Robyn L. Shepardson, PhD, is the 2014 CFHA Fellowship Award Recipient. Below is her reflection on her research project.
As a clinician working in the Primary Care Behavioral Health (PCBH) model in integrated primary care, I have a short amount of time to make a difference with my patients. I figure I have about a half-hour for each session if I’m lucky, or really more like 10-15 minutes after conducting a functional assessment or providing empathic listening when a patient really just needs to share his or her story. I never know if a patient will return for follow-up, as about 50% of patients attend only 1 PCBH session.
With so little time, and perhaps only one chance, to give my patients something (information, support, skills) they can use, I am eager to make a lasting impact. As a result, there are times I am guilty of throwing all but the kitchen sink at my patients and seeing what sticks. Based on the results of a new survey I conducted with PCBH providers, it seems I am not alone in this tendency to offer all but the kitchen sink...
At last year’s CFHA Conference, I received the 2014 Research Fellowship from the CFHA Research and Evaluation Committee. For the fellowship, I conducted a national survey of PCBH providers (N = 291) to identify the types of interventions used for anxiety in real-world clinical practice, as well as the types of comorbid symptoms/problems seen in patients referred for anxiety. I focused on anxiety because it is common and burdensome in primary care, but tends to receive less clinical and research attention compared to depression and PTSD.
I surveyed PCBH providers about their most recent session with a patient referred for anxiety. As anyone working in primary care knows, primary care patients are complex and often present with a multitude of both mental health symptoms and medical problems. In this case, 95% of patients had other behavioral health concerns (e.g., depression, insomnia) besides anxiety.
So, how did PCBH providers handle these complex patients? It appears they used a lot of tools from their clinical toolboxes – an average of 6.5 intervention techniques – despite sessions being less than 40 minutes on average. Clearly providers are drawing upon a variety of interventions to treat anxiety and/or comorbid symptoms. Of necessity, the time spent on any one intervention technique is likely very brief.
The high number of interventions used within a single session brought to mind the idea of "all but the kitchen sink.” Reflecting on my own clinical practice, I often use a combination of elements of various brief interventions, such as psycho-education, relaxation or mindfulness training, cognitive restructuring, and behavioral activation, as well as broader approaches/themes such as supportive therapy, stress management, problem solving, and increasing social support. I weave threads of these concepts into the discussion as appropriate, spending more or less time on a certain topic or skill depending on various patient factors.
Is this a good approach? How much is too much? Could we be overwhelming our patients with so many ideas that they don’t know where to start? How do we find the right amount of education to provide and the right amount of skills to teach? How do we strike a balance between providing support and helping patients develop specific action plans?
I tend to view my role as a PCBH provider as helping patients identify their options. I can provide information and describe skills likely to be helpful, and if time allows I include a brief demonstration of a relevant skill to illustrate how this might help. But in 30 minutes or less, there’s just no way I can learn everything I would need to know to make definitive recommendations on what would be best for them. It’s up to individual patients to decide what resonates and what they are ready and willing to try. We know "one size fits all” approaches will not work because every individual is so different and has unique challenges and psychosocial circumstances. So perhaps the "all but the kitchen sink” approach is not a bad idea after all, as it gives patients a menu of options from which to select what appeals most to them. PCBH providers and PCPs can then support patients in their efforts to make behavior changes and implement healthier coping skills. What do you think about the "all but the kitchen sink” approach we often take in PCBH?
As our field works toward building a larger evidence base on effective brief interventions to inform clinical practice in integrated primary care, clinicians can play an active role in evaluating what works. Clinicians can use program evaluation and quality improvement methods to collect outcome data to monitor individual patients’ progress in treatment. For example, collecting data on the types of interventions we use as well as mental health symptoms and overall functioning would allow us to empirically answer the question of whether "all but the kitchen sink” is a helpful approach. It is not as hard as you might think and could help provide valuable evidence to help us answer this very important question.
One way you might help overcome any fears you might have about doing research is by learning essential basic research skills and how to conduct program evaluation and quality improvement. The new Research and Evaluation track at the 2015 CFHA Conference in Portland provides an opportunity to learn these skills. This track (5 talks) is designed to provide practical "how to” lessons on how to plan and conduct research, quality improvement, and program evaluation in real-world health care settings. Or if you have the skills, but just have not collected the data—help us answer this question in addition to the multitude of others that impact routine PCBH clinical practice.
If you are interested in hearing more of my results or sharing your take on using "all but the kitchen sink,” please join me at 10:30 am on October, 16th at the 2015 CFHA conference in Portland.
Robyn L. Shepardson, Ph.D., recently completed a two-year postdoctoral research fellowship with the VA VISN 2 Center for Integrated Healthcare (CIH) and is now a clinical research psychologist at CIH. She earned her Ph.D. in clinical psychology from Syracuse University after completing a pre-doctoral internship in health psychology/behavioral medicine at the Brown Clinical Psychology Training Consortium in Providence, Rhode Island. Dr. Shepardson’s research interests include developing, testing, and implementing brief, evidence-based interventions for anxiety and depression in primary care patients. She is interested in increasing engagement in integrated behavioral health care by incorporating Veterans’ treatment preferences using novel resources, such as peer support and mobile technology, to reach more patients.