Abstract
A major change is underway in health care practice. Increasing numbers of patients with psychological factors, soaring costs, and the effectiveness of behavioral health interventions is driving the shift to a more integrated model of health care. Behavioral health is becoming increasingly integrated into health care practice. The need for an integrated form of behavioral health is described as well as its theoretical basis, including the medical offset effect. Several emerging trends in psychotherapy practice are also noted as well as the implications of integrated behavioral health for mental health and family counseling practice.
Keywords
Traditionally, most health care is provided in primary care settings by physicians trained in the biomedical model. Not surprisingly, the treatment they provide consists largely of medications, medical procedures, and advice. Since more than half of medical patients have comorbid psychological issues, it was quite common for their psychological issues to exacerbate, complicate, or masquerade as physical symptoms. Sometimes, these patients were referred for psychological treatment by psychologists and mental health counselors. Occasionally, this psychological help was effective. Often, however, that treatment was not effective or patients refuse it. The result was and is overutilization medical services and rising health care costs. Whether the Affordable Care Act—also called Obamacare—is implemented or not, it calls for a shift to an integrative form of health care are inevitable. In broad designs, psychological or behavioral health interventions would be integrated with medical interventions. This is quite different than from the way in which psychological services or behavioral health is currently “carved out” and separate from medical care. Instead, integrated behavioral health is colocated—provided in the same location as primary care—and collaborative, herein the behavioral health provider is an integral member of the treatment team.
This article begins with a description of the need and justification for behavioral health services, including the “medical offset effect.” Next, models and anticipated role in health care settings and the importance of cultural competence in behavioral health care are described. Then, emerging trends in mental health practice are noted. Finally, some implications for individual and family counseling practice are discussed.
Behavioral Health: Need, Models, Roles, Culture, and Clinical Trends
Need
The need for behavioral health is important since about 50% of all patients in primary care present with psychological comorbidities, and 60% of psychological or psychiatric disorders are treated in primary care settings (Pirl, Beck, Safren, & Kim, 2001). Furthermore, the need for integrating behavioral health care has been obvious to many for some time. Simply stated, most physicians cannot provide the psychological care needed by the increasing numbers of medical patients. However, it was not until the financial justification for integrating it was made that behavioral health became a reality. There have been several efforts to integrate behavioral health into medical practice since the 1960s. These include Kaiser Permanente, Health care partners, Group Health Cooperative of the Puget Sound, Kaiser Group Health of Minnesota, and Duke University Medical Center, and more recently, the Veterans Administration (Cummings, O’Donohue, Hays, & Follette, 2001). All of these efforts have consistently demonstrated significant cost savings, referred to as medical cost offset.
A major meta-analysis of 91 studies published between 1967 and 1997 provided evidence for what the researchers called the medical cost-offset effect. Behavioral health interventions including various forms of psychotherapy were provided to medical patients with a history of overutilization as well as to patients being treated only for psychological disorders including substance abuse. Average savings resulting from implementing psychological interventions was estimated to be about 20% (Chiles, Lambert, & Hatch, 1999). In short, the medical cost offset effect occurs when emotionally distressed medical patients receive appropriate behavioral health treatment. As a result of this treatment, they tend to reduce their utilization of all forms of medical care. Even though there is a cost associated with behavioral health treatment, the overall cost savings is considerable.
A second area of medical cost savings is workplace wellness programs. A meta-analysis of the literature on costs and savings associated with such programs found that medical costs fall by about $3.27 for every $1 spent on wellness programs. It also found that costs attributed to absenteeism fall by about $2.73 for every $1 spent (Baicker, Cutler, & Song, 2010). Since more than 130 million Americans are in the workforce, wellness programs are increasingly important in containing health care costs. Presumably, mental health and family counselors can have a central role in both medical settings and wellness program settings.
Models
As already noted, most physicians operate from the biomedical model in which they were trained. An extension of the biomedical model is the biopsychosocial model (Sperry, 2006b) which incorporates the psychological and sociocultural dimensions with the biomedical dimension. The biopsychosocial model fosters integrative care and is the operative model in the practice of behavioral health.
Roles
Currently, behavioral health providers are most likely to be trained as psychologists, social workers, and mental health counselors, or family counselors. They work side by side with the rest of the health care team—physicians, nurses, and other allied health providers—to enhance preventive and clinical care for psychological problems that typically were treated solely by physicians. The role of behavioral health providers is to collaborate with the health care team to develop integrative treatment plans, monitor patient progress, and provide direct behavioral health care to patients.
Cultural Competence
Rapid changing demographics in the United States will increasingly require that cultural competence be incorporated into behavioral health services are delivered. Hunter, Goodie, Oordt, and Dobmeyer (2009) propose a patient-centered, culturally competent approach to behavioral health care that is sensitive to patient’s explanatory model of health and illness, various social and environmental factors affecting treatment adherence, as well as fears and concerns about medication and side effects. With such an approach, behavioral health counselors can effectively assist primary care providers in meeting the medical, psychological, and cultural needs of patients and their families.
Trends in Clinical Practice
The following are some predictions about trends in clinical and psychotherapy practice. First, assuming current reimbursement trends, psychotherapy will be done less by psychologists and more by social workers and mental health counselors. It is predicted that most psychotherapy will occur in integrative medical settings. In contrast, only a small number of clients will pay out of pocket to the few therapists who will be able to make a living serving only self-pay clients. Currently, only 5–7% of patients with insurance benefits will forgo those benefits and pay out of pocket for psychotherapy (Cummings & O'Donohue, 2008).
Second, are predictions about the mode of psychotherapy practice. “Only 25% of the psychotherapy of the future will be individual. Another 25% will be group psychotherapy, while at least 50% will be psychoeducational programs” (Thomas & Cummings, 2000, p. 399).
Third, currently mental health and substance abuse treatment constitutes a mere 5% of the health care budget in the United States. In the future, mental health providers will increasingly provide psychologically oriented services to the other 95% because “that’s where the money is” (Cummings & O'Donohue, 2008, p. 83). Presumably, this will occur in integrated primary care settings by behavioral health providers or behavioral care professionals (BCP), the designation coined by Nick Cummings (Cummings & Cummings, 2013). Instead of practicing in a location different from the primary care site, BCPs are better situated when they are co-located within the primary care site. The rationale for co-location is clear: when the behavioral health provider is off-site about 10% of patients follow through with a physician referral for outpatient mental health treatment. This contrasts with a 90% follow up rate when the BCP is co-located (Cummings & Cummings, 2013).
Fourth, it is predicted that psychotherapy will become briefer and more focused. Third-party payers will increasingly require that psychotherapy be as brief as possible, and not scheduled simply based on tradition or the convenience of the therapist. Reimbursed treatment will increasingly require that it be “medically necessary,” rather than therapy aimed at problems of living, improving self-esteem, pursuing self-actualization, or other nonspecific goals. This emphasis on treating only specific and at least moderately severe disorders means that psychotherapy in the future will look more medical or clinical than it does today. The 50 minute hour will be replaced by the 15 minute hour wherein the therapist will diagnose patients and begin treatment in 15 min, just as physicians (Cummings & O’Donohue, 2008).
Fifth, in addition to becoming briefer, it is predicted that psychotherapy will become more standardized. Rather than occurring weekly, sessions will be spaced further apart. Psychotherapy and other behavioral health services will be provided on as needed basis, rather than on a continuous basis as psychotherapy is practiced today (Cummings et al., 2001). Evidence-based and focused interventions will become the expected standard of practice, in sharp contrast to the way psychotherapy is practiced today (Thomason, 2010). Inevitably, psychotherapy will become a behavioral health intervention rather than a stand-alone profession.
While some of these predictions may seem extreme and far fetched, mental health and family counselors cannot afford to be complacent, given the economic challenges facing Americans (Thomason, 2010). In the next few years, the plausibility of these predictions will become evident as the Affordable Care Act, with its integrative health care vision, is further implemented.
Implications of Integrated Behavioral Health for Individual and Family Counseling
The emerging integrated health care philosophy is that integrated behavioral health care will utilize behavioral interventions for a wide range of health and mental health concerns. The primary focus will be on resolving problems within the primary care setting, as well as on engaging in health promotion and compliance enhancement for “at-risk” patients. The goal of health care integration is to position the behavioral health counselor to support the physician or other primary care provider and bring more specialized knowledge to problems that require additional help.
Accordingly, the behavioral health counselor’s role will be to identify, target treatment, and manage medical patients with health and/or psychological problems using a behavioral approach. They will help patients to replace maladaptive behaviors with more adaptive ones. In addition, they will provide skill training with psychoeducation and client education strategies.
More specifically, the behavioral health counselor will be expected to provide expertise in dealing with under motivated, noncompliant, or otherwise resistant patients. They will utilize motivational interviewing (MI) with individual patients (Rollnick, Miller, & Butler, 2008) and with patients’ families (Sperry, 2012) to increase readiness for change. They will also utilize focused cognitive behavioral strategies to increase compliance with treatment regimens, reduce symptoms, and increase their acceptance of chronic and life threatening illnesses (Sperry, 2006b, 2009).
Increasing Readiness for Change and Treatment Compliance with Family Interventions
Failure to follow treatment regimens or advice is called treatment noncompliance or nonadherence. It is a significant problem. Research indicates that 40–50% of patients in the United States do not comply with the health care plan for treatment such as medication, while nearly double that number fail to comply with dietary restrictions, exercise, or other restrictions of health-compromising behaviors (DiMatteo, Giordani, Lepper, & Croghan, 2002). Typically, health education was the approach or strategy most commonly used to increase treatment adherence.
Unfortunately, this approach is insufficient in changing patients’ behavior probably because it is persuasive, prescriptive, and focused on providing general advice. In contrast, a more collaborative, family-centered approach that focuses on the family’s beliefs, values, and health behaviors; and enhances the family’s self-efficacy and skills, is more likely to increase treatment adherence. Research comparing these two approaches showed a 64% success rate with knowledge or general advice alone and an 85% success rate for the more collaborative, family approach (Burke & Fair, 2003).
Family-focused MI
Because it is a collaborative approach that empowers patients, MI has become the intervention of choice in increasing treatment adherence to medical regimens (Rollnick et al., 2008). Furthermore, using MI with the patient’s family is noted to be superior to using MI with individual patients (Gance-Cleveland, 2005). See Sperry (2012) for a case illustration, including an extended session transcription, of family-based MI and their families.
Family Compliance Counseling
Family compliance counseling (Doherty & Baird, 1983) endeavors to educate patients and their families about their treatment regimen, provide a forum for patients and family members to share their emotional reactions and concerns about the disease and regimen, and achieve an agreement among family as to how the client will be supported in adhering to the treatment program. They offer a six-step process for conducting family-oriented compliance counseling: (1) assemble the family for a family interview, (2) begin with a discussion of the medical or lifestyle problem, (3) seek family feedback, (4) assist the family and client in making a contract about compliance with the prescribed regimen, (5) give them patient information material to read, and (6) schedule a follow-up meeting to monitor progress (Sperry, 2006a). Essentially, this approach is psychoeducational.
Brief Family Psychotherapeutic Strategy
A focused, psychotherapeutic strategy called cognitive behavior analysis system of psychotherapy can be utilized in about 15 min to process a problematic situation, such as treatment noncompliance, and come up with alternatives ways of achieving the expected health outcomes. Unlike clients who present themselves for conventional individual, couples, or family therapy, medical clients are not as likely to be receptive to more conventional therapeutic treatment strategies that are longer in duration and less focused than the treatment strategy described and illustrated here. Typically, these issues involve treatment compliance, denial of illness, difficulty with a physician, and even symptom remission. A detailed case example with session transcription illustrates this family-based intervention to increase treatment compliance (Sperry, 2006a).
Concluding Note
Given the changes already noted, it appears that the practice of individual and family counseling is likely to change, and in some ways the changes may be dramatic. To the extent that integrated health care becomes the norm, the practice of individual and family counseling within an integrated behavioral health context will be notably different. Shorter and more focused interventions will likely replace the 50 minute hour and conventional ways of intervening with individuals and families. As reimbursement shifts to favor integrated health care, increasing numbers of counselors will work in primary care settings, although some may still work in agencies or private practice. Those providing family counseling in integrated behavioral halt settings will be expected to deal with under motivated, noncompliant, or otherwise resistant patients and utilize focused interventions like family MI and family compliance counseling (Sperry, 2006a, 2012) to increase the patient’s readiness for change and enhance treatment compliance. Developing and providing such expertise will greatly increase the credibility and clinical value of family counselors practicing in integrated behavioral health settings.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.