Editor’s Note: As part of the Center for Deployment Psychology’s ongoing mission to provide high-quality education on military- and deployment-related psychology, we are proud to present our latest “Guest Perspective.” Every Tuesday, we will be presenting blogs by esteemed guests and subject matter experts from outside the CDP. This allows us to offer more insight and opinions on a variety of topics of interest to behavioral health providers.
As these blog entries are written by outside authors, one important disclaimer: all of the opinions and ideas expressed in them are strictly those of the author alone and should not be taken as those of the CDP, Uniformed University of the Health Sciences (USUHS), or the Department of Defense (DoD).
That being said, we’re very happy to offer a platform where we can feature these individuals and the information they have to share. We’d like to make this an ongoing dialogue. If you have questions, remarks, or would like more information on a topic, please feel free to leave comments below or on our Facebook page, and we’ll pass them along to the author.
I was trained in the Primary Care Behavioral Health Consultation model (PCBH; Robinson & Reiter, 2016) while I was a pre-doctoral clinical psychology resident (intern) in early 2007. As a young U.S. Air Force (USAF) officer and clinician, I found the primary care rotation to be exciting and exhausting. However, as a colleague of mine says, the primary care bug bit hard and I was hooked! I enjoyed the fast-paced generalist environment and the need to be prepared for anything. After graduation, I was fortunate to continue doing part-time PCBH work until I separated from the USAF in 2015. The USAF calls their PCBH program the Behavioral Health Optimization Program, a.k.a. BHOP (USAF, 2014). I BHOPped along for a few years until I was certified as an official “mentor” by Patti Robinson in 2011. For three years thereafter, I trained residents in BHOP. I truly had no idea that the skills I learned during my residency rotation would prove so valuable not just in primary care clinics, but also in a variety of other military settings, including the deployed environment.
Working in the PCBH model means you are serving as a Behavioral Health Consultant (BHC), currently known in the DoD as an “Internal” BHC (IBHC; DoD, 2013). IBHCs are trained mental health professionals, usually clinical psychologists or licensed clinical social workers and sometimes Nurse Practitioners (Robinson & Reiter, 2016). BHCs work closely with Primary Care Managers (PCMs) to provide team-based care for patients in primary care with a variety of presenting concerns, to include typical mental health complaints (depression, anxiety), chronic health conditions (diabetes, chronic pain) and lifestyle issues (obesity, insomnia). IBHCs usually see patients for 15-30 minutes, and typically for one or two appointments. If a patient is seen for four or more appointments, then a referral to specialty mental health care is usually considered. IBHC visits involve functional analyses, psychoeducation and provision of brief evidence-based interventions. There is early research to suggest that patients significantly improve their mental health—with long-term benefits—following very few IBHC visits (Bryan, Corso, Corso, Morrow, Kanzler & Ray-Sannerud, 2012; Ray-Sannurud et al., 2012). IBHCs can help improve a variety of conditions, with early evidence suggesting significant improvement is possible for insomnia (Goodie, Isler, Hunter & Peterson, 2009) and PTSD (Cigrang 2011; 2015). Training residents in IBHC in the USAF was truly rewarding, and I took satisfaction in knowing these skills would be highly translational across a diversity of settings.
When I was a new clinical supervisor in BHOP, it quickly became evident that not everyone is good at—nor interested in being good at—being an IBHC. All USAF pre-doctoral interns at the three sites have a mandatory rotation in BHOP, and not all military psychologists are a good fit for the primary care environment. Whether you fall into the good fit category or not, and whether you are assigned to a primary care clinic or not, the skills learned in IBHC training are incredibly valuable. I will highlight three key skills that are necessary for being a competent IBHC and an adept military psychologist, particularly in the deployed setting: rapid assessment, brief intervention, and expert consultation.
A typical IBHC visit is only 30 minutes, even the initial encounter. This requires a focused and accurate assessment of the patient’s functioning. First, you have to gather only relevant background information and current functional status in 15 minutes or less, then provide a good biopsychosocial conceptualization and psychoeducation in about five minutes, followed by behavioral recommendations and wrap-up in the remaining five minutes. Honing your clinical acumen to perform in this manner is useful in primary care and in any interpersonal encounter as a military psychologist. In particular, the deployed setting does not always provide the luxury of a 60 minute intake session. It helps to be practiced in conducting rapid and accurate evaluations of personnel in need, not just in clinical settings, but also during command consultation requests or when identifying potential unit concerns on base walk-abouts. Many psychologists get panicky when they don’t have a traditional mental health environment or timeframe, but the military context demands flexibility. After practicing as an IBHC, it can feel painless to do your job when you’re low on time in a unique military environment. While deployed in 2009 to COB Adder in southern Iraq, sometimes a single 50 minute session in our Combat Stress Control (CSC) clinic would be the only visit possible for a Service member. I had to spend that time wisely, knowing I needed to make the best assessment possible and still leave time to deliver a solid intervention. Could this soldier be trusted with their weapon? Were they a risk to self or others? Was their depression or anxiety or other issue severe enough to warrant recommending mission impact by removing from duty? Being able to assess quickly and effectively was useful in the deployed setting, and all that practice getting the job done in 15 minutes made having nearly an hour seem almost excessive!
Although most evidence-based treatments these days are considered “brief,” the distillation of such interventions to less than four visits under 30 minutes is a challenge. After rapidly identifying what the problem is, you have to move along to quickly choosing and implementing an effective solution. There are many opportunities for brief “interventions” in military settings, such as one I recall while deployed. My technician and I had just finished a Traumatic Event Management briefing with a unit whose convoy got blown up two days prior. Thankfully, they hadn’t lost anyone, but several troops had been air-evac’d out of country due to severity of injuries. After we provided education and information to the unit, we had some informal conversation before departing. The Commander came over to thank me for coming, and quietly disclosed some of his personal experiences of the past few day. He used plain language to describe insomnia, flashbacks, and hypervigilence. This was not a guy seeking “treatment,” and the likelihood that he wanted to—or needed to—come into the CSC clinic was extremely unlikely. I had about two minutes to provide something useful, so my training and experience in BHOP came in handy! I gave reassurance of the normalcy of response, how to practice good self-care in that environment and watch for any functional impairment, along with stimulus control tips for him to make sure his sleep didn’t worsen. I was grateful at the time for skills of thinking quickly on my feet and knowing about and providing brief interventions.
A key role of the embedded IBHC is that of consultant to the PCM. Sometimes the consultation occurs without ever seeing the patient of concern, as in a “hallway consult.” However, consultation always happens after a visit with the referring PCM’s patient. As a resident, this was challenging sometimes to act as the “expert” speaking with physicians and physician’s assistants (PAs) who all outranked me. It helped me grow in confidence to see how my skills and training in clinical psychology were valued and appreciated by different disciplines.
The skills of conveying feedback and advice to a higher ranking officer –PCM or not—are quite beneficial for military psychologists. Consultation from psychologists is often sought out by commanders and senior enlisted personnel. There are even occasions when your consultation is not particularly valued, but you have to provide it anyway. When tasked for deployment, I had only been licensed for five months. I was accustomed to being in a large Military Treatment Facility where most psychologists outranked me; I was rarely, if ever, consulted by commanders in that assignment. However, once in country, I frequently consulted with command, typically related to command directed evaluations (CDEs) and/or troop well-being and unit morale. Much of the time, delivering unpleasant news to commanders was difficult, but the information was often appreciated, if not well-received. However, one particular consultation with a commander was truly challenging. Following a CDE, I had to make the recommendation for air-evac to Lundstuhl Regional Medical Center in Germany due to significant risks to the safety of the soldier and his unit. This commander outranked me, was stressed-out himself, and did not appreciate this feedback. I remember the struggle to stand firm in my recommendations that if he did not act, others were at risk; I had to remind myself that I was the expert in clinical psychology and I trusted my evaluation (and invaluable consultation with peers). I did not waiver when he shared doubts about the validity of my findings and frustration because he needed every warm body possible to carry out the mission. I used my best communication skills to highlight that we were on the same team and wanted the same positive outcomes. Now, of course, commanders do not have to do what we medics recommend, but in the end, he did choose to follow my advice and we arranged for departure on the next flight. The practice of providing consultation to high-ranking PCMs paid off, potentially preventing negative patient and unit consequences.
Recently, I have heard it argued that DoD clinical psychology training programs should eliminate their rotations in integrated primary care because most IBHC positions in the DoD are filled by civilian contractors. However, even if military psychologists never work in the primary care setting, the skills gained by learning how to be an IBHC are invaluable. I was privileged to do IBHC work about 10-20% of my time as an active-duty USAF psychologist for nearly eight years following internship. Even if others are not as lucky, military psychologists will certainly benefit from using critical skills reinforced in the primary care environment: rapid assessment, brief intervention and expert consultation. If you are interested in learning more about the PCBH model, BHOP, IBHC and other relevant acronyms, I encourage you to check out these organizations: Society of Behavioral Medicine’s Integrated Primary Care Special Interest Group (SIG; I am Co-Chair, along with Dr. Jim Aikens); Collaborative Family Healthcare Association, the Association for Behavioral and Cognitive Therapies’ Behavioral Medicine and Integrated Primary Care SIG, and American Psychological Association Division 38 (Health Psychology). Please see below for these websites and resources that will help hone your skills as an IBHC and a military psychologist.
Dr. Katie Kanzler is a Board Certified Clinical Health Psychologist serving as Director of Integrated Behavioral Health in the University of Texas Medicine’s Primary Care Center. She is an expert in the Primary Care Behavioral Health (PCBH) model and has co-authored nine peer-reviewed journal articles and given more than a dozen presentations on integrated primary care. Dr. Kanzler served 8.5 years as an active duty USAF psychologist and is an OIF veteran. She made the difficult adjustment to civilian life last year and is getting the hang of academic medicine as an Assistant Professor at the University of Texas Health Science Center at San Antonio, appointed to the departments of Psychiatry & Family and Community Medicine. In her spare time, you might find her trying to decode the civilian wardrobe situation, relaxing with her pug or working on their old house with her architect spouse.
Citations & Resources
Bryan, C. J., Corso, M. L., Corso, K. A., Morrow, C. E., Kanzler, K. E., & Ray-Sannerud, B. (2012). Severity of mental health impairment and trajectories of improvement in an integrated primary care clinic. Journal of Consulting and Clinical Psychology, 80, 396–403.
Cigrang, J. A., Rauch, S. A., Avila, L. L., Bryan, C. J., Goodie, J. L., Hryshko-Mullen, A., & Peterson, A. L. (2011). Treatment of active-duty military with PTSD in primary care: early findings. Psychological Services, 8(2), 104-113.
Cigrang, J. A., Rauch, S. A., Mintz, J., Brundige, A., Avila, L. L., Bryan, C. J., et al. (2015). Treatment of active duty military with PTSD in primary care: A follow-up report. Journal of Anxiety Disorders, 36, 110-114.
Department of Defense (August 8, 2013). Integration of Behavioral Health Personnel (BHP) Services Into Patient-Centered Medical Home (PCMH) Primary Care and Other Primary Care Service Settings. DoD Instruction Number 6490.15 (Incorporating Change 2, Effective November 20, 2014).
Goodie, J. L., Isler, W. C., Hunter, C., & Peterson, A. L. (2009). Using behavioral health consultants to treat insomnia in primary care: a clinical case series. Journal of Clinical Psychology, 65, 294–304.
Ray-Sannerud, B. N., Dolan, D. C., Morrow, C. E., Corso, K. A., Kanzler, K. E., Corso, M. L., & Bryan, C. J. (2012). Longitudinal outcomes after brief behavioral health intervention in an integrated primary care clinic. Families, Systems, & Health, 30(1), 60-71.
Robinson, P. J., & Reiter, J. T. (2016). Behavioral Consultation and Primary Care: A Guide to Integrating Services (2nd ed.). New York: Springer.
United States Air Force (2014). Primary Care Behavioral Health Services: Behavioral Health Optimization Program (BHOP) practice manual. San Antonio, TX: Air Force Medical Operations Agency.
American Psychological Association’s (APA) Special Issue on Primary Care and Psychology in American Psychologist, Vol. 69, No. 4, May–June 2014.
Bryan, C., & Rudd, M. D. (2011). Suicide Risk in Primary Care. New York: Springer.
Hunter, C. L., Goodie, J. L., Oordt, M. S., & Dobmeyer, A. C. (2009). Integrated Behavioral Health in Primary Care: Step-by-Step Guidance for Assessment and Intervention. Washington, DC: American Psychological Association.
Association for Behavioral and Cognitive Therapies’ Behavioral Medicine and Integrated Primary Care SIG: www.abct.org/Members/?m=mMembers&fa=SIG_LinkToAll#behavioral_medicine
APA Division 38, Health Psychology: www.health-psych.org
Collaborative Family Healthcare Association: www.cfha.net
Society of Behavioral Medicine’s Integrated Primary Care SIG: www.sbm.org/about/special-interest-groups/integrated-primary-care