Psychologists as Primary Care Providers
Psychological treatment for chronic pain problems is not new to the practice of pain management. Many of the major Pain Treatment Centers have a long history of employing psychologists as part of a multi-disciplinary team of professionals with a focus on helping patients to learn active behavioral pain management skills. Some of the early Pain Centers were started by psychologists and the early literature focused on the importance of behavioral approaches to pain and associated issues. However, this is rarely acknowledged in the pain literature as the majority of publications in recent years have focused on the use of medications for the treatment of pain problems. While pain medication is important in the treatment of chronic pain, it is only one aspect of the entirety of care for chronic pain patients. Further, many believe the simplistic notion that the psychologist’s role in the treatment of pain problems is to “convince” the patient that their pain problems are “all in their head” and therefore not real. Nothing could be further from the truth and reality in the care of chronic pain patients.
As psychologists, we are presently assessing how our training and skills sets us apart from other mental health providers and what is unique to the training of Doctors of Psychology. This reassessment comes at a time when the health care market is changing and calling for innovation and integration of all health care services.
Common Misconceptions of Psychologist’s Role
The perception of the psychology profession by the lay public, insurers, and other professionals, is still mistaken in the belief that psychology and psychotherapy are a part of the psychoanalytic and disease model. This allows others to define the limits of Doctors of Psychology to a narrow focus of only dealing with diagnosed mental and emotional disorders, thus blurring the distinction between psychologists and other lesser-trained mental health professions. Further, the majority of medically-trained psychiatrists has been limited and focused on the specific provision of psychotropic medications. Nevertheless, there is a critical shortage in the number and availability of psychiatrists even for managing these psychopharmacology issues.
Insurers have traditionally believed that psychological services should be limited in nature and focused on resolving crisis issues with a quick fix primarily to “close the case.” To the insurers, it is of little consequence that the allowed treatment time has not fully assisted the patient in resolving and managing the issues that brought about the crisis. It also ignores the reality of flare-up/relapse planning and longer-term management techniques. A crisis approach, while helpful in some situations, does not adequately address other than the immediate presenting issues. This results in patients returning as “frequent flyers” who are seen as over-utilizing the medical system. Further, some patients need to be managed over time because of the multiple issues they are struggling with in order to just keep functioning. Even when psychologists have provided assistance in developing active self-care skills, some patients do not have the psychological resources to manage their problems over time.
The “medicalization of psychological problems” has been indirectly, and quietly, reduced by the fact that psychologists are providing the appropriate treatments to patients who otherwise would be frequenting emergency rooms and family practice medical clinics. Doctors of Psychology are the de facto primary care psychological providers even though this has never been completely acknowledged by physicians, emergency rooms, and insurers. Outside of medical training programs, psychologists have primarily practiced in isolation and separate from medical care settings. Few are aware of the importance of the “primary psychological care practice settings” of the psychologist’s office. Integrated health care systems, such as Gunderson Lutheran Health Care System in Lacrosse, Wisconsin, have become models for reducing costs primarily because of coordinated and integrated care while, at the same time, improving health outcomes. Such integrated systems are being looked at as potential models for a National Health Care program.
Beyond this, there is a mistaken belief that the provision of psychological services is a costly venture even though there is a great deal of research evidence that points to the importance of early intervention by a psychologist. Such interventions have been shown to reduce overall health care costs, reduce costly hospitalizations, and facilitate medical providers to be better able to provide care to a patient load that involve a number of co-morbid problems, diseases and issues. Ignoring this “evidenced-based practice scientific research” goes against what health care professionals and insurers are citing as the way to reduce health care costs. It also ignores the estimates that up to 80 percent of patients presenting to primary care physicians involve strong psychological issues that would be better handled by psychologists. The actual cost of psychological treatment services is very small when compared with other health care professionals, including costs of hospitalizing patients, or the over-utilization of various diagnostic procedures. Add this to the fact that there are a rapidly decreasing number of physicians going into primary care medicine and, in the long term, the health care system is not going to know what to do with this group of complex patients.
The purpose of this article is to examine the important broad primary care role already being provided by psychologists, together with a discussion on how this role can be expanded in view of the highly specialized and extensive training of a doctoral-level psychologist. This training should be sufficient to allow for official recognition of psychologists specifically as primary care providers (PCP) in the provision of health care services and, in particular, with complex health care and chronic pain patient populations. This article can also be used as a resource to make known and provide education about Doctors of Psychology to the public, insurers, and the medical community.
“Psychologists, who are trained to be both practitioners and scientists, have a long history of working within the medical system.”
Changing Health Care Market
The American Psychological Association, under the leadership of APA President James H. Bay, PhD, has formed a summit of 150 psychologists, along with 30 invited guests, to discuss the expanding role of psychological practice in health care and in the integration of the direct provision of health care services. There is an awareness that the health care marketplace is in the middle of change and it is therefore important for psychology to reassert its lead in designing the models of care.