Feature

Mental health professionals are scarce in Doña Ana County, N.M., a federally designated health professional shortage area. "The most recent estimate is that there are 100 psychiatrists for 2 million people" in the state, says Christina Vento, PsyD, training director in New Mexico State University's psychopharmacology program. The New Mexico Board of Psychologist Examiners estimates that 720 psychologists are practicing statewide. "There is a huge unmet need," Vento adds.

The county is situated 40 miles from the Mexico border, and its fast-growing population is predominantly Hispanic. About one-fourth of residents live below the poverty line, a proportion higher than in the rest of New Mexico or the United States. Per capita income is well below that of the state and the nation, too. Violence and poverty, which can lead to depression, anxiety and post-traumatic stress disorder, beset the county's rural population.

So, when Jonathan Schwartz, PhD, arrived four years ago at New Mexico State University to head the counseling and educational psychology department, he sought to better serve that population by tapping into the department's considerable strengths — the program is one of only three U.S. postdoctoral training programs for prescribing psychologists, and its doctoral program in counseling psychology emphasizes integrated care, a focus of reforms in the Affordable Care Act.

Now, Schwartz and his faculty have succeeded in his goal. They've created a new clinical training ground in partnership with La Clinica De Familia, a federally qualified health center with eight sites in and around Las Cruces, N.M. During the last academic year, six doctoral students and two trainees in the postdoctoral prescribing psychology program together spent 64 hours weekly treating clients who had little or no access to behavioral health care.

"La Clinica didn't have adequate behavioral health services, and in our county La Clinica health professionals really serve the people who don't have resources," says Schwartz.

As a federally qualified health center, La Clinica receives government funds to provide comprehensive health services for underserved populations. Seven of its clinic sites provide primary health and dental care; the eighth is based in a local high school. With a Counseling Psychology Graduate Psychology Education Grant from the federal Health Resources and Services Administration (HRSA) to train health professionals in primary-care medical settings already in place, the match was ideal.

About 20,000 patients seek care annually at La Clinica sites, says its chief executive officer, Suzan Martinez de Gonzales. "About 30 percent to 40 percent of the patients need some type of mental health care," she says.

Onsite learning

Before the partnership began, La Clinica patients who needed behavioral health services were referred to social workers, psychologists and psychiatrists, says Daniel Armistead, MD, its chief medical officer. "But they're overwhelmed, and patients were waiting months to get services," he adds.

Under an agreement forged last year, La Clinica and New Mexico State University split the salaries of two full-time faculty members who spend half their time teaching and supervising students, and the other half providing services at La Clinica.

Of the doctoral students working at clinic sites, one is completing his internship and another works at La Clinica as part of her graduate assistantship. The training at clinic sites is being designed as a behavioral health practicum for third-year doctoral students who have taken the primary-care psychology course.

Vento, a licensed prescribing psychologist, is one of the half-time faculty working at the clinic sites. Depression and anxiety are common among clinic patients, so the prescriptions she writes most often are for selective serotonin reuptake inhibitors and other antidepressants. Her expertise is valuable, says Martinez de Gonzales.

"She has provided training for our physicians on staff, helping to educate them regarding the medications," she says. As the partnership develops, Armistead hopes a prescribing psychologist from the university will contribute to La Clinica's continuing medical education programs for its physicians.

The psychopharmacology residency program at New Mexico State offers psychologists the unique opportunity to work with clients such as those at La Clinica sites while they obtain their certificate to prescribe medications. This type of training is in demand. Schwartz says psychologists travel from as far away as the Netherlands to complete certificates through the program.

Vento offers her patients treatment options that include medication, counseling and self-care techniques, such as spending more time with upbeat, positive people and getting more exercise. "I try to use a patient-centered team approach," she says.

The treatment model doesn't resemble the traditional 50-minute office session, says Schwartz. "You may do rounds with a [physician] seeing a patient who had gallbladder surgery, is having high anxiety now and isn't able to function," he explains. In that scenario, the physician would introduce the patient to a psychologist who would help with anxiety issues.

"It becomes a team approach and patients respond well to caring for them holistically," Schwartz says.

Patients first see a physician for a medical evaluation. If mental health issues arise, Vento or Daubney Harper, PhD, the other half-time faculty member, is contacted. Clinical decision-making involves consultations among physicians, psychologists, nurses, nurse practitioners and the students. "We're constantly having conversations back and forth about the patients' needs," psychology intern Ralph Crabbe says.

"Integrated care is our goal," Armistead says. "Not just to be co-located, but truly integrated."

Second-year doctoral student Laura James spends 20 hours a week at clinic sites as a graduate assistant. She sees a number of patients with emotional trauma. "Domestic violence is common here," she says. High rates of alcohol and substance abuse are contributing factors.

Proximity to the Mexican border also means exposure to drug violence. "Most of the patients have family in Mexico, so they are impacted, even if in an indirect way," says James, a native of Mexico herself.

Overcoming barriers

Behavioral issues also can crop up with diabetes, which is prevalent among La Clinica's patients. Schwartz says interventions may be nontraditional, such as helping patients learn how to prepare healthy foods for glucose control or walking through their neighborhoods to see if obstacles such as no sidewalks or aggressive dogs pose barriers to exercise, for example.

"Being able to see a psychologist to address hurdles from a behavioral health standpoint can help patients take care of themselves better," Armistead says.

Language and cultural differences can impede health care, too. Prior to its partnership with La Clinica, New Mexico State University used funds from the HRSA grant to begin bilingual supervision of doctoral psychology students.

"The idea is to do as much training and supervision in Spanish as possible" with bilingual students, says Eve Adams, PhD, associate professor and director of training in the doctoral counseling psychology program. The training isn't just in conversational Spanish. Students discuss psychology terms and concepts in Spanish. The program is one of only a few in the United States that offers a minor certification in Spanish.

Some La Clinica sites can work only with bilingual students because their patients speak only Spanish, Adams adds. "My schedule is very busy for that reason," says James, whose native language is Spanish. "In psychology, when we're talking about the experiences people have had, it makes a big difference."

Among the program's most tangible benefits is that it has increased interactions and communication between medical and psychology personnel, Martinez de Gonzales says.

"They have grown to understand each other better, and there's a great recognition on both parts that to meet the needs of our patients they need to work closely together," she says.

But a limitation is not having a psychologist or doctoral student available at every clinic seven days a week, she adds.

That might not change in the near future, says Schwartz. "This year, we were just trying to create the infrastructure," he says. "Now, we're working on getting more space and making sure there are behavioral health offices."

But space is hardly the final frontier. Eventually, the model being created probably could be translated to other locations, says Schwartz. "What's exciting is that it allows the people we hire to do clinical work and be faculty," he explains. "They're really on the front lines of behavioral health care."

Rebecca Voelker is a writer in Chicago.