During my years of service on the U.S. Senate staff, it was interesting to reflect upon how those committed to public service were truly fortunate to be able to focus upon developing programs that are effective, rather than exclusively being responsible for individual clinical outcomes, regardless of how personally satisfying that might be. Increasingly, this broader perspective is now occurring within the private sector, particularly with the emphasis upon wellness, prevention, and integrated care fostered by the Patient Protection and Affordable Care Act (ACA) of the Obama Administration. The hallmark of psychology's legislative success used to be whether there was an express mention of the term "psychology" in the underlying federal or state statutes; for example, authorizing the expertise of psychologists within the federal criminal code when issues of mental competence were being deliberated by the federal courts (accomplished at the request of the Reagan Administration, thanks to Bruce Bennett and former Hawaii Psychological Association President Barbara Porteus). Today, there is an increasing emphasis upon whether the functions performed by psychologists are expressly recognized. By definition, this approach reflects the policy recognition that the various behavioral health professions do significantly overlap in their expertise and raises the intriguing question of what is unique about their underlying training orientation that could/should be shared. At the DoD Uniformed Services University of the Health Sciences (USUHS), I have been very impressed by the extent to which psychology and nursing, in particular, have been developing integrated and interdisciplinary oriented training opportunities.
DoD Congressional Vision: During this year's deliberations on its Fiscal Year 2014 recommendations for the Department of Defense, the House Appropriations Committee highlighted several issues of particular interest to public service psychology, especially when one appreciates that the underlying policy recommendations have relevance beyond that of any particular service (e.g., are relevant to those colleagues working within the federal bureau of prisons). Under the Defense Health Program account (recommending $33.5 billion): "Mental Health Access For Servicemembers -- The Committee remains concerned with the ongoing stigma associated with servicemembers seeking assistance for mental and behavioral health issues. The Committee encourages the Assistant Secretary of Defense (Health Affairs) and the Service Surgeons General to leverage all existing resources, within both military and civilian facilities, to provide comprehensive mental and behavioral health services to servicemembers and to continue efforts to reduce this stigma."
The House Committee also expressed its support for the notion of Embedded Mental Health Providers, which was a visionary concept championed by Morgan Sammons when he was psychology specialty leader for the U.S. Navy. "The Committee understands the tremendous toll exacted on all servicemembers and their families, including those in the special operations and National Guard and reserve communities, after more than a decade of war. The Committee has always made the care of forces and their families its highest priority. The Committee appreciates the focus that the Commander, Special Operations Command, has put on the psychological health and well-being of special operations forces and their families and recognizes the importance of providing support to this vulnerable population. Further, the Committee recognizes the success of the embedded behavioral health program and fully supports its expansion to the special operations community. However, the Committee believes that the mental health needs of all servicemembers, including special operators, are most appropriately addressed within the Defense Health Program by the Service Surgeons General to ensure the highest quality continuity of care for the servicemember. Therefore, the Committee recommendation transfers $21,300,000 requested within the Special Operations Command operation and maintenance budget to the Defense Health Program to address the needs of the special operations community. The Committee directs the Service Surgeons General to work with the Commander, Special Operations Command, to implement an embedded behavioral health program for special operations units during fiscal year 2014.
"The Committee also recognizes that National Guard and reserve personnel in states at high risk for suicide and dangerous behavioral health conditions need convenient access to mental health professionals for proper screening and care. Onsite access to embedded mental health specialists during training assemblies has proven successful in overcoming geographical, stigma, and time barriers that might otherwise bar a member from similar services in an underserved community. The Committee encourages the Secretary of Defense to work with the Chief, National Guard Bureau and Service Surgeons General to implement an embedded behavioral health program for National Guard and reserve component servicemembers in order to provide reserve component personnel with ready access to screening and treatment during unit training assemblies and urges the Secretary of Defense to robustly fund these programs."
USUHS's Appreciation of the Future: At USUHS, the Graduate School of Nursing doctoral program recently held its Wellness Boot Camp. "We are all familiar with the scientific foundations of stress and the negative long-term effects of chronic stress -- whether the focus is research, clinical practice or health policy and program development. The rigors of doctoral studies and professional life frequently result in marathon chair time, compressed sleep schedules and little time to exercise and plan healthy nutritional options. These physical and psychological challenges can easily result in poor health habits that carry on well into professional careers. A common complaint is that there is no time for self-care. Ironically, the health goals of the collective international community are expressed in the World Health Organization's (WHO) goal, 'to improve equity in health, reduce health risks, promote healthy lifestyles and settings, and respond to the underlying determinants of health.' The goals and objectives of the AMA, APA, APhA and ANA all share adaptations of this overarching goal. Logically the easiest solution to improved health is through identifying risk factors, building protective factors and targeting preventive measures; however, the complexity of life outside of the research lab is replete with human emotions, behaviors, genetics and environmental factors.
"The USUHS Graduate School of Nursing Ph.D. program recognizes the health risks associated with doctoral studies, values the health of its students and faculty, and practices prevention. Because people are the most important investment, mitigation and prevention of stress-related conditions were the focus of our recent GSN Wellness Boot Camp. Integrative health care and evidence-based modalities for self-care were addressed during the half-day camp. The venue included didactic and experiential learning in the art and science of mindfulness meditation, progressive muscle relaxation, guided imagery, yoga, Reiki and laughter yoga. Significant research relevant to military populations such as imagery rehearsal for post-traumatic nightmares, mindfulness-based stress reduction for healthcare workers and the use of complementary and alternative medicine in VA specialized PTSD treatment programs were highlighted.
"Students and faculty attendees were able to network with the Senior Program Manager for Military Research, and the Optimal Healing Environment Program Manager of the Samueli Institute. The latter provided a review of the physiology of stress and reminded the group that the simple act of three full breaths can change the physiology of both our breathing and our mind. We were led through guided imagery exercises and provided research outcomes on the benefits of guided imagery for pain management in surgical patients, as well as in individuals with phantom limb pain. The Walter Reed National Medical Center's therapeutic yoga instructor demonstrated supportive yoga poses that promote calm, concentration and relaxation, and are frequently used in the rehabilitation of Wounded Warriors. Reiki master Jennifer Rawlings won over the crowd with a brief demonstration of Reiki on our doctoral chair, Dr. Penny Pierce. The camp concluded with roars of laughter as my fellow USAF student Jackie Killian, a certified laughter yogi specialist, provided a preview of her doctoral research in the area of the physiological effects of laughter yoga complete with group exercises of purposeful and spontaneous laughter.
"The take away from Boot Camp is a challenge for all of us. As we continue to conduct research, incorporate finding into practice and design programs to reduce stress, prevent illness and promote resilience, we would each benefit from practicing these evidence-based mind-body modalities in our busy lives. Perhaps the effects would not only be enjoyed by us but by our colleagues, families and patients. It was particularly supportive to see Dr. Chip Rice, USUHS President, present that morning. Our healthcare vision is evolving (Laurie Migliore, USAF)."
The National Institutes of Health: The National Center for Complementary and Alternative Medicine (NCCAM) is the Federal Government's lead agency for scientific research on various complementary health interventions and their potential role in integrative strategies for treating difficult health conditions and promoting better health. NCCAM is committed to building the scientific evidence needed by consumers, providers, and health policymakers regarding the safety and usefulness of these approaches to improve health and health care. The President's Fiscal Year 2014 budget request for NCCAM is $129 million, a slight increase over the previous year. According to its budget justification, nearly 40% of Americans are integrating complementary health interventions into their health care and personal health practices, at an annual cost of $34 billion. While decisions about the use of these interventions are sometimes made with the guidance of a professional health care provider, this is often not the case. Furthermore, both consumers and providers are often confronted with limited objective information about the safety and effectiveness of these approaches. To address these evidence gaps, NCCAM funds research across the continuum of basic, translational, and clinical research, guided by its strategic plan.
A major focus for NCCAM is research related to chronic pain, an enormous public health problem that affects 100 million Americans and costs at least $635 billion per year in treatments and lost productivity, according to the Institute of Medicine (IOM). Current drug-based treatment options are only partially effective and can have serious side effects. Research exploring non-pharmacological approaches for treating chronic pain is a top Center priority. In the past year, one supported study provided strong evidence that acupuncture may be helpful for chronic pain and another study suggested that spinal manipulation or exercise is more effective than medication for acute neck pain. NCCAM will continue to support rigorous basic, translational, and clinical research to understand whether such interventions add value to existing approaches and to identify the biological mechanisms by which they exert beneficial effects. A recent effort focuses on the use of complementary approaches to pain and symptom management in military and veteran populations. This effort encourages collaboration between NCCAM-funded researchers, other NIH institutes and centers, and researchers at DoD and VA.
NCCAM's intramural research program focuses on understanding the central mechanisms of pain and its modulation, with the long term goal of improving clinical management of chronic pain through the integration of pharmacological and non-pharmacological approaches. Of particular interest are the mechanisms by which emotion, attention, placebo effects, and other such processes modulate pain or pain processing. The program will be highly collaborative within the larger NIH neuroscience research enterprise.
Research on the safety of natural products is another major priority, given the widespread availability and use of these products by the public. One area of particular need is better scientific information about interactions between natural products and drugs. The Center also remains committed to strengthening "real world" outcomes and effectiveness research that capitalizes on the reality that many complementary and integrative approaches are in widespread public use. As such, NCCAM leads the development of the complementary health questions, which are included every five years in the National Health Information Survey conducted by CDC and the National Ambulatory Medical Care Survey involving interviews with 30,000 physicians. Data from these two surveys is expected to provide the most current and comprehensive picture of the use of complementary and integrative health practices in the nation. Finally, to help the public and practitioners make informed decisions about the use of complementary and integrative health interventions NCCAM disseminates its research findings, providing reliable, objective, and evidence-based information through multiple channels. Aloha,
Pat DeLeon, former APA President – Division18 – September, 2013
