Team-based approach to managing client’s problem is psychologist’s path for future

 

By Paula Hartman-Stein, Ph.D.

 

Reno, NV - Kirk Strosahl, Ph.D., research and training director of Mountain View Consulting Group from Moxee, WA, long ago abandoned the traditional 50 minute psychotherapy hour and the administration of lengthy psychological assessments. 

“I have ‘crossed over’ to the role of behavioral health care consultant,” he said during his recent presentation at a medical cost offset conference at the University of Nevada at Reno.

In his model of integrated behavioral healthcare, Strosahl explained, “The psychologists’ customer is the medical provider, not the patient.”  The psychologist assesses the patient’s presenting symptoms and designs a team-based approach to managing the problem.. The psychologist who works in the primary care office is not performing specialty services analogous to a “cardiologist of the mind,” according to Strosahl.  Either the primary care physician (PCP) or the psychologist can refer the patient out for individual psychotherapy or neuropsychology services.

Strosahl gained training for his innovative method at a large health maintenance organization (HMO) in Washington State, where he worked from 1984-1999. 

Currently, Strosahl teaches psychologists, medical providers and administrators how to design a team-based primary care medicine approach, often working with large systems such as the Department of Defense and the Air Force.

He pointed to the lack of training on the medical side to integrate behavioral and medical care and similar poor training in psychology graduate training programs to teach and model how to be a consultant in primary healthcare.

Quick with words and displaying a Dennis Miller-like wit and bluntness, Strosahl declared candidly that “the current mental health system in America is a complete flop.” He went on: “There is no other specialty that is so secretive…The primary care physicians (PCP) often see mental health services as a big black box.” The trouble is, he says, that PCPs often complains of receiving no feedback from the psychologist to whom they refer patients in the traditional model of mental healthcare.

In the integrated model, the psychologist works directly in the primary care office setting.  Psychologists must work quickly, taking no more than 15 to 30 minutes to explain the framework of treatment to the patient, complete a diagnostic and functional assessment, and generate targeted interventions for the healthcare team. A total of one to three visits with patients is typical in this model of care. 

Strosahl says that the primary care physician sees 80% of the population in his or her catchment area while specialty mental health providers only see 3 to 5%.  Therefore, it is the primary care team that is seeing most of the behavioral health problems in this country. To convince PCPs of the utility of an integrated model, Strosahl tells physicians that  “we understand you have an impossible job. You will never do it without assistance.”

Strosahl points out that the primary physician is typically doing a good job recognizing and treating emotional disorders.  “When you see 32 patients a day, are you going to ask each and every one of them about their stressors?”  He believes that PCPs are aware which patients in their practice need careful observation because of their tenuous mental health status.

Given the national trend toward population-based healthcare, Strosahl foresees that only one mental health professional group will be hired in the future as the preferred provider in settings that use the integrated primary care model. It is not clear, says Strosahl that psychology will be the winner in such a model. “There is a Darwinian process going on, and psychologists may be on the endangered species list” he says. “There is a widespread perception that psychologists don’t offer anything distinctive.”

He maintains that psychologists need to become proactive at helping to push toward better integration of physical and behavioral health services. “If we are persistent, if we make ourselves available, we have models of service delivery that work.”  Once physicians see how the integrated model works, they will like it and see it as preferable to the old system.

Asked to recommend practical steps for psychologists, Strosahl pointed out the importance of figuring out how to pay psychologists for working as consultants in primary care.  Strosahl’s strategy appears to stand the best chance if private sector insurance companies follow suit with the Health Care Financing Administration in adopting the new health and behavior CPT codes. This would likely motivate more psychologists and primary care providers to adopt Strosahl’s approach.

Hartman-Stein, P.E. (in press) Team-based approach to managing client’s problem is psychologist’s path for future. The National Psychologist, Vol. 10, No. 3, p16.