National Academies Press: OpenBook

Provision of Mental Health Counseling Services Under TRICARE (2010)

Chapter: 5 Research Regarding the Determinants of High-Quality Mental Health Care

« Previous: 4 Independent and Supervised Practice of Counselors in Other Health-Care Systems
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

5
Research Regarding the Determinants of High-Quality Mental Health Care

In this chapter, the committee reviews existing standards and expectations for the delivery of high-quality mental health care with special reference to psychosocial services relevant to the most prevalent conditions in the TRICARE beneficiary population. The statement of task that guided the committee’s work requested that it review the scientific literature regarding the quality and effectiveness of care provided by licensed mental health counselors. The committee was also asked to offer recommendations regarding modifications of current TRICARE policy with respect to allowing licensed mental health counselors to practice independently. Because the policy is built around TRICARE’s system of quality management through the specification of educational, licensing, and clinical-experience requirements of practitioners, it is appropriate to identify and examine other components of a modern quality-management system to assess whether and under what circumstances counselors could serve as independent providers. The material in this chapter thus addresses determinants of high-quality mental health care for all mental health professionals at a clinical and systems level.

Several previous Institute of Medicine (IOM) reports on healthcare quality, mental health and substance-abuse care, and treatment of posttraumatic stress disorder (PTSD) were especially influential in the committee’s deliberations. In particular, the aims, rules, and frameworks set forth in Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001) provide an approach for this chapter and are

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

summarized in the first section. The chapter then examines quality-of-care issues from clinical and systems perspectives and concludes with an examination of barriers to the implementation of clinical and systems strategies.

Appendix C contains the committee’s working definitions of several key terms used in this chapter, including diagnosis, treatment, psychotherapy, and quality.

GENERAL CONCEPTS OF HEALTH-CARE QUALITY AND “EVIDENCE-BASED PRACTICE”

Health-Care Quality

Avedis Donabedian articulated as early as the 1960s a conceptual model for measuring health-care quality that remains highly relevant today. The model assesses three main components of health-care quality: structure, process, and outcome (Donabedian, 1966). Structure refers to characteristics of the health-care system or provider, such as training or clinic resources adequate for serving the population. Process refers to the care that is delivered—assessments, tests, and treatments. Outcome refers to the health status of patients after they receive care. Access to care and patient satisfaction are other important components of health-care quality (Donabedian, 1998).

Although it is desirable to know whether the care that is delivered to patients produces good outcomes, many factors that are independent of treatment quality can also affect a person’s health status after treatment, including illness severity and the patient’s ability and desire to adhere to a treatment regimen. Process measures of care, if they have a demonstrated link with outcomes, can therefore be useful tools for measuring treatment quality.

In the late 1990s, evidence, largely from research in processes of care, that health-care quality in America had serious and pervasive problems was mounting. Examples were inadequate access to care, unacceptable rates of medical errors, and patients receiving care that was not needed or not receiving care that was needed. IOM’s Committee on the Quality of Health Care in America identified several underlying causes of the problems: the growing complexity of science and technology, which made it increasingly difficult for clinicians to stay abreast of new information; the shift from an acute-disease management paradigm to

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

increasing management of chronic conditions; poor organization of the health-care system to meet the demands of the growing complexity and the paradigm shift; and inadequate use of information technology (IOM, 2001).

An IOM committee defined quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (IOM, 1990, p. 4). Good quality means providing patients with services in a technically competent manner with good communication, shared decision making, and cultural sensitivity. Crossing the Quality Chasm laid the groundwork for a quality-driven approach to health care by adopting six aims governed by 10 rules as universal guidance for changes in the system and in provider–patient interactions. These are delineated in Tables 5.1 and 5.2, respectively.

Berwick (2002) noted that the report provided an underlying framework for the changes needed in American health care at four levels:

  • Level A: the experience of patients.

  • Level B: the functioning of small units of care delivery (“micro-systems” such as a cardiac surgical team).

  • Level C: the functioning of organizations that house or support microsystems (such as clinics and hospitals).

  • Level D: the environment of policy, payment, regulation, accreditation, and other factors that influence the organization at Level C.

TABLE 5.1 Aims of the Future Health-Care System

1. Safe—avoiding injuries to patients from the care that is intended to help them.

2. Effective—providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively).

3. Patient-centered—providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.

4. Timely—reducing waits and sometimes harmful delays for both those who receive and those who give care.

5. Efficient—avoiding waste, including waste of equipment, supplies, ideas, and energy.

6. Equitable—providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

SOURCE: IOM (2001).

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

TABLE 5.2 Rules to Guide the Transition to a Health-Care System That Better Meets Patients’ Needs

1. Care based on continuous healing relationships. Patients should receive care whenever they need it and in many forms, not just face-to-face visits. This rule implies that the health care system should be responsive at all times (24 hours a day, every day) and that access to care should be provided over the Internet, by telephone, and by other means in addition to face-to-face visits.

2. Customization based on patient needs and values. The system of care should be designed to meet the most common types of needs but have the capability to respond to individual patient choices and preferences.

3. The patient as the source of control. Patients should be given the necessary information and the opportunity to exercise the degree of control they choose over health care decisions that affect them. The health system should be able to accommodate differences in patient preferences and encourage shared decision making.

4. Shared knowledge and the free flow of information. Patients should have unfettered access to their own medical information and to clinical knowledge. Clinicians and patients should communicate effectively and share information.

5. Evidence-based decision making. Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place.

6. Safety as a system property. Patients should be safe from injury caused by the care system. Reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors.

7. The need for transparency. The health care system should make information available to patients and their families that allows them to make informed decisions when selecting a health plan, hospital, or clinical practice, or choosing among alternative treatments. This should include information describing the system’s performance on safety, evidence-based practice, and patient satisfaction.

8. Anticipation of needs. The health system should anticipate patient needs, rather than simply reacting to events.

9. Continuous decrease in waste. The health system should not waste resources or patient time.

10. Cooperation among clinicians. Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care.

SOURCE: IOM (2001), pp. 8-9.

It is critical that efforts to establish and improve quality address all levels with a central focus on affecting Level A—the experience of patients. Any committee recommendations regarding modifications of

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

TRICARE’s policy on the practice of licensed mental health counselors should reflect the goals articulated in this framework.

Crossing the Quality Chasm called for

purchasers, regulators, health professions, educational institutions and the Department of Health and Human Services [to] create an environment that fosters and rewards improvement by 1) creating an infrastructure to support evidence-based practice, 2) facilitating the use of information technology, 3) aligning payment incentives, and 4) preparing the work force to better serve patients in a world of expanding knowledge and rapid change. (IOM, 2001, p. 5)

That agenda applies directly to the role of TRICARE, its contractors, and mental health professions and organizations that serve the beneficiary population.

Evidence-Based Practice

Achieving the changes described above requires a conceptual framework that uses both a clinical approach and a systems approach to delivering high-quality health care. In this framework, the practice of health care is designed so that each member of the clinical team has a defined role (e.g., physicians focus on acute-care delivery and patients who have not responded to treatment, and nonphysician clinicians focus on supporting chronic-care management that includes supporting patient self-management and follow-up); patients receive education about their illnesses and how to participate fully in their treatment, including self-monitoring of symptoms and behavioral change; clinicians receive continuing education and, when needed, clinical consultation; and clinicians have an information-support system that can provide reminders, monitor patient outcomes, provide feedback, and assist in treatment planning (Wagner et al., 1996).

The shift toward a systems approach to a high-quality infrastructure requires attention to more than the delivery of specific treatments. Nonetheless, evidence-based practice is an important part of the conceptual framework. The goal of evidence-based practice is to improve health-care quality by bringing to the usual practice the knowledge gained by clinical research (IOM, 2001, 2006; President’s New Freedom Commission on Mental Health, 2002). Evidence-based practice applies the best research evidence combined with clinical expertise according to

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

individual patient values (IOM, 2001). The best research evidence is obtained from clinical research and includes research in epidemiology, diagnosis, and treatment. Clinical expertise is gained from clinicians’ training and experience in working with patients. Experience allows clinicians to be thoughtful, efficient, and accurate in providing patient care. It also enables them to provide compassionate care, which takes patients’ values, preferences, and rights into account (Sackett et al., 1996).

High-quality care for mental and substance-use (M/SU)1 conditions has several important components that are independent of the specific diagnosis for which a patient is treated. Clinicians who treat patients with M/SU conditions need to have adequate training. At the outset of treatment, M/SU clinicians need to be able to conduct a thorough clinical evaluation so that they can formulate a diagnosis and develop a treatment plan. Components of the evaluation include reasons for the evaluation; history of the presenting problem; past experiences with M/SU symptoms, behaviors, and treatment; medical history; information about family relationships and history of M/SU illnesses; developmental history; history of interpersonal functioning (family, friends, and work); legal history; a safety assessment that examines whether the patient or others are at risk of harm; and a mental-status examination to assess the patient’s mood state, cognitive processes, and ability to function. Evaluations should include collateral information when possible, such as information from other clinicians, family members, or significant others and results of diagnostic medical tests and evaluations that might be used to exclude medical conditions that are causing or exacerbating symptoms. Clinicians need to determine, on the basis of the above evaluation, the appropriate treatment setting for the patient, such as inpatient versus outpatient (APA, 2006a). It is also important for clinicians to establish a therapeutic alliance with a patient at the outset of treatment to promote the patient’s engagement and adherence, and to educate the patient and his or her family members about the condition for which the patient is being treated and about how to prevent or minimize exacerbations. Continuing tasks for M/SU clinicians include monitoring of a patient’s response to treatment, assessing

1

This chapter follows the convention of abbreviating “mental and substance-use” as “M/SU” established in IOM’s Improving the Quality of Health Care for Mental and Substance-Use Conditions (2006).

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

function and safety, maintaining a therapeutic alliance, and monitoring and enhancing adherence. Systematic monitoring of patient response to treatment with established clinical scales and measures can improve M/ SU outcomes, reducing symptoms and possibly avoiding hospitalization (Slade et al., 2006; Trivedi et al., 2006). Many patients who have M/SU conditions have co-occurring medical or other M/SU conditions, and integrating and coordinating treatment provided by multiple clinicians can be critical.

Once there is a diagnosis, clinicians must determine the most appropriate treatment for an individual patient on the basis of the clinical literature. Randomized controlled trials are an important part of the evidence base for understanding the efficacy of clinical treatments, but they are not the only evidence considered in evidence-based care. Often, patients enrolled in randomized controlled trials can differ substantially from those seen in usual care settings. For many patients and clinical scenarios, evidence from randomized controlled trials is sparse or nonexistent. Observational, nonrandomized studies can provide useful information about patients not typically seen in clinical trials. However, they may be subject to biases, and evidence-based practice requires an ability to evaluate a study systematically to determine whether it is valid in its conclusions and whether it is applicable to an individual patient (Evidence Based Medicine Working Group, 1992).

A barrier to implementing evidence-based practice is that not all clinicians have the appropriate training or adequate time to search the clinical literature independently and repeatedly to obtain the best, most recent evidence and to appraise it critically for validity and applicability. A survey of graduate psychotherapy training in psychiatry, psychology, and social work by Weissman and colleagues (2006) found that programs “often did not require the gold standard of didactic and clinical supervision for [evidence-based training].” Mullen et al. (2007), writing about social work professionals, cite several barriers to facilitating evidence-based training of current practitioners, including a nonsupportive workplace culture, infrastructure that does not provide the time and resources needed to access up-to-date best practices information, and limited resources to support the implementation of practices once they are identified.

There are resources, however, that can assist clinicians in implementing evidence-based care (Guyatt et al., 2000); such resources include reviews and guidelines that systematically review the literature and weigh

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

the strength of evidence. Guidelines and systematic reviews, although useful in implementing evidence-based practices, have their own limitations. For example, they are not available for all clinical circumstances, and research evidence continues to evolve after a guideline or review is researched and published. Therefore, such resources should not be seen as a replacement for a practitioner’s independent inquiry and critique of the diagnostic and treatment literature (Guyatt et al., 2000).

The RAND study described in Chapter 1 found that in the TRICARE population, the most prevalent diagnoses encountered by mental health and general medical clinicians are mood disorders, anxiety disorders, substance-use disorders, and adjustment disorders (Meredith et al., 2005). Many beneficiaries presented with co-occurring or multiple disorders. Although some TRICARE beneficiaries may need subspecialized mental health expertise to be treated for mental health conditions related to deployment and active combat, others can be well served by evidence-based practices available to the general population. Evidence-based guidelines exist to assist practitioners in accurate screening, diagnosis, and pharmacologic and psychosocial treatments for many of the conditions seen in the beneficiary population.

Table 5.3 provides examples of existing evidence-based psychosocial treatments for a sample of M/SU conditions that were either highlighted by TRICARE as conditions of particular interest or found to be among the more prevalent in the RAND study. Chapter 2 provides background information on them, briefly summarizing their signs and symptoms and their incidence rates. If an M/SU clinician is to conduct evidence-based practice, he or she needs to have training and experience in those treatments and have the capacity to learn and adapt as the evidence base on existing and new treatments expands. It is important to note that the table does not encompass all the evidence-based models for the conditions. Following the National Guideline Clearinghouse (2009) criteria for inclusion of clinical practice guidelines (CPGs), the table includes expert guidelines that are no more than 5 years old.2 However, evidence-based practice continually evolves, so even guidelines that have been available for no more than 5 years can be outdated and not reflect the most recent literature. It is important to note that evidence-based medication treatment is available for each of the conditions in the

2

That is, guidelines that were released no earlier than 2004 (the present report was written in 2009).

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

TABLE 5.3 Examples of Evidence-Based Psychosocial Interventions for Selected Disorders Relevant to the TRICARE Beneficiary Population

Disorder

Guideline-Recommended Treatment

Major depressive disorder

Cognitive behavioral therapy (APA, 2000; VA/DOD, 2009a)

Interpersonal therapy (VA/DOD, 2009a)

Dialectical behavioral therapy (VA/DOD, 2009a)

Behavioral couple therapy (VA/DOD, 2009a)

Problem-solving therapy (APA, 2005b; VA/DOD, 2009a)

Schizophrenia

Cognitive behavioral therapy (APA, 2004b; NIMH, 2009d)

Social-skills training (APA, 2004b)

Family intervention (APA, 2004b; NIMH, 2009d)

Assertive community treatment (APA, 2004b)

Supported employment (APA, 2004b; Lehman et al., 2004; NIMH, 2009d)

Acute stress disorder, posttraumatic stress disorder

Cognitive behavioral therapy (APA, 2004a, 2009a; NIMH, 2009c; VA/DOD, 2004)

Exposure therapy (APA, 2004a, 2009a; IOM, 2008; NIMH, 2009c; VA/DOD, 2004)

Eye-movement desensitization and reprocessing (APA, 2004a; VA/DOD, 2004)

Bipolar disorder

Cognitive behavioral therapy (APA, 2002, 2005a; NIMH, 2009b)

Interpersonal therapy (APA, 2002, 2005a; NIMH, 2009b)

Family-focused therapy (APA, 2002, 2005a; NIMH, 2009b)

Substance-use disorders

Cognitive behavioral therapy (APA, 2006b)

Motivational interviewing (APA, 2006b; VA/DOD, 2009b)

Behavioral couple therapy (APA, 2006b; VA/DOD, 2009b)

Cognitive behavioral skills training (VA/DOD, 2009b)

Contingency management (APA, 2006b; VA/DOD, 2009b)

Community reinforcement approach (APA, 2006b; VA/DOD, 2009b)

Generalized anxiety disorder

Cognitive behavioral therapy (DH, 2001; NIMH, 2009a)a

Obsessive-compulsive disorder

Exposure-response prevention (APA, 2007; Hill, 2007)

Panic disorder

Cognitive behavioral therapy (APA, 2009b)

aThe committee was not able to find American Psychiatric Association, Department of Veterans Affairs, or Department of Defense practice guidelines for generalized anxiety disorder.

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

table. For some conditions, such as bipolar disorder and schizophrenia, evidence-based practice recommends that patients receive medication to minimize symptoms or prevent repeated episodes of illness. For others—such as major depression, substance-use disorders, and anxiety disorders—medications can be efficacious, but patients who have symptoms or exacerbations may also be adequately treated with psychosocial interventions alone. Many patients can benefit from a combination of medication and psychosocial treatment.

EVIDENCE-BASED PRACTICE FOR PSYCHOSOCIAL INTERVENTIONS TO ADDRESS CLINICAL ISSUES OF SPECIAL RELEVANCE TO THE TRICARE POPULATION

As noted above, the diagnoses and combinations of diagnoses for which TRICARE beneficiaries receive mental health care are quite varied. Evidence-based guidelines and systematic reviews do not exist for all of them. Even the guidelines that do exist may not apply fully or directly to people who are seeking care. Patients may manifest varying patterns of comorbidity (such as depression and substance abuse and traumatic brain injury), have pressing psychosocial problems that are not well characterized in a simple diagnostic category (such as traumatic grief and sexual assault), or present with clinical problems related to particular issues encountered in military life, such as combat in Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF). Therefore, clinicians must be able to monitor the scientific literature to adapt and adopt promising practices to fill gaps in available guidelines. This section describes examples of particular psychosocial interventions that, although not based on extensive evidence or formally recommended in guidelines, have been studied with regard to the particular needs of subsets of TRICARE beneficiaries.

Several central points should be considered. First, because most of the evidence-based practice models applicable to these issues are focused on remediation and symptom relief for the individual service member, it is important to be mindful of the synergistic effects of individual mental health issues in the context of the couple and family. This section therefore discusses clinical approaches that focus on individual, couple, and family issues.

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

Second, education in specific skills might be conflated with the ability to deliver high-quality care. Several researchers have warned about the danger of focusing too exclusively on operationalizing goals and interventions while sacrificing clinical skills that involve relational capacities, alliance building, and an ability to hold the complexity of the “client in social context” (Stein and Lambert, 1995).

Third, some guiding principles are useful in treating recently returned OIF or OEF service members, including these: establish a facilitative helping context that reduces stigma, facilitate family transitions and reduce conflict, prevent social isolation and withdrawal, support employment productivity, and prevent alcohol and other drug misuse and abuse (Ruzek et al., 2004).

The following subsections discuss various clinical intervention methods that have undergone some empirical study for assisting active-duty service members and their families with their mental health and psychosocial issues. The intent of this material is to illustrate the array of therapies available to clinicians for some conditions, not to be comprehensive. Mention of a particular therapy should not be viewed as an endorsement of its use in the TRICARE beneficiary population.

Posttraumatic Stress Disorder

Several treatment models that address symptoms, affect regulation, and beliefs related to PTSD are oriented to not only the individual service member but partners, children, and other family members.

Treatment approaches include group, couple, and family therapy. Group therapy may focus on rebuilding connections and dealing with trauma-related rage, anger, guilt, and fear (Kingsley, 2007). Couple therapy and family therapy are often useful in educating family members about posttraumatic stress and PTSD responses, promoting communication, strengthening affect regulation, and facilitating new transitions (Harkness and Kador, 2001).

One cognitive-behavioral model specifically focuses on couples in which one partner is an OIF or OEF veteran who has a diagnosis of PTSD. Although the researchers are formally evaluating cognitive-behavioral couple therapy with such couples, they have been using the treatment for some time. The couples appear to benefit, as evidenced by increased relationship satisfaction, but most require more than the expected 15 sessions (Monson et al., 2008). One of the couple-therapy

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

models, emotionally focused couple therapy (EFCT), designed by Susan Johnson as reported in Snyder et al. (2006), reportedly has strong empirical validation. It sustains an experiential, intrapsychic focus on attachment-based themes with an emphasis on interrupting destructive cyclic relational patterns. In four randomized trials, EFCT was superior to a waiting-list control condition in reducing relationship distress and yielded recovery rates of 70–73% and a weighted mean effect size of 1.31.

In addition to psychotherapy models that aim to remediate psycho-pathologic symptoms of covarying diagnoses, other evidence-based approaches focus on prevention and are important models for clinicians to understand and apply. For example, “battlemind training” was developed originally by Carl Castro and his colleagues at the Walter Reed Army Institute of Research and the US Army Medical Research and Materiel Command, who describe the model as evidence-based, explanatory, and focused on strengths rather than weaknesses. Building resilience is a major goal for service members, partners, and clinicians during the predeployment, deployment, and postdeployment phases of the deployment cycle. Rigorous studies that conducted training with a randomized controlled design led to data that suggested that soldiers who receive battlemind training reported fewer PTSD symptoms after deployment than soldiers who received the standard stress-education training. Studies suggest that battlemind training affects solders beyond the 1-hour training period by giving them the vocabulary to talk about mental health issues and normalize their symptoms and reactions. When the entire unit was trained together, members were more likely to talk with each other about their concerns (Castro, 2009; Surgeon General Multinational Force-Iraq, 2006).

The 2004 VA/DOD Clinical Practice Guideline for PTSD identified one pharmacotherapy—selective serotonin reuptake inhibitors (SSRIs)—and four psychotherapy interventions (cognitive therapy, exposure therapy, stress inoculation training, and eye-movement desensitization and reprocessing) as having “significant benefit” and an accompanying “strong recommendation that the intervention is always indicated and acceptable.” A later IOM report on PTSD treatment (IOM, 2008) found that evidence from randomized controlled trials was sufficient to conclude that exposure therapies were effective in the treatment of PTSD but inadequate to draw conclusions on other therapies.

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

It observed, more generally, that research on treatment of PTSD in US veterans is inadequate to answer questions about interventions.

Military Sexual Assault

The consequences of sexual harassment and assault can be complex and severe, including PTSD, but a variety of treatments can substantially reduce psychological symptoms and improve a victim’s quality of life. There is little empirically based information on the treatment of sexual trauma associated with military service. However, extensive information is available on the treatment of civilian populations and can be used to inform treatment of active-duty and veteran populations. Interventions often address health and safety concerns; crisis intervention that provides normalizing posttrauma reactions; education about trauma; validation; support for existing coping and developing new modes of coping, including deep-breathing methods; and affective and cognitive reactions that include fear, self-blame, anger, and disillusionment. Brief psychodynamic therapy (Leichsenring et al., 2004), a form of cognitive restructuring (Foa and Rothbaum, 1998), and cognitive processing therapy (Resick and Schnicke, 2002) are useful treatment interventions. Again, including the partner in couple therapy is important in reducing shame and promoting more open communication.

Depression with Suicidal Ideation or Behavior

Because traumatic grief is related most directly to the population of OEF and OIF service members, the phenomenon is briefly discussed here. Traumatic grief refers to the sudden loss of an important and close attachment. Having lost a close buddy and experiencing multiple losses often bring on immediate or prolonged grief. Survivor guilt, feelings of anger toward others who are thought to have caused the death, not being able to show vulnerability, numbing, and the absence of an opportunity in the field to acknowledge the death all contribute to unresolved grief. If grief symptoms persist beyond 6 months after return home, the service member may experience complicated grief. Clinical experience suggests the importance of recognizing the significance of the loss, restructuring distorted thoughts of guilt, and validating the pain and intensity of the feelings. There are no outcome studies of treatment for veterans for prolonged or complicated grief. When it is accompanied by a diagnosis of

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

acute stress disorder or posttraumatic stress, cognitive therapy might be contraindicated because exposure to memories of traumatic events may cause a soldier even more strain (Jacobs and Prigerson, 2000). In each of those situations, involvement of the partner and other family members can provide necessary social support (IOM, 2008).

VA and DOD released a CPG for the management of major depressive disorder in 2009 (VA/DOD, 2009b). It recommended that cognitive behavioral therapy, interpersonal psychotherapy, and problem-solving therapy be used for the treatment of uncomplicated major depression, classifying the evidence supporting the recommendation as “A”—“good evidence was found that the intervention improves important health outcomes and … that benefits substantially outweigh harm.” Other psychotherapies were identified as treatment options for specific populations or where indicated, based on patient preference. The guideline did not find sufficient evidence to recommend one antidepressant medication over another for all patients, and stated that the choice of medication should be based on “side effect profiles … , history of prior response, family history of response, type of depression, concurrent medical illnesses, concurrently prescribed medications, and cost of medication.”

Substance-Use Disorder

An evidence-based model titled Seeking Safety addresses the complex interaction of trauma-related issues and substance-use disorder (Najavits, 2007). It is one of the few models that focus on the intersection of covarying conditions, and it holds promise for service members who have suffered combat exposure and turn to substances of abuse, especially alcohol. For many of them, the misuse transforms into abuse or addiction. Treatment for substance abuse is enhanced by adjunctive couple or family therapy with involved family members.

The VA/DOD substance-use disorder CPG (VA/DOD, 2009c) recognizes behavioral couple therapy, cognitive behavioral coping skills training, motivational enhancement therapy, community reinforcement approach, and twelve-step facilitation as “first line alternatives at least as effective as other bona fide active interventions or treatment as usual” for at least some disorders. It recommended that motivational interviewing be used no matter which psychosocial intervention was employed.

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

Traumatic Brain Injury

Active-duty service members may suffer traumatic brain injury (TBI) ranging in severity from mild to severe. In one study, only 47% of the troops who had a TBI met with a physician to assess the nature of the condition (Hoge et al., 2008). Symptoms of mild TBI (such as affect dysregulation, irritability, and sleep problems) often mirror the symptom picture of PTSD. After careful assessment with a thorough differential diagnosis, many service members are treated in rehabilitation settings. Treatment approaches may include cognitive rehabilitation with occupational and physical therapy to address the full array of general medical, cognitive, psychological, and psychosocial issues. Mental health approaches are also indicated to ease the transition of adjusting to temporary or permanent disabilities. Supportive, relationally based methods that stress the reparative nature of a positive therapeutic alliance are preferable during the period when the client’s cognitive functioning is impaired. Couple and family therapy methods can help partners and children to understand the effects of polytrauma, defined as damage to more than one organ system (e.g., TBI, hearing loss, amputations, visual impairment, and burns).

The VA/DOD CPG for the management of concussion and mild TBI (VA/DOD, 2009a) indicated that patients be screened for psychiatric symptoms and comorbid psychiatric disorders, specifically mentioning depression, posttraumatic stress, and substance use. It recommended that “[t]reatment of psychiatric/behavioral symptoms following concussion/mTBI should be based upon individual factors and nature and severity of symptom presentation, and include both psychotherapeutic [Strength of Recommendation (SR) = A] and pharmacological [SR = I]3 treatment modalities.”

3

The Guideline defines a Strength of Recommendation (SR) = A as “[a] strong recommendation that the clinicians provide the intervention to eligible patients. Good evidence was found that the intervention improves important health outcomes and concludes that benefits substantially outweigh harm.” An SR = I means that “[t]he conclusion is that the evidence is insufficient to recommend for or against routinely providing the intervention. Evidence that the intervention is effective is lacking, or poor quality, or conflicting, and the balance of benefits and harms cannot be determined.”

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

EMPIRICAL EVIDENCE REGARDING DISTINCTIONS BETWEEN THE PRACTICE OF COUNSELORS AND THE PRACTICE OF OTHER MENTAL HEALTH PROFESSIONALS

The statement of task asked the committee to review outcome studies and the literature on the comparative quality and effectiveness of care provided by licensed mental health counselors. Despite an extensive review, the committee identified no literature bearing directly on that question. Research related to more general characteristics of mental health practitioners and the care delivered by them was found and is discussed below.

A small set of studies compared novice practitioners (typically graduate students) and experienced practitioners. Mayfield et al. (1999) found that graduate students in counseling psychology produced simpler, more hierarchic cognitive maps and required more time to process information than did practicing counselors who held doctoral degrees in that field. Kivlighan and Kivlighan (2009) analyzed knowledge structures of group-counseling trainees and found that, after taking a graduate-level group practicum class, their cognitive maps became more complex and hierarchic and more like those of experienced practitioners. Mallinckrodt and Nelson (1991) examined novice, advanced, and experienced practitioners’ therapeutic alliances and found that counseling psychologists who had higher training levels were given higher client ratings for agreement on overall goals of treatment and tasks relevant to achieving the goals but not on emotional bonds between practitioner and client. Finally, Cummings et al. (1993) found that clients of experienced mental health services practitioners (three PhD psychologists and one advanced graduate student) rated sessions as deeper than did clients of novice practitioners, and experienced practitioners recalled different types of important events than novice practitioners. Experience was used as a proxy for expertise in those studies, and the researchers did not attempt to link differences in cognitive structures, working alliance, or session evaluation to differences in treatment effectiveness. Samples were small, and that might limit the generalizability of the results; and the definitions of novice and experienced were somewhat arbitrary and inconsistent among studies.

A number of meta-analyses and reviews have examined mental health therapy effectiveness, but they do not provide evidence on the comparative effectiveness of treatment by different types of mental health–care providers. Many of the studies grouped various types of

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

mental health providers, often without explicitly including mental health counselors (e.g., Berman and Norton, 1985; Durlak, 1979; Seligman, 1995). Others examined levels of training or experience within a given discipline, typically psychology (McPherson et al., 2000; Spengler et al., 2009; Stein and Lambert, 1995). Some studies were based on practitioners in other countries (Bower and Rowland, 2006)—who have different education, training, and licensure standards from their US counterparts—or were conducted so long ago that their results are no longer relevant to professionals practicing now (Durlak, 1979; Smith and Glass, 1977). Finally, reviewers (Berman and Norton, 1985; Nietzel and Fisher, 1981) asserted that many studies suffered from methodologic flaws, such as inconsistency in defining professional status and improper statistical interpretation.

It can be argued that such systematic reviews yield indirect evidence of provider effectiveness. That at least some of the studies examined documented service provision by counselors with other mental health professionals might suggest that counselors—when provided, like other mental health professionals, with appropriate training and monitoring—can effectively provide evidence-based psychosocial interventions. It is clearly insufficient information on which to base conclusions about the effectiveness of care by any professional group, but it does indicate that each of the professions has the capacity to provide some types of effective evidence-based care under proper conditions.

Arguments of differential effectiveness by mental health–provider type—such as the statement by McPherson et al. (2000, p. 696) that “one would expect that [doctoral-level] psychologists would be better prepared to identify problems and errors with various types of psychological assessment data than would master’s-level providers”—are generally not based on empirical evidence but are instead founded on anecdotal information or supposition. As Spengler et al. (2009, p. 353) noted, “there are no comprehensive quantitative analyses on … whether any form of educational experience is linked to clinical judgment accuracy.”

STRATEGIES FOR MONITORING AND IMPROVING THE QUALITY OF BEHAVIORAL HEALTH CARE

The IOM report Improving the Quality of Health Care for Mental and Substance-Use Conditions (2006) identified a series of problems in quality

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

and reviewed various studies that documented discrepancies between care that is known to be effective and care that is actually delivered, and it reported extensive variations in care from provider to provider. The report also noted that the infrastructure needed to measure, analyze, publicly report, and improve the quality of M/SU health care is less well developed than that of general health care. Nonetheless, the report presented a blueprint for building the infrastructure for M/SU health care that has important implications for the provision of counseling and other mental health services for TRICARE beneficiaries.

Strategies for Measuring the Quality of Care

Throughout the quality-improvement field, the general mantra has been that “you can’t improve what you don’t measure.” The 2006 IOM report Improving the Quality of Care emphasized that effectively measuring quality requires structures, resources, and expertise and strategic efforts among key stakeholders to

  • Conceptualize the aspects of care to be measured.

  • Translate the quality-of-care measurement concepts into performance-measure specifications.

  • Pilot-test the performance-measure specifications to determine their validity, reliability, feasibility, and cost.

  • Ensure calculation of the performance measures and their submission to a performance-measure repository.

  • Audit to ensure that the performance measures have been calculated accurately and in accordance with specifications.

  • Analyze and display the performance measures in a format or formats suitable for understanding by multiple intended audiences, such as consumers, health-care–delivery entities, purchasers, and quality-oversight organizations.

  • Maintain the effectiveness of individual performance measures and performance-measure sets and policies.

The IOM motto—a quote from Goethe—is “Knowing is not enough; we must apply. Willing is not enough; we must do.” In that spirit, simply measuring quality is not enough; measurement is in the service of improving care at all four levels of the health-care system—

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

Levels A–D of Berwick (2002). A substantial literature documents effective strategies for improvement in industry generally, in general health care, and in M/SU health care.

A useful approach to applying quality-measurement and quality-improvement concepts to counseling and other psychosocial interventions in the Donabedian structure–process–outcomes model previously described is outlined below. From a structural point of view, one would want to incorporate measures in the following categories:

  • Are providers trained in evidence-based practices (as incorporated in certification, credentialing, and licensing)?

  • Are providers trained in applying evidence-based practices to different M/SU conditions and developing competences?

  • Do clinicians or organized care settings have mechanisms to ensure that patients are receiving evidence-based care and use mechanisms to measure and improve the quality of care (e.g., as incorporated in provider agreements with TRICARE contractors)?

  • Do care providers have mechanisms to measure, evaluate, and improve the quality of care (including the provision of evidence-based care) of their providers and contractors and for the population to be served?

Process measures might include the following categories:

  • Are providers using evidence-based practices as applied to assessment, diagnosis, and treatment

    • At a level of fidelity that meets accepted standards?

    • Of all disorders or conditions presenting in the treatment setting?

    • By mental health–clinician category?

  • Are clinics and other organized settings using the mechanisms to assess whether patients are receiving evidence-based care and using the data to improve care?

  • Are care contractors using the mechanisms to assess whether patients are receiving evidence-based care and using the data to improve the performance of providers in their network?

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

Finally, from an outcomes perspective:

  • Are providers, clinics, and care contractors systematically gathering appropriate measures of clinical outcomes and using the data to improve outcomes of their patients and populations?

  • Are the outcomes improving?

Systems Approaches for Monitoring and Improving Interventions

Evidenced-based treatments available for some common M/SU conditions vary and multiple psychotherapeutic approaches are used to treat people for the same condition. Some appropriate variation in treatment approaches is expected to align with the aims and rules outlined by Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001) when based on the specific needs that patients bring to the therapeutic setting. Patients presents with symptoms of a condition that support a diagnosis, but the effectiveness of patient treatment is heavily influenced by myriad other factors, such as ability to establish a therapeutic alliance, patient acceptance and motivation to change, cognitive ability to participate in therapy, and ability to learn and improve adaptive skills and generalize the new skills outside the therapeutic setting.

Despite substantial evidence of the efficacy of numerous treatments for M/SU problems and illnesses, treatments delivered in practice—like all health care—often are not consistent with evidence-based practices or consensus guidelines (IOM, 2006), nor are evidenced-based treatments delivered with the same degree of fidelity among therapists. Variation in behavioral health care is driven by a variety of factors, some germane to the structure and process of the behavioral health–service delivery system and others individualized to the needs of patients. Variance to meet the needs of patients is consistent with one of the Crossing the Quality Chasm aims and rules. It is appropriate for trained clinicians to tailor therapeutic regimens to patients’ unique clinical conditions, relevant environmental factors, and patients’ adaptive, cognitive, and motivational levels and skills. Variance due to differences in training and acquired skills and to infidelity in the application of evidenced-based therapies that affect the ability to assess, diagnose, and treat patients effectively for health conditions is considered problematic and inconsistent with high-quality care.

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

Variability of care in behavioral health is confounded by the great variability in the behavioral health workforce in the delivery of nonpharmacologic treatments or interventions for M/SU conditions. The workforce includes licensed clinicians (state designation), certified (specialty societies), paraprofessionals, peers, and in some cases family members. As the present report makes clear, clinicians trained to diagnose and treat M/SU conditions are especially varied. Training in these disciplines differs widely and holds no assurance of exposure or of competence to treat all M/SU conditions. It thus recommends that institutions of higher education place a much greater emphasis on interdisciplinary didactic and experiential learning and bring together faculty and trainees from their various education programs in order to facilitate the development and implementation of core competencies across all M/SU disciplines. Chapter 3 notes that the ability to practice independently as determined by state statutes, boards of regulation and licensure, and various certifications does not require any demonstrations of competence in assessment, diagnosis, or treatment other than those stipulated by the individual training and graduation requirements of each discipline.

Variability in the clinical setting due to the variability from provider to provider is a serious problem. Research has consistently demonstrated that therapists vary in their effectiveness and that the therapist has a great influence on treatment outcomes (Blatt et al., 1996; Crits-Christoph et al., 1991; Luborsky et al., 1997; Project MATCH Research Group, 1998). Wampold and Brown (2005) estimated that ~5% of the variation in outcomes in a managed-care setting was attributable to variability between therapists. An earlier analysis by Wampold (2001) calculated that 1–2% of that variance was due to the type of treatment delivered. The variability among therapists becomes greater as the initial severity of a patient’s illness increases (Kim et al., 2006). In practice settings, some psychotherapists consistently attain better outcomes than others, and this seems to be true regardless of patient diagnoses, age, developmental stage, medication status, and severity—good therapists get consistently better outcomes in a wide array of patients (Wampold and Brown, 2005).

The therapeutic alliance has been conceptualized over the years as an important part of the “glue” that keeps patients in treatment and perhaps explains some of the large differences among therapists beyond differences in training in evidenced-based treatments. Studies have demonstrated that the therapeutic alliance has a substantial effect

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

on and correlation with treatment outcome (Wampold, 2001). The therapeutic alliance has been defined by Bordin (1979) as consisting of mutual construction of a goal shared by patient and therapist, accepted recognition of the task that each person is to perform in the relationship, and the presence of an attachment bond. The question has been whether developing a therapeutic alliance with one’s patients is a skill acquired through training or a personality trait. Over the years, research and training programs have evolved curricula and techniques to enhance a therapist’s ability to be aware of and introduce into the therapeutic setting the building blocks for development (Grace et al., 1995; Lambert et al., 2005; Mallinckrodt and Nelson, 1991; Weiden and Havens, 1994). In a review of that research involving psychologists and counselors, Summers and Barber (2003) concluded that the ability to develop a therapeutic alliance can be developed during training and may improve through acquisition of specific skills, accumulated hours of clinical practice, and more complex case conceptualization. Trainees become more focused on the therapeutic alliance with greater training and clinical experience, but some aspects of the alliance, such as goal setting and task recognition, may be more learnable and teachable than bond development. One important factor is preexisting aspects of a therapist’s personality, which can affect the ability to develop a therapeutic bond. Development of an effective therapeutic alliance does not depend on provider discipline.

With the demonstration of the effectiveness of evidenced-based treatments, delivery of behavioral health treatments with fidelity is important. Treatment fidelity refers to the methodologic strategies used to monitor and enhance the reliability and consistency of clinical services. Consistent psychosocial therapy is more of a challenge than consistent medication, of which Food and Drug Administration requirements ensure the consistency of dosing and ingredients. The goal for therapeutic approaches is to reach a level of accuracy or consistency that is reproducible in each appropriate clinical case and results in the same outcomes in a population of like subjects.

Recognition that there is variability among individual therapists’ techniques and that the therapist has a substantial effect on treatment outcomes points to a need to identify methods to ensure that psychosocial therapies are delivered with fidelity. In research settings where behavioral-change interventions are a part of the design, there is a great need for fidelity. A National Institutes of Health (NIH) workgroup

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

was formed—the Treatment Fidelity Workgroup of the NIH Behavior Change Consortium (BCC)—to identify best practices and recommendations for enhancing the fidelity of behavioral-change interventions (Bellg et al., 2004). The degree of rigor required in research to ensure fidelity is not the same as for clinical practice, but the recommendations from the workgroup are still relevant and outline useful structure and process procedures that can be applied to assessing the quality of providers.

The best practices and recommendations from the BCC consist of the four domains—provider training, delivery of treatment, receipt of treatment, and enactment of treatment skills—and goals for each domain and recommended strategies to achieve them (Table 5.4).

Consistent strategies for improving the fidelity of psychosocial therapies among domains included use of standardized training materials in a manualized format with scripting, video or audio monitoring of intervention periodically by supervisors during and after training, and use of measurement and feedback with the provider and patient. The BCC concluded that the implementation of therapies needs to be evaluated and monitored on an individual basis during the training period and after training is over to prevent drift in skills. Another important conclusion was that measurement and monitoring of patient response (understanding of the intervention and demonstration of response) by the provider is important to reinforce and build treatment fidelity. While many of the recommendations are a part of the structure and process of provider training programs, posttraining systems to reinforce treatment fidelity and prevent a drift in skills are limited. Posttraining providers may be required to demonstrate attendance at and knowledge gained from educational sessions to maintain licensure or certification.

Systems to measure treatment outcome are in place as a part of accreditation of health plans (the National Committee for Quality Assurance and URAC) and delivery systems (the Joint Commission and the Commission on Accreditation of Rehabilitation Facilities). Most focus on structure and process measurement on the basis of best-practice guidelines and systems rather than individual providers. Health plans, hospitals, and accredited clinics and facilities—through their credentialing and recredentialing, their privileging processes, and their continuing monitoring of provider performance through complaints, sentinel events, and satisfaction—have the best view of provider performance

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

TABLE 5.4 National Institutes of Health Behavior Change Consortium Best-Practice Domains and Recommendations

Domain

Goal

Strategies

Provider training

Standardize training for all provider types

Ensure provider skill acquisition

Standardized training manuals, materials, resources, field guides; structure practice and role-playing; use standardized patients; use same instructors, videotape training

Observe intervention implementation with standardized patient or role-playing; score provider according to checklist; conduct debriefing; administer written pretraining and posttraining examinations; certify skills during and after training

 

Minimize “drift” in provider skills

Accommodate provider difference

Conduct booster sessions; conduct in vivo observations scored against checklist; supervise; obtain provider self-report; conduct patient exit interviews or otherwise obtain feedback

Have professional supervise paraprofessional providers; monitor dropout rates, treatment effectiveness

Delivery of treatment

Control for provider difference

Assess patients’ perception of provider via questionnaire, give feedback to provider; audiotape sessions, have different supervisors review; monitor patient complaints; have provider work with all treatment groups

 

Reduce differences within treatment

Use scripted protocols, treatment manuals; have supervisors rate audiotapes, videotapes

 

Ensure adherence to treatment protocol

Audiotape or videotape encounter, review with provider; randomly monitor audiotapes for protocol adherence; have provider complete checklist of intervention components

Receipt of treatment and enactment of treatment skills

Ensure patient comprehension

Ensure patient ability to use cognitive skills

Ensure patient ability to perform behavioral skills

Have provider review participant homework, self-monitoring logs; have structured interview with patient

Have providers review homework; assess, measure participant performance; use questionnaires; use hypothetical scenarios to test patient

Collect patient self-monitoring, self-report data; use behavioral-outcome measures

SOURCE: Excerpted and adapted from Bellg et al. (2004).

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

after training but are aligned with only a few of the BCC recommendations for posttraining strategies.

The health-care professions are also moving toward a more comprehensive view of the means by which practitioners demonstrate that they have retained and updated the fund of knowledge and clinical skills that were initially recognized through the successful completion of training, examinations and licensure at the beginning of their careers. The American Board of Medical Specialties, which sets standards and processes for certifying and recertifying physicians, has adopted standards for mandatory “maintenance of certification” (MOC) programs that focus on professional standing, lifelong learning and self-assessment, cognitive expertise, and evaluation of performance in practice. Psychiatrists who obtained board certification after October 1994 are subject to a 10-year MOC program that will—when fully implemented in 2017—require diplomates to complete broad-based continuing self-assessment educational activities in addition to continuing medical education, an examination testing their knowledge of research developments and practice guidelines, and three rounds of chart and patient/peer reviews as conditions of recertification (ABPN, 2009). Diplomates in some psychiatric subspecialties are additionally required to demonstrate specific knowledge in their field. The 2010 IOM report Redesigning Continuing Education in the Health Professions noted:

[The MOC] concept has not yet been adopted by all professions that grant certification. However, if minimum standards were applied across the health professions (given that different professions require different amounts of learning), the public could be ensured that all practitioners, despite their profession or specialty, have the ability to perform competently and to improve the safety and quality of health care. (pp. 134-135)

Systems that measure ongoing provider performance have been implemented. IOM’s Improving the Quality … report noted (IOM, 2006, p. 160):

In the Veterans Health Administration (VHA), linking outcome data on patients treated for posttraumatic stress disorder with administrative data showed that long-term, intensive inpatient treatment was not more effective than short-term treatment and cost $18,000 more per patient per year (Fontana and Rosenheck, 1997; Rosenheck and

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

Fontana, 2001). In 1999, the VHA mandated that all mental health inpatients be rated at discharge using the GAF instrument,4 and that all outpatients be similarly rated at least once every 90 days during active treatment. The agency now includes GAF outcome measures in its National Mental Health Program Performance Monitoring System (Greenberg and Rosenheck, 2005).

As a part of training and continuous development of therapeutic-alliance competences, Summers and Barber (2003) recommended that, as in clinical research settings, alliance should be rated repeatedly during therapy at sessions 2, 5, and 10 and every 3 months for longer periods of psychotherapy on at least three patients.

Lambert and colleagues (2005) reviewed four studies that evaluated the effect of clinical feedback systems in more than 2,500 cases. They consistently found that outcome feedback systems enhanced the outcome in patients who were not improving early in their treatment: 35% of patients whose therapists received outcome feedback improved in contrast with 21% of patients whose therapists did not receive feedback. Another study (Brown et al., 2001) examined the naturalistic effect of implementing an outcome feedback system in a managed-care outpatient network. The analysis, based on 15,000 cases, confirmed that patients whose therapists received feedback had more than 25% greater improvement than patients whose therapists did not receive feedback.

To assess the quality of behavioral health–care delivery in the TRICARE system, it would be important to use a working definition of high-quality behavioral health care that takes into account the six aims (Table 5.1) and 10 rules (Table 5.2) and—as identified through research and evidence—the key indicators of structure, process, and outcomes. The framework of a high-quality care system encompasses many factors:

  • Use of effectively trained and certified providers in evidenced-based practices applied to specific populations and use of methods to ensure fidelity of technique.

4

The Global Assessment of Functioning (GAF) score is a standardized measure of symptoms and psychosocial function in which 100 represents superior mental health and psychosocial function and 0 represents the worst possible state. The 2007 IOM report PTSD Compensation and Military Service contains a comprehensive review of the usefulness of GAF scores in evaluating PTSD.

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
  • Use of well-trained supervisory systems based on the recommendations of the BCC.

  • Use of objective outcome-measurement systems.

  • Declaration of successful training by technique, conditions, and special populations.

  • Use of postgraduation or postcertification continuous retraining techniques to ensure continued treatment effectiveness, fidelity, and training in new or enhanced treatment techniques as appropriate.

  • Consistent use of evidence-based practices in diagnosis, assessment, and monitoring, supported by the use of validated instruments as an adjunct to clinical judgment.

  • Use of an outcome-informed measurement system to support the effective application of treatment on an individual level and a systems level.

BARRIERS TO IMPLEMENTING CLINICAL AND SYSTEMS QUALITY-IMPROVEMENT STRATEGIES

The ability of health-care organizations to put quality improvement mechanisms in place is limited by various barriers. Among the barriers identified in the 2006 Improving the Quality … report are the following:

  1. Insufficient evidence or guidelines. There is strong evidence of the effectiveness of many treatments for M/SU conditions, but for many conditions, particularly in persons who have co-occurring disorders, there is inadequate evidence of effective treatments. These gaps in the knowledge base hinder the development of evidence-based guidelines for training and measurement.

  2. Lack of standardized elements of care. The ability to measure quality of care depends heavily on access to the data necessary to document the provision of evidence-based care. Ideally, the information can be obtained inexpensively through administrative data, such as claims. However, current systems for coding psychological treatments are not refined enough to characterize the type of therapy or to document the degree of fidelity with which it is provided. Nevertheless, administrative and other elec-

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

tronic data can be useful in assisting clinicians and policy makers in measuring treatment quality.

  1. Variability and lack of specificity of training, accreditation, certification, and licensing procedures that ensure an adequately prepared workforce that can provide evidence-based treatments.

  2. Lack of adequate information systems to measure and monitor the quality of patient care, providers, practices, plans, and purchasers.

Government organizations—including the Department of Veterans Affairs and the Department of Health and Human Services Agency for Healthcare Research and Quality, the Centers for Medicare & Medicaid Services, NIH, and the Substance Abuse and Mental Health Services Administration—have been pursuing research and initiatives intended to overcome such barriers.

QUALITY-OF-CARE INITIATIVES IN TRICARE AND THE MILITARY HEALTH SYSTEM

A thorough review of quality-of-care initiatives in TRICARE and the Military Health System (MHS) is beyond the scope of this report. This section briefly summarizes the results of some of the recent reports published on the topic by DOD and by organizations that were asked to perform work for it.

Health-care quality is identified as a key mission element of the MHS (TRICARE, 2009). In 2008, the Assistant Secretary of Defense for Health Affairs, testifying on mental health before a subcommittee of the House of Representatives Committee on Armed Services, stated that DOD’s quality-of-care initiative “relies on developing and disseminating clinical guidance and standards, as well as training clinicians in clinical practice guidelines and effective evidence-based methods of care” (Casscells, 2008). DOD established the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury in late 2007 to lead the effort.

In response to a mandate contained in the National Defense Authorization Act for Fiscal Year 2007 (Public Law 109-364), DOD contracted for an independent review of its medical quality-improvement program, including efforts by TRICARE’s purchased-care contractors. The resulting report (Lumetra, 2008, p. 2) concluded that “MHS quality and

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

patient safety programs are generally comparable to those found in civilian facilities, and the MHS processes to establish criteria and measure quality are of high standard.” The Lumetra study included a review of mental health quality issues. It reported that purchased-care contractors were critical of what they deemed an expensive and redundant federal requirement for dual certification of mental and behavioral health facilities but had no other specific comments.

Other reviews, however, have provided some details that highlighted quality concerns in the MHS. A directive contained in § 723 of the FY 2006 National Defense Authorization Act (Public Law 109-163) instructed DOD to convene a task force to assess mental health services provided by the MHS and to offer recommendations for improving their efficacy. The task force released its report, titled An Achievable Vision, in June 2007 (DOD Task Force on Mental Health, 2007). It noted (p. 33) that although the department had developed evidence-based CPGs for PTSD, depression, substance abuse, and psychosis,5

these guidelines are not consistently implemented across the DOD and the Task Force was unable to find any mechanism that ensures their widespread use. Furthermore, providers who were interested in utilizing evidence-based approaches complained during site visits that they did not have the time to implement them.

It concluded (p. 20) that “DOD’s mental health providers require additional training regarding current and new state-of-the-art practice guidelines.”

The task force also found that there was “no consistent system for ongoing quality assessment and continuous improvement that includes substantial measurements of psychological health care outcomes” (p. 33). It concluded that “there are not sufficient mechanisms in place to assure the use of evidence-based treatments or the monitoring of treatment effectiveness” and that “the TRICARE network benefit for psychological health is hindered by fragmented rules and policies, inadequate oversight, and insufficient reimbursement” (p. ES-3).

Among the recommendations that were offered in reaction to those findings were two that addressed quality of care:

5

DOD and VA later promulgated an additional CPG for TBI.

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
  • 5.2.3.3: The Department of Defense should ensure that mental health professionals apply evidence-based clinical practice guidelines.

  • 5.2.3.4: The Department of Defense should routinely track and analyze patient outcomes to ensure treatment efficacy.

In addition, the task force underscored the need for TRICARE providers to be specifically trained to meet the needs of their patient population:

  • 5.3.4.9: The Department of Defense should improve TRICARE providers’ training in issues related to military experiences by:

    • Requiring that TRICARE mental health contractors offer mediated training packages to all network mental health providers similar to those available through the National Center for Post-Traumatic Stress Disorder, the Department of Defense Center for Deployment Psychology, and military mental health components.

    • Requiring that TRICARE mental health contractors offer training packages for specific disorders and problems such as post-traumatic stress disorder and other combat stress syndromes each time a treatment plan is approved.

DOD published a response to the Achievable Vision report in September 2007, outlining the steps that it would take to implement the recommendations (DOD, 2007). The department pledged to emphasize the use of CPGs through a policy memorandum, to create and implement new CPGs, and to facilitate training in them. It also stated that it would review its outcome measures and policies, develop new evidence-based measures as needed, and issue directives requiring the use of outcome measures.

Separately, the DOD Inspector General’s office generated observations and a critique of the task force’s work (DOD Office of Inspector General, 2008). It echoed the conclusions regarding evidence-based treatments and indicated that health-care program managers “need to do more to monitor, oversee, and improve effectiveness.”

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

OBSERVATIONS

On the basis of the review of the papers, reports, and other information discussed in this chapter, the committee observes that

  • The statutes and regulations under which TRICARE operates use educational, licensing, and clinical-experience requirements to determine the circumstances under which mental health professionals practice. That constitutes a system of quality management.

  • The scientific literature on the delivery of health services—including mental health services—indicates that high-quality care is achieved through a patient-centered system grounded in the delivery of evidence-based clinical practices and the monitoring of outcomes.

  • There are established clinical evidence-based practices endorsed by professional guidelines relevant to mental health care for the TRICARE population.

  • There is a set of systems practices that are appropriate for monitoring and improving the quality of mental health care (including outcome measurement) and can be applied in the management of the TRICARE system.

  • All providers should be prepared to deliver evidence-based practices in their scope of practice and to be trained in following and evaluating the accumulating evidence base with regard to promising treatments for problems that are particularly relevant to members of the military and their families.

  • TRICARE and its contractors should implement effective systems-level quality-monitoring and quality-improvement practices.

REFERENCES

ABPN (American Board of Psychiatry and Neurology). 2009. The ABPN Maintenance of Certification (MOC) program (rev. 07/26/09). http://www.abpn.com/downloads/moc/moc_web_doc.pdf. (Accessed December 10, 2009).

APA (American Psychiatric Association). 2000. Practice guideline for the treatment of patients with major depressive disorder, 2nd ed. Arlington, VA: APA.

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

APA. 2002. Practice guideline for the treatment of patients with bipolar disorder, 2nd ed. Arlington, VA: APA.

APA. 2004a. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Arlington, VA: APA.

APA. 2004b. Practice guideline for the treatment of patients with schizophrenia, 2nd ed. Arlington, VA: APA.

APA. 2005a. Guideline watch: Practice guideline for the treatment of patients with bipolar disorder, 2nd ed. Arlington, VA: APA.

APA. 2005b. Guideline watch: Practice guideline for the treatment of patients with major depressive disorder, 2nd ed. Arlington, VA: APA.

APA. 2006a. Practice Guideline for the Psychiatric evaluation of adults, 2nd ed. Arlington, VA: APA.

APA. 2006b. Practice guideline for the treatment of patients with substance use disorders, 2nd ed. Arlington, VA: APA.

APA. 2007. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Arlington, VA: APA.

APA. 2009a. Guideline watch: Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Arlington, VA: APA.

APA. 2009b. Practice guideline for the treatment of patients with panic disorder. Arlington, VA: American Psychiatric Publishing, Inc.

Bellg AJ, Borrelli B, Resnick B, Hecht J, Minicucci DS, Ory M, Ogedegbe G, Orwig D, Ernst D, Czajkowski, S. 2004. Enhancing treatment fidelity in health behavior change studies: Best practices and recommendations from the Behavior Change Consortium. Health Psychology 23(5):443-451.

Berman JS, Norton NC. 1985. Does professional training make a therapist more effective? Psychological Bulletin 98(2):401-407.

Berwick D. 2002. A user’s manual for the IOM’s “Quality chasm” report. Health Affairs 21(3):80-90.

Blatt SJ, Sanislow CA, Zuroff DC, Pilkonis PA. 1996. Characteristics of effective therapists: Further analyses of data from the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology 64(6):1276-1284.

Bordin ES. 1979. The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, and Practice 16(3):252-260.

Bower PJ, Rowland N. 2006. Effectiveness and cost effectiveness of counseling in primary care. Cochrane Database of Systematic Reviews 3(CD001025):1-75.

Brown GS, Burlingame GM, Lambert MJ, Jones E, Vaccaro J. 2001. Pushing the quality envelope: A new outcomes management system. Psychiatric Services 52(7):925-934.

Casscells SW. 2008. Statement on mental health by the Honorable S. Ward Casscells, MD, Assistant Secretary of Defense for Health Affairs before the Subcommittee on Military Personnel of the Armed Services Committee, U.S. House of Representatives, March 14. http://www.dod.mil/dodgc/olc/docs/testCasscells080314.pdf. (Accessed October 9, 2009).

Castro C. 2009. Impact of combat on the mental health and well-being of soldiers and marines. Smith College Studies in Social Work 79(3/4):249-264.

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

Crits-Christoph P, Baranackie K, Kurcias JS, Beck AT, Carroll K, Perry K, Luborsky L, McLellan A, Woody G, Thompson L, Gallagher D, Zitrin C. 1991. Meta-analysis of therapist effects in psychotherapy outcome studies. Psychotherapy Research 1(2):81-91.

Cummings AL, Slemon AG, Hallberg ET. 1993. Session evaluation and recall of important events as a function of counselor experience. Journal of Counseling Psychology 40(2):156-165.

DH (Department of Health). 2001. Treatment choice in psychological therapies and counseling: Evidence based clinical practice guideline. London: DH.

DOD (Department of Defense). 2007. The Department of Defense plan to achieve the vision of the DOD Task Force on Mental Health: Report to Congress, September. http://www.dcoe.health.mil/Content/Navigation/Documents/MHTF-Report-to-Congress.pdf. (Accessed October 8, 2009).

DOD Office of Inspector General. 2008. Observations and critique of the DOD Task Force on Mental Health. Report No. IE-2008-003, April 15. www.dodig.mil/Inspections/IE/Reports/IE-2008-003.pdf. (Accessed October 8, 2009).

DOD Task Force on Mental Health. 2007. An achievable vision: Report of the Department of Defense Task Force on Mental Health. Falls Church, VA: Defense Health Board. http://www.health.mil/dhb/mhtf/MHTF-Report-Final.pdf. (Accessed October 8, 2009).

Donabedian A. 1966. Evaluating the quality of medical care. Milbank Quarterly 44(3 Pt. 2):166-203.

Donabedian A. 1998. The quality of health care: how can it be assessed? Journal of the American Medical Association 260(12):1743-1748.

Durlak JA. 1979. Comparative effectiveness of paraprofessional and professional helpers. Psychological Bulletin 86(1):80-92.

Epperson DL, Bushway DJ, Warman RE. 1983. Client self-terminations after one counseling session: Effects of problem recognition, counselor gender, and counselor experience. Journal of Counseling Psychology 30(3):307-315.

Evidence Based Medicine Working Group. 1992. Evidence based medicine: A new approach to teaching the practice of medicine. Journal of the American Medical Association 268(17):2420-2425.

Foa EB, Rothbaum BO. 1998. Treating the trauma of rape. New York: Guilford Press.

Fontana A, Rosenheck R. 1997. Effectiveness and cost of the inpatient treatment of posttraumatic stress disorder: Comparison of three models of treatment. American Journal of Psychiatry 154(6):758-765.

Grace M, Kivlighan DM, Kunce J. 1995. The effect of nonverbal skills training on counselor trainee nonverbal sensitivity and responsiveness and on session impact and working alliance ratings. Journal of Counseling & Development 73(5):547-552.

Greenberg G, Rosenheck R. 2005. Department of Veterans Affairs National Mental Health Program Performance Monitoring System: Fiscal year 2004 report. West Haven, CT: Northeast Program Evaluation Center, VA Connecticut Healthcare System.

Guyatt GH, Meade MO, Jaeschke RZ, Cook DJ, Haynes RB. 2000. Practitioners of evidence based care: Not all clinicians need to appraise evidence from scratch but all need some skills. British Medical Journal 320:954-955.

Harkness L, Kador N. 2001. Treatment of PTSD with families and couples. In Treating psychological trauma and PTSD, edited by Wilson JP, Friedman MJ, Lindy JD. New York: Guilford Press. Pp. 335-353.

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

Hill NR, Beamish PM. 2007. Treatment outcomes for obsessive-compulsive disorder: A critical review. Journal of Counseling and Development 85(4):504-510.

Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC, Castro CA. 2008. Mild traumatic brain injury in US soldiers returning from Iraq. New England Journal of Medicine 358:453-463.

IOM (Institute of Medicine). 1990. Medicare: A strategy for quality assurance, Vol. I. Washington, DC: National Academy Press.

IOM. 2001. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

IOM. 2006. Improving the quality of health care for mental and substance-use conditions: Quality chasm series. Washington, DC: The National Academies Press.

IOM. 2007. PTSD compensation and military service. Washington, DC: The National Academies Press.

IOM. 2008. Treatment of posttraumatic stress disorder: An assessment of the evidence. Washington, DC: The National Academies Press.

IOM. 2010. Redesigning continuing education in the health professions. Washington, DC: The National Academies Press.

Jacobs S, Prigerson H. 2000. Psychotherapy of traumatic grief: A review of evidence for psychotherapeutic treatments. Death Studies 24(6):479-495.

Kim DM, Wampold BE, Bolt DM. 2006. Therapist effects in psychotherapy: A random-effects model of the National Institutes of Mental Health Treatment of Depression Collaborative Research Program data. Psychotherapy Research 16(2):161-172.

Kingsley G. 2007. Contemporary group treatment of combat-related posttraumatic stress disorder. Journal of the Academy of Psychoanalysis and Dynamic Psychiatry 35(1):51-70.

Kivlighan DM, Kivlighan DM. 2009. Training related changes in the ways that group trainees structure their knowledge of group counseling leader interventions. Group Dynamics: Theory, Research, and Practice 13(3):190-204.

Lambert MJ, Harmon C, Slade K, Whipple JL, Hawkins EJ. 2005. Providing feedback to psychotherapists on their patients’ progress: Clinical results and practice suggestions. Journal of Clinical Psychology 61(2):165-174.

Lehman AF, Kreyenbuhl J, Buchanan RW, Dickerson FB, Dixon LB, Goldberg R, Green-Paden LD, Tenhula WN, Boerescu D, Tek C, Sandson N, Steinwachs DM. 2004. The Schizophrenia Patient Outcomes Research Team (PORT): Updated treatment recommendations 2003. Schizophrenia Bulletin 30(2):193-217.

Leichsenring F, Rabung S, Leibing E. 2004. The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: A meta-analysis. Archives of General Psychiatry 61(12):1208-1216.

Luborsky L, McLellan AT, Diguer L, Woody G, Seligman DA. 1997. The psychotherapist matters: Comparison of outcomes across twenty-two therapists and seven patient samples. Clinical Psychology: Science and Practice 4(1):53-65.

Lumetra. 2008. External review of the DOD medical quality improvement program. http://www.tricare.mil/planning/congress/downloads/Review%20of%20DoD%20Medical%20Quality%20Improvement%20Program.pdf. (Accessed October 9, 2009).

Mallinckrodt B, Nelson ML. 1991. Counselor training level and the formation of the psychotherapeutic working alliance. Journal of Counseling Psychology 38(2):133-138.

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

Mayfield WA, Kardash CM, Kivlighan DM. 1999. Differences in experienced and novice counselors’ knowledge structures about clients: Implications for case conceptualization. Journal of Counseling Psychology 46(4):504-514.

McPherson RH, Pisecco S, Elman NS, Crosbie-Burnett M, Sayger TV. 2000. Counseling psychology’s ambivalent relationship with master’s-level training. The Counseling Psychologist 28(5):687-700.

Meredith LS, Tanielian T, Greenberg MD, Suarez A, Eiseman E. 2005. Expanding access to mental health counselors: Evaluation of the TRICARE demonstration. Santa Monica, CA: RAND Corporation.

Monson CM, Fredman SJ, Adair KC. 2008. Cognitive-behavioral conjoint therapy for posttraumatic stress disorder: Application to Operation Enduring and Operation Iraqi Freedom veterans. Journal of Clinical Psychology 64(8):958-971.

Mullen E, Bellamy J, Bledsoe S, Francois, J. 2007. Teaching evidence-based practice. Research on Social Work Practice 17(5):569-573.

Najavits LM. 2007. Seeking Safety: An evidence-based model for substance abuse and trauma/PTSD. In Therapist’s guide to evidence based relapse prevention: Practical resources for the mental health professional, edited by Wiktkiewitz KA, Marlatt GA. San Diego: Elsevier. Pp. 141-167.

National Guideline Clearinghouse. 2009. Criteria for inclusion of clinical practice guidelines in NGC. http://www.guideline.gov/about/inclusion.aspx. (Accessed October 20, 2009).

Nietzel MT, Fisher SG. 1981. Effectiveness of professional and paraprofessional helpers: A comment on Durlak. Psychological Bulletin 89(3):555-565.

NIMH (National Institute of Mental Health). 2009a. Anxiety disorders. http://www.nimh.nih.gov/health/publications/anxiety-disorders/complete-index.shtml#pub8. (Accessed September 29, 2009).

NIMH. 2009b. Bipolar disorder. http://www.nimh.nih.gov/health/publications/bipolar-disorder/complete-index.shtml. (Accessed September 29, 2009).

NIMH. 2009c. Post-traumatic stress disorder (PTSD). http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd/complete-index.shtml. (Accessed September 29, 2009).

NIMH. 2009d. Schizophrenia. http://www.nimh.nih.gov/health/publications/schizophrenia/complete-index.shtml. (Accessed September 29, 2009).

President’s New Freedom Commission on Mental Health. 2002. Achieving the promise: Transforming mental health care in America. http://www.mentalhealthcommission.gov/reports/FinalReport/downloads/FinalReport.pdf. (Accessed November 13, 2009).

Project MATCH Research Group. 1998. Therapist effects in three treatments for alcohol problems. Psychotherapy Research 8(4):455-474.

Resick PS, Schnicke MK. 2002. Cognitive processing therapy for rape victims: A treatment manual. Newbury Park, CA: Sage.

Rosenheck R, Fontana A. 2001. Impact of efforts to reduce inpatient costs on clinical effectiveness: Treatment of posttraumatic stress disorder in the Department of Veterans Affairs. Medical Care 39(2):168-180.

Ruzek JI, Curran E, Friedman MJ, Gusman FD, Southwick SM, Swales P, Walser RD, Watson PJ, Whealin J. 2004. Treatment of the returning Iraq war veteran. In Iraq War clinician guide. White River Station, VT: Department of Veterans Affairs, National

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

Center for PTSD. http://www.ptsd.va.gov/professional/manuals/manual-pdf/iwcg/iraq_clinician_guide_ch_4.pdf. (Accessed October 23, 2009).

Sackett DL, Rosenberg WM, Muir Gray JA, Haynes RB, Richardson WS. 1996. Evidence based medicine: What it is and isn’t. British Medical Journal 312:71-72.

Seligman ME. 1995. The effectiveness of psychotherapy: The Consumer Reports study. American Psychologist 50(12):965-974.

Slade M, McCrone P, Kuipers E, Leese M, Cahill S, Parabiaghi A, Priebe S, Thornicroft G. 2006. Use of standardised outcome measures in adult mental health services: Randomized controlled trial. British Journal of Psychiatry 189(4):330-336.

Smith ML, Glass GV. 1977. Meta-analysis of psychotherapy outcome studies. American Psychologist 32(9):752-760.

Snyder DK, Castellani AM, Whisman MA. 2006. Current status and future directions in couple therapy. Annual Review of Psychology 57(1):317-344.

Spengler PM, White MJ, Ægisdóttir S, Maugherman AS, Anderson LA, Cook RS, Nichols CN, Lampropoulos GK, Walker BS, Cohen GR, Rush JD. 2009. The meta-analysis of clinical judgment project: Effects of experience on judgment accuracy. The Counseling Psychologist 37(3):350-399.

Stein DM, Lambert MJ. 1995. Graduate training in psychotherapy: Are therapy outcomes enhanced? Journal of Consulting and Clinical Psychology 63(2):182-196.

Summers RF, Barber JP. 2003. Therapeutic alliance as a measurable psychotherapy skill. Academic Psychiatry 27(3):160-165.

Surgeon General, Multinational Force-Iraq and the Office of the Surgeon General United States Army Medical Command. 2006. Mental health advisory team (MHAT) IV: Operation Iraqi Freedom 05-07, Final report. http://www.house.gov/delahunt/ptsd.pdf. (Accessed October 23, 2009).

TRICARE. 2009. Evaluation of the TRICARE Program. Fiscal year 2009 report to Congress. http://www.tricare.mil/Transparency/downloads/TRICARE09_4-7-09_full%20size.pdf. (Accessed October 9, 2009).

Trivedi M, Rush AJ, Wisniewski SR, Nierenberg AA, Warden D, Ritz L, Norquist G, Howland RH, Lebowitz B, McGrath PJ, Shores-Wilson K, Biggs MM, Balasubramani GK, Fava M. 2006. Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: Implications for clinical practice. American Journal of Psychiatry 163(1):28-40.

VA/DOD (Department of Veterans Affairs/Department of Defense). 2004. VA/DOD clinical practice guideline for management of post-traumatic stress, version 1.0. Washington, DC: VA/DOD.

VA/DOD. 2009a. VA/DOD clinical practice guideline for management of concussion/mild traumatic brain injury. Washington, DC: VA/DOD.

VA/DOD. 2009b. VA/DOD clinical practice guideline for management of major depressive disorder (MDD), version 2.0. Washington, DC: VA/DOD.

VA/DOD. 2009c. VA/DOD clinical practice guideline for management of substance use disorders (SUD), version 2.0. Washington, DC: VA/DOD.

Wagner EH, Austin BT, Von Korff M. 1996. Organizing care for patients with chronic illness. The Milbank Quarterly 74(4):511-544.

Wampold BE. 2001. The great psychotherapy debate: Models, methods and findings. Mahwah, NJ: Lawrence Erlbaum Associates.

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

Wampold BE, Brown GS. 2005. Estimating variability in outcomes attributable to therapists: A naturalistic study of outcomes in managed care. Journal of Consulting and Clinical Psychology 73(5):914-923.

Weiden P, Havens L. 1994. Psychotherapeutic management techniques in the treatment of outpatients with schizophrenia. Hospital Community Psychiatry 45(6):549-555.

Weissman MM, Verdeli H, Gameroff MJ, Bledsoe SE, Betts K, Mufson L, Fitterling H, Wickramaratne P. 2006. National survey of psychotherapy training in psychiatry, psychology, and social work. Archives of General Psychiatry 63(8):925-934.

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

This page intentionally left blank.

Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 167
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 168
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 169
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 170
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 171
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 172
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 173
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 174
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 175
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 176
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 177
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 178
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 179
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 180
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 181
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 182
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 183
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 184
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 185
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 186
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 187
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 188
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 189
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 190
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 191
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 192
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 193
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 194
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 195
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 196
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 197
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 198
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 199
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 200
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 201
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 202
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 203
Suggested Citation:"5 Research Regarding the Determinants of High-Quality Mental Health Care." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
Page 204
Next: 6 Findings, Conclusions, and Recommendations »
Provision of Mental Health Counseling Services Under TRICARE Get This Book
×
Buy Paperback | $70.00 Buy Ebook | $54.99
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

In this book, the IOM makes recommendations for permitting independent practice for mental health counselors treating patients within TRICARE--the DOD's health care benefits program. This would change current policy, which requires all counselors to practice under a physician's supervision without regard to their education, training, licensure or experience.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    Switch between the Original Pages, where you can read the report as it appeared in print, and Text Pages for the web version, where you can highlight and search the text.

    « Back Next »
  6. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  7. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  8. ×

    View our suggested citation for this chapter.

    « Back Next »
  9. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!