Richard J Seime, Matthew M Clark, Stephen P Whiteside. The Health Psychology Handbook: Practical Issues for the Behavioral Medicine Specialist. Editor: Lee M Cohen. Sage Publications. 2003.
There has been tremendous growth in the number of psychologists with a primary interest in practicing in medical settings. In this chapter, we cannot provide an exhaustive review of the literature but instead present a perspective that will help put the subsequent chapters into a professional context. The goal of this chapter is to briefly review the roles of clinical health psychologists, address some issues of practice in a medical setting, and focus on specific strategies and recommendations on “how to” function as a clinical health psychologist in an academic health science center. The authors of this chapter represent different levels of training and background; therefore, they provide the perspectives of a psychologist in training (Stephen Whiteside), a health psychology researcher/clinician/educator (Matthew Clark), and a senior clinician/educator/administrator (Richard Seime).
Background
The health issues facing Americans have changed greatly over the past century. People live longer, and they experience different challenges to their health. Previously, many died from infectious diseases such as tuberculosis and influenza. The death rate from life-threatening infectious diseases declined during the mid-20th century due to advances in preventive measures and medical care. While the AIDS epidemic has created complex and important new challenges, most Americans will experience health problems related to cardiovascular disease, cancer, cerebrovascular disease, unintentional injuries, and chronic obstructive pulmonary disease (Kaplan, Sallis, & Patterson, 1993). Americans are becoming more obese, are being less physically active, and are consuming more dietary fat (Kottke et al., 2000). It has been estimated that lifestyle behaviors account for more than 50% of the mortality from these diseases (McGinness & Foege, 1993). Smoking, physical activity level, and nutrition all are lifestyle factors, but so are mood, social support, and personality. Thus, clinical health psychology has an opportunity to contribute to the health and wellness of our population. Two case examples may help to highlight these issues.
Case 1: Mr. Smith is a 55-year-old business executive who recently completed his annual physical. His father died at 58 years of age from a myocardial infarction, or heart attack, and Mr. Smith worries frequently about his health. However, he is 40 pounds overweight, has not been a consistent exerciser since college, smokes one pack of cigarettes per day, and has three alcoholic drinks after work to “unwind.” He is on antihypertensive and lipid-lowering medications. His physician is recommending numerous lifestyle changes, and Mr. Smith was referred to you, a clinical health psychologist, for consultation. Case 2: Ms. Jones is a 65-year-old, recently widowed female who has coronary artery disease and had coronary artery bypass surgery. Her cardiologist referred her to a 12-week cardiac rehabilitation program, but Ms. Jones does not attend on a regular basis. When present, she appears lethargic, does not follow instructions, and reports that she is frequently feeling alone and isolated. Her cardiologist wants your assistance in evaluating her mood and providing assistance in her care.
These cases highlight different aspects of clinical health psychology. The first case may benefit from cognitive-behavioral therapy for lifestyle changes. Record keeping, stimulus control, enhancing social support, stress management techniques, and/or goal-setting strategies could be beneficial. The second case portrays how psychiatric comorbidity may affect adherence to recommendations for health behavior changes. Depression in cardiac patients, for example, increases the risk of reoccurrence (Frasure-Smith, Lesperance, & Talajic, 1995) and lowers medication adherence (Carney, Freedland, Eisen, Rich, & Jaffe, 1995). Thus, assessment and treatment of comorbid depression would be important for the second case example.
Unique Contributions of Psychologists
Increasingly over the past 25 years, the field of medicine has been recognizing the benefits of the biopsychosocial model. This philosophy adds an understanding and incorporation of psychosocial variables to the traditional biomedical approach (Engel, 1977). As experts in measuring and altering behavior, psychologists have a unique set of skills to combine with the practice of our medical colleagues in an effort to apply the biopsychosocial model to patient care. In an environment consisting of multiple health and mental health professions, psychology’s most important contributions are its study of complex behavior and its commitment to critical evaluation of treatment strategies and outcomes (cf. Schofield, 1969).
As a subspecialty of psychology, clinical health psychology applies assessment and learning theories to a unified view of physical and psychological health. Through this integration, health psychology can evaluate and treat many areas that frequently have not been addressed by the more traditional practices of clinical psychology and psychiatry. For instance, Belar and Deardorff (1995) identified three areas of consultation that clinical health psychologists address more directly than do other mental health practitioners: (a) treatment involving psychophysiological self-regulation or learning theory to medical problems, (b) predictions of response to medical-surgical treatments, and (c) reduction of health risk behaviors. The distinct ability of clinical health psychology to address these types of questions stems from differences with other mental health fields in four general areas: training, assessment, treatment, and research.
Training
Professional training influences the manner in which health care professionals think about clinical issues and influences the tools with which they evaluate and subsequently treat patients. The training of clinical health psychologists is complementary to the medical training of physicians due to its focus on the empirical investigation of cognition, behavior, emotions, and interpersonal relationships. Specifically, psychologists are trained in research, program evaluation, and measurement of behavior, areas in which psychiatrists and other mental health practitioners are not as thoroughly trained (Belar & Deardorff, 1995). The focus on health behavior change and prevention in training for the clinical health psychology subspecialty equips practitioners with a perspective that has advantages over both traditional clinical psychology and psychiatry training models. Namely, the former two disciplines are often viewed as being overly focused on psychopathology (Belar & Deardorff, 1995), thereby limiting services primarily to individuals with diagnosable mental disorders. This focus on psychopathology excludes patients without psychiatric disorders who, nonetheless, are exhibiting maladaptive cognitive or behavioral patterns that affect their health status and quality of life. Training in clinical health psychology, in contrast, incorporates the study of behaviors that promote good physical and emotional health, such as smoking cessation, weight management, development of adaptive coping mechanisms, and adjustment to chronic illness, in addition to traditional mental health training. Health psychologists are thereby able to assess these areas and intervene to promote healthy behaviors with or without a DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) diagnosis (American Psychiatric Association, 1994).
Assessment
The foundation of clinical health psychology is in standardized assessment, a practice that continues to be a hallmark of the discipline. Consultations often incorporate psychometric assessment, which may be one of clinical health psychology’s most unique contributions to patient care (Belar & Deardorff, 1995). Use of standardized measures, such as self-report questionnaires, reduces the chance of interviewer bias in assessment and adds an objective piece of information that can be used to standardize the assessment and monitor the success of the treatment interventions. No other mental health field has this foundation and expertise in psychometrics.
Another strength of the discipline is the type of information collected by clinical health psychologists. Some disciplines focus primarily on deriving a diagnostic label; in contrast, clinical health psychologists frequently conduct a functional analysis. A functional analysis of the symptoms incorporates the antecedents and consequences of each symptom or behavior. The singular use of psychiatric diagnoses has a number of pitfalls and liabilities. First, DSM-IV diagnoses (American Psychiatric Association, 1994) are not etiology based but rather descriptive in nature. Thus, psychiatric diagnoses do not adequately address or describe the factors that may have precipitated and/or maintained a patient’s symptoms and therefore do not provide sufficient information to determine which treatment interventions are likely to be successful for a given patient (Beutler, Wakefield, & Williams, 1994). Second, diagnostic labels, such as hypochondriasis and borderline personality disorder, can have pejorative or moral connotations that lead to negative effects (Van Egeren & Striepe, 1998). For example, these diagnoses can influence health care professionals to inaccurately attribute patients’ physical complaints to symptoms of psychopathology (Belar & Geisser, 1995) or can increase patients’ fear that their symptoms will not be taken seriously (Van Egeren & Striepe, 1998). Finally, diagnostic labeling can contribute to mind-body dichotomous thinking. For example, although the DSM-IV diagnosis of “psychological factors affecting a medical condition” is an improvement over the previous nomenclature of “psychogenic pain,” this new diagnosis still maintains a unidirectional causal link rather than acknowledging the interaction between patients’ physical symptoms and their behavior and emotional functioning (Van Egeren & Striepe, 1998).
A functional analysis has the strengths of objectively quantifying the frequency and intensity of a target symptom and locating where within the environmental context it occurs. This approach acknowledges that behavioral symptoms interact with emotional, cognitive, social, and physical processes within the patient. The patient is seen as not merely acting on his or her environment but rather as responding and reacting to behaviors from health professionals and the demands of being in the hospital. Moreover, the patient’s environment extends beyond health care factors, so a thorough “assessment requires awareness of life circumstances and an appreciation of expectancies placed on patients by themselves and others” (Rozensky, Sweet, & Tovian, 1997, p. 63). Completing a functional analysis to understand the environment in which a target behavior occurs, including the precipitating stimuli and reinforcing consequences, logically suggests a treatment plan to alter the expression of the symptom. Ultimately, providing information that clearly leads to a treatment is the goal of any clinical health psychology consultation.
More so than any other discipline, psychology has developed a body of knowledge regarding behavioral assessment (through interview and direct observation) that can be applied to understanding maladaptive behaviors not only by the patient but also by caregivers, both familial and professional. This approach stands in stark contrast to a purely biological explanation that locates pathology primarily within the patient. The contribution of clinical health psychology lies in emphasizing the role that learning and reinforcement play in maladaptive behaviors while also acknowledging biologically based personality and psychopathology factors.
Treatment
As in assessment, one of the strengths of psychologists in a medical center is that they can add a unique set of skills and options to the treatment plan. Although many physicians request that complicated psychopharmacological management be managed by their psychiatric colleagues, an attending physician will frequently employ a first-line antidepressant or anxiolytic before requesting a psychiatry consult. However, many physicians understandably lack the training expertise or comfort level to address many of the issues routinely treated by psychologists such as application of motivational interviewing to health behavior change (Bellg, 1998). Thus, consultation to a clinical health psychologist can add a novel treatment approach to a complex and challenging medical patient.
Many of the strengths of the treatments offered by clinical health psychologists emerge directly from their training and assessment. For example, because clinical health psychologists have expanded from a narrow focus on psychopathology, they can offer treatment options for patients who are not described by DSM-IV diagnoses (American Psychiatric Association, 1994). Clinical health psychologists can work with psychologically well-functioning individuals who are faced with challenging health problems. This is an important quality because it is not necessary to suffer from psychopathology to have difficulties in the hospital setting, in coping with illness, or in adhering to medical recommendations. To illustrate, adherence rates in pediatric populations can be as low as 5%, and thus many patients will benefit from assistance with adherence strategies (Dickey, Mattar, & Chudzik, 1975). Clearly, a singular focus on psychopathology, defined in part as a deviation from “normal” functioning, would not address a problem that occurs in the majority of individuals faced with a given medical situation. As a result of this expanded focus, clinical health psychology interventions with nonpsychiatric patients have facilitated health-promoting behavior changes and can have direct effects on biological factors that influence the onset and progression of disease (Bellg, 1998).
An additional strength of the interventions enlisted by clinical health psychologists is that they are theory driven, with an understanding of the mechanism of action. This is particularly true for interventions based on learning and behavioral principles. The opportunities for clinical health psychologists to apply these skills in medical centers are numerous, including stimulus control strategies to help patients with cardiovascular disease manage their environments, treatment of adjustment to medical illness, behavior problems and adherence in chronic health problems, cognitive distortions exacerbating symptoms of anxiety in patients with medical disease, and family problems exacerbating and resulting from health problems faced by the patient (cf. Camic & Knight, 1998).
Research
The fourth general area of unique contributions by clinical health psychology to medical center consultation is the application of research to patient care. Training in research design, implementation, and interpretation is emphasized in doctoral training in psychology to a greater degree than in medical training. These research skills can be applied at the individual patient level or at the treatment team level (Malec, 1991). For example, clinical health psychologists can systematically study the effectiveness of a particular treatment within a single patient or can compare separate treatments within an individual patient. This could be accomplished by obtaining structured behavioral observations of target symptoms before and after interventions from health care providers. Psychologists can also apply their research training to the evaluation of new treatment protocols. To date, among numerous other accomplishments, psychology has demonstrated the effectiveness of psychological interventions in reducing hospitalization rates in asthmatic and diabetic children (Christie-Seely & Crouch, 1987) and in managing chronic pain (Hardin, 1998).
Summary
Clearly, because of the nature of their training, clinical health psychologists have a multitude of unique skills and techniques that can be applied to the assessment and treatment of patients in medical centers. The contribution of a psychological consultation is being able to assess the biopsychosocial factors that affect a patient and then provide a cogent explanation to the patient for why he or she is experiencing difficulties. This empirically based explanation focuses on the patient as an individual with a history of experiences interpreted through the patient’s specific cognitive and emotional processing and logically suggests potential interventions. However, communicating and applying these skills effectively in the medical center, an environment that can feel alien to the inexperienced psychologist, can be challenging.
Important Issues in Medical Settings that Affect Psychological Practice
The Medical Model
Clinical health psychologists have clinical and research training and skills that are transportable from the doctoral training arena to the medical setting (cf. Belar, 1980). However, psychologists frequently confront a setting that is steeped in the medical model. The medical model is the cornerstone of clinical practice in health science centers. The medical model assumes that a practitioner will diagnose a problem, identify etiological factors, and ultimately correct the underlying issues that result in the overt dysfunction or problem. This is often seen initially by psychologists and psychologists in training who are unfamiliar with practice in a medical setting as antithetical to behavioral or psychological formulation. As Shows (1976) pointed out, doctoral students often emerge from their doctoral training with negative attitudes about the medical model. Mistakenly, psychologists’ initial reaction to the medical model is that physicians may be trying to find a disease where none exists. In fact, historically some of the tension between psychologists and psychiatrists in the medical setting is around the medicalization or pathologizing of behavioral issues or emotional distress. At its worst, the medical model can “portray the patient as sick and dependent and the professional as imperialistic and heroic” (Belar & Deardorff, 1995, p. 30). So, psychologists must come to terms with the medical model.
Psychologists often malign the medical model, but it is a “fact of life” in medical settings. Therefore, it is important to address one’s attitude about the medical model so that one can effectively communicate, collaborate, and intervene in the medical setting. It may be helpful to reframe this model as representing an empirical approach to diagnosis and treatment. A common value held by both clinical health psychologists and our medical colleagues is an emphasis on empiricism. Likewise, it is important to get to know colleagues and to ascertain their attitudes toward psychology and psychologists. With the increased representation of psychologists in medical settings, medical colleagues have become aware of the unique skills that psychologists bring to the medical setting. It has been our experience that these colleagues appreciate the clinical health psychologist who is able to help both the patient and the physician to understand problematic emotions and behavior and to intervene effectively.
Concerns Related to the Medical Model
Diagnosis by Exclusion. It is essential that clinical health psychologists avoid making a diagnosis by exclusion. Often patients are referred when there are no positive physical findings but there is dysfunction, and referring colleagues may erroneously conclude that this equates with the assumption that “there must be something psychologically wrong.” In such a circumstance, we as psychologists must still identify positive findings to conclude that psychological or behavioral factors can account for a problem. Here is where our skills in functional analysis, use of data gathering, and psychometric assessment all can play a role in determining what might account for dysfunction in the absence of physical findings. It is important to have a working knowledge of the pathophysiology, behavioral, and psychological issues common with medical disorders that we are called on to evaluate as a consultant. Keep in mind also that some diseases, such as multiple sclerosis, have elusive or equivocal findings. In most cases, it is far too simpleminded to dismiss as psychological or functional a patient’s presenting problems if no definitive physical signs or findings are obtained. In cases such as this, it behooves us to recognize that we play an important role in ensuring that the patient continues to feel that we will encourage an ongoing consultation with the referring physician as we also work to help the patient get well. Somatizing patients in particular can represent a real challenge, but even patients with somatization disorders have legitimate needs for ongoing medical evaluation and care. What we have to offer these difficult patients is a different model for addressing their dysfunction that looks at behavioral, social, and psychological factors as they interact with biological factors to account for their difficulties and dysfunction.
Ignoring Psychological Factors. This is the converse in a sense of diagnosis by exclusion. In this pitfall, a physician may have recently diagnosed a physical or biological problem after having not been able to do so for some time. Perhaps a patient has been suffering from distress or depression, engaging in maladaptive behaviors, or reinforced for sick role behavior. Now the patient has received a medical diagnosis, and this new “organic” finding is seen as accounting for all of his or her difficulties and symptoms. This error in thinking can lead to poor patient management in some cases. For example, assume that an individual has been having severe anxiety and panic attacks that have led to agoraphobic behaviors. A recent physical now reveals abnormally high thyroid hormone levels. Does the fact that this individual may be more prone to anxiety as a result now account for the behavioral dysfunction? The basic principle is simply that in the process of serial diagnosis of problems, it is not necessarily the case that a particular physical finding accounts for all of the subsequent or preceding problems. From a biopsychosocial perspective, many factors are at work simultaneously. What we are best at doing as psychologists is assessing what is happening in the dimensions of behavior, cognition, and emotion as well as in the social milieu of the patient that provides some avenue for understanding the current dysfunction and how to ameliorate the dysfunction.
Medical Background versus Psychology Background
There are obvious differences between psychologists and physicians in the nature of their training. From the time a physician graduates from medical school, he or she is expected to be caring for patients, making decisions, being on the “front line,” and quickly diagnosing and treating medical issues. However, physicians frequently have limited confidence in their ability to counsel patients or deal with psychological and behavioral issues due to a lack of training. Thus, it is important to realize that physicians often feel quite inadequate in addressing the behavioral and emotional factors that are present in so many of the patients they evaluate and treat (e.g., Kroenke & Mangelsdorff, 1989; Philbrick, Connelly, & Wofford, 1996).
The psychology trainee who is new to the medical setting, or the psychologist who has little experience in the medical setting, can find the medical environment quite intimidating. Besides often feeling as though his or her medical knowledge is lacking, the psychologist can be intimidated by the pace, the presumed expectation of certainty about psychological formulations and interventions, and the expectation of “answers.” To manage these feelings and assumed expectations, remember that although physicians have had a different “track” in their training compared with other health professionals, this does not in any way invalidate the unique knowledge, clinical assessment, and intervention skills that clinical health psychologists bring to the health care arena. In terms of training, Belar and Deardorff (1995) stated that didactic experiences alone are not sufficient for the practice of health psychology. They emphasized the importance of appropriate role models, supervisors, and mentors. This is consistent with our experience in having trained and supervised practicum students, predoctoral interns, and postdoctoral fellows. Those trainees and psychologists who have had mentors working in medical settings, who have had physician collaborators and mentors, and who have had the opportunity to train side by side with physician trainees have an appreciation for physician knowledge without being intimidated.
Working Within the Organizational and Political Structure of a Medical Setting
The clinical health psychologist with a solid training background in assessment, intervention, and professional skills enters a challenging environment in the medical setting. It is an environment governed by formalized rules (e.g., hospital bylaws, staff privileging) and informal “rules,” many of which are not familiar to psychology graduate students. Therefore, we emphasize the importance of receiving training in a medical setting from mentors who are familiar with the medical setting. It has been our experience that physicians and other allied health professionals are welcoming of psychologists—but pitfalls abound. Belar and Deardorff (1995) discussed the implicit and explicit power hierarchy that affects a psychologist’s role function in a medical setting. Psychologists, especially those who are new to the field or who are still in training, need to be especially sensitive to the role of the referring physician—the provider who is in charge of ordering consultations and who ultimately is responsible for the patient in a hospital setting. A clinical health psychologist is invited to see a patient by the physician who orders a consultation. Although it is important to have excellent relationships with an entire treatment team, ultimately it is the attending physicians who have the final say as to who sees their patients and what is offered to the patients. This process can be confusing to the clinical health psychology trainee or psychologist more familiar with outpatient practice, where several consultants may be working with the same patient. In our experience, a psychologist needs to consider both the formal aspects (i.e., rules and regulation governing practice) of how to function as a psychologist in a consultative role and the informal aspects of how best to be effective in a consultative role. The informal aspects of effectiveness include the quality of the collaborative relations with other disciplines (Sweet & Rozensky, 1991) and the psychologist’s personal style. For example, Belar and Deardorff (1995) suggested that the most effective clinical health psychologists in a hospital setting are those who are “active, open, direct, assertive, and energetic” (p. 33) and who have a higher tolerance for frustration. We would add that the most effective psychologists are those who have the background, knowledge, interest, clinical training, and interpersonal skills needed to deal with both complex patient care issues and a complex, multilayered health care delivery environment.
At a minimum, the clinical health psychologist who intends to work effectively in a medical setting needs to understand the formal governance aspects of psychological practice in a medical setting. This topic is addressed only briefly here, and the reader is referred to expanded yet succinct coverage of these issues by others (e.g., Belar & Deardorff, 1995; Rozensky et al., 1997). The medical staff/hospital bylaws, rules, and regulations govern how psychologists are formally recognized in the hospital setting. What a psychologist is able to do professionally in a hospital or medical center is governed by staff privileges (i.e., what a psychologist is permitted to do once granted a formal status with the hospital). Whether a psychologist participates in formally determining rules and in setting standards for practice in the hospital organization is determined by the category of staff membership (e.g., active staff, consulting staff, courtesy staff, allied heath staff). Only voting staff membership (i.e., active staff) permits a formal voice in medical staff/hospital staff affairs.
A clinical health psychologist also needs to be well aware of the administrative structure of psychology in the medical setting where he or she works. The psychologist needs to know the organized “unit,” whether it be a section or division within other clinical departments or an independent department of psychology. An organized psychology unit facilitates the individual psychologist’s professional role function in the medical setting. Frank (1997) and Seime (1998) reviewed some of the issues associated with the organizational structures within health science settings. Connecting with the administrative structure for psychology is required in most institutions. The medical setting provides such an enticing wealth of professional opportunities that novice psychologists can make serious mistakes, without intending to do so, that may jeopardize their future practice. Thus, as Rozensky (1991) pointed out, it is important to both understand and master a specific hospital’s “political milieu.” Fortunately, we are now at a stage in the development of clinical health psychology throughout many medical settings and academic health science centers where seasoned clinicians/mentors are readily available to assist the junior psychologist in how to be effective in medical settings.
Consulting and Liaison Opportunities
The role of a consultant in a medical setting can take many forms, and serving as such is the most common role for clinical health psychologists. Typically, a consultation involves an evaluation whereby the patient is provided with a formulation and treatment recommendations. Often, the patient is referred for further services that may require additional medical consultation, mental health services, and/or other health care services (e.g., occupational or physical therapy, nutritional counseling). This consultation model fits well with a traditional outpatient practice. There also has been a recent surge of interest in psychologists affiliating with primary care clinics or departments of family practice where ongoing consultation is provided to both patients and health care professionals. In this capacity, the psychologist serves the dual role of a consultant and a liaison psychologist (e.g., being involved with a program, regularly interacting about psychological and behavioral adjustment of patients, consulting with staff, treating patients). As the clinical health psychologist gets involved in a liaison role, he or she begins to move away from a more traditional mental health practice and toward a clinical health psychology practice. Liaison roles provide a rich opportunity for both research and clinical collaboration. The physician or other health care professional is not directly referring patients “to the psychologist,” but the psychologist becomes a regular part of the program’s evaluation and service delivery. A liaison role also provides an excellent opportunity for the psychologist to intervene with the treatment team, to educate, and to affect program development.
Typically, consulting roles involve fee-for-service. The psychologist interviews the patient and assesses for behavioral, cognitive, social, and/or mental health difficulties. There may be difficulties in billing for these services, particularly for patients who do not have a mental health diagnosis under the DSM-IV criteria. However, as of January 2002, there are now “current procedural codes” (American Medical Association, 2001) that include health and behavior assessment and intervention codes for patients whose primary diagnosis is physical. This is a major breakthrough to permit appropriate reimbursement for the delivery of psychological services to the patient with significant physical problems requiring psychological intervention but without a DSM-IV mental health diagnosis.
Liaison roles for psychologists are satisfying, but practical fiscal issues can limit the psychologist’s time in such activities. It is important to negotiate with a program to compensate for the psychologist’s time that does not involve direct billable services. In our experience, it is not uncommon for programs to greet the involvement of a clinical health psychologist in the liaison role but to not be able to pay for the intensive time involved in such efforts. In academic health science settings, one strategy is for psychologists to pair the ongoing liaison role with a research endeavor funded by a grant that serves to both purchase time and fulfill research interests and goals.
Training Background and Skills
Belar and colleagues (2001) noted that graduate students now have a multitude of opportunities to obtain appropriate preparatory supervised experiences as graduate students, predoctoral interns, or postdoctoral fellows. Graduate school training serves as the foundation by providing training in the biological, cognitive, affective, social, and psychological bases of behavior. Such training could be integrated with graduate training, but it has been our experience that this training more typically is obtained during the predoctoral internship year or as a postdoctoral fellow.
Although postdoctoral fellowship programs have existed for a number of years, only recently has there been an emphasis on having organized, structured, and accredited postdoctoral fellowship training. Recently the Committee on Accreditation of the American Psychological Association (APA) has recognized specialty postdoctoral fellowship programs in clinical health psychology. There are a few postdoctoral programs that have received APA accreditation, with others soon to be added. Training at the predoctoral internship level in an APA-accredited program within a medical setting will ensure supervised experience in the medical environment. The opportunity to practice under supervision, to consult regularly with other health professionals, and to evaluate and treat medically referred patients is an invaluable training experience. The opportunity to then obtain further depth and breadth of experience and expertise is provided by postdoctoral fellowship training. Postdoctoral fellowship training will also go a long way toward assisting the psychologist in becoming board certified in clinical health psychology. The American Board of Professional Psychology has recognized clinical health psychology as a specialty since 1990 (Belar & Jeffrey, 1995).
As we advance in our careers, we all will need to constantly further our knowledge and develop new skills. For a practicing psychologist, whether early or late in his or her career, there are suggested principles that can guide self-directed learning to remain competent and to develop new areas of competency as a psychologist providing services to medical-surgical patients. Belar and colleagues (2001) developed a template for self-assessment for the practicing clinical health psychologist. The template is presented in Table 1.1.
Translating Psychology Practice and Skills Into a Medical Setting
As noted previously, graduate education may provide doctoral students with training that will facilitate their functioning as clinical health psychologists. These educational experiences include course work and clinical training in epidemiology, health psychology, psychological testing, behavior therapy, family therapy, geriatrics, and psychopharmacology. Unfortunately, it has been our experience that some needed skills are not taught and that some psychology practices do not translate well into medical centers.
Pitfalls. There are many skills that are critical for the successful practice of clinical health psychology but that are overlooked during graduate training. Some skills are unique to health settings (e.g., managing on-call schedules, learning ICD-10 [International Classification of Diseases, 10th edition] codes), whereas other skills are general practice skills often overlooked in graduate education (e.g., billing procedures, documentation requirements and modalities). Many clinical health psychology trainees are not initially prepared for the unique challenges posed by medical centers. It is not uncommon for trainees to be asked to make a diagnosis after conducting a brief bedside consultation (e.g., 15 minutes) with a client in a medical setting, whereas mental health clinics would frequently set aside at least 1 full hour for an initial intake interview. Likewise, trainees are often taught to write extensive evaluation reports primarily intended for other psychologists, whereas clinical health psychology reports are expected to be brief and to use language easily understood by a number of different health care professionals. In a mental health care setting, psychologists are providing most (if not all) of the treatment, whereas in a health care setting, psychologists are only part of the treatment team where psychological interventions must be coordinated with medical treatments. This transition is not always easy for individuals who have little or no experience with interdisciplinary teams.
| Table 1.1 Template for Self-Assessment of Readiness for Delivery of Services to Patient With Medical-Surgical Problems | |
| 1. | Do I have the knowledge of the biological bases of health and disease as related to this problem? How is this related to the biological bases of behavior? |
| 2. | Do I have knowledge of the cognitive-affective bases of health and disease as related to this problem? How is this related to the cognitive-affective bases of behavior? |
| 3. | Do I have the knowledge of the social bases of health and disease as related to this problem? How is this related to the social bases of behavior? |
| 4. | Do I have the knowledge of the developmental and individual bases of health and disease as related to this problem? How is this related to the developmental and individual bases of behavior? |
| 5. | Do I have the knowledge of the interactions among biological, affective, cognitive, social, and developmental components (e.g., psychophysiological aspects)? Do I understand the relationships between this problem and the patient and his or her environment (including family, health care system, and sociocultural environment)? |
| 6. | Do I have the knowledge and skills in the empirically supported clinical assessment methods for patients with this problem and how assessment might be affected by information in areas described by Questions 1 to 5? |
| 7. | Do I have knowledge of, and skill in implementing, the empirically supported interventions relevant to patients with this problem? Do I have knowledge of how the proposed psychological interventions affect physiological processes and vice versa? |
| 8. | Do I have knowledge of the roles and functions of other health care professionals relevant to this patient’s problem? Do I have skills to communicate and collaborate with them? |
| 9. | Do I understand the sociopolitical features of the health care delivery system that can affect this problem? |
| 10. | Do I understand health policy issues relevant to this problem? |
| 11. | Am I aware of distinctive ethical issues related to practice with this problem? |
| 12. | Am I aware of the distinctive legal issues related to practice with this problem? |
| 13. | Am I aware of special professional issues associated with practice with this problem? |
| SOURCE: Copyright © 2001 by the American Psychological Association. | |
In spite of the challenges and pitfalls, it has been our experience that the transition to a medical center is a rewarding yet challenging experience that can be facilitated through adequate preparation. A template for effective practice is described in the next section.
Strategies for Effective Practice
First, the psychologist should select an area of high interest. The patient population needs to be one for which the provider has a “passion.” Much time, energy, and devotion will be needed to develop expertise, so being passionate about one’s work is important. The psychologist should also pursue additional training through seminars, workshops, readings, and supervised clinical experience as suggested in the self-assessment template presented in Table 1.1. Once the psychologist has the expertise, forming an alliance with physicians will ensure continuity of medical care and will facilitate referrals. Completing comprehensive evaluations with clear recommendations will enhance satisfaction from referring physicians. Ongoing communication with health care providers is essential for patient care and will promote future referrals (Jowsey, Taylor, Schneekloth, & Clark, 2001). Maintaining contact with applied psychologists and other mental health providers will enhance the psychologist’s effectiveness with his or her medical colleagues. For example, “No, I’m not able to assist your patient with couples counseling, but I can offer an excellent referral” is a more useful response than “Sorry, I don’t provide couples counseling.” We do not expect physicians to treat all problems, but we do expect them to refer as needed.
Finally, developing research projects focusing on program evaluation will assist in solidifying a clinical practice and will allow for documentation of effectiveness of services. As noted earlier, one of the distinctive skills that psychology brings to the medical setting is psychologists’ extensive training in research. Psychologists are in the unique position of continuing to contribute to scholarly endeavors as part of their professional practice.
Psychologists have professional ethical guidelines and standards of practice to follow that may differ from those of other professions. It has been our experience that direct clear communication can prevent many dilemmas and will be well received by one’s medical colleagues. For example, the importance of limiting and preventing dual relationships can be explained in a manner that is well received. In addition, discussions about how psychological test data and reports are different from lab work, and thus have different needs for confidentiality, have been well received by our medical institutions.
Trainees can be wonderful bridge builders. Having psychology trainees mentored, educated, or supervised by physicians has built many bonds for us. Similarly, mentoring, educating, or supervising medical students, residents, and fellows builds relationships with potential future colleagues and builds relationships with the medical training faculty. Our predoctoral interns and postdoctoral fellows have established numerous collaborative clinical and research projects with our medical staff. Collaborative research not only improves the quality and comprehensiveness of the research but also fosters collaborative clinical projects. Struggling through a grant application, preparation for a presentation, or a chart review can be a wonderful team-building experience (Bock et al., 1997).
The Future is Bright
Although psychologists have been an integral part of medical settings for a long time, the past quarter century has been a time of rapid growth. Many professional societies have emerged as a result of the new and exciting opportunities for psychologists in medical settings. These organizations include the Society of Behavioral Medicine and the Association for the Behavioral Sciences and Medical Education. In addition, divisions of APA, such as Division 38 (Health Psychology), Division 40 (Clinical Neuropsychology), Division 54 (Society of Pediatric Psychology), and Division 12 (Society of Clinical Psychology), have grown and developed around the interests of those working in medical settings. There are a host of APA-accredited internships in medical settings and a growing number of postdoctoral fellowship programs focusing on clinical health psychology. Likewise, journals that have clinically relevant research specifically related to medical settings have emerged (e.g., Annals of Behavioral Medicine, Health Psychology, Journal of Behavioral Medicine, Journal of Clinical Psychology in Medical Settings). The growth of information technology offers incredible opportunities for psychologists to be informed and to practice in an evidence-based fashion. Journal articles are available online, and literature searches are readily accessible through resources such as PsycINFO, MEDLINE, and EBM (Evidence-Based Medicine) -Cochrane Database of Systematic Reviews. Information relevant to psychological practice now is at our fingertips. Psychologists will continue to play a significant role in medical settings through the delivery of clinical services, teaching, research, and health service administration. Perhaps the next frontier will be the involvement of clinical health psychologists in the genomic revolution as advances in the understanding and use of genetic data affect how diseases are treated, prevented, and understood (Patenaude, Guttmacher, & Collins, 2002).