunities.

Adams also helps educate nurses and other health-care professionals, offering trainings on understanding grief and loss in their patients and themselves and on preventing compassion fatigue and burnout in their professional roles. "I urge them to look for opportunities for self-care for themselves and others just in the course of their day and also to make aggressive self-care—exercise, massage or other practices—a regular part of their lives," says Adams, who has also worked with the Wishbone Foundation to train more than 300 nurses in nine hospital systems how to support families who've lost their babies.

The training also helps nurses work more effectively with patients, adds Adams. Often, she says, there are communication problems because patients and their families are interacting angrily with nurses and other providers. "I help providers reframe that anger as fear, which helps them respond differently," she says.

Kelly Huffman is helping patients overcome pelvic pain

Dr. Kelly Huffman specializes in treating pelvic painKelly Huffman, PhD, specializes in another type of care for women: treating pelvic pain. "Women are overrepresented in chronic pain populations," says Huffman, a psychologist at a pelvic pain clinic "by and for women" within the Cleveland Clinic's Center for Neurological Restoration.

Pelvic pain can have many causes. No matter what the etiology, it can leave women depressed or anxious about what's wrong with them. Pelvic pain can also cause sexual dysfunction and thus relationship problems.

And psychological distress can make pain worse, says Huffman, who did a postdoctoral fellowship in psychology and pain medicine at the Cleveland Clinic after earning her doctorate from the University of Wisconsin–Madison in 2008.

"If you have a lot of stress, depression, anxiety and other things going on in your life, it can amplify pain perception," she says. The opposite is true, too. "If you don't have a lot going on in your life, pain can become front and center in your life because you have nothing else to focus on."

When patients with pelvic pain come to the clinic, they consult with Huffman, plus a physician, physical therapist, occupational therapist and other team members who create individualized treatment plans. For some, that might mean surgery; for others, pelvic floor therapy, a type of physical therapy designed to rehabilitate pelvic floor muscles. The clinic also weans patients off opioid analgesics, if necessary. For patients who need more help, the clinic runs a three-week, full-time rehabilitation program.

Huffman's role on the team is to address any psychological issues. She might counsel couples on relaxation techniques they can use to enhance sexual functioning, for instance. Or she might help a sexual assault survivor work through the trauma that's contributing to her pain.

Working collaboratively can prevent unnecessary medical interventions, says Huffman. One patient, for example, had such severe pain with intercourse that she was scheduled for a vestibulectomy—surgical removal of some flesh at the vagina's opening. When Huffman talked with the patient, however, it turned out that it wasn't a physical problem that was holding her back but instead uncertainty about her sexual orientation. "If you don't have a partner you're attracted to, of course it would make intercourse difficult," says Huffman. The surgery was canceled.

Because many patients are convinced they need opioids to manage their pain, Huffman also provides psycho-education. "The common perception is, ‘If I have pain, the answer is to take opioid analgesics,'" says Huffman. Addiction isn't the only danger of opioid use: Opioids can also make pain worse. "Most patients don't know about acute versus chronic pain," says Huffman. "Opioids are actually contraindicated for chronic pain."

This kind of integrated approach works, Huffman and her colleagues have found. In a study of 36 patients with pelvic pain, Huffman and co-authors found that interdisciplinary treatment including medication management, occupational and physical therapy, and individual, group and family therapy significantly improved pain severity, disability, depression, anxiety and "catastrophizing" (Journal of Pain, 2016).

And word is getting out, says Huffman. "The pelvic pain clinic has only been open for about a year," she says. "At this time, we have more volume than we can handle."

Rosalie C. Diaz is helping veterans heal

Dr. Rosalie C. Diaz treats female veterans in a women’s healthcare clinicIn the military, seeking mental health care can be especially stigmatizing. That's one reason why psychologist Rosalie C. Diaz, PsyD, is happy to be treating female veterans in a stand-alone women's clinic at the Louis Stokes Cleveland Veterans Affairs (VA) Medical Center. "Having a psychologist be part of their primary-care team isn't seen as stigmatizing by our veterans," says Diaz. "I'm just part of the team."

The VA began emphasizing coordinated, co-located care in 2010 as a way of decreasing stigma and improving access to care, says Diaz, who did her predoctoral internship at Louis Stokes in 2003 and started her current position in 2013. "It's also seen as cost-effective because you're being more preventive," she says. A physician or other provider might be worried about a patient's depression, substance use or cognitive capacity, for example, so Diaz meets with the patient, screens for the problem and works with the provider on treatment recommendations. Other patients may have mood disorders, insomnia or difficulties with medical compliance. Infertility, pregnancy loss and post-traumatic stress disorder are also common.

Military sexual trauma—and the wide range of psychological emotions that often accompany it—is another big issue. "If you review their records before they see you, they'll sometimes deny to a provider that there has been any assault," says Diaz. "Then you're seeing them for therapy, and they'll share something that they've never confided before."

On an individual level, a veteran might also need Diaz to accompany her to gynecological exams to help her cope and avoid panic, for example. More broadly, Diaz and others are also working to raise awareness of military sexual trauma among patients and providers alike with an annual monthlong education campaign. For the veterans, she says, the campaign emphasizes that they're not alone and that there's an advocate for them. For providers, the message is that trauma is often hidden. "The provider might see anger in the forefront, but underneath there's fear or vulnerability," says Diaz. By working alongside the physician or other provider, Diaz can help ensure the patient gets the care she needs.

Diaz also works with the center's transgender clinic, which addresses physical, social and mental health issues. As part of that interdisciplinary team, she helps patients manage their transitions and explore their gender identity. She also helps screen patients to see if they're candidates for hormone therapy. Many of these patients have experienced bullying and harassment and may feel depressed, anxious or just uncertain. "We're looking at stability, support and their use of coping skills," says Diaz, who works alongside a primary-care physician, a psychiatrist, nurses, a social worker and another psychologist.

The biggest challenge with providing collaborative, multidisciplinary care that involves so many specialty providers in the same place at the same time is that it requires a good amount of time and space for them to collaborate on the best plans of care for their patients, says Diaz. "We have a lot of providers ready and willing to see veterans, but sometimes it's hard to coordinate with all the different disciplines and find rooms because we're growing," she says. "That's probably a good problem to have."

More on integrated care

Every 2016 issue of the Monitor features a profile of a psychologist on an integrated-care team. To access the full series, visit our digital edition at www.apa.org/monitor/digital.

By Rebecca Clay


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01 Jun 2017

Working with an Accountable Care Organization

Working with an Accountable Care Organization

Arnold D. Holzman and his practice are joining forces with hundreds of physicians.

Ask Arnold D. Holzman, PhD, how he sees the future of psychology, and he lays out a vision of psychologists working side by side with physicians in accountable care organizations — groups of health-care providers who come together to provide care for a particular patient population and enjoy bonuses for keeping their patients healthy. That's why Holzman quickly agreed when an accountable care organization called the Community Medical Group asked his practice for help last year.

The idea behind the accountable care organization was to better serve patients in Connecticut's New Haven and Fairfield counties. But the several hundred physicians involved soon realized they couldn't go it alone.

"They kept coming back to the need for high-quality psychological intervention," says Holzman, co-founder and managing partner of Behavioral Health Consultants, LLC, in Hamden, Connecticut. "Many of the problems that bring individuals to physicians' offices, particularly primary-care offices, are psychologically based."

As a result, the accountable care organization turned for help to Behavioral Health Consultants, which has 11 psychologists and three master's-level clinicians on staff and subcontracts with other mental health professionals — about half of them psychologists — as needed.

Accountable care organizations are springing up in response to the Affordable Care Act, which is intended to improve care and reduce costs by encouraging reimbursement focused on the quality — not the number — of services provided. Physicians share accountability for the cost and quality of care delivered to a patient population, with insurers rewarding improved outcomes and lower costs. The organizations can not only develop their own treatment protocols but also share electronic medical records and back-office functions, such as billing and appointments.

Realizing that integrating medical and psychological services was key, Community Medical Group recruited Behavioral Health Consultants, whose providers already had relationships with many of the physicians in the organization, to provide the psychological services its patients need.

Behavioral Health Consultants and the accountable care organization are currently separate entities, but the two are discussing the possibility of co-located services. That way, says Holzman, patients will see psychologists as "a routine extension of their work with a doctor as opposed to something separate." He hopes that eventually his practice will be able to enjoy such benefits of integration as shared administrative and support services and electronic medical records, joint negotiations with payers, even profit-sharing. "This is a process that will take years," he predicts.

So far, the relationship consists of referrals.

"The problem with more traditional relationships, as many physicians have told us, is they'll often tell patients they should go see someone, but they don't know whom to refer them to," says Holzman. "And they don't know if they got there because there's no [follow-up] communication."

The physicians now tap Holzman and his colleagues when they suspect patients have emotional or behavioral problems that are impairing their health. One young man, for example, came to Holzman after tests could find no medical reason for his chest pain and other symptoms of a possible heart problem. The real issue turned out to be anxiety. "Once we reframed his symptoms as anxiety, we could approach the problem as a psychological one, not a medical one," says Holzman, who used cognitive-behavioral therapy to teach the man how to better manage the stressors in his life and the resulting anxiety.

But Holzman and his colleagues also assist patients with medical problems. In fact, they are developing the accountable care organization's protocol for treating patients who have diabetes along with depression, obesity or other problems, yet aren't following their physicians' recommendations. The protocol will lay out how referrals will be made, as well as guidelines for individual and group treatment and outcome measures so all of the providers can determine whether treatment is successful.

Holzman is also in discussions with insurers who may provide seed money for demonstration projects to show that adding psychologists' interventions keeps patients healthier. "They see our work as potentially reducing their financial exposure if patients get better sooner," he says.

He encourages other psychologists to get involved with accountable care organizations, either by developing relationships with physicians who are members of one or more organizations or by joining practices like his own that have already developed those relationships.

Holzman's background in pain management and health psychology prepared him well for working with an accountable care organization, he says. "When you're trained in pain management, communicating with physician referral sources is second nature," says Holzman, who earned a doctorate in clinical psychology from the State University of New York at Binghamton in 1981.

Such integrated care, he adds, is not only good for patients. It's also good for the bottom line. Because of the new relationship with the accountable care organization, Holzman anticipates substantial growth and expects to bring on many more clinicians and subcontractors.

"That's really the motivation here: to provide high quality service and be successful at the same time," he says.

By Rebecca A. Clay 


This article was originally published in the May 2016 Monitor on Psychology

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24 May 2017

Primary-Care Practices Appreciate Having Integrated Behavioral Health Consultants

Primary-Care Practices Appreciate Having Integrated Behavioral Health Consultants
When a new patient burst into tears in his office at Mercy Heath's Springfield Family Medicine Clinic in Cincinnati, physician Douglas L. Hancher, MD, suspected she needed more help than she would admit, even though she denied she was suicidal.

"In the old days, we would have had to look at her insurance, check who was in her plan and seeing new patients and refer her to someone who might have been 20 miles on the other side of town," says Hancher. "Then it could take six weeks to get an appointment."

Not anymore. Thanks to Mercy Health's commitment to embedding behavioral health consultants in primary-care practices, psychologist Leslie Instone, PhD, was just across the hall and able to see the patient immediately. She discovered that the woman had tried to kill herself before and had a plan to try again soon. She sent the patient to the psychiatric emergency room, where she got the help she needed.

"I would have felt terrible if I had missed someone who was suicidal and she went on to commit suicide," says Hancher. "Having a back-up is good."

Stories like that are one reason why Mercy Health—one of the nation's 10 largest nonprofit health systems—is moving aggressively to integrate behavioral health consultants into its family medicine, internal medicine and pediatric clinics in Ohio and Kentucky. The goal is to achieve the triple aim of better health, lower costs and enhanced patient satisfaction, says Martyn Whittingham, PhD, the psychologist who launched the initiative in 2014 as chief of clinical integration and research at Mercy's Behavioral Health Institute. (Whittingham has since left the organization.)

According to Mercy Health's preliminary data, Hancher isn't the only physician who appreciates having a behavioral health consultant as part of the team. In a survey of 100 physicians and staff members at seven Cincinnati practices involved in the integration project, participants gave almost everything at least four points on a five-point scale:

  • Access to care. Providers and practice staff, such as practice managers and care coordinators, gave an average rating of 4.7 when asked how helpful integration has been for patients and how it has increased ease of access to behavioral health services for patients. That's an especially important figure given Mercy's mission of serving the underserved, says Whittingham.
  • Helpfulness. The survey also asked questions aimed specifically at providers. When asked how helpful having a behavioral health consultant was in terms of providers' ability to do their own jobs, for example, the average rating was 4.5.
  • Improved work flow. Providers gave a 4.2 average response when asked how much the integrated behavioral health model improved the work flow in their day-to-day practice. "The behavioral health consultant could have been seen as invasive or blocking work flow," says Whittingham. "Instead, they improve work flow, even in this really early stage."
  • Satisfaction. The 4.7 average score for a question about how likely providers are to recommend behavioral health integration to their colleagues is a key indicator of success, says Whittingham. "That's the final test," he says, adding that momentum is building as participating physicians like Hancher share their experiences with behavioral health consultants with their colleagues. "Physicians are coming to us and asking, 'When am I getting mine?'"

There are already 14 behavioral health consultants—primarily psychologists, plus a couple of social workers—in 24 of the system's 150-plus primary-care clinics. Another three are under contract but haven't yet started. And the system plans to hire many more this year. About 25 percent of the system's 600,000 patients already have access to a behavioral health consultant. It has been a challenge to find enough psychologists ready and willing to work in these fast-paced, integrated settings. "There aren't enough people trained in primary-care integration," says Whittingham, who earned his doctorate in counseling psychology from Indiana University in 2006. "I've visited multiple universities and told deans, 'If you train them, we have positions they can apply for.'"

To make up for that lack of preparation, Mercy Health has developed an intensive training regimen for new hires. In addition to watching training videos, new behavioral health consultants "shadow" more seasoned consultants in their own practices for a week. Then they flip positions, moving into their new settings with their colleagues alongside them to supervise them for a week.

On the medical side, physicians are discovering that behavioral health consultants can help not just with psychological problems but with physical problems, too, including medication adherence, exercise and smoking cessation, says Mbonu N. Ikezuagu, MD, MBA, the attending physician for the internal medicine residency program at Mercy St. Vincent Medical Center in Toledo.

"Integrating a behavioral health consultant into our office has moved us closer to achieving our goal of delivering amazing patient care," says Ikezuagu, adding that both the attending physicians and 36 residents use the service on a daily basis. "This is the wave of the future."

By Rebecca A. Clay


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