Daily Archives: August 10, 2010

State of the Union in Mental Health


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The first ever surgeon general’s report on the “state of the union” in mental health was issued in 1999.  David Satcher, (now former) Surgeon General of the United States, emphasized the importance of adopting a public health perspective, accepting that mental disorders are disabling, and seeing both mental health and mental illness as points on a continuum.  (U.S. Department of Health and Human Services, 1999)  He highlighted overarching themes of reducing and eliminating the stigma associated with mental illness, the importance of a solid research base to evaluate the practicality and effectiveness of new approaches, and overall accountability to the individuals for whom and intervention is intended.  (Satcher, 2000)  Satcher’s submission represents a blueprint for change.  It’s been 10 years since this comprehensive report. This essay will attempt to access the following question: “How have we done?”

The foundation of Satcher’s public health perspective was rooted in the concept of preventive interventions.  Since 1999 we have made significant progress in developing family-focused preventative interventions (Redmond, Spoth, Shin, & Lepper, 1999) including mother and mother-child programs for children of divorce (Wolchik et al., 2000).  We have adopted an early intervention strategy and attempted to focus our preventative efforts on the individuals who have the most to gain/lose, children.  Preventative efforts focused on coping with anger and stress, family bereavement, bullying, early conduct disorder, social relations, stress inoculation, and suicide prevention are yielding significant results among school-aged children.  (Greenberg, Domitrovich, & Bumbarger, 2001; Shaw, Dishion, Supplee, Gardner, & Arnds, 2006; Weissberg, Kumpfer, & Seligman, 2003)  The underlying theory of many, if not most, of these research efforts is that “prevention programs enhance children’s socio-emotional competence and prevent the emergence of behavior problems.”  (Webster-Stratton, 2003)

Although research suggests that there are correlates of life satisfaction in those with disabling conditions, much of the work has been focused on physical disabilities as opposed to mental illness.  (Mehnert, Krauss, Nadler, & Boyd, 1990; Schröder et al., 2007)  More work remains to be done regarding overall public awareness of exactly how debilitating mental illness can be.  This is particularly true in the cases where individuals whom are heavily medicated may be more disabled by their medication than by the mental illness itself.  (Waldman, 1999)

If we consider seeing mental health and mental illness as points on a continuum a goal, then we should consider ourselves closer to that goal then we were 10 years ago.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000)  Differential diagnosis is more prominent in the DSM-IV-TR than it was in any previous revision of the DSM, and we have every expectation that we will continue to see movement towards continuum based differential diagnosis in the upcoming DSM-V.    As a profession, we can expect that the differentiation between normal psychological functioning and pathological functioning will continue to be defined, or redefined.  (Widiger & Clark, 2000)  We can expect that diagnostic categories be removed, added, merged, linked, or otherwise cross referenced to reflect the “points on a continuum” perspective.  If I could predict the specific changes we should expect I wouldn’t be here, but I can be fairly certain that we should expect change in general.

Reducing and eliminating the stigma associated with mental illness is a tall order that is constantly in the process of fulfillment.  Despite persistent efforts, anti-stigma campaigns have not yet resulted in the desired changes in public attitudes and perceptions.  (McNulty, 2004)  “Many people who would benefit from mental health services opt not to pursue them or fail to fully participate once they have begun.  One of the reasons for this disconnect is stigma; namely, to avoid the label of mental illness and the harm it brings, people decide not to seek or fully participate in care.”  (Corrigan, 2004, p. 614)  The availability of accurate information, persistent social marketing, and direct contact with the mentally ill can effectively combat the negative stereotypes associated with individuals who suffer from mental illness.  (Kirkwood & Hudnall, 2006)  Nonetheless, there is much work to be done… it is certainly a work in progress.  Furthermore, the DSM has made an effort to reduce stigma by changing verbiage.  For example, people who suffer from alcoholism are no longer referred to as “alcoholics” in an effort to focus on the disease, not the deficiency of the individual.

Nowhere have we made more progress than in the arena of developing a solid research base.  Never before in human history have individual clinicians had access to the depth, breadth, and quality of research that we have today.  This is due, in large part, to technology and the advent of reference-able online material.  Scholars are no longer required to scour books at the library in search of support… we simply find a keyword and plug it into resources like Google, ProQuest, PsycARTICLES, WilsonWeb, ERIC or MEDLINE.  The efficient dissemination of information is critical to our success as a mental health community because it prevents duplicate research efforts.  It also provides instant access to research that can justify both diagnosis and treatment modalities.

We have also made significant progress in the form of accountability.  Federal and state regulatory authorities are constantly reviewing, revising, and reinforcing quality control practices with regard to education and credentialing of mental health professionals.  (Nelson, 2007)  Despite the fact that outcome evaluation programs are becoming more common with regard to child welfare services, they are still lacking in the field of mental health as a whole.  (Wall et al., 2005)  Informed consent is now mandatory in most states, although there is a definitive lack of consistency in terms of what that informed consent document should contain, or how clearly it should be worded.  (Walfish & Ducey, 2007)

There’s more work to be done, so the progress doesn’t stop here.  Our profession is currently being assaulted by rigorous cost control efforts in the form of managed care.  Increasingly, insurance companies are making the decision what is best for clients, not their caregivers… or, if the caregivers do weigh in on the decision, it is with the constraints of a limited number of sessions or available treatments.  Although we have made considerable progress on a number of fronts, including information dissemination, accountability efforts, reducing stigmas, and prevention… all of these avenues of progress will need continued emphasis into the 22nd century in order to have a lasting effect on the profession as a whole.

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Corrigan, P. (2004, Oct). How stigma interferes with mental health care. American Psychologist, 59(7), 614-625. doi: 10.1037/0003-066X.59.7.614

Greenberg, M. T., Domitrovich, C., & Bumbarger, B. (2001, March). The prevention of mental disorders in school-aged children: Current state of the field. Prevention & Treatment, 4(1), [np]. doi: 10.1037/1522-3736.4.1.41a

Kirkwood, A. D., & Hudnall, S. B. (2006, Oct). A social marketing approach to challenging stigma. Professional Psychology, 37(5), 472-476. doi: 10.1037/0735-7028.37.5.472

McNulty, J. P. (2004). mmentary: Mental illness, society, stigma, and research. NIMH, Schizophrenia Bulletin, 30(3), 573-575. Retrieved from http://ft.csa.com.ezproxy.bellevue.edu/ids70/resolver.php?sessid=ruib4jnm5uafkc6aefn5lthuo0&server=csaweb106v.csa.com&check=ab5542fe87c5d81a32140a205b771a50&db=psycarticles-set-c&key=SZB/30/szb_30_3_573&mode=pdf

Mehnert, T., Krauss, H. H., Nadler, R., & Boyd, M. (1990). Correlates of life satisfaction in those with disabling conditions. Rehabilitation Psychology, 35(1), 3-17. doi: 10.1037/h0079046

Nelson, P. D. (2007, Feb). Striving for competence in the assessment of competence: Psychology’s professional education and credentialing journey of public accountability. Training and Education in Professional Psychology, 1(1), 3-12. doi: 10.1037/1931-3918.1.1.3

Redmond, C., Spoth, R., Shin, C., & Lepper, H. S. (1999, Dec). Modeling long-term parent outcomes of two universal family-focused preventive interventions: One-year follow-up results. Journal of Consulting and Clinical Psychology, 67(6), 975-984. doi: 10.1037/0022-006X.67.6.975

Satcher, D. (2000, Feb). Mental health: A report of the Surgeon General–Executive summary. Professional Psychology, 31(1), 5-13. doi: 10.1037/0735-7028.31.1.5

Schröder, C., Johnston, M., Morrison, V., Teunissen, L., Notermans, N., & Van Meeteren, N. (2007, Aug). Health condition, impairment, activity limitations: Relationships with emotions and control cognitions in people with disabling conditions. Rehabilitation Psychology, 52(3), 280-289. doi: 10.1037/0090-5550.52.3.280

Shaw, D. S., Dishion, T. J., Supplee, L., Gardner, F., & Arnds, K. (2006, Feb). Randomized trial of a family-centered approach to the prevention of early conduct problems: 2-year effects of the family check-up in early childhood. Journal of Consulting and Clinical Psychology, 74(1), 1-9. doi: 10.1037/0022-006X.74.1.1

U.S. Department of Health and Human Services. (1999). Mental health: A report of the surgeon general. Retrieved from http://www.surgeongeneral.gov/library/mentalhealth/home.html

Waldman, E. (1999, Dec). Substituting needs for rights in mediation: Therapeutic or disabling?. Psychology, Public Policy, and Law, 5(4), 1103-1122. doi: 10.1037/1076-8971.5.4.1103

Walfish, S., & Ducey, B. B. (2007, April). Readability level of Health Insurance Portability and Accountability Act notices of privacy practices used by psychologists in clinical practice. Professional Psychology, 38(2), 203-207. doi: 10.1037/0735-7028.38.2.203

Wall, J. R., Busch, M., Koch, S. M., Alexander, G., Minnich, H., & Jackson-Walker, S. (2005). Accountability in child welfare services: Developing a statewide outcome evaluation program. Psychological Services, 2(1), 39-53. doi: 10.1037/1541-1559.2.1.39

Webster-Stratton, C. (2003). Aggression in young children services proven to be effective in reducing aggression. Retrieved August 8, 2010, from http://www.child-encyclopedia.com/en-ca/child-aggression/according-to-experts/webster-stratton.html

Weissberg, R. P., Kumpfer, K. L., & Seligman, M. E. (2003, June/July). Prevention that works for children and youth: An introduction. American Psychologist, 58(6-7), 425-432. doi: 10.1037/0003-066X.58.6-7.425

Widiger, T. A., & Clark, L. (2000, Nov). Toward DSM—V and the classification of psychopathology. Psychological Bulletin, 126(6), 946-963. doi: 10.1037/0033-2909.126.6.946

Wolchik, S. A., West, S. G., Sandler, I. N., Twin, J., Coatsworth, D., Lengua, L., … Griffin, W. A. (2000, Oct). An experimental evaluation of theory-based mother and mother–child programs for children of divorce. Journal of Consulting and Clinical Psychology, 68(5), 843-856. doi: 10.1037/0022-006X.68.5.84

Ooops! …on the potential for malpractice when serving diverse populations.


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If there is anything that keeps a therapist up at night, it’s the potential for a malpractice suit… misdiagnosis, diagnostic errors, and/or delayed diagnosis are at the forefront of our concerns.  “What if I get it wrong?”

Braun & Cox (2005) suggest some measures that can be implemented to reduce likelihood of getting into this legal or ethical dilemma.  Informed consent can help clients understand benefits, and allow the clinician to properly set expectations around the services that are covered… especially with regard to termination since additional sessions are likely to be expensive in some cases.  Furthermore, clients need to be aware that counselors can no longer ensure privacy of disclosure because managed care organizations (MCOs) may require sensitive information.  The release of this information may precipitate changes in treatment and outcome due to the fact that MCOs typically determine the type of treatment that should be employed and/or would be covered.  We would also need to familiarize ourselves with “brief therapy models” in order to be competent at providing services through MCOs.  (Braun & Cox, 2005, p. 426)  If we intend to work with this specific client population we need to be well versed in all of the above considerations before we even consider taking a client that intends to utilize them as a 3rd party payer.

Although I do not consider it to be a personal deficit, historically, there is a general mistrust and underutilization of the medical and mental health communities as it relates specifically to people of color.  Adequately addressing this climate of mistrust demands that we engage in an “honest and thorough self-examination of conscious and unconscious attitudes about race and the legacy of racism in the United States.”  (Suite, La Bril, Primm, & Harrison-Ross, 2007, p. 883)  Furthermore, Suite and associates (2007) suggest we “keep at arm’s length assumptions of cultural homogeneity and offer contextually based mental healthcare.”  They define contextually based mental healthcare as “extensive and critical interpretation of the historical, cultural, spiritual, political, social and philosophical underpinnings of racism in medicine and draw connections on how these factors impact the self-identities of communities and individuals therein.”  In my opinion, it is absolutely imperative that we attempt to understand how individual people of color perceive mental healthcare as an institution, as well as rebuild trust in the institution as a whole by delivering culturally sensitive options at every step of the therapeutic process.

References

Braun, S. A., & Cox, J. A. (2005, Fall). Managed mental health care: Intentional misdiagnosis of mental disorders. Journal of Counseling and Development : JCD, 83(4), 425-433. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=916199881&sid=10&Fmt=3&clientId=4683&RQT=309&VName=PQD

Suite, D. H., La Bril, R., Primm, A., & Harrison-Ross, P. (2007, Aug). Beyond misdiagnosis, misunderstanding and mistrust: Relevance of the historical perspective in the medical and mental health treatment of people of color. Journal of the National Medical Association, 99(8), 879-885. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1319356711&sid=10&Fmt=3&clientId=4683&RQT=309&VName=PQD

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Evidence Based Practice (EBP) and Managed Care


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Evidence-based Practice (EBP) is based on three pillars: “looking for the best available research, relying on clinical expertise, and taking into consideration the client’s characteristics and preferences.”  (Corey, Schneider-Corey, & Callanan, 2007, p. 446)  The suggestion is that we, as practitioners, should strive to provide minimum amount of treatment that gives maximum benefit in the least amount of time… as supported by the managed health care system that has been “the driving force in promoting empirically supported treatments (EST).”  (Corey et al., 2007, p. 443)

Where the EST system falls short is the fact that there can be a wide variation in presentations within one specific categorical diagnosis.  I agree with the premise that “this approach is mechanistic and does not take into full consideration the relational dimensions of the psychotherapy process.”  (Corey et al., 2007, p. 443)  What if, for example, the recommended treatment modality is obviously not sufficient to effectively treat an individual client?  What if, at the close of the 5th or the 6th session, the client has made little or no progress as a result of the ESTs?  Despite the focus on “best available research,” there is no single identified treatment method that works for everyone.  When EST fails, is the system flexible enough to recognize its shortcomings?

The concept of EBP and EST are in fact theory laden, but I question whether ever practicing clinician subscribes to that theory.  It is generally acknowledged that a practicing clinician should anchor his or her methodology to a theory… but if that theory differs from the 3rd party payer, I suspect that the clinician would be better off working outside of the managed care system.  My question is this… is that even possible today?  Can you effectively run a private practice and not accept EAP or managed care as a 3rd party payer?  If we choose not to accept those types of clients, isn’t that discrimination in its own right?

I am in support of the general underlying premise of EBP and EST, lowering costs and raising the quality of care should be something we should all aspire to.  However, I fail to see how force feeding a theoretical system on practitioners is in any way conducive to raising the quality of care… it would appear that it is 100% focused on lowering costs.  After all, lower costs are quantifiable (measured in $), and the relative quality of care is subjective.

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