Mental Health Professionals in Medical Settings: A Primer

American Journal of Clinical Hypnosis, Apr 2003 by Weisberg, Mark B

Mental Health Professionals in Medical Settings: A Primer. JoEllen Patterson, C.J. Peek, Richard Heinrich, Richard Bischoff, & Joseph Scherger. New York: W.W. Norton & Co., Inc. (2002). 232 pages, $ 40.00 (hardcover). Reviewed by: Mark B. Weisberg, Ph.D., ABPP, Minneapolis, Minnesota.

Our health care system has traditionally been based on the Cartesian mindbody split. We all know about the chasm that has existed between physical and mental health care. Some mental health professionals are insufficiently aware of the neurophysiologic underpinnings of their work. Some physicians, nurses and dentists may not be informed about psychophysiologic factors in physical illness, viewing them merely as reactive or secondary in importance. Clinicians, professional guilds, insurers, and consumers alike increasingly express their frustration with this fragmented system of care.

Problems relating to this healthcare duality are well documented, especially in regard to chronic illnesses. Ninety percent of the 10 most common complaints in the primary care setting have significant psychological contributing factors (Strosahl, 1998). Only a small percentage of patients with mental disorders will ever see a mental health professional, being treated instead by their primary care physicians (Barrett et al., 1988). Psychological factors are significant not only in reaction to physical illness, but can be formative in the initiation, maintenance or exacerbation of many disease processes (Weisberg & Clavel, 1999).

Mental Health Professionals in Medical Settings: A Primer was written in the hopes of making a practical contribution to mending the divide. The authors of this book (three psychologists, a psychiatrist and a family practice physician) come from a background of family practice training and primary care/mental health integration programs. Their intention is to help mental health professionals change their practices to bridge the gap between physical and mental health care in hospitals and clinics. They describe this text as a primer for the mental health professional wishing to work in medical settings.

In Part I the authors address essential differences in the cultures of primary care, specialty care, and mental health care. Emphasized here are essential differences between traditional physical health versus mental health care systems, such as length of patient contacts, locus of responsibility for treatment, and reimbursement mechanisms for services.

In Part II they spell out their model for building a collaborative medical care system, including a five-stage model for developing integrated care. Much of their attention is directed to trying to help mental health professionals integrate on a collaborative multidisciplinary team, within the organizational framework of a hospital or primary care clinic. Particular emphasis is devoted to professionals consulting for the first time in medical settings, discussing how useful consultation services are different from traditional psychotherapeutic treatment.

Program development themes abound here, including frequent discourses about balancing clinical, operational and financial considerations in integrative health care. This certainly reflects the input of some of this book's authors who have firsthand experience in setting up such programs. Accordingly, parts of this text would be of unique interest to the program administrator in a medical setting.

Notable problems, other than limited scope, diminish the book's usefulness, however. One significant problem with the book pertains to the concept of "mental health professional", which includes (not inclusively) social workers, clinical psychologists, psychiatrists, psychiatric nurses and nurse practitioners, and marriage and family therapists. The authors appear to consider all mental health professionals within the single category of "therapist". Of course this is misleading, as the abovementioned clinicians come from different traditions and scope of training, and may be trained to engage not only in psychotherapeutic treatment but also in psychological and neuropsychological assessment, research design, consultation-liaison activities, systems analysis, or scientific studies in physiological mechanisms. When a clinician is defined by a treatment they use (e.g., "therapist") rather than by their professional background and training, this is not unlike defining a physician as a "medication prescriber." When recommendations are given for how the "therapist" should behave on the multidisciplinary team, this aim is fraught with difficulties because they are attempting to conceptualize a heterogeneous group in a monolithic way. It doesn't work well.

Many statements regarding a "therapist's" appropriate role and professional identity on the health care team are questionable, perhaps due to viewing mental health professionals as a unidimensional group. Explicit in the text is the notion that "therapists" are needed in these settings because the primary care physician (who could otherwise apparently address all of his/her patients' mental health problems) is simply too busy and has insufficient time to do so. While there is no disputing the short amount of time the primary care physician has to see each patient, this does not speak to the issue of lack of different, specialized training of mental health clinicians. It is like saying that their primary care physicians could meet all of the patients, dermatological, rheumatological, or surgical needs except that they don't have enough time. The authors view the "therapist" as someone who should serve as a patient advocate relieving the burden from the rest of the team. (If advocacy is needed, wouldn't all team members share in this role?) Also, when the authors caution that "psychotherapists ... must understand ... the reliance of medical practitioners on research to inform clinical practice" (p. 111), the logical implication is that mental health practitioners are unfamiliar with the scientist-practitioner model of practice.