Health Improvement Practitioners
Dr Peter Stanley, Retired Counselling Psychologist, Tauranga
Integrated Services
I strongly suspect that we are about to embark on a major round of social service provisions that is poorly conceptualised, and that contains elements that are quite inappropriate and inadequate for the task that has been set. Mind you, I understand the pressure that the Government is under. The Inquiry into Mental Health and Addiction revealed a plethora of unmet psychological needs in the community. In addition, there is our country’s surfeit of social casualty statistics for problem behaviours including suicide, drug use, and imprisonment. The new Integrated Primary Mental Health and Addiction Services creates two additional mental health workers who will typically be located in general medical practices. The first line of engagement for a patient could be with a peer and/or cultural Health Coach who might be BTDT qualified (been there/done that). These unregistered workers will support and help others to navigate systems. After some training, they will also provide interventions such as “Triple P training, Ready Steady Quit, Motivational Interviewing, Alcohol Brief Interventions, Stanford
Self-Management Support and Flinders Self-Self-Management” (Request for Proposal, Government Electronic Tenders Service).
The centerpiece of the new arrangement, however, are Health Improvement Practitioners. HIPs will come from a variety of professional backgrounds (psychology and psychotherapy, but also nursing, social work, and
occupational therapy) and they are expected to have skills in psychological therapies. The task of HIPs is to work with patients of all ages, as individuals, groups, and whanau; and to provide them with evidence-based interventions to enhance their health and wellbeing. Treatment sessions will be “generally of 30 minute’s duration,” and “around 50% of people will choose to be seen just once” (Request for Proposal, GETS). Nevertheless, there is to be no limit to the number of times that a patient can come back. HIPs are to receive three stages of training: Phase 1, four classroom days; Phase 2, 1-to-1 in a workplace setting; and Phase 3, a series of webinars. Registration under The Health
safeguard of the system. Interestingly, exceptions to this registration are to be made for social workers and addiction workers; while NZAC counsellors remain out in the cold for now.
HIPs and Health Coaches are two core components of Integrated Services, which actually has three other key constituents. These additional features are: ensuring effective links between primary and secondary mental health
services, accessing Non-Governmental Organisation (NGO) supports for patients, and enhancing the competence and confidence of General Medical Practitioners and Practice Nurses in responding to mental health and addiction concerns. Collectively, these five elements will lead the Government’s $1.9 billion investment in mental health over the next five years. The funding for Integrated Services is to be distributed equitably across the country but based on population characteristics. Maori, Pacific Peoples, and youth (13-25 years) are the priority groups. Resources are to be administered by a lead District Health Board (DHB) in a geographical area with Primary Health Organisations, DHBs, and NGOs acting as service providers. Proposals to provide services for the first funding round closed in October 2019 and are being judged according to the following assessment criteria: (i) Focus on equity and priority
populations, 15%; (ii) Collaborative service development and delivery, 20%; (iii) Service provision capacity, 30%; (iv) Workforce capacity and capability to
deliver, 20%; and, (v) Robust implementation plans, 15%.
Professional capacity
The Integrated Services initiative will not succeed when it is taken to scale because it is based on misapprehensions. Probably the most fundamental error is the belief that helping people with problems of living can be regularly achieved by people with some background in counselling or with the slick application of standard treatment packages. I had presumed that it was fairly obvious, but the reason that it takes years for a person to become a
psychologist (and a psychiatrist or psychotherapist) is that there is a lot of important content to learn. Effective therapists need to acquire the substantiated principles and processes of change that afford them the
crucial to the real-life helping skills that they possess. Generally, HIPs will not have an equal professional preparation and will be less likely to be able to fully understand the complex situations that they will inevitably encounter.
Similarly, it is less likely that they will have the same facility to mount individualised interventions that achieve lasting personal change. Furthermore, HIPs may lack the relevant research abilities to be able to
evaluate interventions and to critique other available treatments. Finally, it is unlikely that these practitioners will have the background to be able to make original contributions themselves to the vast store of psychological knowledge from which they intend to benefit.
Quite simply, there are few shortcuts with individual psychotherapeutic approaches; or in the application of evidence-based psychology treatment packages. For instance, it usually takes between 2-3 years to become fluent in Acceptance and Commitment Therapy; and other therapy systems can take as long, or even longer, to master. Likewise, group programmes, such as the Incredible Years series of Parent, Teacher, and Child Programmes, which have achieved such multiagency acceptance in this country, start with three-day courses but then go on to demand fairly strenuous apprenticeships from group leaders. A critical component in all therapy is fidelity; whether this is to
substantiated principles of change, or to an original research protocol. And near enough is never good enough because a partially delivered intervention or programme may have no effect at all, or it may have deleterious effects. Moreover, to ensure treatment fidelity there needs to be systems of training, support, supervision, evaluation, and research around the therapists and therapies. In part, Integrated Services understands this last point. However, the Request for Proposal approach and its assessment criteria, the reliance on a number of different contractors, the expectation that NGOs and others can find suitable workforces and maintain their performance, all suggest an
incomplete understanding of the nature of the task that is being undertaken. Rather than the proposed response, psychologist leadership should be
centralised within the Ministry of Health (perhaps by having a Chief
Psychologist to complement the Chief Medical Officer, Chief Nursing Officer, and Chief Allied Health Professions Officer). After all, which profession
HPCA registration
There are two other sources of criticism for Integrated Services. One of these arises from its reliance on professional registration under HPCA, and the other one concerns the negative consequences that could ensue from the new service. Integrated Services is presumably connecting itself to HPCA for many (but not all) of its workers for reasons of accountability, and possibly for an appearance of competence as well. However, scopes of practice, which are a mainstay of HPCA, are largely being ignored. In the HPCA framework,
proficiency in psychological assessment and intervention is the domain of psychologists; and protection of the public is ensured by insisting that psychologists are proficient in their particular scope of practice and do not venture beyond it. As we know, an extensive infrastructure, consisting of a regulatory authority (Psychologists Board), numerous specialist university training courses, and regular accreditation processes support the psychologist scope of practice. The option that psychologists can become HIPs, and the fact that psychologists will continue to work in secondary mental health services, is irrelevant to the central point. Under Integrated Services, occupational
therapists and nurses, and possibly podiatrists and chiropractors, will be rebranded, and will provide psychological services. The abrogation of scopes of practice, and the disrespecting of professional psychology, that is being perpetrated here is equivalent to psychologists providing massage therapies if there was a shortage of physiotherapists.
Stigma
The language in the RFP documents suggest that Integrated Services is trying to avoid an exclusively medical response to problems of living. There is talk of “high impact” problems that are commonly experienced by people; and
‘access,’ ‘choice,’ and ‘self-management’ are emphasised. Avoiding rampant diagnosis, and all the other commitments of the biomedical approach to
psychological problems, is in keeping with some of the sentiments expressed in He Ara Oranga Report of the Government Inquiry into Mental Health and
professionals and most of them will be located in general medical practices. As well, there is obviously going to be reliance on highly individualised talking therapies; and these inherently reflect biases about personal causation. Moreover, brief consultations, significant client throughput, a diverse workforce, sizeable data collection systems, and feelings of practitioner insufficiency all tend to encourage dependence on the Diagnostic and
Statistical Manual of Mental Disorders. Government officials will probably say that this is something that will have to be guarded against; and such a
response would be in keeping with the clear and concerning sense that Integrated Services are being made up as the project goes along. In effect, a diagnostic and biomedical edifice is currently being created and it is naïve to think otherwise.
Therapism and absence of prevention
As it happens, there is another possibility that is as likely as the expansion of stigmatising diagnoses and it is that we will become a country of therapists and their clients. In itself, this is a perturbing consequence, but it also reflects the reality that Integrated Services have nothing to say about the social and structural determinants of mental health issues. As worrying, Integrated Services documents do not concern themselves with the prevention of problems of living; in the sense of providing people with the skills and motivations that allow them to avoid coming to notice in the first place.
Significantly, the threat of therapism could be partially answered by the further development of an existing community resource. The Incredible Years
prevention programmes, which have already been mentioned, have the proven capacity to alter life trajectories that are associated with a multiplicity of problem behaviours in children and youth including delinquency, bullying, depression, and suicide. In the delivery of these programmes, group leaders work alongside parents and caregivers who are treated as the experts on their own children. In fact, Incredible Years is a really successful story for our human services and for the 20,000 New Zealand parents and whanau that have now received this training in child management.
Conclusion
development. The Government is spending colossal money on mental health; and funding of this order could substantially, and comparatively easily, expand psychology professional training, and the psychology prevention programmes, that currently span the country. Specifically, there could be a substantial increase in workplace-based schemes for psychologist registration that are open to students with Master’s degrees in psychology. To the charge that it couldn’t be done in time, there is the precedent of the Veterans’
Administration in the US; which immediately after WWII, very rapidly
increased the number of clinical psychologists that were needed to respond to returning service people who were traumatised. Universities and hospitals provided new courses, and even the US Public Health Service provided a training programme. Money and facilities were also made available for
research. This was a truly transformational move, and one that was devoid of the organisational, professional, and ethical slights of hand which are so
