Ethical Issues
Peter Stanley wrote a column in the November edition of Connections on “Health Improvement Practitioners”. In this edition, Aaron O’Connell and Marcia Sasano respond to Peter’s article, and Peter responds below.
A response to Peter Stanley’s item “Health Improvement Practitioners”
Aaron O'Connell and Marcia Sasano
Aaron and Marcia are the clinical leaders who worked in the pilot to provide the evidence for the New Zealand trial of Primary Care Behavioural Health and are now the senior trainers for this new initiative.
We believe it is passed the time for an approach that delivers the
high-quality healthcare that modern New Zealand needs. In our opinion, the current system fails to adequately address the increased demand for health services, deeming it unsustainable. Several contextual factors contribute to this increasing pressure but put simply: poor psychological health and social difficulties exacerbate physical health problems.
Psychological and specialty mental health services are also under considerable pressure to address the increased utilization needs. Like many experienced mental health clinicians, we both have recent experiences of working in systems
where patients are waiting excessive lengths of time (i.e. 6-8 months) for
psychological/talking therapy for serious and debilitating psychological distress, often in the context of suicidal ideation or self-harm. More frustrating, ‘conversion’ rates within referral-based services for psychological care are very poor
with many missing booked appointments, declining treatment, or dropping out. Currently, primary care is treating up to 30% of its patients for mental health
problems, and undoubtedly is the only source of care for most of them. This is even more relevant when we start to consider inequalities in access to care across ethnic and other deprived minorities. Primary care is in a strategic position to drive better engagement and improve physical, psychological, and social outcomes.
Peter Stanley suspicions are true (see Ethical Issues “Health Improvement
Practitioners” Connections, November 2019). New Zealand is about to embark on a major round of service provisions to change the way psychological interventions are offered to the general population. The change is supported by a considerable
increase in funding for primary care – $455 million boost to establish a new frontline service announced in the government’s 2019
We have experienced this transformation first-hand – working in the pilot
programme for almost 2 years (www.tetumuwaiora.co.nz) and are now positioned to lead the next phase as New Zealand rolls out the programme . We believe that this
will revolutionise how services and the public conceptualise who, why, and what is deserving of publicly funded care in New Zealand, well beyond the current service model that imposes barriers based on the diagnosis of human distress.
The active ingredient of the programme is based on the significant advances in behavioural science technology over the past 50 years.
A technology that has yet to be offered to the general population, despite an abundance of documented scientific evidence that it can significantly improve mental, social and physical health outcomes and will prevents the progression of more serious conditions (Bigan, 2015).
Many of the programmes cited by Peter Stanley (Triple P, smoking cessation, motivational interviewing, Incredible Years) are well known by our psychology colleagues as meaningful and effective treatment approaches that are yet to find an
efficient means to reach all those consumers that they could help.
We believe the government has recognised the need for a more integrated and collaborative care provision and is using a well-researched model to offer these brief evidence-based interventions to the general population,
namely Primary Care Behavioural Health (Robinson and Reiter (2016), Reiter, Dobmeyer & Hunter (2018)). Unfortunately, these official government documents and tendering requests understandably focus on the finer details and mechanisms of the model, without conveying the underlying vision and values that are inherent in
the programme. We have found it to be a fundamental shift in the way our services
respond to human distress. It offers open and accessible care to many, without the need for diagnostic labels. Instead, the service targets any immediate presenting concern the patient prioritises, regardless of needing to conceptualise this as being
mental, physical, or social distress.
Central to this approach is embedding professionals with behavioural and psychological expertise in the primary care team. The Te Tumu Waiora’s pilot evaluation began to replicate the outcome from the international experience (see Hunter, Funderburk, Polaha, Bauman, Goodie and Hunter (2017) for a summary of the current outcomes), in that local health practitioners with some experience of talking therapies can quickly be taught to offer these brief interventions to a high number of patients. Furthermore, they are effective and acceptable to
patients, and showed evidence of symptom improvement after very few
The Health Improvement Practitioner (HIP) (or international term Behavioural Health Consultant) supports the primary care team through training and consultancy that encourage staff to better promote behavioural change with their patients. The role requires a registration to practice but also relevant post-qualification experience (behavioural change interventions, self-management, mental health training). HIPs are experts in delivering high-intensity behavioural change interventions at an individual level but also preventively, at a population level. HIPs and their Health Coach colleagues are an additional resource to the current services offered by
primary and secondary care. They do not replace secondary mental health specialists nor the vast range of other services already available to the health consumer. Our own experiences have shown a paradoxical impact – both significantly reduced referrals to our local mental primary and secondary psychological teams and, at the same time, screened and identified
numerous previously undiagnosed needs that are directed to the appropriate services and correct service intensity (from ACC sensitive claims, early psychosis teams, Shine, to online self-management tools).
Psychologists are best placed to lead and implement new paradigms, especially when our current systems have been unable to relieve human suffering, improve the
well-being of the general population, and generally ignored scientific best practice. The
increasing demands on specialist mental health services is unsustainable, despite the hard work and dedication of all our health colleagues. This new initiative will
require all our professional psychological expertise, from the psychologically
treatment capable workforce to measure and improve outcomes for both individuals and health systems; and skills to implement the rollout and facilitate complex health and social systems changes. The New Zealand we know prides itself
in developing unique solutions and has the capability and willingness to do what other larger nations are unable to implement easily.
This is a truly transformative move and one that will need the
organisational, professional and ethical support from the psychology community in
New Zealand. The current government has provided the resource and outlined a scientifically robust model. Let’s get on and use it wisely.
The opinions expressed are professional and personal views of the authors and are not representative of their employers or any organisational affiliations.
References
• Biglan, A., (2015). The Nurture Effect: How the Science of Human Behavior Can
• Hunter, C. L., Funderburk, J. S., Polaha, J., Bauman, D., Goodie, J. L., & Hunter,
C. M. (2017). Primary care behavioral health (PCBH) model research: Current
state of the science and a call to action. Journal of Clinical Psychology in Medical Settings. https://doi.org/10.1007/s10880-017-9512-0
• Perrot, A. (2019, October). Quality HIPs mean fewer sleepless night for GPs
worrying about mental health patients. New Zealand Doctor, 9th October, pp10.
• Reiter, Jeffrey & Dobmeyer, Anne & Hunter, Christopher. (2018). The Primary
Care Behavioral Health (PCBH) Model: An Overview and Operational Definition. Journal of clinical psychology in medical settings. 25. 10.1007/s10880-017-9531-x.
• Robinson, P. J., & Reiter, J. T. (2016). Behavioral consultation and primary
care: A guide to integrating services (2nd edn.). Geneva: Springer International
Integrated Primary Mental Health: An individual response to O’Connell and Sasano
Dr Peter Stanley, Retired Counselling Psychologist, Tauranga
Like O’Connell and Sasano, who have replied to my Ethics Column in the November 2019 issue of Connections, I also want to see real reductions in psychological
suffering in our communities. As well, I would like to see the blanket availability of empirically supported primary prevention programmes (and specifically parent training) that can ameliorate the root causes of a myriad of personal and social problems. Where O’Connell and Sasano, and the NZ Government, and I differ is in our understandings of how the overarching objective might be reached. The official view is that social workers, nurses, and occupational therapists, and others, with additional training, can usefully and efficiently respond to people with psychological problems who currently cannot access mental health services. My position is that the Integrated Services that are about to be rolled out in this country have been
Evaluation
In October 2018 an independent evaluation report was submitted to the Ministry of Health on Integrated Services (Appleton-Dyer, Andrews, Reynolds, Henderson, & Anasari, 2018) and this statement very probably influenced official decisions to further develop the new scheme. This evaluation report contains interesting data. For instance, most clients reported improvements in wellbeing. The problem with the evaluation is what is missing from it. The inconsistent use of measures, the lack of information on long-term effects, the limitations associated with the study only being in our largest city, and the lack of a comparison group all represent significant difficulties that were probably connected with the newness of Integrated Services. Nevertheless, it would have been really helpful to decision makers and others to have some systematic information on the treatments offered by Integrated Services to its clients.
Was the intervention that was applied really FACT, or aspects of CBT, and
motivational interviewing? And how well was it delivered? Who knows, but the sense is that clients were offered one or more problem-solving strategies that a therapist thought were relevant at the time. And apart from self-reported
improvements in wellbeing, how were clients now functioning at work, at home, and in other contexts? This disregard for clinical models and methods means that the evaluation is actually restricted in its findings to treatment process issues like how promptly people were seen and the number of sessions that they engaged in. Clearly, government policy makers should appreciate that the evaluation cannot be taken as an ‘evidence base’ for psychosocial work in primary health settings that will have substantial and sustained effects on people’s lives.
Health Improvement Practitioners
‘mild to moderate’ problems and to ‘the missing middle’ of people. But HIPs can also be described as ‘generalists;’ and as practitioners they seem to take on all comers. For instance, the 2018 survey found that HIPs were dealing with people with “low functioning,” “really high need,” and “high levels of distress.” This evaluation also reports that few clients are referred onto secondary mental health services by HIPs.
In reality, we do not know who HIPs are, who they work with, or what they actually do. Nevertheless, whatever is done by them is achieved remarkably speedily as 80 percent of HIP consultations are for 30 minutes or less and 68 percent of referrals have just one consult (Appleton-Dyer et al., 2018). O’Connell and Sasano exhort psychologists to appreciate the vision and values of this ‘revolution,’ and
‘transformation’, in mental health care. The banners are certainly flying ahead of what is presently intended. In the circumstances, it could be that people like me are just being difficult and obstructive. Let’s face it, there are ranks of clients waiting for assistance. GPs simply can’t respond to them in 15-minute consultations. And there are some good people down the corridor who can talk to these clients right now. So, let’s just get on with it.
There is an interesting idea about aims and means in analytical philosophy that probably applies to the present discussion. In democratic societies, mental health services of all stripes are likely to be well-intentioned but it’s what they actually do in their interactions with clients and patients that defines and differentiates them. Contrary to popular belief, counselling and psychotherapy are not unitary, and
inevitably positive, activities. Equally, psychiatric hospitals and state care are not ipso facto beneficial, or malevolent, options as they tend to be distinguishable from each other by what transpires behind their separate, and closed, doors. Within this
framework, Integrated Services ought to be applauded for tackling the really
important process issue of access to services but the core of the matter has yet to be resolved. Moreover, as the innovator of a new way of working the responsibility to provide proof of therapeutic efficacy rests with them.
As it happens, there are bunches of other conceptual issues that pertain to Integrated Services depending on whether HIPs are a component in a stepped system of care and whether they are effectively substitute psychologists.
of evident severity and urgency. By contrast, a person can present to a psychologist with a plethora of risk factors and distress but actually be functioning competently and well. Meanwhile, there are clients in psychological practice who seem in good shape but with whom it may take many sessions to discern that they are struggling with a severe and intractable difficulty. These different practice realities challenge the relevance of stepped-care approaches in psychosocial work, and they also mean that it is very important to have highly competent and experienced practitioners at the first point of client engagement.
The government special education sector in NZ has made a number of attempts to establish new occupational classes, and often this has been in an attempt to remedy the shortage of psychologists. Past exemplars are Visiting Teachers and Guidance and Learning Teachers; while Special Education Advisers are a present day example of these initiatives. Frankly, these new services can be shaky management enterprises as they attract significant individual variations in practice and performance that no amount of role clarity, best practice guidelines, and quality leadership can effectively direct and contain. Issues and questions around capacity, capability, and risk are probably related to the absence of a common core, and a sufficient depth, of specialist training. It is also likely, among the new practitioners, that there is heightened vulnerability to disengagement and burnout. In addition, there can be significant worries for the professionals in a practice or centre (psychologists,
medical practitioners) when they continue to hold clinical responsibility for cases but have no real influence over the work that is done with clients by others.
Conclusion
Anyone who attended public consultations held by the Inquiry into Mental Health and Addiction knows how inadequate our present mental health provisions are. Many of the stories that were told in these settings were truly harrowing. Integrated Services have done very well in demanding innovation, responsiveness, and flexibility from a tired and seriously under-performing system. It is also special that the new approach appears to be largely avoiding diagnosis and the medicalisation of
The new mental health services are definitely underway, and it is highly unlikely that the government will now consider an alternative scheme. Nonetheless, it could do two things that would likely have a profound influence on the success of the goals that it is pursuing in mental health. The first recommendation continues to be that it very substantially increases the production of psychologists, but that it now
systematically integrates these new psychologists into the spaces that are being made available for HIPs. It would also be important to give these practice
psychologists the necessary numbers of treatment sessions with clients to do the job that they are trained to do. What is being suggested here is a fairly obvious
amendment, although it would require significant will to do it. It is probable that there is likely to be an ongoing shortage of HIPs, and particularly in rural and isolated locations. More to the point, therapeutic psychologists have the specialist
competencies, and capability, to regularly and efficiently deliver effective mental health services to clients in everyday settings who present with the full range of personal difficulties and adjustment issues.
My second recommendation has also already been written about before and it is that government seriously increases funding to primary prevention services.
Integrated Services may argue that it is a preventive service already, but primary (or universal) prevention is actually about keeping psychological problems from
occurring at all. Integrated Services, while located in primary health care settings, attempt to assist with personal problems, and to stop matters getting worse. This is really secondary (or selective) prevention, which is complemented by tertiary (or indicated) prevention where services are provided for clients with problems of living that have additional effects and complications (Kaufman & Landrum, 2018). These distinctions are very important because if we do not take primary prevention seriously, we can never hope to reduce the demand for one-to-one psychological services, however quickly they may be applied. It is for this reason that I continue to champion the Incredible Years (IY) series of programmes which can fulfil an array of preventative functions (http://www.incredibleyears.org; Stanley & Stanley, 2018). Like Integrated Services, IY is readily accessible; but it also has a deep evidence base (including NZ evaluations), multinational uptakes and respect, cultural endorsements and adaptions, and an existing infrastructure of trainers in this country.
References
Kaufman, J. M., & Landrum, T. J. (2013). Characteristics of emotional and behavioural disorders of children and youth (10th ed.). Upper Saddle River, NJ: Pearson.
