Comprehensive behavioral medicine in community mental health

Comprehensive behavioral medicine in community mental health

Evaluation and Program Planning, Vol. 11, pp. 297-306, 1988 Printed Copyright in the USA. All rights reserved. 0 0149-7189188 $3.00 + .OO 1988 Per...

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Evaluation and Program Planning, Vol. 11, pp. 297-306, 1988 Printed


in the USA. All rights reserved.


0149-7189188 $3.00 + .OO 1988 Pergamon Press plc


that Needs Assessment

DAVID Midland-Gladwin






Services and Central Michigan University

RICHARD L. SPOTH Iowa State University

ABSTRACT It is suggested that the massive costs incurred nationally in health care are in large part a fitting concern of Community Mental Health (CMH). There is considerable data available to suggest that as much as half of the variance in common health disorders is associated with behavioral factors. There is a rapidly growing movement to provide interventions geared toward these behavioral components in health disorders, but much of this has occurred outside of the traditional mental health environment. There are arguments to suggest that CMH should be more involved in the development of comprehensive behavioral medicine services, both in terms of the expertise and resources that it can bring to bear upon these problems, and its potential to reach segments of the population which are otherwise likely to be underserved, if served at all. Implications for CMH planning and financing are discussed, drawing upon a selective literature review and clinical illustrations,

Behavioral medicine is a rapidly expanding service area for health and mental health professionals. Its interventions have been applied as preventive, palliative, or curative aids to problems as diverse as cardiovascular disorders, cancer, diabetes, gastrointestinal disorders, pulmonary disease, chronic pain, and many other health problems (e.g., Mostofsky & Piedmont, 1985; Pinkerton, Hughes, & Wenrich, 1982). Yet surprisingly, most behavioral health services have sprung from outside of the national community mental health (CMH) system,

the largest provider of mental health care. Relaxation training, biofeedback, stress management, and other selective elements of behavioral medicine care are offered in some CMH centers, but the literature provides little evidence of widespread interest in behavioral medicine services within CMH. The present paper examines the issues impinging upon the entry of comprehensive behavioral medicine programs into community mental health, and the resultant considerations for needs assessment in the CMH planning processes.

THE SCOPE OF THE PROBLEM Behavioral medicine has existed formally for only a decade, and its definition is still evolving (Brady, 1981; Matarazzo, 1980; Schwartz, 1982; Weddington & Blindt,

1983). For present purposes, it is broadly defined (and undoubtedly oversimplified) as the interface of psychology and medicine. This encompasses (a) psychological

This paper is based in part upon presentations by the first author at the 1985 and 1987 annual meetings of the National Council of Community Mental Health Centers. Much of the material is based upon a behavioral medicine program developed by the second author at Iowa Lutheran Hospital. Requests for reprints should be sent to David M. Dush, Pain Management Center, 4909 Hedgewood, Midland, Ml 48640.




factors that may cause or contribute to a medical problem, (b) medical problems that contribute to the cause of psychological distress, and (c) psychological concerns that predictably accompany medical concerns, without implication of causality. An example of the latter would be the psychological anguish of the physically abused: the medical problems and the psychological distress of the victim covary, but both are caused by other, external factors. With this definition of behavioral medicine, a very large number of disorders and potential applications is encompassed. The sweep becomes broader still when it is recognized that prevention of most major physical disorders also rests heavily upon behavioral factors. For example, the incidence of lung cancer, the leading cause of death from cancer, could be greatly reduced by one behavioral change: stopping smoking. Other lifestyle factors include work patterns, substance use, stress management skills, social support systems, exercise, nutrition, etc. Changing these features of lifestyle is very much within the domain of behavior modification, to which CMH has an important contribution to make. There are a number of factors that would seem to compel CMH toward behavioral medicine. First, as we will illustrate in detail, the magnitude of need is immense. CMH represents the largest collective resource of mental health personnel and resources available to respond to this need. Secondly, an expansion into be-

ILLUSTRATIONS Data from a variety of sources illustrate the diversity and magnitude of behavioral medicine needs in the population at large. A compelling perspective can be gained from examination of the leading causes of death in the United States (see Table 1). Even without departing far from conventional notions of mental health, the magnitude of interface between psychological concerns and physical health impact is evident. Suicide, of course, is a traditional CMH concern. Substance abuse plays a contributory role in accidents, liver disease, and elevated risk for many other illnesses. Homicide, birth defects, infant deaths, etc. are influenced by a variety of sociological and psychological factors that fall within CMH’s prevention mandate. Even more dramatic is the impact of disorders which are generally excluded from consideration in CMH. Cancer and cardiovascular disease are excellent examples, collectively accounting for about two-thirds of all deaths in the United States. With both disorders there are established or hypothesized behavioral contributions from all clinical vantage points: prevention, treatment, rehabilitation, and palliation. Much of the study of the cause, treatment, and prevention of heart disease has been directed toward hy-


havioral medicine promises new linkages with the medical community. This may introduce complications if territoriality and competition are at the forefront. On the other hand, it promises an expanded network of communication with potential referral sources, and could provide access to clients in need of CMH services who might otherwise be inaccessible. An additional potential benefit is access to new sources of funding and reimbursement. There are certainly a number of grant sources available to “health” programs that are not as accessible to mental health programs. Community financial support mechanisms can be rallied around new specialized target problem areas in the health promotion areas. Additionally, there may be an expanded base for third party reimbursement through private insurance or government programs: we have encountered insurers who will not reimburse “counseling” but will, in contrast, reimburse therapy for reduction of stress contributing to a gastric disorder, chronic pain, etc. Perhaps the most persuasive argument for behavioral medicine in CMH stems from fundamental CMH ideology: the provision of primary, secondary, and tertiary levels of prevention and treatment, according to need, regardless of ability to pay. Unless CMH provides access to behavioral medicine, those with limited ability to pay or limited access to specialized regional medical facilities are likely to remain underserved.

OF NEED pothesized behavioral risk factors: Type A behavior, emotional reactivity, inadequate stress management, coping skills, exercise, obesity, smoking, substance abuse, hypertension, and nutrition (e.g., Friedman et al., 1984; National Diet-Heart Research Group, 1968; National Heart Institute, 1968; Stamler, 1979). Treatments for cardiovascular disease attend to weight reduction, increased exercise, and changes in nutritional patterns. Behavioral techniques have been used to improve compliance with prescribed medical treatment. Biofeedback and relaxation training have been used to treat hypertension, a major cardiovascular risk factor. Preparatory coping interventions prior to surgery or other stressful medical procedures may help to reduce distress and enhance recovery. Heart disease may produce significant limitations and losses for the patient; rehabilitative interventions are frequently indicated. Additionally, some patients cannot be medically cured. Terminal care then warrants psychosocial intervention directed toward palliation of the patient and the family. Cancer is another area where psychosocial considerations abound (Dush, 198_5a, 1988; Feinstein, 1983; Redd & Hendler, 1983). The implication of psychosocial factors as causal in the etiology of cancer ranges




Percent of All Deaths

Heart Disease Cancer Stroke Accidents Lung Disease Pneumonia and Flu Diabetes Suicide Liver Disease Artery Disease Homicide Infant Death Kidney Disease Birth Defects Blood Poisoning

755,592 433,795 157,710 94,082 58,869 48,886 34,583 28,242 27,690 26,823 22,358 20,794 18,102 13,604 11,493

38.3% 21.9% 8.0% 4.7% 3.0% 2.5% 1.8% 1.4% 1.4% 1.4% 1 1% 1 1% 0.9% 0.7% 0.5%

Top 15 (Total)



aSource. National Center for Health Statistics,


from obvious to highly speculative. The least disputed causal factors pertain to lifestyle: exposure to toxic environments, smoking, sunbathing, compliance with preventive measures, etc. At a more controversial level, psychological factors have been posited as relevant to the disease process itself and to individual variance in response to medical treatment (Newton, 1980; Simonton, Matthews-Simonton & Creighton, 1978; Simonton, Matthews-Simonton & Sparks, 1980). A popular explanatory mechanism is impact of stress upon the immune system: higher external stress or reduced coping resources may suppress immunocompetence and increase vulnerability to cancer and to illness in general. Behavioral interventions for the cancer patient may also be viewed as adjunctive to medical treatment. Psychosocial preparatory techniques may improve compliance and reduce distress associated with stressful or painful medical treatments and side effects (Redd & Hendler, 1983). Compliance levels in cancer care may be dangerously low. For example, while nearly all women (92%) in a recent survey were aware of recommendations for monthly breast self-examination, only a third complied (Glass, 1987). The cancer patient may meet with new handicaps and losses, including distortions of body image following radical surgeries. It is best not to assume too quickly that all persons with serious health problems require psychotherapy (Turk & Salovey, 1985). Programs to attempt to screen those most likely to have a difficult and complicated adjustment, however, have been quite successful. Sobel and Worden (1979) devised an index predicting 75% of those cancer patients likely to experience high levels of distress. Weisman, Worden, and Sobel (1980) were able to obtain 86% predictive



accuracy in another screening study, and 88% accuracy in their replication sample. Cancer remains, for many, a fight to prolong life rather than to cure. Thus, a major role of the mental health professional lies in palliation of the many concerns, fears and adjustments as one faces loss, pain, and death. Treatment, prevention, rehabilitation, and palliation needs also exist in many of the other categories of mortality factors represented in Table 1. If, indeed, stress and coping skills play a role in the body’s general immunocompetence, then psychosocial functioning plays a contributory role in most illness. Combined with concern for lifestyle, exercise, nutrition, etc., the diversity of fronts for the behavioral medicine practitioner is overwhelming. An examination of Table 1 suggests that the majority of leading causes of death fall either within the domain of conventional CMH or are substantially relevant to behavioral medicine. How much impact on health problems can we expect from behavioral interventions? The evidence of efficacy of behavioral medicine is not without controversy and inconsistency (e.g., Fielding, 1982; Kaplan, 1984). However, the potential for impact is considerable. Michael (1982) examined the literature for four categories of health risk variables: (1) behavioral and lifestyle factors, (2) environmental hazards, (3) human biological variables, and (4) inadequacies in the health care system. He concluded that 50% of mortality associated with the leading causes of death were associated with behavioral and life style factors, and that the remaining contributions were fairly evenly distributed between environmental factors (2007o), human biological factors (2OVo), and inadequacies in the health care system (10%). Breslow (1979) reviewed data suggesting: (a) persons with healthier lifestyles, on the average, outlive persons with poor lifestyle and health habits by 11 years; (b) 18% of deaths through age 70 may be attributable to cigarette and alcohol use alone; (c) regular checkups and diagnostic screening may reduce mortality by 30% to 40%; (d) constellations of high risk factors increase chances of cardiovascular disease by up to 25 times. The scope of potential impact widens further still when one looks beyond mortality data. For example, problems with medical compliance extend to most areas of medicine. Noncompliance with medications alone ranges from 15% to 93%, varying with the population studied and the nature of the drug regimen (Greenberg, 1984). Additionally, a large number of low mortality disorders consume medical and social resources and reflect a great deal of distress and suffering: chronic pain, tension and migraine headaches, gastrointestinal disorders, eating disorders, sexual disorders, skin disorders and dermatological conditions, sleep disorders, etc.




If a primary role exists for CMH in behavioral medicine, it must also be demonstrated that these needs are not already being met by the existing health care system. There are considerable data bearing on this point. For example, it has suggested that the majority of patients treated in general medical practice have significant psychological problems (Locke & Gardner, 1969), and that nearly a third may have complaints which are predominantly or entirely psychogenic (Davies, Rose, & Cross, 1983). Barnes and Prosen (1984) found that about one-third of the patients presenting themselves to their physician showed at least mild levels of depression. The rate of visits to the family physician is substantially higher for persons with stress-related problems (Locke & Gardner, 1969), yet referral for mental health or behavioral intervention is infrequent. Neilsen and Williams (1980) found that psychosocial problems were detected only 50% of the time, and that these kinds of problems were less likely to be noted in the chart, even if discussed. There is apparently a reluctance to refer for mental health services, even when problems are detected. The available data suggests that CMH is commonly viewed as an avenue of last resort in the physician’s list of recommendations. In hospitalized medical patients, Steinberg, Torem, and Saravay (1980) found a 30-60’70 level of psychiatric morbidity, with usually only one or two percent of the patients referred for psychiatric consultations. They suggested that the resistance to referral was not apparently a concern about upsetting OI offending patients as much as it was a doubt about the need for, or likely effectiveness of, psychiatric intervention. Collectively, the data seem to indicate that the traditional health care system does not fully attend to the psychological components in physical illness and treatment. Conversely, the research cited generally supports the efficacy of many behavioral medicine and psychosocial interventions in impacting these problems. The remaining objective is to explore some of the program models that CMH might consider, toward development of comprehensive behavioral medicine services to meet these needs. Referral Based Services One model of program development is to make a package of behavioral medicine services available to physicians on a referral basis. This may provide the easiest (in some states, the only) access to the sizable pool of patients hospitalized in local general hospitals. A key characteristic of this program model is that the point of access to patients is through physicians. In many communities, the majority of these physicians are likely to have little or no history of referrals to CMH. Thus, the viability of this program model rests upon establish-


NEEDS ment and nurturance of new formal and informal linkages to the medical community. A referral program implemented by the authors may be a useful illustration. This program was initiated by the second author in a 300 bed private hospital, serving both psychiatric and general medical patients. It concentrated upon a tertiary level of care: direct clinical intervention with active inpatients and outpatients. Primary and secondary prevention services were also offered, as described in later sections. The array of services offered (see Table 2) was made




I. Problems


A. Stress,




for Referral

and Fear

B. Habit or Lifestyle


1. Smoking 2. Type

A Behavior

3. Sleeping


4. Drinking/Substance


5. EattngiNutrition 6. Sexual


7. Medical


C. Pain D. Depresslon

or Distress

E. Adjustment

to MedIcal




Il. Evaluation



A. Diagnostic B. Behavior


and Testing


IntervIew Assessment

C. Problem-Specific (The Health





D. Formal Testing (IQ, Neurological, Ill. Referral and Response Procedures A. Physfcian


B. Initial Service C. Verbal





3. Ongoing Considerations A. Written


Protocol hours)

to Physician

if Prescribed Evaluation Consultation In Treatment



by Physician

B. Individualization C. Acceptance D. Staff





E. Follow-up,





D. Written

by Illness


per Evaluation and Motivation


1 Cognitive

and Methods Behavioral


of Patient Available


2. Traditional Psychotherapy 3. Behavior Modification 4. Hyponotherapy 5. Biofeedback and Stress 6. Skills Training E. Specialized


1. Headache



2. Cancer 3. Smoking 4. Hypertension 5. Cardiology 6. Neurological




Behavioral Medicine visible to the physician, nursing, and ancillary staff through professionally prepared handouts, brochures, formal presentations and foremost, individual contacts with the various medical personnel. The list is by no means an exhaustive compilation of possible behavioral medicine services, but it proved to have sufficient breadth to encompass most kinds of problems encountered in the present medical facility.

Referral and Evaluation. The first section of Table 2 describes the type of problems portrayed as appropriate for referral. The response of physicians to this material varied widely. For those with orientations and backgrounds conducive to the behavioral medicine framework, the kinds of problems appropriate for referral were clear and referral and consultation relationships tended to proceed rather smoothly. In most cases, however, there was a process of a “trial” referral by a new physician who was unsure or skeptical of the service’s approach. The referral relationships that were developed tended to proceed via a sequence of individual contact with the physician, discussion about the presenting problem and the reasons for the evaluation, and ongoing discussion and tailoring of the intervention as needed. As would be expected, there were often important differences in perspective to negotiate. For example, with evaluations of pain patients the referral question commonly amounts to “Is this psychogenic pain or not?” In most cases, the response from evaluation of a patient of this type is not the yes-or-no answer requested. Rather, the report that followed would examine the relative contribution of psychological factors, environmental stress and secondary reinforcement to the total pain picture. Physician accommodation to this type of response varied. In some cases, referrals would not continue. More often, the process was productive, as indicated by the growth of the behavioral medicine program in question from one to four full-time psychologists within a period of two years. Except in emergency situations, the “intake” upon a referral to the behavioral medicine program was a problem-specific stress assessment and general background/ psychological evaluation, augmented by standard problem checklists and a locally developed “Health Concerns Questionnaire” (Spoth & Dush, 1988). The latter is a brief symptom checklist heavily weighted toward evaluation of affective, behavioral, and psychophysiological symptomatology, based upon the most commonly appearing descriptors in DSM-III. Similar tailored procedures were developed for specialized assessment in other areas, such as drug abuse, pain, headache pain, and alcohol use. Additionally, when indicated by evaluation or referral, patients were administered additional formal tests such as objective personality inventories,


intelligence tests, projective tests, or neuropsychological assessment. For some physicians it appeared that the availability of good test data to assist in decision making was the most highly valued feature of behavioral medicine consultation. The process of referral entailed a number of considerations that are especially critical and to some extent unique to a behavioral medicine program. It proved to be important, for example, to have a streamlined, standardized protocol for referral. This was made repeatedly visible to both physicians and the nursing staff (who often initiated or facilitated the referral). The required promptness of replies and interactions after referral also differed from the slower pace of events typical of our experiences in traditional CMH. Decisions in the medical setting generally need to be made very quickly, sometimes within hours. It is vital to have the staffing capacity for prompt interaction and recommendations in highly specific form which, to the extent possible, specify a clear, recommended course of action. The authors’ experience has been that, minimally, an initial contact should be made with routine referral patients within 24 hours and a preliminary evaluation communicated to the referring physician within 48 hours. Some physicians rely primarily on a verbal report, in which case the written report need not present as much urgency. In any case, verbal contact and consultation with the physician is invaluable, especially if follow-up evaluation or treatment is recommended.

Follow-up Treatment. The majority

of patients seen for evaluation were also seen for follow-up treatment. This ranged from very short term (one or two contacts) to long term therapy. Points emphasized in the evaluation’s recommendations were (a) individualization of treatment according to client and problem characteristics, (b) consideration of patient motivation, and (c) consideration of available staff expertise versus the need for outside referrals. As indicated in Table 2, a wide variety of approaches were represented within the service, prescribed on the basis of the individualized assessment and evaluated on an ongoing basis for effectiveness. Most forms of intervention incorporated behavioral or self-monitoring procedures such as daily subjective ratings of distress or pain. This was useful not only clinically but also in ongoing consultations with physicians about patient progress. Additionally, these outcome indicators provided data for periodic program evaluations. Ongoing visibility in this environment is critical, especially when one considers the hundreds of decisions, tests, and services that can be entertained for any given patient. It proved helpful to given frequent presentations to the hospital staff, especially the results of evaluation studies addressing treatment efficacy. It was always stressed that behavioral medicine served an




adjunctive role, to assist the physician and staff with that component of the problem for which we had expertise, Direct Marketing Another kind of entry into behavioral medicine for CMH is through directly marketed services. The authors used direct marketing to develop specialized programs for headache pain, smoking cessation, hypertension, etc., in the same behavioral medicine service described above. At regular intervaIs, a new series in each of these areas was announced through local press announcements and paid advertising. A free orientation session initiated each series, with one to two hours of genera1 discussion and pr~en~ti~ns about the problem of interest and the program to follow. Those who att,ended were invited to sign up if interested. A suitable illustration is the headache pain series, an educational group program for migraine and tension headache that ran for six 90 minute sessions after a free introductory meeting. Participants were required to obtain approval from their primary physician, indicating that there were no medical reasons to preclude or delay involvement. Extensive assessment instruments were filled out in the first session, to provide data for both pretest evaluation and individualization of the intervention. The program was largely didactic, with some rehearsal of strategies during the sessions and extensive homework assignments between the sessions. Patients monitored pain and medication intike daily. ‘These were reviewed with indiv~d~ali~ng comments at the beginning of each session. A cognitive behavioral intervention strategy was empIoyed, based on the work of HoIroyd, BIanchard, Andrasik, and coEeagues ~Bl~chard* Andrasik, Guarnieri, Neff, & Rodiehok, 1987; Hohoyd & Andrasik, 1982,. This attended to irrational beliefs, self statements, behavioral patterns, and coping skill deficits which may precipitate or contribute to headache pain. There was also extensive concentration on relaxation training, generalization of relaxation skills, and pain control techniques such as guided imagery and cognitive distraction techniques. Relaxation tapes were pravided for home practice. For patients with unusually severe pain problems or related psychological probiems, individual suppIementa1 tre~tme~~t was providedEvaluation data collected for the program suggested a 50% average reduction in subjective ratings of pain across the program. Additionally, while medication reduction was not an expressed goal of the program, 80% of the participants reported some reduction in the use of pain medications. P~~~~a~~~~~~ ~~~~~~~~~~~~ ttf &ecf

~~~~~~~~~~~ Dirmt

marketing has several advantages for program development. Foremost, it provides direct access to the patient. However, it has been our policy to request physician


approval for participation, for a number of reasons: (a) it is important to have input from the physician most familiar with the patient; (b) this approval insures that the physician is aware of symptomatology currently manifested; (c) approval reinforces the adjunctive role relative to traditional medical care, and helps to establish a referrat r~I~~~~nshipwith the patient’s physician; (d) in some cases, physician approval enabled the patient to obtain third party reimbursement. Directiy marketed services can be efficiently provided in a group format with costs kept Iow. The orientation sessions constitute a free public service, added visibility in the community, and access to repeated attention from the media. New referral sources may also be generated or enhanced, Addition~ly, this program model provides a vehicle conducive to prevention oriented services. ftreening Programs A substantial portion of stress-related problems presented in health care settings may not. be detected or referred for psychosocial interventions implying a need for expanded secondary prevention programs designed toward early identification of untreated or incipient disorders. Locke and Gardner (1969) suggest that up to 60% of patients seen by physicians have ‘~si~nifi~ant” emoticmal problems. Byrne (1984) found a 46% incidence of significant emotional stress on the General Health Questionnaire administered to 35 gynecological patients. Psychosociaf problems are unlikely to be documented in medicai assessments, even when they are discussed in the medical interview: Lau, Williams, Wiiliams, Ware, and Brook (1982) found that psychosocial issues were discussed in 80% of the phys~ci~ contacts but documented in only 25%. Even when psychosociat problems are detected, community mental health facilities are often the last resort in favor of Social Services departments, public health, etc. (Donovan 62 Aldrich, 1981). Screening protocols may be of assistance to both referral and directfy marketed programs, by bypassing some of the poteatial resistances and obstacles to medicaf and self-referrals. Simply the availability of screening data may not substantialiy alter physicians’ diagnosis OF referral patterns (Hoepcr, Nycz, Kessler, Burke, 8% Pierce, 1984). However* it has been our experience that when objective data are personally provided to physicians, they rarely fail to respond with an appropriate referral or intervention. Moreover, just screening itself may be of therapeutic benefit. Bartlett, Peques, Shaffer, and Crump (1983) administered a “health hazard appraisal” to 69 family practice patients and mailed the resuits of this risk assessment to the patients. In a phone call three to five months later, 41 r”ioclaimed to have begun exercise programs, 28% had stopped smoking, 20% had reduced alcohol consumption, 24% had reduced driving mile-


age, and 75% of the women had started breast selfexaminations. The reliance on self report in this study may be problematic, but the data suggest considerable benefit simply from alerting persons to particular areas of psychosocial and lifestyle risk. Another illustration is a screening program developed in the authors’ studies of cardiovascular risk reduction (Spoth & Dush, 1987; Spoth, Dush, & Jones, 1983). A battery of tests were used to assess risks such as stress, percent body fat, blood pressure, nutrition, exercise, and other lifestyle factors in the general population. Participants received individualized feedback in the form of a normed profile, graphically portraying their risk in different categories. Educational interventions were then offered to participants to help them to modify their high risk behaviors. Significant gains at follow-up were found in areas such as nutritional behavior, Type A personality, and smoking cessation. Research underway is attempting to extend this model to high risk patients under active medical treatment for major cardiovascular problems. Consultation Services A fourth arena for behavioral medicine in CMH is community consultation and education. The potential clients range from hospitals to home health care and visiting nurse associations, public health departments, nursing homes, human service agencies, and others who deal directly or indirectly with health. Perhaps the largest potential for fee generation is consultation to industry, particularly employee assistance and health promotion programs. One illustration is consultation to cancer community support groups and organizations, such as American Cancer Society chapters and their “I Can Cope” series. This support program is generally cosponsored by local hospitals, and offers weekly presentations providing information on cancer, treatment, and coping. The cancer patients and family members who attend these functions are, almost by definition, interested in that



which behavioral medicine can offer. They are struggling with a life-threatening and frightening disease, an overwhelming amount of information, and yet few answers to their many questions. Presentations on coping mechanisms, applied coping strategies, and the relationship between stress and illness are well received by these groups, and they frequently seek our further information or contact. Another front scarcely touched is the hospice movement. Hospices have only become prevalent in the last 10 years and yet already they exist in each of the United States and number nearly 2000. The hospice concept is quite compatible with the notions of behavioral medicine: interdisciplinary care integrating physical, psychosocial, and spiritual needs of the dying. However, to date hospices are predominantly staffed by medical and nursing professionals. A recent survey of 80 hospices found that only 10% had input from a psychologist (Foster, Dush, Olson, & Perlstadt, 1986). Formalized involvement of CMH in hospice care is more rare still. The potential involvement of the behavioral medicine consultant in hospice ranges from advisory committees to staff training, patient care (Dush, 1985a; 1988), research and evaluation (Dush & Cassileth, 1985), bereavement care (Dush, 1985b), and participation on the interdisciplinary team. In hospice, as in most medical settings, it is preferable to avoid unnecessarily sending in psychologists, social workers or psychiatrists when people are weak, in physical distress, and easily offended by the implication that they have “mental problems.” Screening instruments may be of value in helping to identify patient and family needs for additional psychosocial intervention with the least inconvenience and intrusion (Dush, 198%). The hospice also provides unusually direct access to the bereaved after the patient’s death, when the family is at increased risk for both medical and psychological distress and pathology (Parkes & Weiss, 1983; Stroebe, Stroebe, Gergen, & Gergen, 1981).


The extension of CMH into comprehensive behavioral medicine care raises complex and potentially costly considerations for the administrator and planner. Obviously, sizable funds must be secured to fuel programmatic expansion of the scale implied. Redirection of health cost savings is one possibility. There is certainly a great deal of health cost to consider. It is estimated that the cost of health care programs for General Motors alone is $2.2 billion, adding $480 to the average cost of a car. Ford’s health expenses are estimated at $743 million. U.S. businesses are estimated to pay $77 billion annually for health insurance alone, and this does not even speak to the indirect costs in lost time, productivity, etc.



Some preliminary data suggest that behavioral meditine programs reduce health care costs and are themselves cost efficient. Schlesinger, Mumford, Glass, Patrick, and Sharfstein (1983) studied federal employees under Blue Cross from 1974 to 1978, particularly those who were diagnosed with a chronic disease in 1975. They contrasted those who subsequently received mental health treatment within a year after this diagnosis with those who had not. For the group of patients who had 7 to 20 mental health visits, there was an average cost reduction in medical care of $309. For those receiving 21 or more visits, the average cost reduction was $289. In an earlier study, Schlesinger, Mumford, and Glass



(1980) conducted a meta-analysis of 510 outcomes from different studies of behavioral health interventions. They found an average effect size of .51 to .78 standard deviations on various indicators of favorable outcome, such as reduction in days lost at work and in days of hospitalization. They also found a 20% reduction in use of other medical services in studies that examined this outcome. Similarly, Jameson, Shuman, and Young (1978) found an average reduction in use of medical services of 30 percent. Schlesinger et al. (1980) also found that informational behavioral interventions with heart surgery patients in 34 studies produced an average reduction of two days of hospitalization.

Planning Considerations.

It is advisable for an agency considering the development or expansion of behavioral medicine services to proceed carefully through a needs assessment and a checklist of considerations such as staff resources, administration and board interest, start-up funds and costs, continuation funds, competition, and the local mix of health services. CMH has typically made ample use of census, demographic and utilization data in local planning and needs assessments, resulting in many innovations and refinements of CMH beyond its original service mandates. Such data may also be used to address health needs. A useful beginning is to obtain local epidemiological data or calculate projections from demographically matched national data on incidence and prevalence of major health disorders and risk. It is also important to consider market patterns. For example, if a large regional cancer center falls within the catchment area, one may find a much larger than expected need for behavioral medicine cancer support services. Conversely, if the community trend for a specific disorder is to seek medical services outside of the catchment area, this may suggest likely under-utilization of local behavioral medicine services. In many communities, competition will be an equally important consideration. CMH’s movement into behavioral health services may be viewed as direct competition (at least for paying customers) by existing facilities and private practice professionals. There may also be similar territorial concerns among organizations such as pain clinics, weight loss clinics, health clinics, health promotion programs in industry or other human service organizations, or health educational programs through the schools or hospitals. Establishing linkages, liaisons, and contractual relationships with existing services of-


fers perhaps the best prospect for assurance of minimal conflict. Aside from competition issues, there remains the probability that stigma may be attached to mental health services, for both patients and potential referral agents. Indeed, the factors which account for low referral rates from the medical community for traditional CMH will likely continue to plague CMH behavioral medicine programs to some degree. This may lessen if behavioral medicine services are developed as a separate program with a separate title, perhaps housed in a local medical setting. The development of an adequate referral base also depends on the ability of CMH to adapt to the medical environment and to establish credibility in the medical community. Recommendations in this respect, from the authors’ experience are (a) to build the program upon a well developed research data base, so that effectiveness can be documented and made visible, and (b) to develop mechanisms for prompt follow-up, tuned toward providing services adjunctive to existing medical involvement with the patient. In traditional CMH, it is common that case management and medication needs of the patient, once referred, become the responsibility of the CMH center. This is unlikely to work in most referral based CMH behavioral medicine programs. Preferably, the patient’s existing medical team should remain closely involved and integrated into ongoing care. Lastly, it is recommended that CMH carefully train or recruit staff with specific behavioral medicine expertise, preferably with ample seasoning in medical settings. In many areas, CMH has increasingly relied upon “generalists,” counselors who see all kinds of clients with all kinds of problems. In our experience, this approach is destined to fail in all but the simplest levels of behavioral medicine services. Potential referral sources may soon observe that the “new behavioral medicine program” is really just the old CMH service. More importantly, behavioral medicine is not simply the application of psychotherapy or counseling to medical patients. Its interventions are strongly rooted in experimental research and-perhaps with the exception of general services such as stress management workshops -largely specific to the type of medical concern at hand. It also draws heavily upon specialties such as biofeedback and neuropsychology that are unlikely to be well developed in the generalist’s training.

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