Education Leadership Conference

A 12-year-old boy with stomach pains. A 50-year-old woman with fibromyalgia. A 40-year-old heart attack survivor who seems to run a meth lab. These aren't the type of patients who usually show up in a psychologist's office. But for those who work in community health centers, treating such patients — as well as those with standard mental health issues — is just part of a typical day's work, said Dennis Freeman, PhD, Chief Executive Officer of Cherokee Health Systems in Knoxville, Tenn.

“If we can really integrate behavioral health into primary care, that’s a game changer,” said Dr. Seiji Hayashi, chief medical officer in the Bureau of Primary Health Care at the U.S. Health Resources and Services Administration.Freeman and others spoke about psychologists' work as part of interdisciplinary teams at community health centers at APA's 2011 Education Leadership Conference.

In 1969, when Freeman began working in a community mental health center in Tennessee, such facilities played a key role in providing services to the underserved and training to psychologists. But today those roles are fading away, said Freeman, citing shifts in state and federal policies, budget reductions and waiting lists.

Fortunately, "federally qualified health centers (FQHCs) are thriving," he said. But while nearly three-quarters of FQHCs provide behavioral health services, only 112 of the 1,000-plus centers employ a psychologist and just 46 train psychologists.

Cherokee is one that fulfills both missions. The organization, which began as a community mental health center, is now an FQHC as well, creating what Freeman called "a hybrid safety net organization." Behavioral health consultants — almost always psychologists — are an integral part of Cherokee's primary-care teams and provide real-time assessments and brief interventions to address behavioral health issues related to asthma, diabetes, hypertension, mental disorders and other conditions.

"This isn't traditional psychotherapy co-located in a primary-care office," Freeman emphasized. "It's a new paradigm."

Training future psychologists and other health-care professionals is a key part of Cherokee's mission, Freeman added.

Gilbert Newman, PhD, director of clinical training at the Wright Institute in Berkeley, Calif., described the program he created to prepare psychology students and psychologists to work in integrated primary-care settings.

Many psychologists who work in primary care weren't trained to do so, said Newman. "They learned a lot by the seat of their pants," he said, adding that many think that primary-care psychology should be a postdoctoral specialization.

Psychologists at Cherokee Health Systems in Knoxville, Tenn., treat a wide variety of patients and health and behavioral conditions, said Cherokee chief executive officer Dr. Dennis Freeman. “This isn’t traditional psychotherapy co-located in a primary-care office,” he said. “It’s a new paradigm.”Believing that students need preparation much earlier in their training, Newman launched a primary-care training program in 2004. A grant from the federal Graduate Psychology Education program allowed him to expand his efforts, as has a grant from the Mental Health Service Administration in California, designed to enhance programs for mental health and the homeless.

"With health-care reform, there's a strong effort afoot to rebuild the primary-care workforce and invest in the community health center system," Newman said. "We have an opportunity here ... to really repopulate the public health system with psychologists."

De-emphasizing psychotherapy, the training emphasizes consultation skills, rapid interventions, leadership and advocacy — something Newman said is crucial given the fact that leaders in FQHCs and other public systems often confuse psychologists and social workers.

Seiji Hayashi, MD, chief medical officer in the Bureau of Primary Health Care at the U.S. Health Resources and Services Administration, ended with a look at the role of behavioral health within FQHCs.

Incorporating a psychologist into an FQHC — especially a small, rural facility — can be challenging, Hayashi admitted, but doing so can be transformative.

"If we can really integrate behavioral health into primary care, that's a game changer," he said.

One of Hayashi's own patients illustrates the urgent need for integration. After seeing the woman for two years, Hayashi still couldn't get her diabetes under control. Finally, he thought to ask if she ever heard voices. It turned out she did and was seeing a psychologist and psychiatrist at a community mental health center. Hayashi hadn't known about them and they weren't aware of all the medications he was giving the woman for her diabetes, hypertension and hepatitis C. "It was an ‘Aha' moment," said Hayashi.

—R.A. Clay