Janet L. Cummings

The Unmet Educational Agenda in Integrated Care

One of the reasons integrated care has not become a dominant service delivery model is the unmet training agenda. This article argues that the typical mental health professional is not trained to adequately address the challenges of integrated care. To insure competency both a macro and clinical training agenda are needed. At the macro-level, mental health professionals need to understand healthcare economics and basic business principles as any integrated care service delivery system is embedded and driven by economic forces. Integrated care practitioners also need some basic business skills to understand these forces and to create and manage a financially viable system, given the future flux of the system. Traditional mental health professionals also do not have the clinical skills to implement integrated care. Integrated care is not simply placing a traditionally trained mental health professional and letting them practice specialty mental health in a medical setting. Thus, the special skills needed in integrated care are enumerated and discussed. Finally, a new degree program is described as it is time given the huge need and advantages of integrated care to develop specialty training in integrated care.

We are not a Healthcare Business: Our Inadvertent Vow of Poverty

Psychology has been fractionated from mainstream healthcare delivery and this schism has resulted in huge costs to psychologists and our intended customers. Psychology has also been naïve economically. The authors suggest three revolutions: (1) for clinical psychology to be better integrated into the healthcare delivery system; (2) for psychologists to better understand healthcare economics and business; and (3) for psychologists to become more entrepreneurial, i.e., see needs in healthcare (such as those of the elderly, obesity, improved access and value through ehealth) and systematically fill these. We note high quality businesses help many individuals (customers, family members, employees) not typically recognized by anti-business psychologists.

PSYCHOEDUCATION IN CONJUNCTION WITH PSYCHOTHERAPY PRACTICE

Publisher Summary Psychoeducation is health psychology combined with behavioral counseling and even psychotherapy. It is applied in a group setting that is specific to a diagnosis and is both structural and open-ended as may be therapeutically appropriate. The behavioral counseling component of psychoeducation deals with emotions, perceptions, coping, relaxation, and self-care, whereas the educational component imparts knowledge about the physical or psychological condition that is shared by the participants in the group. There are four components in psychoeducation, which may vary in their concentration depending upon the condition being addressed, but it is not psychoeducation unless all four components are present, including treatment of the condition; management of the condition, especially those that are chronic and intractable; compliance with the medical and psychological regimen; and prevention of progression, exacerbation, or relapse. Psychoeducational programs are of value to several categories of patients, spanning chronic physical disease, intractable psychological conditions, and certain life situations. Psychoeducation improves health outcomes and reduces healthcare costs with patients with chronic physical diseases, psychological conditions, high utilizers (somatizers) of medical services, substance abusers, and patients pre- or postsurgery. Beginning with one-on-one programs administered by nurses and health educators, psychoeducation has moved to sophisticated group programs extensively used in disease management and other settings. Effectiveness is somewhat limited in most group programs because of an over-reliance on educative features and a lack of intensive behavioral interventions, especially when the skills of a psychotherapist are required.

What Are “Best Practices,” Anyway?

This chapter deals with the explanation of guidelines and standards that are followed in psychotherapy. Further discusses the advantages and disadvantages of standards. Most guidelines are premature, while standards are way off into the future. Guidelines are just that; they serve as a guide to the practitioner who may deviate from them with good reason. Standards, on the other hand, are requirements or imperatives of practice. Standards not only require an enormously accurate body of knowledge, they raise the danger that practice is locked into a set of requirements and thus stifle innovation and progress. Standardization elevates the general base of competence for the entire profession, and thus enhances the effectiveness of the poorly trained or mediocre therapist. Standardization curtails the abuses of overtreatment and undertreatment by providing an identifiable standard for each case and each condition. This is the arena of most of the contentiousness occurring between payers and practitioners. Standardization enables the public to differentiate legitimate (verified) treatment from the fanciful. Whatever the practitioner might perform, as long as both the practitioner and the patient believe it is effective, there will be about a 35% placebo effect, leaving both patient and therapist with the illusion that the treatment is effective.

HOLISTIC AND ALTERNATIVE MEDICINE AS ADJUNCTIVE TO PSYCHOTHERAPY

Publisher Summary This chapter addresses the need for alternative and holistic medicine while striking a note of caution to both the unwary consumer and the well-meaning professional. Psychotherapists are often called upon to make recommendations or to otherwise comment on various alternative treatments that the client may be considering or already using. As a licensed provider, one may be held accountable should there be untoward effects on ones client from such use after one has given ones positive or even implied recommendation. With appropriate knowledge, however, alternative medicine can be a valuable adjunct to psychotherapy. Alternative medicine includes wide disparate procedures like relaxation techniques, yoga, New Age approaches, spiritual healing, and prayer. The latter often includes prayers offered by others on behalf of someone who does not know he or she is being prayed for. Because those who dispense alternative and holistic medicine often are not health professionals but often mystics, cultists, self-appointed experts, and even health spa employees, the public is not accorded the protections found in the regulated healthcare system. Despite the dangers inherent in some alternative treatments and the precariousness of relying on nonvalidated techniques while rejecting validated ones, many alternative treatments have merit, especially when used as adjuncts to traditional medical treatments and even psychotherapy.

Enhancing Psychotherapy through Appropriate Entry Points

Publisher Summary This chapter presents various techniques for enhancing psychotherapy by utilizing appropriate entry points. An entry point is defined as a therapeutic aperture characteristic of the patient and his or her personality at the moment that enables a treatment intervention to achieve a degree of success and understanding what otherwise would have been attenuated or even blunted. It is an opening peculiar to that patient that guides the therapist in the selection and timing of an intervention for maximum benefit to the patient. Without the appropriate entry point, what the therapist intends is not heard, or it has a deleterious effect, with the ultimate negative response being that the patient gets worse or quits therapy. The entry point for patients suffering from severe anxiety and panic attacks is to help the patient in creating a repertoire of alternative responses to threatened abandonment of medication. With continued therapy, and without medication, the patient would turn more and more to the alternatives and less and less to panic attacks when threatened. The initial entry point in the treatment of phobias is a gentle desensitization using readily available retreats from the feared object. In case of chronic depression, the entry is to acknowledge frankly that their chronic depression cannot be eliminated, but they can learn to live beautiful lives in spite of it. In case of hysteria and conversion hysteria, the entry point is to ignore the repressed sexual material and concentrate on the defenses, strengthening them sufficiently so that the patient is eventually able to confront his or her inner feelings.

The Art and Science of Psychotherapy

Publisher Summary Psychotherapy is both an art and a science. Understanding the contribution of both these elements and achieving a proper balance in actual episodes of therapy is essential to optimize therapeutic success. As behavioral health professionals have often emphasized one aspect and neglected the other, this chapter aims to readdress this imbalance. A key task in therapy is creating and maintaining an optimal therapeutic relationship, which has to involve elements such as empathy, positive regard, and instilling hope. The relationship must also involve persistence in moving the client to explore areas they do not want to; giving honest, useful, but perhaps unwanted feedback; drawing clear boundaries (particularly with certain clients such as those with borderline personality disorder); and tough love, which necessitates the art of establishing and maintaining a therapeutic relationship. Another common mistake is to view psychotherapy as entirely an art. This view misses the point that there are causal relations in therapy that science is best at discovering. As all measurements contain error, knowing the scientific literature about the validity and limitations of the validity of psychological assessments is also essential knowledge in psychotherapy. Additionally, only testing can ensure that the intervention is safe. Finally, the advantage of scientific knowledge is that it has a large and known generalizability, which can be used to find out about what constitutes good therapy and teach others to implement this knowledge.

Suicidal Patients: The Ultimate Challenge for Master Psychotherapists

Publisher Summary The finality of suicide constitutes a formidable challenge to psychotherapists, most often prompting them to overly hospitalize these patients to be on the safe side. However, unnecessary hospitalization, the belief that only a psychiatrist can manage suicidal patients, or the converse, attempting to take responsibility for a patients life can all be counterproductive and even harmful to the patient, increasing the risk of suicide. A master therapist can differentiate the lethal patient from the nonlethal patient and proceed appropriately to prevent both death in the first and eliminate repetitive threats and attempts at suicide in the latter. Master therapists understand the three-stage suicidal process and can recognize the warning signs with each, know how to intervene, and prevent what would otherwise be the imminent death of their lethal patients, and are adept at developing tailored treatment interventions for their nonlethal patients. There are verbal, nonverbal, and tactile indicators of lethal suicide, and there are three stages in the lethal process—ideation, planning, and autopilot. Having missed indicators and the first two stages, autopilot is the last opportunity to intervene and prevent the suicide, but this autopilot is usually manifested and disguised in outward improvement and the imminent lethality is missed by the therapist.

A Sampling of Current Masters

This chapter presents the work of various psychotherapist based on their therapeutic point of view. To name a few psychotherapist whose worked are presented in this chapter are Dr. Simon H. Budman, Dr. Elizabeth and Dr. James et. Bugental. Each of these master therapists has many years of experience and is theoretically grounded, in addition to being a psychological artist. Most are also skilled researchers, and all are scholars. The cases are presented in alphabetical order by author. All of the examples from this sampling of current master therapists have a number of things in common. Each therapist is profoundly devoted to helping the patient, and each is conscious of the patients pain, with a desire to ameliorate it as soon as possible—sometimes in the face of severe resistance. These master therapists began honing their skills long before the advent of managed care. They did it for the effective and efficient care of their patients, not out of cost consciousness.

Intermittent Focused Psychotherapy Throughout the Life Cycle

This chapter presents the case study of Denise, who went through forty years of intermittent focused psychotherapy, 1959 to 1999. Denise symptom was the recurring obsession that she would stab her 6-month-old Connie (her baby). This was especially strong when she was diapering the infant and a rack of kitchen knives was nearby. In desperation she got rid of all sharp knives, but the obsession persisted. Denise was seen as an obsessional hysteric, and the treatment called for being in the space opposite where she was at any given moment. When she was being obsessional, the therapist would interpret the hysteria, and vice versa. The treatment plan was as follows: First, the entry point was to go in the direction of the patients resistance. Second, when she was being hysterical (seductive) the therapist would address the obsession, and vice versa. Third, the goal was for her to see the parataxic distortions: husband as father, not as the brother she now saw, and later to see that she equated Jeff (her husband) as rejecting, both as mother and brother, toward both of whom she harbored unconscious murderous thoughts. A lifetime of problems requires mere total of 23 sessions with a therapist. Denise also took her 23 sessions over 40 years and overcame her problem.