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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