Help Seeking – The Relevance of Clinical Psychology in the Medical Settings
Since the beginning of history, even before Psychology became a field, there were people with depression, anxiety, relationship problems and questions about children with difficulties and vocational choices or about problem children, and these people sought out individuals they believed had the ability to help them. The biomedical model, which has been around since the 19th century, has not demonstrated its ability to adequately address the different forms of illnesses that humans experience (Wade & Halligan, 2004), as these illnesses are often a result of the complex interplay between physical symptoms, emotional factors and socio-cultural settings. For example, many of the somatic symptoms such as irritable bowel syndrome and chronic pain have no links to any discernible pathology, and an understanding into these symptoms from a different perspective, such as considering a patient’s psychological state, may be a more useful alternative in helping these patients alleviate the cause of their symptoms. In fact, up to 70% of primary care appointments in medical settings are for problems arising from psychosocial issues (Gatchel & Oordt, 2003), and up to 84% of these somatic complaints had no organic causes (Kroenke & Mangelsdorff, 1989). As such, engaging the role of clinical psychologists in addressing these issues becomes an integral part of the total treatment for the patient.
The biopsychosocial model has been increasingly preferred and shown to provide a more holistic understanding to medical illnesses (Tuck, 1996) – this model acknowledges that a patient with a distressing and persistent medical condition is negatively affected in a complex variety of ways, and therefore psychological and social factors such as cognitive beliefs and social support have to be taken into account in addition to biological consideration, to address all aspects of care. Clinical psychology bridges this gap between the biomedical model and biopsychosocial model, and further espouses its application to the latter in medical settings.
Clinical psychologists working in medical settings apply the biopsychosocial model by first helping patients to overcome their psychological barriers and stigma in accepting psychological in order to understand their persisting difficulties. Some of the barriers can include the misconception that only patients with mental issues need to see clinical psychologists. Clinical psychologists, with their broad clinical skills, can identify each of these factors and work collaboratively with patients to address them. For example, a patient who suffers from panic attacks as a result of stress from work may believe that medication is all that is required to “cure” his or her condition and lacks the understanding that acquiring stress coping strategies may be more helpful in the long term to handle his stress. The role of the clinical psychologist thus becomes crucial in not only educating patients regarding the relevance of the underlying psychological rationale to their overall health, but also to implement appropriate treatment interventions which may be more effective in the long run than relying on medication alone for mere alleviation of symptoms. In other words, clinical psychologists are able to effectively address the difficulties that physicians encounter such as medication non-adherence and somatic symptoms in addition to the physical problems that patients are experiencing, as these difficulties are usually beyond the physicians’ area of expertise. Thus, the role of clinical psychologists in medical settings is not to discredit the biomedical model, but to work collaboratively with physicians and other health care colleagues in a multi-disciplinary team to offer valuable insight and input so as to achieve optimum positive outcomes for patients.
The nature of illnesses has changed since the last century. People are no longer dying from acute infectious diseases such as smallpox and measles; rather, people are now suffering from chronic health conditions such as cancer and diabetics (Sanderson, 2004), which involve a complex interplay of behavioural choices, stress and social factors. Help seeking in the form of psychological intervention has been documented to benefit patients with both acute and chronic physical illnesses. In fact, the US Public Health Service reported that lifestyle factors and behaviours comprise 7 out of 10 leading health risk factors in the United States. Patients who have higher levels of social support and hold more positive beliefs about their health condition are also more likely to engage in health-promoting behaviours (Sanderson, 2004), and this can inform a clinical psychologist’s treatment plan resulting in a more successful intervention.
The focus on improving wellbeing and the quality of life becomes especially salient when the life expectancy has increased dramatically over the years and people may have to live with chronic health problems for longer. As many of the behavioural health needs of patients are often overlooked by the medical team (Hunter & Goodie, 2010), the role of clinical psychology in medical settings comes into play as clinical psychologists can target these behavioural, stress and environmental components, and help people manage their chronic illnesses psychologically and socially by various treatment interventions, such as providing psycho-education, stress management and self-care strategies, and family therapy. Consequently, the quality of life not only improves for the patients but also improves for their family members as the burden of care decreases.
Health care costs have rising dramatically globally. In Singapore for example, the total budget for the Ministry of Health (MOH) in 2010 was $4 billion and another $3 billion would be needed by 2020. Research has shown that many patients in medical settings present with behavioural health problems such as anxiety, depression and substance abuse, and the costs of treatment for chronic psychological and medical problems incurred were disproportionately high. In fact, research has also consistently shown that patients with psychological problems use medical services more than those without diagnosable psychological problems, depression and generalized anxiety disorder.
Clinical psychologists can effectively help to identify these comorbid psychological disorders. Many patients also do not seek medical help based solely on physical problems as other psychosocial factors such as stigma, attitudes and health beliefs, inadequate health information, unhealthy lifestyle habits, problems with treatment adherence and psychological distress can influence their decision. The need to reduce such high health care costs incurred by this group of patients with multifactorial presentations has therefore given impetus for clinical psychologists working in medical settings to deliver effective psychosocial interventions. Thus, if psychosocial factors play a significant role in health care operation, then successful interventions should result in reduced health care costs for the medically ill.
In addition, patients can fall along a continuum ranging from relative minor physical symptoms stemming from psychological stressors to chronic illness stemming from severe psychological distress; physicians may not only be untrained to detect and/or manage the nuances between such psychological distresses or manage them, but they also do not have the time to do so. This is supported by research which has found that physicians have repeatedly failed to appropriately detect patients with psychological problems in primary care medical settings. Failure to appropriately detect, diagnose and treat these conditions can have serious clinical implications, and the onus thus falls in the hands of clinical psychologists. It is the unique characteristics of the medical settings whereby a patient presents primarily to the physician with a conglomeration of biological and psychosocial issues manifested as physical symptoms, which justify the need for clinical psychologists. The availability of clinical psychology services means that physicians can refer patients to their clinical psychologist colleagues for further assessment. Consequently, fewer patients would fall through the system and more would benefit from a heuristic approach of providing a comprehensive and coordinated service within the medical settings.
Taylor (2012) proposed that an effective relationship between the patient and practitioner can serve to achieve three outcomes: reduce the duration of the illness, enhance the patient’s use of services, and improve the efficacy of treatment. For that reason, clinical psychologists can exercise their distinct advantageous position and clinical skills in the therapeutic alliance with patients to achieve all three outcomes based on the biopsychosocial model in four ways. Firstly, clinical psychologists can be heavily involved in the prevention of illnesses which encompasses three levels of primary, secondary and tertiary prevention: primary prevention aims to target the risk and protective factors that may influence the onset of an illness such as altering a patient’s attitudes and beliefs about his or her illness, thereby promoting a healthier lifestyle; secondary prevention aims at reducing the severity of an illness through early identification and treatment which includes addressing the psychosocial factors; tertiary prevention aims at alleviating the suffering of the patient from an illness through various interventions such as cognitive behavioural therapy. Secondly, clinical psychologists can conduct competent assessments for a wide range of complaints and conditions from patients in the medical settings which may include mental health status and psychological factors such as coping strategies and adaption to the illness. Clinical psychologists are distinguished from other medical health professionals with their specially trained skills in developing and using scientifically-based instruments to diagnose patients objectively. Moreover, not only do clinical psychologists have the competency to conduct psychometric assessments to assess a wide range of functions such as motivations and cognitive functioning, they are the only professionals who have the legal right to use, administer and interpret psychological assessments (APA, 2010). Thirdly, as physicians do not usually have the time or training to provide psychotherapy or closely monitor patients with more complex needs in the medical settings, clinical psychologists can add immense value by their provision of evidence-based interventions to address mental health needs, enhance heath behaviours, and manage chronic illnesses and their co-morbidities such as depression. These interventions can range from relaxation techniques to family therapy, all of which include an additional focus on culture-specific issues. Fourthly, clinical psychologists can liaise with other health care professionals to address patients’ issues such as collaborating with occupational therapists for overall pain management, and provide consultation, education and training to other staff members on topics or issues that will make a difference to the patients’ well-being. For example, an educational training session for other staff may cover a topic on how depression may exacerbate the experience of pain in patients suffering from chronic pain.
In addition to the clinical skills and knowledge which will benefit patients directly in the medical settings, clinical psychologists also bring in their research skills from their academic training to enhance the overall health care delivery service. They can aid in the development and standardization of clinical tools, evaluation of psychological and biological interventions to promote health, the analysis of cultural factors involved in psychosocial issues, and supervising other projects. Clinical psychologists can even set up and manage the development of viable research divisions within clinical departments that will consolidate and translate research findings into teaching and clinical services. For example, research can be conducted in the area of patients living with late-stage cancer within the medical settings to document their experiences of living with the illness; the findings of this research will then have important implications, including providing a better understanding of how these patients can be better supported with their diagnosis as well as formulation of interventions to tailor the provision of psychological-specific support to them. Similar to how the gap between the biomedical and biopsychosocial models is bridged, clinical psychologists can also bridge the gap between research and practice due to their combination of sound clinical and research skills.
Psychology has been traditionally perceived as an academic profession with little practical involvement; the physician is the sole person in charge who is responsible for all the treatment plans of patients with or without the input from other professions. However, for patients to receive the most comprehensive care with the latest behavioural science knowledge, input from all the staff members in a medical setting is necessary. A holistic approach based on the biopsychosocial model is therefore needed to improve the experiences of patients and to address the complexity of the human condition in today’s world. Patients are not objects and should be treated with respect and dignity – the significant contribution made by clinical psychology is therefore unequivocal, and its need for a place in medical settings is not only essential but also necessary for anyone who seek help.
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