Tackling complex conditions with behavioral health

Psychologists are essential partners on integrated specialty care teams, delivering evidence-based behavioral interventions that improve clinical outcomes, reduce costs, and support value-based care.

Psychologists are moving into a niche area with significant growth potential: integrated specialty care, or team-based care, provided in medical specialty areas such as oncology, diabetes, cardiology, chronic pain management, and many others. It’s an area of increasing need and opportunity, both because of its scope—medical specialists currently make up at least 60%opens in new window of the physician workforce, according to Statistica, a data analytics system—and because specialty care patients’ issues consume the lion’s share of overall health care dollars, according to the Peterson-KFF Health System Trackeropens in new window, an online hub that analyzes the performance of the U.S. health care system.

Psychologists are essential members of these teams, particularly given their ability to deliver evidence-based behavioral interventions that improve clinical outcomes, reduce total cost of care, and support value-based payment models that emphasize quality over volume of care, said Amy Walters, PhD, director of behavioral health services at St. Luke’s Humphreys Diabetes Center in Meridian, Idaho, and a member of APA’s Integrated Specialty Care (ISC) Advisory Group, a work group striving to increase the presence and impact of psychologists in specialty care.

[Related: Read profiles of psychologists working on integrated care teams] 

“Many specialty care practices want patients to make a lot of health behavior changes—to work on improving their sleep, their eating habits, their physical activity, and their stress levels,” said Walters. “Psychologists can help them make and sustain those changes as well as support their social and emotional health.”

Psychologists take on other important roles in these settings as well, said Wendy Ward, PhD, a veteran integrated care psychologist who is now associate provost for faculty at the University of Arkansas for Medical Sciences College of Medicine in Little Rock. These roles include clinical and program leadership, education and training leadership, research and scholarly leadership, assessment and evaluation, quality and outcomes improvement, administration and operations, financial stewardship, interprofessional team building, and strategic partnership development.

“We have a spectrum of skills that are really needed,” she said.

For all these reasons, specialty care psychologists are highly valued by physicians and patients alike. But getting adequately reimbursed and trained remains challenging, said Erin Swedish, PhD, MBA, APA’s director of health integration and head of APA’s ISC advisory group.

At present, reimbursement remains largely tied to fee-for-service structures that inadequately capture the full scope of psychologists’ contributions, including care coordination, team-based consultation, and population health management, she said.

In addition, major health care funders like the Centers for Medicare and Medicaid Services continue to view psychologists strictly as mental health providers rather than as behavioral health experts who also treat the behavioral aspects of medical conditions and chronic disease management, not to mention substance abuse issues, said Stephen Gillaspy, PhD, director of health and health care at APA. “We have a role to play in mitigating those disease processes, whether a patient has a mental health condition or not,” he said.

Fortunately, health care trends are moving toward models more favorable to psychologists’ holistic training, and APA is tapping into these trends in its advocacy and policy work, Swedish said. For instance, there is increased emphasis on population- and value-based care, where providers are paid for health outcomes, quality of care, and cost efficiency rather than on the volume of services provided. Likewise, there is a greater national effort to integrate behavioral health into health care systems in general. These trends align with the broader federal and commercial payer movements toward supporting behavioral health integration, which recognizes the role of behavioral interventions in improving outcomes for chronic medical conditions, Swedish said.

These directions suggest that integrated specialty care “is one of the most important frontiers for psychology,” Swedish said. “When psychologists are embedded in medical settings, we don’t just treat behavioral health—we improve medical outcomes, patient adherence, and whole person care.”

APA data show that about 14% of licensed psychologists call clinical health psychology their major specialty. While it’s unknown how many of these providers work in integrated specialty care, the APA ISC advisory group has discovered that psychologists work in at least 41 medical specialty areas and 137 subspecialty areas. The group is also surveying members of Division 38 (Society for Health Psychology) to learn more about psychologists’ tasks, hours, practices, and models in these settings (see sidebar).

Integrated specialty care psychologists note that while specialty care is similar to primary care, there are key differences. Both roles involve working together with medical teams, understanding the culture and language of medicine, and using evidence-based interventions like cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) to address patients’ psychological needs and foster healthy lifestyle change. However, psychologists in specialty care practice with a more defined scope and work with patients who have more serious, chronic health problems than the average primary care patient. Because of these problems, the patients often have higher levels of depression and anxiety as well.

“These are patients who have been diagnosed with one, if not multiple, chronic health conditions, so they’re really struggling with their health,” Walters said.

These complexities are challenges that integrated specialty care psychologists take on wholeheartedly. An example is Shannon Virtue, PsyD, who is passionate about her work in two related roles at ChristianaCare, a large regional health care system based in Wilmington, Delaware.

In one of these roles, she is an integrated member of the oncology team, where she helps cancer patients cope with active treatment and then adjust afterward. She also supports caregivers and fosters cancer prevention through group treatments like tobacco-cessation programs.

“Cancer can and does touch people across all walks of life, whether by direct impact or indirect impact on a loved one,” she said. “Psychology can make a huge difference in all these levels of care.”

As an oncology team member, Virtue also regularly consults with medical providers on how to better communicate with and treat patients who are dealing with medical anxiety and other treatment-related issues. Being able to coordinate with providers in real time also means patients don’t have to hassle with disjointed schedules or unnecessary travel at a time when they are physically and emotionally depleted.

“The nice thing about being on site is that we can coordinate or piggyback off of other appointments,” she said.

In her other role, Virtue serves as clinical leader of ChristianaCare’s embedded psychology program, where she oversees psychologists embedded in several of the system’s specialty clinics and helps them build, tailor, and implement their services. One bariatric psychologist, for example, recently sought Virtue’s help in launching a psychological support group for patients newly out of surgery, which she saw as an important but untapped window for intervention.

“I thought that was a great clinical idea, and I wanted to support that growth with her,” said Virtue.

Meanwhile, Laurie Ivey, PsyD, serves as director of integrated behavioral health at the University of Colorado’s Anschutz Medical Campus, where she oversees psychologists who are integrated into specialty areas such as physical medicine and rehabilitation, transplant, burn and frostbite, bariatrics, transgender health, and functional neurological disorders.

Ivey also provides clinical services to patients in the campus’s Sleep Medicine Clinic who have been referred by specialists, including ear, nose, and throat physicians, neurologists, and pulmonologists. She enjoys helping untangle the puzzle pieces of how patients’ diverse health conditions are related to sleep problems and vice versa. While her main treatment approach is CBT for insomnia, or CBT-I, patients often have related behavioral issues such as struggling to get off sleep medications, adjusting to CPAP machines, and coping with trauma histories that exacerbate sleep disturbances.

“As psychologists, we know that nothing is separate—that people come in with everything they’ve experienced,” she said.

Ivey also likes collaborating with medical providers to solve issues with both medical and psychological aspects. If a patient is struggling to get off a sleep medication, for example, she works with their physician to find an interim medication and then with the patient to lower their fear about giving up the original medication. “That kind of teamwork is really valuable,” she said.

Thanks to their wide-ranging expertise, it is not uncommon for psychologists in these settings to also be tapped for leadership roles. Kathleen Ashton, PhD, ABPP, who worked for 20 years in bariatrics and oncology at the Cleveland Clinic in Cleveland, Ohio, was recently scouted to start a psycho-oncology program at MetroHealth, the main hospital serving low-income patients in the city.

“It’s very exciting because I get to start from scratch and build a program the way I like,” she said. To do that, Ashton has learned about the program’s needs, built relationships with staff, coordinated all of the hospital’s oncology clinics to allow patients to see psychologists on the same day as their medical treatments, and expanded access by building group programs and digital interventions such as a virtual CBT group for breast cancer survivors called Thrive Forward. She plans to continue that work and to get interns on board to help.

Working with people who have limited resources but high medical needs is extremely rewarding, added Ashton, who is also lead psychologist for the hospital’s blood and bone marrow transplant program. “Patients are really happy to be here, and they absolutely understand the quality of help they are getting,” she said. “They want to take advantage of that, and they’re lovely to work with because they’re motivated and they can see the value in having this kind of care.”

Psychologists have also been proactive in helping systems recognize and remunerate their value. A leader in this domain is Ward, who before her role at the University of Arkansas for Medical Sciences, was an integrated specialty care psychologist working with pediatric obesity patients at the Arkansas Children’s Hospital in Little Rock. Taking her strong training in communication, education, research, and clinical service model design, she persuaded the hospital to expand and integrate the psychology service throughout the system.

“The hospital felt that we had documented how much our services were needed beyond simply reimbursed billing, so they put money behind the resource,” said Ward. In fact, her approach—which entails learning a clinic’s needs, understanding implementation issues, finding a champion, launching a pilot, and assessing progress over time—was eventually adopted by 41 other specialty clinics at the hospital (Clinical Child Psychology and Psychiatry, Vol. 26, No. 2, 2021opens in new window). In the meantime, Ward’s students have gone on to replicate the model at many other sites both nationally and abroad.

Integrated specialty care work is exciting and rewarding, but these psychologists also say more training opportunities are needed. Many doctoral programs still lack foundations in integrated care, and many seasoned psychologists had to gain their knowledge piecemeal along the way. Ashton, for example, entered integrated care somewhat by accident while in graduate school, when she applied for a rotation in women’s post-traumatic stress disorder at the Veterans Administration (VA). When that wasn’t available, she took a rotation in primary care health psychology instead and ended up loving the work. Her interest in health psychology led to a health psychology internship at the VA and a health psychology postdoctoral fellowship at the Cleveland Clinic, with supervised specialty training in a variety of health psychology specialties, including bariatrics, sleep management, and oncology. She’s continued that work as a staff member at the Cleveland Clinic and now at MetroHealth.

Fortunately, outside formal training opportunities are on the rise. For predoctoral psychology students and recent graduates, there is an increasing number of relevant practica, postdocs, fellowships, and internships available in larger medical centers and health systems. And while there are fewer formal opportunities for mid- and late-career psychologists, there are many ways to gain knowledge in the area. One is to get involved in organizations relevant to the specialty one is interested in: Ashton, for example, actively participates in APA Division 38 and in the American Psychosocial Oncology Society. Such organizations can provide high-level specialty continuing education with other specialists in health psychology, as well as opportunities to network and stay abreast of developments in the field, she noted.

Ashton also recommends getting board-certified in health psychology. The credential demonstrates a high level of training and competence in this specific area of psychology and “communicates this expertise to the hospital and the public,” she said.

Once a psychologist is established on a site, there are multiple additional opportunities to get up to speed in one’s medical specialty area, Walters said. This can include attending medical conferences in one’s specialty area, as well as on-site educational programs, grand rounds, and tumor boards, where multidisciplinary teams of cancer specialists meet to discuss complex cancer cases. In her specialty area of diabetes, Walters has attended the same trainings as certified diabetes educators and pharmaceutical reps, as well as weekly endocrinology case meetings focused on the most challenging cases. Thanks to this input, “I’m learning about all of these more complex conditions,” she said.

In general, the idea is to learn as much as one can about the medical aspects of an area while remaining in your zone of expertise, Ashton added. “It’s important to be well versed in the medical specialty you are working in and to work closely with the medical team,” she said.

Integrated specialty care psychologists uniformly report on how valued they feel in these settings, but as noted, payment is still an issue. What is needed, leaders in the area say, is work on multiple fronts to change billing codes, the way that psychologists are paid, and the way that systems and providers view psychologists’ range of expertise.

Some of that work is happening at APA, where Swedish’s office is developing, refining, and expanding on billing codes so that psychologists in these settings can charge more comprehensively for their services (see October 2025 Monitor). Likewise, a bill heavily championed by APA that is pending in Congress—the Connecting Our Medical Providers with Links to Expand Tailored and Effective Care Actopens in new window, or COMPLETE Care Act (S. 931/H.R. 2509)—includes key provisions that would improve integration of psychologists in primary and specialty care settings. These include providing technical and financial assistance to help primary care practices adopt integrated care models and supporting greater integration of behavioral health providers to improve the management of chronic care conditions (see January 2026 Monitor). If enacted, these provisions would help address long-standing structural barriers to integrating psychologists into team-based medical care, Swedish noted.

Meanwhile, APA ISC advisory group members and individual psychologists are promoting messaging intended to show the pivotal role that psychologists can play in the health care movement known as the “quadruple aim,” originally promulgated by the Institute for Healthcare Improvement. This framework seeks to bolster population health, reduce costs, enhance the patient experience, and improve provider well-being—aims that psychologists are well positioned to fill, said Walters.

APA’s Gillaspy is exploring a related advocacy avenue, demonstrating that psychologists are behavioral health experts who are adept at addressing not only mental illness but also prevention, early intervention, and wellness, as well as cultural phenomena associated with mental health problems, such as social media and AI.

“When others see psychologists as only dealing with mental health problems, I think that puts us in a box,” he said.

Finally, to better make the case that integrated care psychologists can improve care and reduce costs, providers in these roles are gathering data at their sites with the aim of eventually turning it into formal research. In Ivey’s Denver setting, for example, psychologists are conducting evaluations that show their work is related to successful bariatric and transplant surgeries and keeping post-op patients from extensive hospital stays. At MetroHealth in Cleveland, Ashton is tracking quality of life and mood throughout patients’ treatment and showing that both improve with psychological care. And in Idaho, Walters is documenting how her services help patients with diabetes or obesity eat healthier foods, consume fewer sugary drinks, get more exercise, and lose their depression.

Working in this space gives psychologists a golden opportunity to improve the nation’s health and quality of life while lowering costs—and it needs more providers, Ward added.

“The integrated specialty arena is a dynamic, exciting, fulfilling place to be,” she said. “I would encourage psychologists who haven’t been exposed to this work—even more senior psychologists—to put a toe in the water and try it.”