09 Mar 2017
A Quarter Century of Mental Health Care
Changes in the Mental Health Care Helping Profession
As we mark the silver anniversary of the founding of Family Psychology Associates, it is important to notice the way in which service delivery for mental health care has changed in the past 25 years.
Family Psychology Associates, Inc. originally opened its doors on February 1, 1992 in Dunedin. There were originally three partners and one office staff member. Our slogan continues to be “Strengthening Relationships…Improving Lives.” After three years, we moved to a new location in Clearwater. We grew to 12 professional staff and three office staff. However, the impact of managed mental health care led some of our professional staff to leave private practice to return to the security of public agencies. We downsized and moved to Safety Harbor in 2000. There were 8 professionals at that time. However, we began to grow again and expanded to our current location in Safety Harbor in 2008. In 2011, we opened a second suite of offices in our current building. On February 1, 2015, we opened our new office in Trinity. Our current roster of professionals is up to 18 and our office staff includes 8 team members.
We have witnessed substantial changes in the mental health care marketplace during our first quarter of a century. The changes encompass the prevalence of mental health conditions, the tools for assessment and treatment, therapeutic interventions, the role of technology in assessment and documentation, and changes in the services that various practitioners can offer.
- Autism: The incidence of autism for children born in 1992 and studied by the Centers for Disease Control and Prevention in 2000 was 1 in 150. The most recent data was collected in 2014 for children born in 2004. The incidence is now 1 in 68. Asperger’s Disorder is no longer part of the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders. Asperger’s has been replaced by Autism Spectrum Disorders, Autistic Disorder and Semantic-Pragmatic Language Disorder.
- Behavioral Analysis: Board Certified Behavior Analysts possess a Master’s degree in Behavioral Analysis. They specialize in the treatment of individuals on the autism spectrum, as well as other developmental disabilities.
- Continuous Performance Test (CPT): A CPT uses computer technology to measure reaction time and response accuracy as part of a psychoeducational evaluation. Due to the belief that AD/HD is overdiagnosed, we began using a CPT in 1993 to measure sustained attention and impulse control, the hallmarks of AD/HD.
- Computer Assisted Psychological Testing: When we opened our practice in 1992, the pioneers of psychological testing interpretation software were produced on floppy disk. Today, programs are housed in the cloud, allowing clients to take the test from an internet connection, while the examiner can analyze the data from anywhere. This creates more accurate diagnostics and better treatment outcomes.
- Cross Battery Assessment: A psychoeducational evaluation may include more than half a dozen different instruments. The Cross Battery software permits factor analysis of learning abilities across different tests.
- Curriculum Based Measurements: In 2004, the Individuals with Disabilities Act was reauthorized by the Department of Education. The law changed the primary method for determining the presence of a learning disability. Rather than conducting a psychoeducational evaluation, schools would provide enhanced instruction for any child who scored below the 25th percentile on benchmark tests of reading and math calculations. The aim was to intervene more quickly when a student was considered at risk, but the unintended consequence was a reduction in resources for psychoeducational evaluations conducted in public schools.
- Electronic Medical Records: Electronic Medical Records have been encouraged in order to assist with coordination of care between different providers. The transition to electronic records was encouraged by the Accountable Care Act; however, there is no uniform standard that allows different EMR programs to communicate electronically with each other.
- Eye Movement Desensitization Response (EMDR): EMDR is a therapeutic intervention used for the treatment of trauma, OCD, anxiety, panic attacks, phobias and depression. The process combines emotions and the senses so that the individual is able to process their traumatic experiences and reduce their distress reaction. This treatment approach has been studied for 20 years and is appropriate for use with adults and children as young as age 6.
- Health and Behavior Codes in Primary Care: Psychological care used to require a mental health diagnosis. With the integration of mental health care in primary care, mental health practitioners can provide brief interventions in a medical home for conditions such as diabetes, hypertension and obesity using Health and Behavior Codes. The typical intervention is educational, goal-oriented and brief (only 1 to 4 sessions). Each session consists of 1 to 2 units of 15 minutes each.
- Integrated Primary Behavioral Healthcare: One of the promises of the Accountable Care Act is the encouragement of new payment systems that will be indexed to patient satisfaction and improved health outcomes. In order for primary care to become more cost effective, it must include behavioral interventions designed to improve patient compliance with medical advice, as well as address the psychological problems that are often related to the health problem that is being treated. Integrated Primary Behavioral Healthcare pilot programs are found in the Veterans Administration Health Centers, Federally Qualified Health Systems and universities.
- Mental Health Parity: In 1996, the most liberal member of the House of Representatives (Rep. Paul Wellstone) and the most conservative member of the Senate (Senator Pete Domenici) co-sponsored the Mental Health Parity Act. They both had members of their family who suffered from major mental illnesses and they encountered discrimination in the way that services were funded. The Mental Health Parity Act equalized the amount of benefits available to treat mental illnesses with the benefits that had been provided for the treatment of physical illnesses. This law was modified in 2008 to include addiction recovery services. In 2010, it was incorporated in the Accountable Care Act and the full impact of the original law was finally felt.
- Mindfulness Meditation: Mindfulness is the awareness that arises through paying attention to the present moment non-judgmentally. Mindfulness Meditation is the practice and training of that awareness. It involves being aware and observing the thoughts, emotions and sensations that arise throughout each day, pausing and coming back to the present moment. Guided meditations (e.g. mindful breathing, body scan, walking meditations and mindful eating), as well as personal daily meditation practice, movement practice (i.e. yoga, qiqong, tai chi) and silent meditation practice can train individuals to become more mindful throughout the day, especially during difficult life challenges. Research has shown positive effects on physical and psychological symptoms (e.g. lowered blood pressure, stress reduction, improved immune system functioning, reductions in GI discomfort), as well as improvements in health attitudes and behaviors. Mental and Physical Health professionals have been incorporating complementary therapies such as mindfulness and meditation practice, as part of an integrative medicine approach, more readily within the last decade.
- Neurobiofeedback: Due to the advances during the 1990s Decade of the Brain, new computerized games can train specific brain functions. The core symptoms of AD/HD, working memory and processing speed, can be improved with this form of brain training. There are a number of commercially available programs that claim success in improving brain functioning, but the only approach that enjoys support in research is CogMed.
- Neuroimaging: Due to diagnostic advances such as functional MRIs, we can now see how specific brain regions are related to particular behaviors or learning processes. This has enhanced our understanding of learning disabilities, AD/HD, post-concussion syndrome and dementia.
- Nurse practitioners: Due to the rise in demand for healthcare of all sorts, Nurse Practitioners and Physician’s Assistants have gained much greater latitude to practice. With the aging of the population of Psychiatrists in the state of Florida, we will see more services delivered by “physician extenders”.
- Obamacare (ACA): The Accountable Care Act has not only provided healthcare to over 20 million Americans, it has also improved the mental health benefits that they receive. No longer are pre-existing conditions a reason to be excluded from healthcare coverage. With parity for mental health, now subscribers have greater coverage for mental illness and substance abuse treatment.
- Patient Centered Medical Homes: Physicians and healthcare organizations have been studying the Medical Home concept for over a decade, wherein the primary care physician serves as the care coordinator for an individual patient. The healthcare industry is moving away from reimbursement for procedures and to a more accountable system, where physicians can receive financial incentives for providing a population of patients more effective care at lower cost. Behavioral health services will be the key to making the patient centered medical home and integrated primary behavioral healthcare the hub of the new healthcare system.
- Prescription Privileges for Psychologists: In the state of Florida, psychologists are the only doctoral level trained clinicians who are not permitted limited prescription privileges. Four states and Puerto Rico have authorized psychologists to prescribe. There are psychologists who work on federal property in the state of Florida who have been prescribing for a decade. Granting psychologists who complete specialized training in psychopharmacology the privilege to prescribe psychoactive medication will increase access to care for citizens in the state of Florida.
- Psychological Assessment on an iPad: Personality evaluations, behavior rating scales and intelligence tests are now configured to be administered on iPads or other tablet computers.
- Rapid Resolution Therapy: Using principles of hypnosis, the individual is encouraged to envision a representation of their desired outcome. They do not have to re-experience the trauma. This technique has not been widely studied and would still be considered a “controversial treatment.”
- Response to Intervention: When IDEA was reauthorized, an innovative idea that was included in the law initiated a progress monitoring system of providing early intervention to public school students. The theory was to identify students performing in the lowest 25% of the class and immediately provide more intensive instruction. The student’s performance would then be measured against other classmates to observe how well they were responding to the enhanced instruction. The previous approach was to wait for a school psychologist to evaluate the student to identify if they have a learning disability. This might take the better part of a school year. While Response to Intervention provides more immediate instruction to at-risk students, it is not necessarily effective in identifying students who have a need for special education services.
- Self-Directed Search on-line: One of the most scientific aspects of psychology is vocational assessment. By age 14, career interests are stable enough to measure reliably. In an economy that demands post-secondary education, students may believe that college is the best career path for all high school graduates. However, there are many careers that do not require a college degree. Vocational schools and certificates through a community college may be the most economical route to a well-paying career. The on-line version of the Self-Directed Search provides an objective measure of a student’s occupational type. The test is also the foundation of the Department of Labor’s database on over 2,000 careers. This allows the student to plug their results into search engines that provide forecasts for demand for certain careers over the next decade. The Self-Directed Search can also be used by adults in mid-career transition.
- Self-harm: Self-harm is the deliberate harming of oneself without the intent to commit suicide. This may take the form of cutting, burning, hitting, biting oneself or the reinjury of a wound that is healing. Self-harm is used as a means for coping with emotional pain. These feelings may include numbness, the need to feel alive, or an attempt to calm oneself. Most adolescents who self-injure do not have serious mental disorders, but they may struggle with anxiety and depression. Support is provided at our practice with individual and peer group therapy sessions, as well as parent support meetings.
- Telepsychology: Advances in technology are making psychological services more accessible to more of our citizens. Programs that teach mindfulness, mood management, and anxiety reduction are now available on line. These interventions have been evaluated in studies conducted in Europe. On-line instruction can be an adjunct to therapy or may be a substitute for therapy. In addition, videoconferencing technology is allowing clients currently in therapy to conduct a remote interview with their therapist when work or family obligations interfere with their ability to see their therapist in their office. Preliminary outcome studies suggest that patient satisfaction is at least as good as with face to face therapy. As smartphones become more prevalent and social media penetrates everyday life, new platforms for telepsychology will continue to evolve.
- Transgenderism: A recent National Geographic Magazine (January 2017) describes the genetic, hormonal and social factors that contribute to the understanding of transgender individuals in different cultures. In the United States, transgenderism is no longer considered a mental illness. Transgender individuals feel that their sexual characteristics do not agree with their internal conceptualization of their sexual identity. They may seek hormone replacement therapy or sexual reassignment therapy to feel congruence. Psychotherapy is an essential part of the medical treatment process to help the individual consolidate their sexual identity, learn to express their sexual identity in ways that are authentic for the individual and to prepare for the impact of their transition on family, friends and coworkers.