Mental Health Professionals in Medical Settings: A Primer

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.

Another problem relates to recommendations about the appropriate scope of services. The authors focus only on the brief psychotherapeutic services needed in these settings. But, in my experience, there are many other skills needed to be an effective mental health consultant in a medical or primary care setting. Other requisite skills include the ability to do a quick assessment of a patient's mental status, psychological and psychophysiological functioning; discern and clarify the "real" referral question; quickly and concisely interview the patient, family, nursing staff, referring physician, etc. to ascertain contributing factors; be an effective systems analyst on multiple levels, including the clinic, family, and hospital; be well informed on relevant physical diagnoses and treatments, medications, and dosages (particularly psychotropics) and be able to speak to the relative and complimentary contributions of psychotropics versus psychotherapy. They must be able to assess quickly and effectively problems of compliance with treatments, and to understand (and be able to convey in simple language) the myriad ways in which a "somatizing patient" may represent a complex combination of neurophysiologic pathways intensified by excessive autonomic arousal and vigilance.

I believe that the inexperienced mental health professional in a medical setting requires the development of a different sense of professional role identity than that suggested in this text. Given that this book is described as a "primer", it attended very little to the elaboration of essential training and skills necessary for the clinician to learn about effective functioning.

The authors should be commended on their desires to contribute to the integration of mental and physical health services. If a clinician wants to learn about financial accountability or administrative startup issues in collaborative care, this book might be a useful resource. However, for novice professionals just learning about consultation in medical settings, I would recommend other texts (e.g., Johnson, Perry & Rozensky, 2002) that do a better job of describing some of the tasks, underlying skills, and conceptual underpinnings required.

References

Barrett, J.E., Barrett, J.A., Oxman, T.E., & Gerber, P.D. (1988). The prevalence of psychiatric disorders in a primary care practice. Archives of General Psychiatry, 45,1100-1106.

Johnson, S.B., Perry, N.W. & Rozensky, R.H. (Eds.), Handbook of clinical health psychology: Medical disorders and behavioral applications. Washington, DC: American Psychological Association Press.

Strain, J. (1982). Collaborative efforts in liaison psychiatry. In T. Millon, C. Green, & R. Meagher (Eds.) Handbook of clinical health psychology. New York: Plenum.

Strosahl, K. (1998). Integrating behavioral health and primary care services: The primary mental health model. In A. Blount (Ed.), Integrated primary care: The future of medical and mental health collaboration (pp. 139-166). New York: W.W. Norton.

Weisberg, M.B. & Clavel, A.L. (1999). Why is chronic pain so difficult to treat? Psychological considerations from simple to complex care. Postgraduate Medicine, 106, 6,209-220.

Copyright American Society of Clinical Hypnosis Apr 2003
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