Health Service Psychology
What does it mean for counseling center internship
programs?
Joyce Illfelder-Kaye, Ph.D.
Penn State University
Kathlyn Dailey, Ph.D.
Texas State University
OUTLINE




Overview of changes in the field
What Counseling Centers are currently doing that can
be considered health service provision
What lessons can be learned from those centers that
are providing integrated health care in primary care?
Discussion
IMPACT OF THIS ON COUNSELING CENTER
INTERNSHIP TRAINING DIRECTORS

Anxiety and questions ????
Are we Health Service Psychologists?
 What would we have to change to be HSP’s?
 What will we lose or gain if we have to
change?
 What sort of training should we be providing
to interns so they will be trained for the
world they are entering?

OVERVIEW OF CHANGES IN THE FIELD
Resolution on Accreditation for Programs that Prepare
Psychologists to Provide Health Services states:
“Psychologists are recognized as Health Service Providers if they
are duly trained and experienced in the delivery of preventive,
assessment, diagnostic and therapeutic intervention services
relative to the psychological and physical health of consumers
based on: 1) having completed scientific and professional training
resulting in a doctoral degree in psychology; 2) having completed
an internship and supervised experience in health care settings;
and 3) having been licensed as psychologists at the independent
practice level” (APA,1996; APA, 2011);
From 2010 APA Model Act for State Licensure of Psychologists
WHERE IS THIS PRESSURE COMING FROM?

Movement to rebrand ourselves as “Health
Service Psychologists” (not Health Psychologists)
is coming from APA


Reflections on the Future: Psychology as a Health
Profession, Cynthia Belar, PPRP, 2012
Abstract: “The author describes a vision of psychology’s
future as a health profession. In broadening its focus
from mental health to a range of health issues, the
profession is faced with a number of challenges related
to establishing its identity, ensuring public confidence,
and participating in the health care system…”
SEPTEMBER 2013- AMERICAN PSYCHOLOGIST


Professional Psychology in Health Care Services
A Blueprint for Education and Training
Authors are listed as
Health Service Psychology Education
Collaborative
Who are they and how did they come to be?
BACKGROUND- FROM THE ARTICLE


In March 2010 CCTC approached APA BEA “to
request action be taken” about what?
Efforts to deal with the match imbalance
“brought increased attention to a number of
important issues facing professional psychology
education and training. It became widely known
that the imbalance was one component of a
larger set of problems that needed to be
addressed.”
BACKGROUND (CONT.)
“Advances in psychological science have moved
psychology from focusing on mental health
problems to being a broad health profession in
which mental health remains an important
subset….”
 “Psychologists must be prepared to work in the
health care system of the 21st century”
 Many articles articulating these changes were
cited including articles by Belar (1989,1995,
1997, 2012)

WHO WAS ON THIS GROUP?
BEA authorized funds to support an interorganizational working group that was later
funded through the APA strategic plan initiatives
and came to be known as the Health Service
Psychology Education Collaborative”
 A small group comprised of representatives
appointed by the APA Board of Educational
Affairs( BEA), Council of Graduate Departments
of Psychology (COGDOP), and the Council of
Chairs of Training Councils (CCTC) and
supported by APA.

WHO WERE THEY?
Cynthia Belar and Cathy Grus- APA
 Frank Andraski- Univ. of Memphis
 Sharon Berry-Children’s Hospital & Clinics of
Minnesota
 Clark Campbell-Biola University
 Margaret Gatz- University of Southern California
 Carol Goodheart-Independent Practice
 Cindy Juntunen-University of North Dakota
 Elizabeth Klonoff-San Diego State University

Theresa M. Lee- University of Michigan
 Janet R. Matthews- Loyola University
 M. Ellen Mitchell- Illinois Institute of Technology
 Celiane M. Rey-Casserly- Boston Children’s
Hospital
 Michael C. Roberts- University of Kansas

WHO WASN’T THERE?
Anyone from a university counseling center
internship training program even though we
represent the greatest number of internship
sites!
 Sharon Berry is an internship person
 Celiane Rey-Casserly is a post doc person
 Both are at children’s hospitals.

FROM THE INTRO TO THE ARTICLE

“HSPEC was initiated to address mounting
concerns related to education and training for the
professional practice of psychology. Given that
professional psychology includes diverse areas of
practice and the mounting concerns about
psychology’s role in a reformed health care
system, HSPEC chose to focus on preparation of
psychologists for the delivery of health care
services and made seven recommendations that
constitute the core of a blueprint for the future.
So
that is the lesson on
process and now for the
actual content!
WHAT IS A HEALTH SERVICE PSYCHOLOGIST?


“Overarching conceptual framework that encompasses a
number of the recognized specialties in professional psychology.
(see figure, next slide) The term reflects the reality that most
of the accredited doctoral education and training currently
conducted in professional psychology is for health care
services…. There may be some communities within clinical,
counseling and school psychology that do not focus on the
provision of health care services (e.g. educational assessment,
vocational counseling, executive coaching), but it is estimated
that the bulk of practitioners in these areas do provide health
care services.”
“HSP is not a specialty itself and should not be confused with
the specialties of either clinical health psychology or clinical
psychology. HSP includes those psychologists whose focus is
on physical health problems as well as those who focus
primarily on mental health issues.”
WHAT ARE THE HSPEC COMPETENCIES?

I.
Science
A. Scientific Knowledge and Methods
 B. Research/Evaluation


II.
Professionalism
A. Professional Values and Attitudes
 B. Individual and Cultural Diversity
 C. Ethical and Legal Standards and Policies
 D. Reflective Practice/Self-Assessment/Self-Care


III. Relational: Interpersonal Skills and
Communication
HSPEC COMPETENCIES (CONT.)

IV. Applications
 A. Evidence-Based Practice
B. Assessment
 C. Intervention
 D. Consultation


V.
Education

A. Teaching

B. Supervision

VI Systems

A. Interdisciplinary/Interprofessional Systems
B. Professional Leadership Development
 C. Advocacy (Local, State, and National)

WHERE DOES THE COA STAND IN THIS?
The proposed draft of the revised Standards of
Accreditation did not adopt these competencies
as the core for the revised accreditation
standards.
 Instead the CoA looked at the variety of
benchmark competencies that have been
proposed and included those competencies that
appeared in all of the major competency
documents

REQUIRED PROFESSION-WIDE COMPETENCY
AREAS INCLUDED IN SOA FOR INTERNSHIPS:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Evidence-based practice in intervention.
Evidence-based practice in assessment.
Ethical and legal standards.
Individual and cultural diversity.
Research.
Professional values and attitudes.
Communication and interpersonal skills.
Consultation/interprofessional/interdisciplinary.
Supervision.
Reflective practice
The implications of this is that a program is free
to include all the HSPEC competencies in their
program if they choose but would not have to
include them to become accredited or to maintain
accreditation.
 In any case the draft of the new SoA does refer to
accreditation for Health Service Psychologists.

INTEGRATED HEALTH CARE

How does this fit into the picture?

Development of Competencies for Psychology Practice
in Primary Care – Report of the Interorganizational
Work Group on Competencies for Primary Care
Psychology Practice (March 2013) –available on APA
Education Directorate website

Movement of the VA system to Primary Care-Mental
Health Integration
MY OWN CONTEXT

Penn State Counseling and Psychological
Services and University Health Services
Co-located in the University Health Services Building
 Administratively separate
 Separate medical records systems
 I have led several joint CAPS/UHS work groups over
the years to improve collaboration

TRUTH IN ADVERTISING
We do not currently have a concentration in integrated
healthcare
 I wanted to learn what others are doing
 Doing a presentation would provide the impetus to
learn

 Interviews
with an additional 12 university
counseling center training directors (of 16 listed in
the APPIC Directory on Line) who indicated that
their internship programs offered a concentration
in integrated care-primary.
15 minute interviews
 6 questions

INTERVIEW QUESTIONS
1.
2.
3.
4.
5.
6.
7.
What are you currently doing with interns in the area of
integrated healt
h care, primary?
Do all interns have the opportunity to participate in this
area of concentration?
What is working well?
What have been the challenges of implementing this
concentration for interns?
What lessons have you learned
Are you a merged center?
ARE YOU A MERGED CENTER?
Same Building
Merged Center
Not Merged Center
Not Same Building
6
2
PSU
4
WHAT ARE YOU CURRENTLY DOING WITH INTERNS
IN THE AREA OF INTEGRATED HEALTH CARE, PRIMARY?







Regular consultation and referral with medical staff
Eating Disorder Treatment Teams and AOD Treatment Teams
Sharing of medical records to varying degrees
Didactics for interns on integrative care with health services
Senior staff embedded in the health center, providing consults
and “soft hand offs”, “warm hand offs” to mental health folks with
interns shadowing and eventually spending a half day
Health center staff providing training on how to collaborate
effectively
Shared case conferences/grand rounds/in-services
WHAT ARE YOU CURRENTLY DOING WITH INTERNS
IN THE AREA OF INTEGRATED HEALTH CARE, PRIMARY?
(CONT.)





Providing immediate response to requests from medical providers
for referrals from urgent care
Involvement with behavioral health in health center- one session
interventions provided by interns on smoking cessation, stress
management
Collaborating on cases where psychiatric medications are being
prescribed, chronic mental health issues
Collaborating on cases that emerge as a result of health center
screenings
Co-facilitating a group within the health center for health related
issues like chronic pain
DO ALL INTERNS HAVE THE OPPORTUNITY
TO PARTICIPATE IN THIS AREA OF CONCENTRATION?
In general it seems that the more elaborate and
extensive the actual experience the less likely that all
interns were getting to do it.
 May be one of a menu of options for interns.
 Several folks said they carefully selected the person
who would go to the health center.
 Many experiences seem “hit or miss”, e.g. do they have
an eating disorder client, did they get called to see a
crisis in urgent care.

WHAT WAS WORKING WELL?





Increased collegiality with medical staff has led to better
consultation and collaborative care for students.
Multidisciplinary treatment teams leading to better care.
Increased appreciation by medical staff of what psychology has to
offer.
Increased appreciation among mental health providers about the
importance of sleep, exercise, eating.
Interns are getting training in how to express themselves in
professionally appropriate ways- learning to talk to physicians, be
brief and concise
WHAT WAS WORKING WELL?
(CONT.)
Increased appreciation for the mind-body connection
 Made us less scary to students who for cultural
reasons may never have come to the counseling center
 Medical providers are getting better at speaking to
patients sensitively.
 Making interns marketable for hospital post-docs and
work in other settings

WHAT HAVE BEEN THE CHALLENGES
OF IMPLEMENTING THIS CONCENTRATION
FOR INTERNS?
General challenges of providing integrated care







It is time intensive for programs that are doing anything more
extensive- work schedules are a challenge
Having the expertise, the energy, and the desire on the part of
staff members to do the groundwork and have a model
Frustration of different medical records systems
Lack of time to make transitions to new ways of operating
Having office space to embed a counseling center person in a
health center space- construction, money and time
Unrealistic expectations on part of medical staff for how quickly
change should happen
Cross cultural experience related to differences in medical
training and psychological training
WHAT HAVE
BEEN THE CHALLENGES
OF IMPLEMENTING THIS CONCENTRATION
FOR INTERNS? (CONT.)
Training specific challenges
 Lots of opportunities for interns - the tradeoffs of adding more
 Providing a reliable experience for ALL interns
 Getting administrative support for medical providers to engage in
training and to collaborate
 High intensity training for trainees who have no experience with
this
 Challenge of subjecting interns to difficult staff at some sites
(pushy, not respecting boundaries of office space, safeguarding
confidentiality)
 Needing to build intern credibility and helping interns to
communicate across disciplines and get providers to talk directly
to interns and not go over their head
EXAMPLE
“Medical people ask very pointed questions as rapidly as
possible and immediately go into treatment mode. Most
psychologists have an approach where they sit down and
engage in a relationship, and want the person to feel safe
and gather information to collaboratively work towards a
resolution. It is a real different approach. An intern is
expected to talk to a woman on an exam table while the doc
is not leaving the room, the nurse walks in and puts a blood
pressure cuff on her, people are in an out and putting
needles in her and the intern is supposed to do a suicide
assessment. That was not going to happen in that scenario.”
WHAT LESSONS
HAVE YOU LEARNED?
Before implementing training in this area you need an
infrastructure in place for providing integrated care
 Don’t use the training program to work out kinks in
the system
 Students understand trend toward integrative care
more than senior staff who have been around for a
while
 Importance of good communication-establishing a
common language, clear referral questions, and clarity
of diagnosis

WHAT LESSONS HAVE
YOU LEARNED? (CONT.)
Figure out who is invested politically
 Work directly with those who are receptive rather than
going through the administration
 Upper level support may come once there are good
results
 Provide time during orientation for training from both
departments
 Don’t just offer a seminar- provide an actual
experience
 Flexibility and willingness to go outside of normally
expected therapy are needed

WHAT LESSONS
HAVE
I LEARNED
FROM CONDUCTING THESE
INTERVIEWS








?
Some folks are doing great things in this area
We don’t have to be doing this to have an accredited program
There are pieces of this most of us probably can do and should dohow to collaborate effectively with the health service providers on
our campus
The training component can only be as strong as the integrated
care program itself
The time has to come from somewhere- where is it coming from?
Who is paying for it?
The physical setting is important- co-located, in the same building
verses across campus
Are the players reasonable? Can you build a coalition among the
reasonable players?
CONCLUSIONS



We are all providing training in Health Service Psychology
by virtue of our settings, our services and our missions
Much of this is a change in language from Professional
Psychology to Health Service Psychology
There is always politics in change and it is a work in
progress- what HSPEC wanted is not exactly what CoA has
proposed



Some of us may be providing training in Integrated
Health Care and some may not- we don’t have to be
providing that training.
Either way it is probably good for us to consider
changes we need to make to provide training that will
be applicable across settings- our interns don’t always
get jobs in counseling centers
Our interns should know how to interact with
members of other disciplines and speak their
language in order to be understood


Our interns should understand when a medical
problem may be contributing to a psychological
problem and should know how and when to refer
We don’t have to throw the baby out with the
bath water. There is nothing in this that prevents
us from continuing to work on advocacy, issues of
social justice or multiculturalism.
OVERVIEW OF HEALTH SERVICE
PSYCHOLOGY
 What
are we doing already?
PERSPECTIVE
Many counseling center psychologists talk about
their work related to mental health and mental
illness but may not consider themselves to be
health service psychologists or think of their
centers as health care settings
 Those with stand-alone counseling centers may
question their ability to provide or train for
integrated health care
 A change in perspective may help you realize
that you already train for health service
psychology and integrated health care –
counseling centers are naturally collaborative

INTEGRATED HEALTH CARE
 Treating
the whole person (mind-body
connection) by addressing primary health,
mental health, and substance use problems in
a coordinated manner (systemic collaboration)


Emphasizes wellness and prevention, provides
holistic care, and improves continuity of care
Biopsychosocial model
LEVELS OF INTEGRATION BETWEEN
PRIMARY AND MENTAL HEALTH CARE
DOHERTY, BAIRD, REYNOLDS, MCDANIEL (1996)
IT’S IMPORTANT TO REMEMBER
 Health
Service Psychology ≠ Integrated Health
Care
 Integrated Health Care ≠ Integrated Primary
Care
 “Psychology is both a primary care profession and
a specialty care profession” Belar (2012)
 Accreditation Standards will require broad
training but will leave room for site-specific
training
ACCTA MEMBER SITES
According to the 2014 ACCTA Member Survey:
 60.7% are administratively and operationally
separate from their student health centers
 16.1% are administratively combined but operate
separately
 13.4% are administratively and operationally
combined
COMMON CASES INVOLVING COLLABORATION
WITH OTHER HEALTH PROVIDERS

Those that require medication:






Depression
Bipolar Disorder
Anxiety
Panic Disorder
OCD
Schizophrenia, Schizoaffective, other psychotic
disorders
COMMON CASES INVOLVING COLLABORATION
WITH OTHER HEALTH PROVIDERS (CONT.)

Those that require medication (continued):
 Premenstrual Dysphoric Disorder
 Chronic Illness
 Chronic Pain
 ADHD
 Transgender students transitioning
 Sleep Disorders
COMMON CASES INVOLVING COLLABORATION
WITH OTHER HEALTH PROVIDERS (CONT.)

Those in which physical health is co-morbid with
mental health:





Depression and anxiety are adverse outcomes of
diabetes, heart disease and asthma and/or vice versa
Stress is frequently accompanied by high blood
pressure
Lack of sleep, inadequate nutrition and/or substance
abuse can present as a variety of medical conditions
Thyroid disease can be mistaken for depression
Celiac disease may be experienced as anxiety
EXAMPLES
 Shared
OF INTEGRATED
HEALTH CARE
clients/patients
 Referrals to physicians/psychiatrists – call
from office, help schedule appointment,
request consultation
 Referrals from physicians/psychiatrists –
collaboration, consultation
 Obtaining records from other providers
 Hospitalization
 Eating disorder treatment teams
EXAMPLES OF INTEGRATED HEALTH CARE
(CONT.)






Regular meetings with psychiatrist to discuss mutual
cases
Flu outreach – “wash hands” sign and hand sanitizer
in waiting room
Therapy or support groups for students with medical
problems – physical disabilities, chronic pain
A psychiatrist(s) is housed in the CC
Counseling Center Director oversees Health Center or
vice versa
Annual meet-and-greet between Counseling Center
clinical staff and Health Center medical providers to
facilitate referrals
HEALTH SERVICE PSYCHOLOGY
SERVICES/ACTIVITIES COMMON IN
COUNSELING CENTERS
Assessment
 Screening – depression, anxiety, eating disorders,
online screenings
 Diagnosis
 Meditation, mindfulness, relaxation training,
diaphragmatic breathing
 Referral for medication; inquiring about medication
compliance
 Consultation (internal and external)

HSP SERVICES/ACTIVITIES COMMON IN
COUNSELING CENTERS (CONT.)
Training
 Supervision
 Massage chairs
 Biofeedback
 Stress management
 Behavioral change groups or programs
 Attention to physical effects of substance abuse

HSP SERVICES/ACTIVITIES COMMON IN
COUNSELING CENTERS (CONT.)
Consideration of symptoms as consistent with physical
illness (thyroid, seizures, celiac disease)
 Education on sleep hygiene
 1 time sessions, walk-ins, triage
 Multidisciplinary staff
 Health promotions/prevention – stress reduction, mood
management, etc.

HSP SERVICES/ACTIVITIES COMMON IN
COUNSELING CENTERS (CONT.)
Peer educators – presentations on safer sex and
sexual health
 Participation in wellness fairs and programming
 Alcohol and other drug interventions
 Case disposition team
 Case presentations

HSP SERVICES/ACTIVITIES COMMON IN
COUNSELING CENTERS (CONT.)
Collaborate with Health Center staff on mental health
or substance abuse advisory committees
 Utilize evidence based treatments
 Provide neuropsychological assessment
 Use of the DSM and/or ICD
 Utilize electronic health records
 Take health insurance

HSP SERVICES/ACTIVITIES COMMON IN
COUNSELING CENTERS (CONT.)
Follow laws and ethics that apply to providing
health services
 Outreach, groups, and education related to
diversity
 Provide free or reduced fee services for students
without insurance – social justice focus on health
inequities
 Patient/client satisfaction evaluations
 Outcomes assessment/program evaluation

INTERNSHIP TRAINING
Seminars on psychotropic medication, mindbody connection, etc.
 Physicians or psychiatrists provide trainings
 Rotations at Student Health Center
 Grand Rounds if have a medical school with
psychiatry
 Joint professional development programs –
training on psychotropic medication; training
MDs about depression; psychological conditions
that manifest somatically and organic
conditions that manifest psychologically

INTERNSHIP TRAINING (CONT.)
Training in the delivery of preventive,
assessment, diagnostic and therapeutic
intervention services (what you currently do),
including a broader knowledge of, and
collaboration with, other areas of health care
 Training to work in a CC is in essence training
for health service psychology and integrated
health care

FROM COUNSELING CENTER TO
INTEGRATED PRIMARY CARE – WHAT
HELPED?







Clinical staff with diverse integrative theoretical
orientations
Opportunity for “hallway consultation”
Use of CCAPS for brief symptom assessment
Crisis intervention during daytime
Students worked with in Health Center suffer from same
stress, anxiety, depression as those worked with in
Counseling Center
Provision of generalist training
Triage approach to students initiating treatment
SUGGESTED ADDITIONS TO COUNSELING
CENTER TRAINING
Train in Mindfulness Based Cognitive Therapy
(MBCT) and Mindfulness Based Stress Reduction
(MBSR)
 Present educational workshops or therapy groups to
students in the Health Center
 Anything that can be viewed as working from a
multidisciplinary approach
 Consulting experience and team oriented work

DISCUSSION
 Thoughts
 Questions
 Reactions