1. Health Service Psychology What does it mean for counseling center internship programs? Joyce Illfelder-Kaye, Ph.D. Penn State University Kathlyn Dailey, Ph.D. Texas State University

2. O UTLINE Overview of changes in the field What Counseling Centers are currently doing that can be considered health service provision What lessons can be learned from those centers that are providing integrated health care in primary care? Discussion

3. I MPACT OF THIS ON COUNSELING CENTER INTERNSHIP TRAINING DIRECTORS Anxiety and questions ???? Are we Health Service Psychologists? What would we have to change to be HSP’s? What will we lose or gain if we have to change? What sort of training should we be providing to interns so they will be trained for the world they are entering?

4. O VERVIEW OF CHANGES IN THE FIELD Resolution on Accreditation for Programs that Prepare Psychologists to Provide Health Services states: “Psychologists are recognized as Health Service Providers if they are duly trained and experienced in the delivery of preventive, assessment, diagnostic and therapeutic intervention services relative to the psychological and physical health of consumers based on: 1) having completed scientific and professional training resulting in a doctoral degree in psychology; 2) having completed an internship and supervised experience in health care settings; and 3) having been licensed as psychologists at the independent practice level” (APA,1996; APA, 2011); From 2010 APA Model Act for State Licensure of Psychologists

5. W HERE IS THIS PRESSURE COMING FROM ? Movement to rebrand ourselves as “Health Service Psychologists” (not Health Psychologists) is coming from APA Reflections on the Future: Psychology as a Health Profession, Cynthia Belar, PPRP, 2012 Abstract: “The author describes a vision of psychology’s future as a health profession. In broadening its focus from mental health to a range of health issues, the profession is faced with a number of challenges related to establishing its identity, ensuring public confidence, and participating in the health care system…”

6. S EPTEMBER 2013- A MERICAN P SYCHOLOGIST Professional Psychology in Health Care Services A Blueprint for Education and Training Authors are listed as Health Service Psychology Education Collaborative Who are they and how did they come to be?

7. B ACKGROUND - FROM THE ARTICLE In March 2010 CCTC approached APA BEA “to request action be taken” about what? Efforts to deal with the match imbalance “brought increased attention to a number of important issues facing professional psychology education and training. It became widely known that the imbalance was one component of a larger set of problems that needed to be addressed.”

8. B ACKGROUND ( CONT.) “Advances in psychological science have moved psychology from focusing on mental health problems to being a broad health profession in which mental health remains an important subset….” “Psychologists must be prepared to work in the health care system of the 21 st century” Many articles articulating these changes were cited including articles by Belar (1989,1995, 1997, 2012)

9. W HO WAS ON THIS GROUP ? BEA authorized funds to support an inter- organizational working group that was later funded through the APA strategic plan initiatives and came to be known as the Health Service Psychology Education Collaborative” A small group comprised of representatives appointed by the APA Board of Educational Affairs( BEA), Council of Graduate Departments of Psychology (COGDOP), and the Council of Chairs of Training Councils (CCTC) and supported by APA.

10. W HO WERE THEY ? Cynthia Belar and Cathy Grus- APA Frank Andraski- Univ. of Memphis Sharon Berry-Children’s Hospital & Clinics of Minnesota Clark Campbell-Biola University Margaret Gatz- University of Southern California Carol Goodheart-Independent Practice Cindy Juntunen-University of North Dakota Elizabeth Klonoff-San Diego State University

11. Theresa M. Lee- University of Michigan Janet R. Matthews- Loyola University M. Ellen Mitchell- Illinois Institute of Technology Celiane M. Rey-Casserly- Boston Children’s Hospital Michael C. Roberts- University of Kansas

12. W HO WASN ’ T THERE ? Anyone from a university counseling center internship training program even though we represent the greatest number of internship sites! Sharon Berry is an internship person Celiane Rey-Casserly is a post doc person Both are at children’s hospitals.

13. F ROM THE INTRO TO THE ARTICLE “HSPEC was initiated to address mounting concerns related to education and training for the professional practice of psychology. Given that professional psychology includes diverse areas of practice and the mounting concerns about psychology’s role in a reformed health care system, HSPEC chose to focus on preparation of psychologists for the delivery of health care services and made seven recommendations that constitute the core of a blueprint for the future.

14. So that is the lesson on process and now for the actual content!

15. W HAT IS A H EALTH SERVICE PSYCHOLOGIST ? “ Overarching conceptual framework that encompasses a number of the recognized specialties in professional psychology. (see figure, next slide) The term reflects the reality that most of the accredited doctoral education and training currently conducted in professional psychology is for health care services…. There may be some communities within clinical, counseling and school psychology that do not focus on the provision of health care services (e.g. educational assessment, vocational counseling, executive coaching), but it is estimated that the bulk of practitioners in these areas do provide health care services.” “HSP is not a specialty itself and should not be confused with the specialties of either clinical health psychology or clinical psychology. HSP includes those psychologists whose focus is on physical health problems as well as those who focus primarily on mental health issues.”

17. W HAT ARE THE HSPEC COMPETENCIES ? I. Science A. Scientific Knowledge and Methods B. Research/Evaluation II.Professionalism A. Professional Values and Attitudes B. Individual and Cultural Diversity C. Ethical and Legal Standards and Policies D. Reflective Practice/Self-Assessment/Self-Care III. Relational: Interpersonal Skills and Communication

18. HSPEC C OMPETENCIES ( CONT.) IV. Applications A. Evidence-Based Practice B. Assessment C. Intervention D. Consultation V. Education A. Teaching B. Supervision

19. VISystems A. Interdisciplinary/Interprofessional Systems B. Professional Leadership Development C. Advocacy (Local, State, and National)

20. W HERE DOES THE C O A STAND IN THIS ? The proposed draft of the revised Standards of Accreditation did not adopt these competencies as the core for the revised accreditation standards. Instead the CoA looked at the variety of benchmark competencies that have been proposed and included those competencies that appeared in all of the major competency documents

21. R EQUIRED PROFESSION - WIDE COMPETENCY AREAS INCLUDED IN S O A FOR INTERNSHIPS : 1. Evidence-based practice in intervention. 2. Evidence-based practice in assessment. 3. Ethical and legal standards. 4. Individual and cultural diversity. 5. Research. 6. Professional values and attitudes. 7. Communication and interpersonal skills. 8. Consultation/interprofessional/interdisciplinary. 9. Supervision. 10. Reflective practice

22. The implications of this is that a program is free to include all the HSPEC competencies in their program if they choose but would not have to include them to become accredited or to maintain accreditation. In any case the draft of the new SoA does refer to accreditation for Health Service Psychologists.

23. I NTEGRATED HEALTH CARE How does this fit into the picture? Development of Competencies for Psychology Practice in Primary Care – Report of the Interorganizational Work Group on Competencies for Primary Care Psychology Practice (March 2013) –available on APA Education Directorate website Movement of the VA system to Primary Care-Mental Health Integration

24. M Y OWN CONTEXT Penn State Counseling and Psychological Services and University Health Services Co-located in the University Health Services Building Administratively separate Separate medical records systems I have led several joint CAPS/UHS work groups over the years to improve collaboration

25. T RUTH IN A DVERTISING We do not currently have a concentration in integrated healthcare I wanted to learn what others are doing Doing a presentation would provide the impetus to learn

26. Interviews with an additional 12 university counseling center training directors (of 16 listed in the APPIC Directory on Line) who indicated that their internship programs offered a concentration in integrated care-primary. 15 minute interviews 6 questions

27. I NTERVIEW QUESTIONS 1. What are you currently doing with interns in the area of integrated healt 2. h care, primary? 3. Do all interns have the opportunity to participate in this area of concentration? 4. What is working well? 5. What have been the challenges of implementing this concentration for interns? 6. What lessons have you learned 7. Are you a merged center?

28. A RE YOU A MERGED CENTER ? Same BuildingNot Same Building Merged Center62 Not Merged CenterPSU4

29. W HAT ARE YOU CURRENTLY DOING WITH INTERNS IN THE AREA OF INTEGRATED HEALTH CARE, PRIMARY ? Regular consultation and referral with medical staff Eating Disorder Treatment Teams and AOD Treatment Teams Sharing of medical records to varying degrees Didactics for interns on integrative care with health services Senior staff embedded in the health center, providing consults and “soft hand offs”, “warm hand offs” to mental health folks with interns shadowing and eventually spending a half day Health center staff providing training on how to collaborate effectively Shared case conferences/grand rounds/in-services

30. W HAT ARE YOU CURRENTLY DOING WITH INTERNS IN THE AREA OF INTEGRATED HEALTH CARE, PRIMARY ? ( CONT.) Providing immediate response to requests from medical providers for referrals from urgent care Involvement with behavioral health in health center- one session interventions provided by interns on smoking cessation, stress management Collaborating on cases where psychiatric medications are being prescribed, chronic mental health issues Collaborating on cases that emerge as a result of health center screenings Co-facilitating a group within the health center for health related issues like chronic pain

31. D O ALL INTERNS HAVE THE OPPORTUNITY TO PARTICIPATE IN THIS AREA OF CONCENTRATION ? In general it seems that the more elaborate and extensive the actual experience the less likely that all interns were getting to do it. May be one of a menu of options for interns. Several folks said they carefully selected the person who would go to the health center. Many experiences seem “hit or miss”, e.g. do they have an eating disorder client, did they get called to see a crisis in urgent care.

32. W HAT WAS WORKING WELL ? Increased collegiality with medical staff has led to better consultation and collaborative care for students. Multidisciplinary treatment teams leading to better care. Increased appreciation by medical staff of what psychology has to offer. Increased appreciation among mental health providers about the importance of sleep, exercise, eating. Interns are getting training in how to express themselves in professionally appropriate ways- learning to talk to physicians, be brief and concise

33. W HAT WAS WORKING WELL ? ( CONT.) Increased appreciation for the mind-body connection Made us less scary to students who for cultural reasons may never have come to the counseling center Medical providers are getting better at speaking to patients sensitively. Making interns marketable for hospital post-docs and work in other settings

34. W HAT HAVE BEEN THE CHALLENGES OF IMPLEMENTING THIS CONCENTRATION FOR INTERNS ? General challenges of providing integrated care It is time intensive for programs that are doing anything more extensive- work schedules are a challenge Having the expertise, the energy, and the desire on the part of staff members to do the groundwork and have a model Frustration of different medical records systems Lack of time to make transitions to new ways of operating Having office space to embed a counseling center person in a health center space- construction, money and time Unrealistic expectations on part of medical staff for how quickly change should happen Cross cultural experience related to differences in medical training and psychological training

35. W HAT HAVE BEEN THE CHALLENGES OF IMPLEMENTING THIS CONCENTRATION FOR INTERNS ? ( CONT.) Training specific challenges Lots of opportunities for interns - the tradeoffs of adding more Providing a reliable experience for ALL interns Getting administrative support for medical providers to engage in training and to collaborate High intensity training for trainees who have no experience with this Challenge of subjecting interns to difficult staff at some sites (pushy, not respecting boundaries of office space, safeguarding confidentiality) Needing to build intern credibility and helping interns to communicate across disciplines and get providers to talk directly to interns and not go over their head

36. E XAMPLE “Medical people ask very pointed questions as rapidly as possible and immediately go into treatment mode. Most psychologists have an approach where they sit down and engage in a relationship, and want the person to feel safe and gather information to collaboratively work towards a resolution. It is a real different approach. An intern is expected to talk to a woman on an exam table while the doc is not leaving the room, the nurse walks in and puts a blood pressure cuff on her, people are in an out and putting needles in her and the intern is supposed to do a suicide assessment. That was not going to happen in that scenario.”

37. W HAT LESSONS HAVE YOU LEARNED ? Before implementing training in this area you need an infrastructure in place for providing integrated care Don’t use the training program to work out kinks in the system Students understand trend toward integrative care more than senior staff who have been around for a while Importance of good communication-establishing a common language, clear referral questions, and clarity of diagnosis

38. W HAT LESSONS HAVE YOU LEARNED ? ( CONT.) Figure out who is invested politically Work directly with those who are receptive rather than going through the administration Upper level support may come once there are good results Provide time during orientation for training from both departments Don’t just offer a seminar- provide an actual experience Flexibility and willingness to go outside of normally expected therapy are needed

39. W HAT LESSONS HAVE I LEARNED FROM CONDUCTING THESE INTERVIEWS ? Some folks are doing great things in this area We don’t have to be doing this to have an accredited program There are pieces of this most of us probably can do and should do- how to collaborate effectively with the health service providers on our campus The training component can only be as strong as the integrated care program itself The time has to come from somewhere- where is it coming from? Who is paying for it? The physical setting is important- co-located, in the same building verses across campus Are the players reasonable? Can you build a coalition among the reasonable players?

40. C ONCLUSIONS We are all providing training in Health Service Psychology by virtue of our settings, our services and our missions Much of this is a change in language from Professional Psychology to Health Service Psychology There is always politics in change and it is a work in progress- what HSPEC wanted is not exactly what CoA has proposed

41. Some of us may be providing training in Integrated Health Care and some may not- we don’t have to be providing that training. Either way it is probably good for us to consider changes we need to make to provide training that will be applicable across settings- our interns don’t always get jobs in counseling centers Our interns should know how to interact with members of other disciplines and speak their language in order to be understood

42. Our interns should understand when a medical problem may be contributing to a psychological problem and should know how and when to refer We don’t have to throw the baby out with the bath water. There is nothing in this that prevents us from continuing to work on advocacy, issues of social justice or multiculturalism.

43. O VERVIEW OF H EALTH S ERVICE P SYCHOLOGY What are we doing already?

44. P ERSPECTIVE Many counseling center psychologists talk about their work related to mental health and mental illness but may not consider themselves to be health service psychologists or think of their centers as health care settings Those with stand-alone counseling centers may question their ability to provide or train for integrated health care A change in perspective may help you realize that you already train for health service psychology and integrated health care – counseling centers are naturally collaborative

45. I NTEGRATED H EALTH C ARE Treating the whole person (mind-body connection) by addressing primary health, mental health, and substance use problems in a coordinated manner (systemic collaboration) Emphasizes wellness and prevention, provides holistic care, and improves continuity of care Biopsychosocial model

46. L EVELS OF I NTEGRATION BETWEEN P RIMARY AND M ENTAL H EALTH C ARE D OHERTY, B AIRD, R EYNOLDS, M C D ANIEL (1996)

47. I T ’ S I MPORTANT TO R EMEMBER Health Service Psychology ≠ Integrated Health Care Integrated Health Care ≠ Integrated Primary Care “Psychology is both a primary care profession and a specialty care profession” Belar (2012) Accreditation Standards will require broad training but will leave room for site-specific training

48. ACCTA M EMBER S ITES According to the 2014 ACCTA Member Survey:  60.7% are administratively and operationally separate from their student health centers  16.1% are administratively combined but operate separately  13.4% are administratively and operationally combined

49. C OMMON C ASES I NVOLVING C OLLABORATION WITH O THER H EALTH P ROVIDERS Those that require medication: Depression Bipolar Disorder Anxiety Panic Disorder OCD Schizophrenia, Schizoaffective, other psychotic disorders

50. C OMMON C ASES I NVOLVING C OLLABORATION WITH O THER H EALTH P ROVIDERS ( CONT.) Those that require medication (continued): Premenstrual Dysphoric Disorder Chronic Illness Chronic Pain ADHD Transgender students transitioning Sleep Disorders

51. C OMMON C ASES I NVOLVING C OLLABORATION WITH O THER H EALTH P ROVIDERS ( CONT.) Those in which physical health is co-morbid with mental health: Depression and anxiety are adverse outcomes of diabetes, heart disease and asthma and/or vice versa Stress is frequently accompanied by high blood pressure Lack of sleep, inadequate nutrition and/or substance abuse can present as a variety of medical conditions Thyroid disease can be mistaken for depression Celiac disease may be experienced as anxiety

52. E XAMPLES OF I NTEGRATED H EALTH C ARE Shared clients/patients Referrals to physicians/psychiatrists – call from office, help schedule appointment, request consultation Referrals from physicians/psychiatrists – collaboration, consultation Obtaining records from other providers Hospitalization Eating disorder treatment teams

53. E XAMPLES OF I NTEGRATED H EALTH C ARE (C ONT.) Regular meetings with psychiatrist to discuss mutual cases Flu outreach – “wash hands” sign and hand sanitizer in waiting room Therapy or support groups for students with medical problems – physical disabilities, chronic pain A psychiatrist(s) is housed in the CC Counseling Center Director oversees Health Center or vice versa Annual meet-and-greet between Counseling Center clinical staff and Health Center medical providers to facilitate referrals

54. H EALTH S ERVICE P SYCHOLOGY S ERVICES /A CTIVITIES C OMMON IN C OUNSELING C ENTERS Assessment Screening – depression, anxiety, eating disorders, online screenings Diagnosis Meditation, mindfulness, relaxation training, diaphragmatic breathing Referral for medication; inquiring about medication compliance Consultation (internal and external)

55. HSP S ERVICES /A CTIVITIES C OMMON IN C OUNSELING C ENTERS (C ONT.) Training Supervision Massage chairs Biofeedback Stress management Behavioral change groups or programs Attention to physical effects of substance abuse

56. HSP S ERVICES /A CTIVITIES C OMMON IN C OUNSELING C ENTERS (C ONT.) Consideration of symptoms as consistent with physical illness (thyroid, seizures, celiac disease) Education on sleep hygiene 1 time sessions, walk-ins, triage Multidisciplinary staff Health promotions/prevention – stress reduction, mood management, etc.

57. HSP S ERVICES /A CTIVITIES C OMMON IN C OUNSELING C ENTERS (C ONT.) Peer educators – presentations on safer sex and sexual health Participation in wellness fairs and programming Alcohol and other drug interventions Case disposition team Case presentations

58. HSP S ERVICES /A CTIVITIES C OMMON IN C OUNSELING C ENTERS (C ONT.) Collaborate with Health Center staff on mental health or substance abuse advisory committees Utilize evidence based treatments Provide neuropsychological assessment Use of the DSM and/or ICD Utilize electronic health records Take health insurance

59. HSP S ERVICES /A CTIVITIES C OMMON IN C OUNSELING C ENTERS (C ONT.) Follow laws and ethics that apply to providing health services Outreach, groups, and education related to diversity Provide free or reduced fee services for students without insurance – social justice focus on health inequities Patient/client satisfaction evaluations Outcomes assessment/program evaluation

60. I NTERNSHIP T RAINING Seminars on psychotropic medication, mind- body connection, etc. Physicians or psychiatrists provide trainings Rotations at Student Health Center Grand Rounds if have a medical school with psychiatry Joint professional development programs – training on psychotropic medication; training MDs about depression; psychological conditions that manifest somatically and organic conditions that manifest psychologically

61. I NTERNSHIP T RAINING ( CONT.) Training in the delivery of preventive, assessment, diagnostic and therapeutic intervention services (what you currently do), including a broader knowledge of, and collaboration with, other areas of health care Training to work in a CC is in essence training for health service psychology and integrated health care

62. F ROM C OUNSELING C ENTER TO I NTEGRATED P RIMARY C ARE – W HAT H ELPED ? Clinical staff with diverse integrative theoretical orientations Opportunity for “hallway consultation” Use of CCAPS for brief symptom assessment Crisis intervention during daytime Students worked with in Health Center suffer from same stress, anxiety, depression as those worked with in Counseling Center Provision of generalist training Triage approach to students initiating treatment

63. S UGGESTED A DDITIONS TO C OUNSELING C ENTER T RAINING Train in Mindfulness Based Cognitive Therapy (MBCT) and Mindfulness Based Stress Reduction (MBSR) Present educational workshops or therapy groups to students in the Health Center Anything that can be viewed as working from a multidisciplinary approach Consulting experience and team oriented work

64. D ISCUSSION Thoughts Questions Reactions