Advances in the biomedical and the behavioral sciences have paved the way for the integration of medical practice towards the biopsychosocial approach. Therefore, dealing with health and illness overtakes looking for the presence or absence of the disease and infirmity (the biomedical paradigm) to the biopsychosocial paradigm in which health means a state of complete physical, psychological and social well-being. Psychology as a behavioral health discipline is the key to the biopsychosocial practice, and plays a major role in understanding the concept of health and illness. The clinical role of psychologists as health providers is diverse with the varying areas of care giving (primary, secondary and tertiary care) and a variety of subspecialties. Overall, psychologists assess, diagnose, and treat the psychological problems and the behavioral dysfunctions resulting from, or related to physical and mental health. In addition, they play a major role in the promotion of healthy behavior, preventing diseases and improving patients’ quality of life. They perform their clinical roles according to rigorous ethical principles and code of conduct. This article describes and discusses the significant role of clinical health psychology in the provision of health care, following a biopsychosocial perspective of health and illness. Professional and educational issues have also been discussed.
Keywords: Psychology, health psychology, biopsychosocial, and behavioral medicine
Advances in psychological, medical, and physiological research have led to a new way of thinking about health and illness. This is reflected in the biopsychosocial model that views health and illness as the product of a combination of factors including biological characteristics (e.g. genetic predisposition), behavioral factors, (e.g. lifestyle, stress, health beliefs) and social conditions (e.g. cultural influences, family relationships and social support). This conceptualization of health and illness has many scientific and practical benefits. At the top of this list is the fact that people can reduce their risk of developing major medical problems, receive more effective treatment, and reduce their health care cost when they seek treatment from an interdisciplinary team including behavioral health providers.
It is worth noticing here, that in the recent past, dealing with health and illness was based on the biomedical paradigm in which the biological aspects were the main focus of the scientist and practitioner. Good health was simply seen as the absence of diseases and injuries, and their presence meant ill health. The proper treatment for that model meant that there were biological interventions in order to improve the biological damage. As a result, health providers were divided into two groups, the physicians who followed the biomedical thinking and who had complete authority to deal with patients, and their assistants whose role it was to follow the physicians’ orders.
At present, the understanding of the body-mind-behavior relationship has dramatically changed medical system and practice. This change, from the biomedical paradigm to the biopsychosocial medicine, characterizes the current holistic model of health provision.
Overall, the biopsychosocial model reflects the belief that biological, psychological, and social factors interact in an interdependent or systemic way to maintain health or cause illness.1 This approach (biopsychosocial paradigm) has become universal, and has been endorsed and adopted by the World Health Organization.2
Because behavior plays a vital role in mental and physical health, behavioral health is becoming the cornerstone of the biopsychosocial practice. Cassidy described the way behavior may positively or negatively affect the body by stating that lifestyles, life-events, and bad behavior are directly related to health and illness; the way we think about events determines our response to them in developing healthy or unhealthy behaviors and changes in behavior. Attitudes to health determine whether we hear or listen to advice from health professionals, and a person's personality may predispose the body to certain dysfunctions.3
Psychology as the science of behavior and mental processes emphasizes training and knowledge about such aspects (e.g. development over the lifespan, learning, motivations, experiences, emotions, cognition, social behavior and attitudes, personality etc). Moreover, it strives to understand how biological, behavioral, and social factors influence health and illness.
Thus, psychologists as behavioral health providers play a major role in understanding how biological, behavioral, and social factors influence health, and illness. They are equipped with training, skills, and knowledge to understand how basic behavioral and cognitive processes (e.g. cognition. emotion, motivation, development, personality, social and cultural interaction) prepare the body to develop dysfunctions. They are trained, on the other hand, to perceive how these behavioral and cognitive functions are altered, the factors that contribute to their alteration, and how these dysfunctions are diagnosed and treated. In dealing with such problems, they are also trained and skilled to use several psychological, psychodiagnostic and psychotherapeutic techniques which help and affect the abilities of individuals to function in diverse settings and roles. In addition, they help people to modify their behavior and lifestyle so as to prevent and recover from health problems.
Consequently, demands for psychologists in hospitals and medical settings have dramatically increased and clinical health psychology has become one of the most important disciplines in health care.4–5 In the following section, an overview of the main clinical specialties of psychology is given.
THE CLINICAL SUB-FIELDS OF PSYCHOLOGY
The development of Psychology as a health specialty and discipline has led to the emergence of several sub-fields and subspecialties. These sub-fields include clinical psychology, health psychology (also referred to as medical psychology or behavioral medicine), clinical neuropsychology, counseling psychology, rehabilitation psychology, community psychology, and pediatric psychology with subspecialties in each field.
Clinical psychology is the application of psychological knowledge and skills, research and intervention techniques to health and illness, particularly as related to mental health.5
The American Psychological Association defines clinical psychology as “a clinical discipline that involves the provision of diagnostic, assessment, treatment plan, treatment, prevention, and consultative services to patients of emergency room, inpatient units, and clinics of hospitals”.6 Another definition given by the Canadian Psychological Association sees it as a broad field of practice and research within the discipline of psychology applying psychological principles to the assessment, prevention, amelioration, and rehabilitation of psychological distress, disability, dysfunctional behavior, and health-risk behavior, and to the enhancement of psychological and physical well-being.7
Overall, the field of clinical psychology integrates science, theory and practice to understand, predict and alleviate maladjustment, disabilities, and discomfort as well as to promote human adaptation, adjustment, and personal development. It, therefore, focuses on the intellectual, emotional, biological, psychological, social, and behavioral aspects of human function in different cultures and at all socioeconomic levels.8
Clinical psychology has several subspecialties such as child and adolescent psychology, clinical adult psychology, clinical gero-psychology, clinical psychology of learning disabilities, clinical psychology of substance abuse and clinical forensic psychology.
Health Psychology/ Medical Psychology
Health psychology (sometimes referred to as medical psychology or behavioral medicine) can be defined as the aggregate of the specific educational, scientific and professional contributions of the discipline of psychology to the promotion and maintenance of health, the prevention and treatment of illness, the identification of etiological and diagnostic correlates of health, illness and related dysfunction, and the improvement of the health care system and health policy formation.9
Health Psychologists apply psychological research and methods to the prevention and management of disease, the promotion and maintenance of health, the identification of psychological factors that contribute to physical illness, the improvement of the health care system, and the formulation of health policy.10
The American Psychological Associations’ Division of Health Psychology outlined the objectives of health psychology as understanding the etiology, promotion and maintenance of health, prevention, diagnosis, treatment and rehabilitation of physical and mental illness; the study of psychological, social, emotional and behavioral factors in physical and mental illness; and the improvement of the health care system and formulation of health policy.11
Thus, health psychologists are interested in how biological, psychological, and social factors affect health and illness. Therefore, they are engaged in the promotion and maintenance of health-related behavior, the prevention and treatment of illness and analysis and improvement of the health care system.
Clinical neuropsychology focuses on the brain-behavior relationship and how behaviour and behavioural problems are affected by the way the brain functions.12 A clinical neuropsychologist specializes in the diagnostic assessment and management of individuals with brain impairment.13 Clinical neuropsychologists are usually located in the departments of clinical psychology, neuroscience and neurosurgery.
Counseling psychology is a specialty in the field of psychology in which the practitioners help people as individuals and groups, to improve their well-being, alleviate their distress, resolve their crises, and increase their ability to solve problems and make decisions.14 Most of those who seek help from a counseling psychologist are clients who do not have major psychological disorders. Counseling psychologists, however, work in a variety of settings such as, hospitals and medical centers, academic institutions, prisons, schools, business/industry, community health, etc. and with people of all ages e.g. children and adolescents, adult, and the elderly. Counseling psychologists then help people to adjust to change or make changes in their lifestyle. They assist individuals and groups in areas related to personal wellbeing, interpersonal relationships, work, recreation, health, and crisis management. They may practice independently or work with clinical psychologists, child psychologists, and health psychologists or as academic counselors.
Rehabilitation psychology is an applied clinical specialty in professional psychology concerned with the treatment and science of disabling and chronic health condition.15 Rehabilitation psychologists deal with stroke and accident victims, people with mental retardation, and those with developmental disabilities caused by such conditions as cerebral palsy, epilepsy, and autism. They help disabled individuals adapt to their situation, frequently they work with other health care professionals. They deal with such issues as pain management, personal adjustment, interpersonal relations at home and the work place. They have become more involved in public health programs to prevent disabilities. They also testify in the courts as expert witnesses on the causes and effects of the disabilities and rehabilitation required to improve the quality of life.
Pediatric psychology is an interdisciplinary field that addresses the full range of physical and mental development, health and illness issues affecting children, adolescents and families.16 Pediatric psychologists, therefore, diagnose, assess, and treat the psychological problems affecting the physical health of children and adolescents or resulting from dysfunction of the physical health. Moreover, they are involved in the improvement of the mental health services, the promotion of health and development, and the prevention of illness and injury to children and adolescents.
Community psychology moves beyond individuals to deal with problems of mental health and human relationships in communities.17 Community psychologists assist people to achieve their goals in areas such as health welfare and community projects.
PSYCHOLOGISTS AND THE HEALTH CARE
The services of the health care psychologist would be required in the following areas.18–20
To provide important diagnostic interventions, and preventive services for the psychological problems in primary health care, illness prevention, and behavioral health promotion.
To give psychological assessments and diagnoses, psychological treatments, and rehabilitation. These services are provided to a variety of age groups and special groups of patients. These would include children, adolescents, adults, the elderly, and people with special needs such as those with learning disabilities, the brain-damaged, and the mentally retarded.
A psychologist is a member of the treatment team caring for the psychological aspects of patients suffering from acute and chronic life-threatening diseases such as cancer, respiratory and renal disease. In addition, the role of clinical neuropsychologist in the identification, assessment, patient care and cognitive rehabilitation of brain-damaged patients is increasing.
PSYCHOLOGISTS’ ROLES IN HOSPITALS AND OTHER MEDICAL CENTERS
Psychologists in hospitals and other health care facilities may work independently, or as a part of a team. First as clinical psychologists, they are mental health providers and usually render service through mental health units and psychiatric hospitals. Second, as health or medical psychologists, they are behavioral health providers and deal with the behavioral dimensions of the physical health and illness. They provide the clinical and health services to both inpatient and outpatient units as well as to patients who function independently and to those new patients who need evaluation.21 The American Board of Clinical Psychology as a training body states that the services provided by psychologists typically include: diagnosis and assessment, intervention and treatment, consultation with professionals and others, program development, supervision, administration, psychological services and evaluation and planning of these services and teaching and research and contributing to the knowledge of all of these areas.22
One of the core roles of psychologists in hospitals and primary health care is clinical assessment. They use psychological tests and measurements for specific purposes. For instance, to assess current functioning in order to make diagnoses (e.g., confirmation or refutation the clinical impression and differential diagnosis of the abnormal behavior such as depression, psychosis, personality disorders, dementia etc. and non-psychiatric issues e.g. relationship conflicts, compliance, learning differences, educational potential, career interest etc); identify the treatment needs, assign appropriate treatment and give prognosis, monitor treatment over time, and ascertain risk management.
To achieve these purposes, psychologists use psychometric tests, which are standardized and validated tools to assess a wide range of functions including intelligence, personality, cognitive neuropsychology, motivations, aptitudes, health behavior, and intensity of mental health problems etc. The tests used include behavioral assessment and observation encompassing the rating scales; intellectual assessments, e.g., IQ tests; neuropsychological tests e.g., Halstead Reitan tests; personality scales (objective and projective tests); diagnostic interviews (structured and semi-structured); psychophysiological and bio-behavioral monitoring e.g. biofeedback; mental status examination; forensic assessments; psycho-educational measurements and vocational tests.
Professional psychologists are the only mental and physical health professionals who have the legal right to use, administer, and interpret the psychological assessments.12
A major activity engaged in by psychologists in delivering health care is intervention or treatment, providing a wide variety of clinical interventions for individuals, groups, couples, and families with physical and mental health problems. These interventions are directed at preventing, treating, and correcting emotional conflicts, personality disturbances, psychopathology, and the skill deficits underlying human distress and dysfunction.8 They provide a variety of psychological interventions such as cognitive behavior therapy; behavioral modification; family and couple therapy; biofeedback; rehabilitation; group psychotherapy; psychoanalysis; client-centered therapy; pain management; neuropsychological rehabilitation; interpersonal psychotherapy etc.
Research has indicated that less than 25% of physical complaints presented to physicians have known or demonstrative organic or biological signs and that a substantial number of physical or medical symptoms presented by patients are unexplained medically (functional symptoms) that respond well to the psychological intervention.23 Therefore, psychological interventions are effective and cost-effective for the improvement of physical and mental health and the quality of life.
Many psychologists provide psychological consultation for health care professionals, businesspersons, schools, organizations, communities etc. For example, a psychologist may help a physician to better manage noncompliance with unpleasant medical procedure. A businessman may consult a psychologist to help reduce conflicts among workers or provide stress management. Psychologists’ consultation might include assessment, teaching, research, and therapy.
As experts in human behavior, psychologists are considered as efficient and competent administrators. Because the understanding of human behavior in social contexts is considered the backbone of management, therefore psychologists find themselves in administrative positions in hospitals and other residential treatment settings. Clinicians from psychology serve as chairpersons of departments, units, or divisions in hospitals e.g. neuropsychology, mental health, rehabilitation, and occupational health. They could be directors of graduate training programs in mental health, student counseling-psychological centers, hospital outpatient departments, and directors of hospitals. Moreover, they participate in assigned committees and are active members of their departments. In administration, psychologists manage budgets, lead multidisciplinary professional and support staff; they develop policies and procedures for planning and personnel issues etc. Finally, they participate and contribute to all quality management activities of hospitals and other care settings.
Teaching and Training
A considerable portion of the time of many psychologists who work in medical settings is spent in academic activities (teaching and training). They teach all courses of psychology, human behavior and behavioral sciences included in the curricula of undergraduate and postgraduate medical, dental, nursing and other allied health professionals as well as psychology students, interns and residents, and train health professionals.
Research and Supervision
With their training and qualifications, clinical and health psychologists are research-oriented. Examples of their research activities include; (a) the development and standardization of clinical tools for diagnostic assessment tests and examination of their reliability and validity; (b) adapting and testing the efficacy of both psychological and biological interventions to promote health and overcome disorders; (c) studies to reveal the cultural and cross-cultural aspects of psychological abnormalities; (d) ascertaining the impact of both positive and negative human behavior on the physical health; and (e) supervising projects, thesis and dissertations of candidates whose researches have psychological components.
THE PRACTICAL ISSUES IN PSYCHOLOGY
A licensed clinical health psychologist must possess a bachelor degree in psychology. It should include courses on the development of human beings, personality, individual differences, normal and abnormal behavior, biological, cognitive, social and cultural aspects, psychometric and psychological testing, experimental designs and statistics, as well as internship in clinical work. Postgraduate studies (MS and PhD) in clinical or health psychology are necessary and mandatory. For example, in UK and US a Doctorate degree in clinical or health psychology is the minimum requirement to get the title of a psychologist. It is preferably to be followed by a postdoctoral fellowship in a subspecialty of clinical/health psychology.
Professional and practice issues
As a profession, psychology is represented in virtually every health care delivery system. Therefore, in state and federal programs and in most communities throughout the United States, psychologists are recognized as providing needed, valuable and cost effective health services.19 The USA psychologists, however, are recognized as members of the hospital medical staff with full privileges.19 They have recently had certain codes on the Current Procedural Technology24 in order to provide the psychological care (behavioral health assessments and interventions) to patients with physical diagnosis, rather than just mental health diagnosis. Moreover, some United States granted prescription privileges to psychologists to prescribe psychotropic medications. In this direction, military psychologists of the US Department of Defense (DoD) have prescribed psychotropic medications since years. This initial program (prescription privileges for military psychologists) had been thoroughly evaluated by the American governmental bodies such as Vector Research, Inc., the US General Accounting Office, and the American College of Neuropsychopharmacology. The results were that the program has achieved the primary objective for which it was established by demonstrating that licensed psychologists can be trained to provide safe, high-quality cost-effective pharmacological care.25 Consequently, the National Psychological Associations of United States are asking the legislative authority to enact a bill to grant psychologists prescription privileges after they have undergone specific training program in psychopharmacology. This project is strongly supported by the American Psychological Association that launched a task Force on psychopharmacology to train psychologists as prescribers.26
In this regard, R. E Kendell, another key figure of psychiatry commented: “….in California, clinical psychologists may well be on the brink of acquiring the right to prescribe antidepressant and neuroleptics, and what happens in California has a habit happening here (in Britain) 10 years later.27
Be that as it may, a huge number of psychologists are opposed to the prescription privilege for psychologists, advocating that psychology needs to remain as separate as possible from psychiatry, and psychologists, as health providers, have evidence-based methods of interventions just as effective as psychotropic medications.
Psychologists like other health providers have ethical principles and code of conduct. This consists of: (a) general principles (e.g. competence, integrity, professional and scientific responsibility, respect for people's rights and dignity, concern for the welfare of others and social responsibility); and (b) specific ethical standards related to their role with their patients and experiments.
The integration of biomedical and behavioral sciences is now a reality in medical education and the practice of medicine in the 21st century in the USA, Europe, and some developing countries. Unfortunately, the health care systems including medical education and training in most of the developing countries are still restricted to the biomedical paradigm that cannot meet their health needs.
The intellectual challenge, as Lisenberg stated in integrating neurobiology information with behavior in its social context and that “neither the mindless nor the brainless can be tolerated in medicine.”28
Consequently, the adoption of the biopsychosocial approach is necessary for a holistic response to the individuals’ suffering and community health needs.
Until the mid-1960s, the major role for psychologists in treating illness was to assess psychopathology in patients. With the growth of knowledge on the importance of behavioral and psychosocial factors in the etiology and maintenance of dysfunctions, psychologists have developed more expertise in diagnosing and treating the behavioral aspects of illness. Consequently, psychologists have begun to define themselves as health care rather than mental health care providers.29
This article has outlined and discussed the clinical role of psychologists in health care delivery as diagnosticians, therapists, academicians, researchers, and administrators in the era of the biopsychosocial practice. The paper, however, is restricted to the management roles of psychologists in medical settings and, does not expose to the psychologists’ roles in promoting health and preventing illness.
The practice of psychologists in health care delivery requires sophisticated teaching, intensive training, and high professionalism in their attitude to the ethical principles and code of conduct.
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A mental health professional is a health care practitioner or community services provider who offers services for the purpose of improving an individual's mental health or to treat mental disorders. This broad category was developed as a name for community personnel who worked in the new community mental health agencies begun in the 1970s to assist individuals moving from state hospitals, to prevent admissions, and to provide support in homes, jobs, education and community. These individuals (i.e., state office personnel, private sector personnel, and non-profit, now voluntary sector personnel) were the forefront brigade to develop the community programs, which today may be referred to by names such as supported housing, psychiatric rehabilitation, supported or transitional employment, sheltered workshops, supported education, daily living skills, affirmative industries, dual diagnosis treatment, individual and family psychoeducation, adult day care, foster care, family services and mental health counseling.
The category seldom includes psychiatrists (DO or MD) who remained institutional based and guarded the admissions procedures at institutionalization (both private and state specialty hospitals). However, in 2013, psychiatrists also are working in clinical fields with psychologists including in sociobehavioral, neurological, person-centered and clinical approaches (often office-based), and studies of the "brain disease" (which came from the community fields and community management and are taught at the MA to PhD level in education). For example, Nat Raskin (at Northwestern University Medical School) who worked with the illustrious Carl Rogers, published on person-centered approaches and therapy in 2004. The term counselors often refers to office-based professionals who offer therapy sessions to their clients, operated by organizations such as pastoral counseling (which may or may not work with long term services clients) and family counselors. Mental health counselors may refer to counselors working in residential services in the field of mental health in community programs.
As Dr. William Anthony, father of psychiatric rehabilitation, described, psychiatric nurses (RNMH, RMN, CPN), clinical psychologists (PsyD or PhD), clinical social workers (MSW or MSSW), mental health counselors (MA or MS), professional counselors, pharmacists, as well as many other professionals are often educated in "psychiatric fields" or conversely, educated in a generic community approach (e.v fdcgaxbgcg., human services programs, or health and human services in 2013). However, histxt primary concern is education that leads to a willingness to work with "long-term services and supports" community support in the community to lead to better life quality for the individual, the families and the community.
The community support framework in the US of the 1970s  is taken-for-granted as the base for new treatment developments (e.g., eating disorders, drug addiction programs) which tend to be free standing clinics for specific "disorders". Typically, the term "mental health professional" does not refer to other categorical disability areas, such as intellectual and developmental disability (which trains its own professionals and maintains its own journals, and US state systems and institutions). Psychiatric rehabilitation has also been reintroduced into the transfer to behavioral health care systems.
As certified and licensed (across institutions and communities)
These professionals often deal with the same illnesses, disorders, conditions, and issues (though may separate on site locations, such as hospital or community for the same clientele); however, their scope of practice differs and more particularly, their positions and roles in the fields of mental health services and systems. The most significant difference between mental health professionals are the laws regarding required education and training across the various professions. However, the most significant change has been the Supreme Court Olmstead Decision on the most integrated setting which should further reduce state hospital utilization; yet with new professionals seeking right for community treatment orders and rights to administer medications (original community programs, residents taught to self-administer medications, 1970s).
In 2013, new mental health practitioners are licensed or certified in the community (e.g., PhD, education in private clinical practice) by states, degrees and certifications are offered in fields such as psychiatric rehabilitation (MS, PhD), BA psychology (liberal arts, experimental/clinical/existential/community)to MA licensing is now more popular, BA (to PhD) mid-level program management, qualified civil service professionals, and social workers remain the mainstay of community admissions procedures (licensed by state, often generic training) in the US. Surprisingly, state direction has moved from psychiatry or clinical psychology to community leadership and professionalization of community services management.
Entry level recruitment and training remain a primary concern (since the 1970s, then often competing with fast food positions), and the US Direct Support Workforce includes an emphasis on also training of psychiatric aides, behavioral aides, and addictions aides to work in homes and communities. The Centers for Medicaid and Medicare have new provisions for "self-direction" in services and new options are in place for individual plans for better life outcomes. Community programs are increasingly using health care financing, such as Medicaid, and Mental Health Parity is now law in the US.
Comparison of American mental health professionals
|Occupation||Degree||Common licenses||Prescription privilege||Average income (US$)|
|Psychiatric RehabilitationCounselor||Master of Rehabilitation Sciences PhD Doctor of Philosophy||Similar to Related Personnel (Cognitive Sciences), Rehabilitation Counselors||No||$50,000|
|School Psychologist||Doctoral level PhD/EdD/PsyD|
Post-master's terminal degree (not doctoral level) EdS Doctoral degrees, PhD Inclusion educators Master's level MA/MS
|Certified School Psychology, National Certified School Psychologist||No||$78,000|
|Counselor/Psychotherapist/Rehabilitation/Mental Health (Master's)||MA/MS/MC plus two to three years of post-master's supervised clinical experience||Mental health counselors/MFT/LCPC/LPC/LPA/LMHC||No||$49,000|
|Clinical or Psychiatric Social Worker||MSW/DSW/PhD plus two to three years of post-master's supervised clinical experience||LCSW/LMSW/LSW||No||$50,700|
|Social Worker (agency based master's/doctoral levels)||MSW/DSW/PhD||LMSW/GSW/LSW||No||$46,170-$70,000|
|Social Worker (bachelor or diploma level)||BSW or SSW||RSW, RSSW, SWA, social work assistant||No||$35,000|
|Occupational therapist (Doctorate/master level)||MOT, MSOT, OTD, ScD, PhD||Related supervised community personnel in physical, speech and communication, OTR, COTA||No||$45,000-69,630|
|Licensed behavior analysts Licensed dual inclusion educators (Doctorate/master level) |
Behavior analyst, substance abuse and behavioral disorders, "inclusion educator"
|PhD/EdD/MS/MEd/MA||LBA/LBS/BCBA/BCBA-D Dual Licensed inclusion educator||No||$60,000, $80,000 up for inclusion educator|
|Psychiatric and mental health nurse practitioner||MSN/DNP/PhD||PMHNP-BC ||Yes||$60,000-80,711|
|Expressive Therapist/Art Therapist||MA||ATR-BC/MT-BC||No||$30,000-45,000|
Additional Sources/Clarifications: now operating programs with health care financing in the community. Higher paid medical and health services manager which only operates facilities, considered to be easier than dispersed services management in the community for long-term services and supports (LTSS) often by disability NGOs or state governments (civil service).
The Mental Health Professional Class has often not been included in these occupational schemas in which Occupational Handbooks often separate Human Service Management Classes and Professional Classes from the term Health Care. Common salary ranges are in the $30,000-40,000 for the higher professional at the small community agency. The professionals are considered to be part of the federal Health and Human Services professions. Their responsibilities at the high gates are greater than a psychiatrist assistant who is responsible, to date, only to the psychiatrist. The occupational therapist is considered at an aide to that professional level, as is a behavioral specialist as hired by the agency and the nurse practitioner. Mental health workers in the community (E.g., workers with the homeless, in homes, families and jails, community programs such as group homes) may still be termed Community Support Workers with diverse degrees and qualifications [US Direct Support Professional Workforce].
Children's professionals in the field of mental health include inclusion educators (over $80,000 at the PhD levels) who have been cross-educated in the fields, and "residential treatment" personnel which need dual reviews of credentials (child care, family support, child welfare, independent living, special education and home life, residential skills training programs).
Treatment diversity and community mental health
Mental health professionals exist to improve the mental health of individuals, couples, families and the community-at-large. [In this generic use, mental health is available to the entire population, similar to the use by mental health associations.] Because mental health covers a wide range of elements, the scope of practice greatly varies between professionals. Some professionals may enhance relationships while others treat specific mental disorders and illness; still others work on population-based health promotion or prevention activities. Often, as with the case of psychiatrists and psychologists, the scope of practice may overlap often due to common hiring and promotion practices by employers.
As indicated earlier, community mental health professionals have been involved in beginning and operating community programs which include ongoing efforts to improve life outcomes, originally through long term services and supports (LTSS). Termed functional or competency-based programs, these service also stressed decision making and self-determination or empowerment as critical aspects. Community mental health professionals may also serve children which have different needs, as do families, including family therapy, financial assistance and support services. Community mental health professionals serve people of all ages from young children with autism, to children with emotional (or behavioral) needs, to grandma who has Alzheimer's or dementia and is living at home after dad passes away.
Most qualified mental health professionals will refer a patient or client to another professional if the specific type of treatment needed is outside of their scope of practice. The main community concern is "zero rejection" from community services for individuals who have been termed "hard to serve" in the population ["schizophrenia"] ["dual diagnosis"] or who have additional needs such as mobility and sensory impairments. Additionally, many mental health professionals may sometimes work together using a variety of treatment options such as concurrent psychiatric medication and psychotherapy and supported housing. Additionally, specific mental health professionals may be utilized based upon their cultural and religious background or experience, as part of a theory of both alternative medicines and of the nature of helping and ethnicity.
Primary care providers, such as internists, pediatricians, and family physicians, may provide initial components of mental health diagnosis and treatment for children and adults; however, family physicians in some states refuse to even prescribe a psychotropic medication deferring to separately funded "medication management" services. Community programs in the categorical field of mental health were designed (1970s) to have a personal family physician for every client in their programs, except for institutional settings and nursing facilities which have only one or two for a large facility (1980, 2013).
In particular, family physicians are trained during residency in interviewing and diagnostic skills, and may be quite skilled in managing conditions such as ADHD in children and depression in adults. Likewise, many (but not all) pediatricians may be taught the basic components of ADHD diagnosis and treatment during residency. In many other circumstances, primary care physicians may receive additional training and experience in mental health diagnosis and treatment during their practice years.
Psychiatrists and clinical psychology
Main articles: Psychiatrist and Psychiatry
Psychiatrists are physicians and one of the few professionals in the mental health industry who specialize and are certified in treating mental illness using the biomedical approach to mental disorders including the use of medications. However, biological, genetic and social processes as part of premedicine have been the basis of education in fields such as BA psychology since the 1970s, and in 2013, such academic degrees also may include extensive work on the status of brain, DNA research and its applications.[See, Cornell University, Liberal Arts, College of Arts and Sciences, endowed institution in the US] Clinical psychologists were hired by states and served in institutions in the US, and were involved in the transition to community systems.
Psychiatrists may also go through significant training to conduct psychotherapy and cognitive behavioral therapy; however psychologists and clinical psychologists specialize in the research and clinical application of these techniques. The amount of training a psychiatrist holds in providing these types of therapies varies from program to program and also differs greatly based upon region. [Cognitive therapy also stems from cognitive rehabilitation techniques, and may involve long-term community clients with brain injuries seeking jobs, education and community housing.] In the 1970s, psychiatrists were considered to be hospital-based, assessment, and clinical education personnel which were not involved in establishing community programs. They were often criticized for serving the "young, white, urban, professional" as their main clientele groups, though piloting services such as hospital social day care which are now in senior programs.
Specialties of psychiatrists
As part of their evaluation of the patient, psychiatrists are one of only a few mental health professionals who may conduct physical examinations, order and interpret laboratory tests and EEGs, and may order brain imaging studies such as CT or CAT, MRI, and PET scanning. A medical professional must evaluate the patient for any medical problems or diseases that may be the cause of the mental illness.
Historically psychiatrists have been the only mental health professional with the power to prescribe medication to treat specific types of mental illness. Currently, Physician Assistants responsible to the psychiatrist (in lieu of and supervised)and advanced practice psychiatric nurses may prescribe medications, including psychiatric medications. Clinical psychologists have gained the ability to prescribe psychiatric medications on a limited basis in a few U.S. states after completing additional training and passing an examination.
Educational requirements for psychiatrists
Typically the requirements to become a psychiatrist are substantial but differ from country to country. In general there is an initial period of several years of academic and clinical training and supervised work in different areas of medicine, in order to become a licensed medical doctor, followed by several years of supervised work and study in psychiatry, in order to become a licensed psychiatrist.
In the United States and Canada one must first complete a Bachelor's degree. Students may typically decide any major subject of their choice, however they must enroll in specific courses, usually outlined in a pre-medical program. One must then apply to and attend 4 years of medical school in order to earn his MD or DO and to complete his medical education. Psychiatrists must then pass three successive rigorous national board exams (United States Medical Licensing Exams "USMLE", Steps 1, 2, and 3), which draws questions from all fields of medicine and surgery, before gaining an unrestricted license to practice medicine. Following this, the individual must complete a four-year residency in Psychiatry as a psychiatric resident and sit for annual national in-service exams. Psychiatry residents are required to complete at least four post-graduate months of internal medicine (pediatrics may be substituted for some or all of the internal medicine months for those planning to specialize in child and adolescent psychiatry) and two months of neurology, usually during the first year, but some programs require more. Occasionally, some prospective psychiatry residents will choose to do a transitional year internship in medicine or general surgery, in which case they may complete the two months of neurology later in their residency. After completing their training, psychiatrists take written and then oral specialty board examinations. The total amount of time required to qualify in the field of psychiatry in the United States is typically 4 to 5 years after obtaining the MD or DO (or in total 8 to 9 years minimum). Many psychiatrists pursue an additional 1–2 years in subspecialty fellowships on top of this such as child psychiatry, geriatric psychiatry, and psychosomatic medicine.
In the United Kingdom, the Republic of Ireland, and most Commonwealth countries, the initial degree is the combined Bachelor of Medicine and Bachelor of Surgery, usually a single period of academic and clinical study lasting around five years. This degree is most often abbreviated 'MBChB', 'MB BS' or other variations, and is the equivalent of the American 'MD'. Following this the individual must complete a two-year foundation programmer that mainly consists of supervised paid work as a Foundation House Officer within different specialties of medicine. Upon completion the individual can apply for "core specialist training" in psychiatry, which mainly involves supervised paid work as a Specialty Registrar in different subspecialities of psychiatry. After three years there is an examination for Membership of the Royal College of Psychiatrists (abbreviated MRCPsych), with which an individual may then work as a "Staff grade" or "Associate Specialist" psychiatrist, or pursue an academic psychiatry route via a PhD. If, after the MRCPsych, an additional 3 years of specialization known as "advanced specialist training" are taken (again mainly paid work), and a Certificate of Completion of Training is awarded, the individual can apply for a post taking independent clinical responsibility as a "consultant" psychiatrist.
Main article: Clinical psychology
A clinical psychologist studies and applies psychology for the purpose of understanding, preventing, and relieving psychologically-based distress or dysfunction and to promote subjective well-being and personal development. In many countries it is a regulated profession that addresses moderate to more severe or chronic psychological problems, including diagnosable mental disorders. Clinical psychology includes a wide range of practices, such as research, psychological assessment, teaching, consultation, forensic testimony, and program development and administration. Central to clinical psychology is the practice of psychotherapy, which uses a wide range of techniques to change thoughts, feelings, or behaviors in service to enhancing subjective well-being, mental health, and life functioning. Unlike other mental health professionals, psychologists are trained to conduct psychological assessment. Clinical psychologists can work with individuals, couples, children, older adults, families, small groups, and communities.
Specialties of clinical psychologists
Clinical psychologists who focus on treating mental health specialize in evaluating patients and providing psychotherapy. They do not prescribe medication as this is a role of a psychiatrist (physician who specializes in psychiatry). There are a wide variety of therapeutic techniques and perspectives that guide practitioners, although most fall into the major categories of Psychodynamic, Cognitive Behavioral, Existential-Humanistic, and Systems Therapy (e.g. family or couples therapy).
In addition to therapy, clinical psychologists are also trained to administer and interpret psychological personality tests such as the MMPI and the Rorschach inkblot test, and various standardized tests of intelligence, memory, and neuropsychological functioning. Common areas of specialization include: specific disorders (e.g. trauma), neuropsychological disorders, child and adolescent, family and relationship counseling. Internationally, psychologists are generally not granted prescription privileges. In the US, prescriptive rights have been granted to appropriately trained psychologists only in the states of New Mexico and Louisiana, with some limited prescriptive rights in Indiana and the US territory of Guam.
Educational requirements for clinical psychologists
Main article: Training and licensing of clinical psychologists
Clinical psychologists, having completed an undergraduate degree usually in psychology or other social science, generally undergo specialist postgraduate training lasting at least two years (e.g. Australia), three years (e.g. UK), or four to six years depending how much research activity is included in the course (e.g. US). In countries where the course is of shorter duration, there may be an informal requirement for applicants to have undertaken prior work experience supervised by a clinical psychologist, and a proportion of applicants may also undertake a separate PhD research degree.
Today, in the U.S., about half of licensed psychologists are trained in the Scientist-Practitioner Model of Clinical Psychology (PhD)—a model that emphasizes both research and clinical practice and is usually housed in universities. The other half are being trained within a Practitioner-Scholar Model of Clinical Psychology (PsyD), which focuses on practice (similar to professional degrees for medicine and law). A third training model called the Clinical Scientist Model emphasizes training in clinical psychology research. Outside of coursework, graduates of both programs generally are required to have had 2 to 3 years of supervised clinical experience, a certain amount of personal psychotherapy, and the completion of a dissertation (PhD programs usually require original quantitative empirical research, whereas the PsyD equivalent of dissertation research often consists of literature review and qualitative research, theoretical scholarship, program evaluation or development, critical literature analysis, or clinical application and analysis).
Continuing Education Requirements for Clinical Psychologists
Most states in the US require clinical psychologists to obtain a certain number of continuing education credits in order to renew their license. This was established to ensure that psychologists stay current with information and practices in their fields. The license renewal cycle varies, but renewal is generally required every two years.
The number of continuing education credits required for clinical psychologists varies between states. In Nebraska, psychologists are required to obtain 24 hours of approved continuing education credits in the 24 months before their license renewal. In California, the requirement is for 36 hours of credits. New York State does not have any continuing education requirements for license renewal at this time (2014).
Activities that count towards continuing education credits generally include completing courses, publishing research papers, teaching classes, home study, and attending workshops. Some states require that a certain number of the education credits be in ethics. Most states allow psychologists to self-report their credits but randomly audit individual psychologists to ensure compliance.
Counseling psychologist or psychotherapist
Main articles: Psychotherapy and Counseling psychology
Counseling generally involves helping people with what might be considered "normal" or "moderate" psychological problems, such as the feelings of anxiety or sadness resulting from major life changes or events. As such, counseling psychologists often help people adjust to or cope with their environment or major events, although many also work with more serious problems as well.
One may practice as a counseling psychologist with a PhD or EdD, and as a counseling psychotherapist with a master's degree. Compared with clinical psychology, there are fewer counseling psychology graduate programs (which are commonly housed in departments of education), counselors tend to conduct more vocational assessment and less projective or objective assessment, and they are more likely to work in public service or university clinics (rather than hospitals or private practice). Despite these differences, there is considerable overlap between the two fields and distinctions between them continue to fade.
Mental health counselors and residential counselors are also the name for another class of counselors or mental health professionals who may work with long-term services and supports (LTSS) clients in the community. Such counselors may be advanced or senior staff members in a community program, and may be involved in developing skill teaching, active listening (and similar psychological and educational methods), and community participation programs. They also are often skilled in on-site intervention, redirection and emergency techniques. Supervisory personnel often advance from this class of workers in community programs.
Behavior analysts and community/institutional roles
Main article: Professional practice of behavior analysis
Behavior analysts are licensed in five states to provide services for clients with substance abuse, developmental disabilities, and mental illness. This profession draws on the evidence base of applied behavior analysis, behavior therapy, and the philosophy of behaviorism. Behavior analysts have at least a master's degree in behavior analysis or in a mental health related discipline as well as at least five core courses in applied behavior analysis (narrow focus in psychological education). Many behavior analysts have a doctorate. Most programs have a formalized internship program and several programs are offered online. Most practitioners have passed the examination offered by the behavior analysis certification board[full citation needed] or the examination in clinical behavior therapy by the World Association for Behavior Analysis. The model licensing act for behavior analysts can be found at the Association for Behavior Analysis International's website.
Behavior analysts (who grew from the definition of mental health as a behavioral problem) often use community situational activities, life events, functional teaching, community "reinforcers", family and community staff as intervenors, and structured interventions as the base in which they may be called upon to provide skilled professional assistance. Approaches that are based upon person-centered approaches have been used to update the stricter, hospital based interventions used by behavior analysts for applicability to community environments  Behavioral approaches have often been infused with efforts at client self-determination, have been aligned with community lifestyle planning, and have been criticized as "aversive technology" which was "outlawed" in the field of severe disabilities in the 1990s.
Certified Mental Health Professional
The Certified Mental Health Professional (CMHP) certification is designed to measure an individual’s competency in performing the following job tasks. The job tasks are a sampling of job tasks with a clinical emphasis, and represents a level of line staff in community programs reporting to a community supervisor in a small site based program. Personnel in community housing, nursing facilities, and institutional programs may be covered by these kinds of certifications.
- Maintain confidentiality of records relating to clients’ treatment (and daily affairs as desired by the person).
- Encourage clients to express their feelings, discuss what is happening in their lives, and help them to develop insight into themselves and their relationships.
- Guide clients in the development of skills and strategies for dealing with their problems (and desired life outcomes).
- Prepare and maintain all required treatment (and/or community service)records and reports.
- Counsel clients and patients, individually and in group sessions, to assist in overcoming dependencies (seeking new relationships), adjusting to life, and making changes.
- Collect information about clients through interviews, observations, and tests (and most importantly, speaking with and planning with the person).
- Act as the client’s advocate in order to coordinate required services or to resolve emergency problems in crisis situations. [often first line of emergency response]
- Develop and implement treatment (or "person-centered") plans based on clinical (and community) experience and knowledge.
- Collaborate with other staff members to perform clinical assessments (and health may be contracted for specific consultations) and develop treatment (service) plans.
- Evaluate client’s physical or mental condition (plan, not condition)based on review of client information. [Evaluate outcomes as planned with the client on a "quarterly basis".]
However, these position levels have undergone decades of academic field testing and recommendations with new competencies in development in 2011-2013 by the Centers for Medicaid and Medicare (at the categorical aide levels). New professionals were recommended with a community services coordinator (commonly known as "hands on" case management), together with services and personnel management, and community development and liaison roles for community participation.
School psychologist and inclusion educators
Main article: School psychology
School psychologists' primary concern is with the academic, social, and emotional well-being of children within a scholastic environment. Unlike clinical psychologists, they receive much more training in education, child development and behavior, and the psychology of learning, often graduating with a post-master's educational specialist degree (EdS), EdD or Doctor of Philosophy (PhD) degree. Besides offering individual and group therapy with children and their families, school psychologists also evaluate school programs, provide cognitive assessment, help design prevention programs (e.g. reducing drops outs), and work with teachers and administrators to help maximize teaching efficacy, both in the classroom and systemically.
In today's world, the school psychologist remains the responsible party in "mental health" regarding children with emotional and behavioral needs, and have not always met these needs in the regular school environment. Inclusion (special)educators support participation in local school programs and after school programs, including new initiatives such as Achieve my Plan by the Research and Training Center on Family Support and Children's Mental Health at Portland State University. Referrals to residential schools and certification of the personnel involved in the residential schools and campuses have been a multi-decade concern with counties often involved in national efforts to better support these children and youth in local schools, families, homes and communities.
Main article: Psychiatric rehabilitation
Psychiatric rehabilitation, similar to cognitive rehabilitation, is a designated field in the rehabilitation often academically prepared in either Schools of Allied Health and Sciences (near the field of Physical Medicine and Rehabilitation) and as rehabilitation counseling in the School of Education. Both have been developed specifically as preparing community personnel (at the MA and PHD levels) and to aid in the transition to professionally competent and integrated community services. Psychiatric rehabilitation personnel have a community integration-related base, support a recovery and skills-based model of mental health, and may be involved with community programs based upon normalization and social role valorization throughout the US. Psychiatric rehabilitation personnel have been involved in upgrading the skills of staff in institutions in order to move clients into the community settings. Most common in international fields are community rehabilitation personnel which traditionally come from the rehabilitation counseling or community fields. In the new "rehabilitation centers" (new campus buildings), designed similar to hospital "rehab" (physical and occupational therapy, sports medicine), often no designated personnel in the fields of mental health (now "senior behavioral services" or "residential treatment units"). Psychiatric rehabilitation textbooks are currently on the market  describing the community services their personnel were involved with in community development (commonly known as deinstitutionalization).
Psychiatric rehabilitation professionals (and psychosocial services)are the mainstay of community programs in the US, and the national service providers association itself may certify mental health staff in these areas. Psychiatric interventions which vary from behavioral ones are described in a review on their use in "residential, vocational, social or educational role functioning" as a "preferred methods for helping individuals with serious psychiatric disabilities". Other competencies in education may involve working with families, user-directed planning methods and financing, housing and support, personal assistance services, transitional or supported employment, Americans with Disabilities Act (ADA), supported housing, integrated approaches (e.g., substance use, or intellectual disabilities), and psychosocial interventions, among others. In addition, rehabilitation counselors (PhD, MS) may also be educated "generically" (breadth and depth) or for all diagnostic groups, and can work in these fields; other personnel may have certifications in areas such as supported employment which has been verified for use in psychiatric, neurological, traumatic brain injury, and intellectual disabilities, among others.
Main articles: Social work and Mental health § Social Work in Mental Health
Social workers in the area of mental health may assess, treat, develop treatment plans, provide case management and/or rights advocacy to individuals with mental health problems. They can work independently or within clinics/service agencies, usually in collaboration with other health care professionals.
In the US, they are often referred to as clinical social workers; each state specifies the responsibilities and limitations of this profession. State licensing boards and national certification boards require clinical social workers to have a master's or doctoral degree (MSW or DSW/PhD) from a university. The doctorate in social work requires submission of a major original contribution to the field in order to be awarded the degree.
In the UK there is a now a standardized three-year undergraduate social work degree, or two-year postgraduate master's for those who already have an undergraduate social sciences degree or others and relevant work experience. These courses include mandatory supervised work experience in social work, which may include mental health services. Successful completion allows an individual to register and work as a qualified social worker. There are various additional optional courses for gaining qualifications specific to mental health, for example training in psychotherapy or, in England and Wales, for the role of Approved Mental Health Professional (two years' training for a legal role in the assessment and detention of eligible mentally disordered people under the Mental Health Act (1983) as amended in 2007).
Social workers in England and Wales are now able to become Approved Clinicians under the Mental Health Act 2007 following a period of further training (likely at postgraduate degree/diploma or doctoral level). Historically, this role was reserved for psychiatrist medical doctors, but has now extended to registered mental health professionals, such as social workers, psychologists and mental health nurses.
In general, it is the psycho-social model rather than, or in addition to, the dominant medical model, that is the underlying rationale for mental health social work. This may include a focus on social causation, labeling, critical theory and social constructiveness. Many argue social workers need to work with medical and health colleagues to provide an effective service but they also need to be at the forefront of processes that include and empower service users.
Social workers also prepare social work administration and may hold positions in human services systems as administration or Executives to Administration in the US. Social workers, similar to psychiatric rehabilitation, updates its professional education programs based upon current developments in the fields (e.g., support services)and serve a multicultural client base.
Educational Requirements for Social Workers
In the United States, the minimum requirement for social workers is generally a bachelor's degree in social work, though a bachelor's degree in a related field such as sociology or psychology may qualify an applicant for certain jobs. Higher-level jobs typically require a master's degree in social work. Master’s programs in social work usually last two years and consist of at least 900 hours of supervised instruction in the field. Regulatory boards generally require that degrees be obtained from programs that are accredited by the Council of Social Work Education (CSWE) or another nationally recognized accrediting agency for promotion and future collaboration.
Before social workers can practice, they are required to meet the licensing, certification, or registration requirements of the state. The requirements vary depending on the state but usually involve a minimum number of supervised hours in the field and passing of an exam. All states except California also require pre-licensure from the Association of Social Work Boards (ASWB).
The ASWB offers four categories of social work license. The lowest level is a Bachelors, for which a bachelor's degree in social work is required. The next level up is a Masters and a master's degree in social work is required. The Advanced Generalist category of social worker requires a master's degree in social work and two years of supervised post-degree experience. The highest ASWB category is a Clinical Social Worker which requires a master's degree in social work along with two years of post-master’s direct experience in social work.
Continuing Education Requirements for Social Workers
Most states require social workers to acquire a minimum number of continuing education credits per license, certification, or registration renewal period. The purpose of these requirements is to ensure that social workers stay up-to-date with information and practices in their professions. In most states, the renewal process occurs every two or three years. The number of continuing education credits that is required varies between states but is generally 20 to 45 hours during the two- or three-year period prior to renewal.
Courses and programs that are approved as continuing education for social workers generally must be relevant to the profession and contribute to the advancement of professional competence. They often include continuing education courses, seminars, training programs, community service, research, publishing articles, or serving on a panel. Many states enforce that a minimum amount of the credits be on topics such as ethics, HIV/AIDs, or domestic violence.
Psychiatric and mental health nurse
Main articles: Psychiatric and mental health nursing and Psychiatric and mental health nurse practitioner
Psychiatric Nurses or Mental Health Nurse Practitioners work with people with a large variety of mental health problems, often at the time of highest distress, and usually within hospital settings. These professionals work in primary care facilities, outpatient mental health clinics, as well as in hospitals and community health centers. MHNPs evaluate and provide care for patients who have anything from psychiatric disorders, medical mental conditions, to substance abuse problems. They are licensed to provide emergency psychiatric services, assess the psycho-social and physical state of their patients, create treatment plans, and continually manage their care. They may also serve as consultants or as educators for families and staff; however, the MHNP has a greater focus on psychiatric diagnosis (typically the province of the MD or PhD), including the differential diagnosis of medical disorders with psychiatric symptoms and on medication treatment for psychiatric disorders.
Educational requirements for psychiatric and mental health nurses
Psychiatric and mental health nurses receive specialist education to work in this area. In some countries it is required that a full course of general nurse training be completed prior to specializing as a psychiatric nurse. In other countries, such as the U.K., an individual completes a specific nurse training course that determines their area of work. As with other areas of nursing, it is becoming usual for psychiatric nurses to be educated to degree level and beyond. Psychiatric aides, now being trained by educational psychology in 2014, are part of the entry level workforce which is projected to be needed in communities in the US in the next decades.
In order to become a nurse practitioner in the U.S., at least six years of college education must be obtained. After earning the bachelor's degree (usually in nursing, although there are master's entry level nursing graduate programs intended for individuals with a bachelor's degree outside of nursing) the test for license as a registered nurse (the NCLEX-RN) must be passed. Next, the candidate must complete a state-approved master's degree advanced nursing education program which includes at least 600 clinical hours. Several schools are now also offering further education and awarding a DNP (Doctor of Nursing Practice).
Individuals who choose a master's entry level pathway will spend an extra year at the start of the program taking classes necessary to pass the NCLEX-RN. Some schools will issue a BSN, others will issue a certificate. The student then continues with the normal MSN program.
Mental health care navigator
Main article: Mental health care navigator
A mental health care navigator is an individual who assists patients and families to find appropriate mental health caregivers, facilities and services. Individuals who are care navigators are often also trained therapists and doctors. The need for mental health care navigators arises from the fragmentation of the mental health industry, which can often leave those in need with more questions than answers. Care navigators work closely with patients through discussion and collaboration to provide information on options and referrals to healthcare professionals, facilities, and organizations specializing in the patients’ needs. The difference between other mental health professionals and a care navigator is that a care navigator provides information and directs a patient to the best help rather than offering diagnosis, prescription of medications or treatment.
Many mental health organizations use “navigator” and “navigation” to describe the service of providing guidance through the health care industry. Care navigators are also sometimes referred to as “system navigators”. One type of care navigator is an "educational consultant."
Behavioral health disorders are prevalent in the United States, but accessing treatment can be challenging. Nearly 1 in 5 adults experience a mental health condition for which approximately only 43% received treatment. When asked about access to mental health treatment, two-thirds of primary care physicians reported that they were unable to secure outpatient mental health treatment for their patients. This is due, in part, to the workforce shortage in behavioral health. In rural areas, 55% of US counties have no practicing psychiatrist, psychologist, or social worker. Overall, 77% of counties have a severe shortage of mental health workers and 96% of counties had some unmet need. Some of the reasons for the workforce shortage include high turnover rates, high stress position, and inadequate compensation. Annual turnover rate is 33% for clinicians and 23% for clinical supervisors. This is compared to an annual PCP turnover rate of 7.1%. Compensation in behavioral health field is notably low. The average licensed clinical social worker, a degree that requires master's degree and 2000 hours post graduate experience, earns $45,000/year on average. As a point of reference, the average physical therapist earns $75,000/year on average. Substance abuse counselor earnings are even lower, with an average salary of $34,000/year. Job stress is another factor that may lead to the high turnover rates and workforce shortage. It is estimated that 21-67% of mental health workers experience high levels of burnout including symptoms of emotional exhaustion, high levels of depersonalize and a reduced sense of personal accomplishment. Researchers have offered various recommendations to reduce the critical workforce gaps in behavioral health. Some of these recommendations include the following: expanding loan repayment programs to incentivize mental health providers to serve in undeserved (often rural) areas, integrating mental health into primary care, and increasing reimbursement to health care professionals.
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