Feature

In the usual primary-care health system, physicians identify about 40 percent of their patients as needing some form of mental health treatment, but less than 10 percent of these patients actually see a mental health provider, according to research summarized in "Behavioral health in primary care: A guide for clinical integration" (Psychosocial Press, 1997). The reasons vary but often include the stigma associated with seeking mental health treatment or the hassle of making a separate appointment and getting to a different building in a different part of town, experts say.

"However, when a physician can just walk a patient a few steps down the hall to a psychologist's office, we find that 85 to 90 percent of the people who needed psychotherapy and are so walked down the hall will enter treatment," says Nicholas Cummings, PhD, who was APA's 1979 president.

The statistics inspired Cummings and his wife Dorothy to team with the American Psychological Foundation (APF) to create the APF Cummings PSYCHE Prize. The $50,000 prize, made possible through annual gifts from the Nicholas and Dorothy Cummings Foundation and administered by APF, recognizes practicing midcareer psychologists who have successfully incorporated behavioral and physical health care. The Cummingses have ensured the perpetuity of the prize through a $1 million bequest in their wills.

The winners of the 2007 prizes are Michael F. Hoyt, PhD, a staff psychologist at one of the nation's largest integrated health-care organizations, Kaiser-Permanente Medical Center in San Rafael, Calif., and Susan H. McDaniel, PhD, a family psychologist who trains psychologists and physicians in the biopsychosocial model of medicine at the University of Rochester Medical Center.

"Much of Michael's work has laid the foundation for integrative care, and Susan has been a very integral part of the whole movement for the last 20 years," says Cummings.

'The flywheel of integrated care'

As an undergraduate at Duke University, McDaniel majored in anthropology, and she credits her studies on how context, culture and environment affect behavior with leading her toward family therapy.

"Psychology and studying small groups seemed a lot like applied cultural anthropology to me," she explains.

McDaniel went on to study clinical psychology at the University of North Carolina at Chapel Hill, and then did her internship at the University of Texas Medical Branch at Galveston. There, she focused on child and family issues under the direction of Harold Goolishian, PhD, a pioneer of family therapy. After completing a dissertation on psychotherapy outcome, McDaniel returned to Texas to complete a postdoctoral fellowship in family therapy at the Texas Research Institute of Mental Sciences in Houston.

From Texas, she made her way to Rochester, N.Y., where her husband, a pediatrician and internist, was completing his residency, and she worked in a mental health clinic for two years.

In 1982, the University of Rochester Medical Center residents were agitating for a more organized behavioral science curriculum with a focus on families, McDaniel says, and she was hired to develop that curriculum along with Thomas L. Campbell, MD, a family physician.

"I brought a family psychology conceptual framework to the table, and Tom brought an understanding of the everyday life of a primary-care clinician," says McDaniel. "Together we developed a very practical approach to teaching primary-care doctors and nurses about the psychosocial issues of patients from a family systems orientation."

By 1984, they had taught many physicians how to detect depression, anxiety and other behavioral health problems, says McDaniel, but they were having difficulty getting physicians and mental-health providers to collaborate on patient care. For a year, McDaniel went into the community to talk to psychologists about how to communicate with physicians through phone calls and referral letters, but she admits that it wasn't a strong enough intervention.

Then, she says, in a bid to strengthen connections, they decided to hire psychologists to work at the medical center.

They hired psychologist David Seaburn, PhD, in 1986 followed by two more family therapists in 1987, and a new, integrated system was born.

"We were just kind of amazed that most of the problems of collaboration seemed to melt away when you put people in the same place working together and they can get to know each other and develop relationships," says McDaniel.

In her current positions as professor and associate chair of the department of family medicine and a professor of psychiatry, McDaniel enjoys teaching both psychologists and physicians how to work in harmony.

"We've created a need in the medical community for psychologists who know how to work in primary care and know how to work in medical settings. I have more requests for people who are trained than I have people who are trained," she adds.

She's written several textbooks on integrating mental and physical health care, one of which is "Medical Family Therapy: A Biopsychosocial Approach to Families with Health Problems" (Basic Books, 1992). With her APF Cummings PSYCHE Prize award money, she plans to revise the work to include recent clinical innovations, new research and the financial structures necessary for integrated services.

She'd also like to continue studying the psychological effects of new technologies in primary care, such as genetic testing.

She feels it's critical that psychologists continue to turn "the flywheel of integrated care" until it becomes the dominate paradigm in health care.

"It is vital that we continue to train medical residents with psychology trainees, who then take what they learn to new environments," she says, citing an informal survey of Rochester Family Medicine residents from the past 20 years. It found that 75 percent now practice with a psychologist.

Integrated care and brief therapies

When Hoyt, in 1979, became a staff psychologist at Kaiser-Permanente, a health-maintenance organization (HMO) and one of the nation's largest integrated systems, he found the interface between psychology and physical health impossible to ignore.

"Some patients would come in primarily with a psychological focus-they'd be depressed or anxious or having relationship issues-but lots of people were having some kind of related medical issue," he says. "Either their stress and anxiety were causing medical problems or they were having concurrent medical problems that they needed help managing psychologically."

Hoyt provides clinical care to patients on medical and surgical hospital floors, in the emergency room, and to outpatients with concurrent medical conditions such as cancer, diabetes and lung disease.

"I always see myself primarily as a direct patient-care clinician," he says.

To that end, Hoyt became interested in brief therapies, which are especially applicable in integrated health-care systems.

"These brief techniques are so vital because in the primary-care setting, the first interview when the primary-care provider walks the patient to the psychologist's office is only 15 to 20 minutes," says Cummings. "In that first 15 to 20 minutes, you set the whole stage for continued treatment."

And, adds Hoyt, some patients may feel better after as little as one session, which could be provided on the same day they are introduced to a psychologist by their primary-care physician.

"To me, brief is more an attitude of making the most of each session, no more than needed, rather than a specific number like less than five or up to 20," he says.

Brief therapy is closely aligned with the positive psychology model, says Hoyt, and focuses on empowering patients to create achievable goals. This type of therapy is particularly relevant when patients are noncompliant with medical treatment, such as taking their medication, he says.

"Oftentimes," he explains," by forming an alliance with the patient and beginning to understand some other stresses in their life and helping them manage those better, they are able to focus more on their compliance with the medical regimen."

Hoyt's experience has driven him to be a strong advocate for psychologists as primary-care providers. He has presented more than 200 workshops across the world on the basics of HMO practice to psychologists, other mental-health clinicians, medical personnel and administrators, as well as authored several books, including the bestselling "Brief Therapy and Managed Care" (Jossey-Bass, 1995). He plans to use some of his APF Cummings PSYCHE Prize money to write more books and articles about the role of psychologists in primary health care.

As a primary-care psychologist, Hoyt stresses that although he sees many patients in regular outpatient psychotherapy who don't present with a primary medical issue, doing good outpatient psychotherapy prevents them from developing medical problems in the future.

"That's one of the ways we sell this to different administrators," he says. "If we don't see these patients in therapy, we're going to see them in gynecology or pediatrics or the emergency room. We tell them, 'If we don't see them at two in the afternoon, you're gong to see them at two in the morning.'"

Further Reading

For more information on the APF Cummings PSYCHE Prize, visit www.thecummingsfoundation.com.