ORIGINAL PAPER Rethinking the Mental Health Treatment Skills of Primary Care Staff: A Framework for Training and Research Jonathan D. Brown • Lawrence S. Wissow Ó Springer Science+Business Media, LLC 2011 Abstract Health care reforms may offer several oppor- tunities to build the mental health treatment capacity of primary care. Capitalizing on these opportunities requires identifying the types of clinical skills that the primary care team requires to deliver mental health care. This paper proposes a framework that describes mental health skills for primary care receptionists, medical assistants, nurses, nurse practitioners, and physicians. These skills are orga- nized on three levels: cross-cutting skills to build thera- peutic alliance; broad-based, brief interventions for major clusters of mental health symptoms; and evidence-based interventions for diagnosis specific disorders. This frame- work is intended to help inform future mental health training in primary care and catalyze research that exam- ines the impact of such training. Keywords Primary care Á Training Á Skills Á Mental health Introduction The Patient Protection and Affordable Care Act of 2010 (ACA) provides several opportunities to strengthen the mental health treatment capacity of primary care. These opportunities included $125 million in fiscal year 2010 for primary care training programs, with preference given to training focused on the integration of physical and mental health services and enhancing communication with patients. ACA authorized another $25 million for grants to provide mental health training for social workers, psy- chologists, behavioral pediatricians, nurses, and parapro- fessionals, as well as financial incentives for primary care practices and health plans to adopt the medical home model (Bernstein et al. 2010). Medical home certification requires the implementation of a continuous, comprehen- sive, and coordinated team-based approach to care—fea- tures of primary care that have been found to facilitate the delivery of mental health services (Bower et al. 2006; Wulsin et al. 2006; Gilbody et al. 2003; Croghan and Brown 2010). To help practices become certified, ACA established primary care ‘‘extension’’ services, comple- menting ongoing efforts of the Substance Abuse and Mental Health Services Administration (SAMHSA), the Agency for Healthcare Research and Quality (AHRQ), and other federal and state agencies to redesign service systems and develop reimbursement strategies that promote greater integration between primary care and specialty mental health services. These training and service re-organization efforts will be essential if ACA is fully implemented and demand for primary care-based mental health services increases. By 2014, changes in Medicaid eligibility requirements and the establishment of health insurance exchanges are pro- jected to result in coverage being extended to an esti- mated 5.4 million additional Americans with mental health problems (Donohue et al. 2010). ACA also requires insurers to provide a minimum package of mental health benefits and expands requirements to cover preventive J. D. Brown (&) Mathematica Policy Research, Inc., 600 Maryland Ave., SW, Suite 550, Washington, DC 20024, USA e-mail: [email protected] L. S. Wissow Department of Health, Behavior, and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA e-mail: [email protected] 123 Adm Policy Ment Health DOI 10.1007/s10488-011-0373-9
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ORIGINAL PAPER
Rethinking the Mental Health Treatment Skills of Primary CareStaff: A Framework for Training and Research
Jonathan D. Brown • Lawrence S. Wissow
� Springer Science+Business Media, LLC 2011
Abstract Health care reforms may offer several oppor-
tunities to build the mental health treatment capacity of
primary care. Capitalizing on these opportunities requires
identifying the types of clinical skills that the primary care
team requires to deliver mental health care. This paper
proposes a framework that describes mental health skills
for primary care receptionists, medical assistants, nurses,
nurse practitioners, and physicians. These skills are orga-
nized on three levels: cross-cutting skills to build thera-
peutic alliance; broad-based, brief interventions for major
clusters of mental health symptoms; and evidence-based
interventions for diagnosis specific disorders. This frame-
work is intended to help inform future mental health
training in primary care and catalyze research that exam-
ines the impact of such training.
Keywords Primary care � Training � Skills �Mental health
Introduction
The Patient Protection and Affordable Care Act of 2010
(ACA) provides several opportunities to strengthen the
mental health treatment capacity of primary care. These
opportunities included $125 million in fiscal year 2010 for
primary care training programs, with preference given to
training focused on the integration of physical and mental
health services and enhancing communication with
patients. ACA authorized another $25 million for grants
to provide mental health training for social workers, psy-
chologists, behavioral pediatricians, nurses, and parapro-
fessionals, as well as financial incentives for primary care
practices and health plans to adopt the medical home
model (Bernstein et al. 2010). Medical home certification
requires the implementation of a continuous, comprehen-
sive, and coordinated team-based approach to care—fea-
tures of primary care that have been found to facilitate the
delivery of mental health services (Bower et al. 2006;
Wulsin et al. 2006; Gilbody et al. 2003; Croghan and
Brown 2010). To help practices become certified, ACA
established primary care ‘‘extension’’ services, comple-
menting ongoing efforts of the Substance Abuse and
Mental Health Services Administration (SAMHSA), the
Agency for Healthcare Research and Quality (AHRQ), and
other federal and state agencies to redesign service systems
and develop reimbursement strategies that promote greater
integration between primary care and specialty mental
health services.
These training and service re-organization efforts will
be essential if ACA is fully implemented and demand for
primary care-based mental health services increases. By
2014, changes in Medicaid eligibility requirements and
the establishment of health insurance exchanges are pro-
jected to result in coverage being extended to an esti-
mated 5.4 million additional Americans with mental
health problems (Donohue et al. 2010). ACA also requires
insurers to provide a minimum package of mental health
benefits and expands requirements to cover preventive
J. D. Brown (&)
Mathematica Policy Research, Inc., 600 Maryland Ave.,
SW, Suite 550, Washington, DC 20024, USA
e-mail: [email protected]
L. S. Wissow
Department of Health, Behavior, and Society, Johns Hopkins
University Bloomberg School of Public Health,
Baltimore, MD, USA
e-mail: [email protected]
123
Adm Policy Ment Health
DOI 10.1007/s10488-011-0373-9
health screening, including screening for depression.
Considering the short supply of mental health specialists
(Ellis et al. 2009), many of these newly insured individ-
uals will likely receive mental health services in primary
care.
Reforming financial disincentives and organizational
barriers may help facilitate delivery of mental health
services in primary care (Mauch et al. 2008; Cunning-
ham 2009; Kisely et al. 2006), but there is also a need
to bolster the skills of primary care staff and the spe-
cialists who support them. The majority of primary care
providers believe they should take some responsibility
for some types of mental health care (Stein et al. 2008;
Olson et al. 2001), but they also report that providing
such care is frustrating and burdensome (Brown et al.
2007a), and they receive little formal training in specific
mental health treatments or in patient communication
necessary for mental health treatment (Levinson et al.
2010). Successful integration of the primary care and
mental health systems will need to be based on the
ability of primary care staff to identify mental health
concerns, communicate with patients about those con-
cerns, and engage patients in treatment (Fremont et al.
2008; Brown et al. 2007b; Van Os et al. 2005). Both
medical home models and evidence from primary care
and other settings suggest that these skills must be
developed by everyone on the primary care team with
whom the patient comes into contact. Primary care-
based mental health services are best delivered using a
team approach (Butler et al. 2008; Bower et al. 2006)
and engagement in care happens not just with a primary
provider, but with other members of the team and with
the site itself (Ware et al. 1999; Pulido et al. 2008).
This paper thus proposes a three-level framework of
mental health treatment skills for primary care targeted
to all members of the primary care team and the mental
health specialists who support them. Thus, the frame-
work takes an organizational perspective that posits
training needs should be conceptualized within the
context of how primary care practices work and the job
functions of different staff. This is not a prescriptive
framework but, rather, one that could be adapted to the
different staffing structures, resources, and patient pop-
ulations of practices. It is also not intended to provide a
treatment guideline or propose specific training pro-
grams, but instead describes the types of skills needed
by primary care staff and mental health specialists who
work in primary care. We hope that the ideas presented
will stimulate the development of further training and
catalyze research to better understand what types of
training are effective in different settings. We expect
readers will offer alternative perspectives that strengthen
and refine this framework.
Rethinking the Nature of Mental Health Treatment
in Primary Care
While much thought has been given to methods of pro-
viding mental health training to primary care providers
(World Health Organization 2008), only recently has
concern shifted to the actual content of the training (Foy
and American Academy of Pediatrics Task Force on
Mental Health 2010; World Health Organization 2010).
Historically, such training has attempted to fit versions of
mental health treatments, developed in specialty care, into
primary care practices. Notable successes have occurred in
the treatment of adult depression (Simon et al. 2001) and
pediatric attention deficit disorder (ADD) (Foy and Earls
2005). For both conditions, primary care providers can use
brief paper and pencil questionnaires to make reasonably
accurate diagnoses and measure outcomes, and treatment
for many patients can primarily involve titrating relatively
safe medications to achieve a desired clinical effect.
Another feature of these conditions is that while they often
co-occur with other mental health problems, initial treat-
ment generally results in noticeable improvement. Much
less consistent success has been observed for attempts to
adapt treatment for conditions that cannot be readily
identified, that require non-pharmacological treatment
(including anxiety problems, management of medically
unexplained symptoms, depression among patients who
prefer psychotherapeutic treatment, and behavioral prob-
lems in children), or for problems that do not meet criteria
for a particular disorder.
We—and others—have argued that if primary care
providers are to address the broad range of mental health
problems they encounter, they must have an alternative
formulation of what constitutes mental health ‘‘diagnosis’’
and treatment in primary care (Wissow et al. 2008a;
Bickman 2005; Cape et al. 2000). This formulation must
build on the existing skills and knowledge of primary care
practices to the greatest extent possible. It must also
incorporate procedures that are practical in fast-paced
primary care settings (Williams et al. 1998), where mental
health treatment must compete and integrate with the many
other claims on staff time, including a surveillance and
counseling agenda that ranges from dental prophylaxis to
immunization campaigns. Providers and health plans are
unlikely to adopt treatment strategies that decrease pro-
vider efficacy or create additional burden.
Staff Involved in Mental Health Care
Before moving to the framework, we need to outline the
range of staff members who we believe need to be involved
in delivering mental health services in primary care
Adm Policy Ment Health
123
settings. Primary care practices vary in their staffing
structures, but patients often first encounter receptionists or
office staff, followed by a medical assistant (MA) or nurse,
and finally a nurse practitioner, physician, or physician
assistant. When available or necessary, the patient may
interact with a care coordinator or mental health specialist.
Receptionists initiate the visit, collect payment, and may
gather health information, including administering screen-
ing forms. Receptionists may also assist patients after the
visit with scheduling or facilitating the treatment plan in
some other way, such as filling prescriptions. Thus,
receptionists interact with patients at critical points during
the visit, and may influence the course of the visit and
patients’ perceptions of care. Professional and courteous
office staff can create an environment in which patients feel
comfortable, potentially strengthening the patients’ bond
with the clinic (Ware et al. 1999). Supportive receptionists
may ease patients’ worries and set the stage for a positive
therapeutic encounter with clinical staff.
Paraprofessional MAs are typically responsible for
escorting the patient to an examination room, measuring
vital signs, gathering health information (including identi-
fying the reason for the visit or chief complaint(s)), and
orienting the patient to the visit. MAs may also perform
procedures before or after a visit, such as administering
screening forms, giving immunizations, or collecting
specimens. Although paraprofessionals have had some
success as mental health outreach workers (Waitzkin et al.
2011), particularly in Latino communities, they typically
lack formal mental health training and have not had a
prominent role in the delivery of mental health treatment in
primary care.
Nurses, nurse practitioners, and physicians (hereafter
referred to as ‘‘providers’’ for brevity) have ultimate
responsibility for care. They are called upon to integrate
clinical information from a variety of sources, work with
patients to arrive at a formulation of the problems at hand,
and develop a plan for further diagnostic steps or treatment.
They often rely on other office staff members to collect and
organize information prior to their time with the patient,
and to implement plans or collect further data afterwards.
As noted above, providers vary in the mental health con-
ditions for which they feel capable of providing care. Some
will have brief training in mental health as part of their
degree or specialty requirements, but few (with the
exception of developmental and behavioral pediatricians)
will have had more extensive training in mental health
diagnosis or counseling skills.
Mental health specialists can help primary care provid-
ers identify patients likely to have a mental problem,
diagnose disorders, develop treatment plans, and monitor
treatment. Specialists may only play a consulting or sup-
portive role with primary care retaining responsibility for
patient care, or the specialist may assume care, particularly
for patients with severe disorders. Specialists may have had
training in working with medical generalists (consultation/
liaison psychiatry, for example), but this usually empha-
sizes problems that arise during hospitalization. Many
specialists have little understanding of the context of a
primary care practice or the kinds of interventions that
primary care providers can and cannot implement (Gask
et al. 2010). Across medical specialties, the prevailing
model of medical training emphasizes teaching generalists
what the specialist knows and does, rather than asking the
specialist to adapt specialty knowledge to the populations
and decisions encountered in primary care (Hodges et al.
2001). There is often a disconnect between the mental
health specialist’s interest in training primary care pro-
viders to diagnose mental health problems correctly and
deliver specific treatment, and the primary care provider’s
interest in wanting to learn about management of problems
that transcend diagnoses, such as somatization and stress
management (Hodges et al. 2001; Kerwick et al. 1997).
Throughout this paper, we describe the role that specialists
can play in supporting primary care.
A Framework for Primary Care Mental Health Skills
We propose a new framework for conceptualizing the types
of skills primary care staff can use to have therapeutic
encounters with patients who have mental health problems,
as well as the skills that mental health specialists can
employ to support primary care. The skills in this frame-
work are derived from a diverse body of literature on
doctor–patient communication, patient-centered care, psy-
chotherapy, and evidence-based mental health treatments,
in addition to reflections on past efforts to improve the
delivery of mental health services in primary care. As
illustrated in Table 1, this framework has three levels: (1)
cross-cutting ‘‘common factors’’ skills to build alliance, (2)
broad-based ‘‘common elements’’ skills for major symptom
clusters, and (3) evidence-based treatments for common
diagnosable mental health disorders. The framework pro-
poses that each member of the primary care team can use
certain skills to have therapeutic encounters with patients
who have mental health problems, and to support the
delivery of mental health services in the context of their
own job function. Receptionists and MAs may require the
most basic skills, while providers require more sophisti-
cated but complementary skills. Although we present these
skills as hierarchical for simplicity, we recognize that the
need for different staff to master a particular skill may vary
depending on the role of that person in any given practice.
But we emphasize that all staff members can take part,
because all are capable of having therapeutic encounters
Adm Policy Ment Health
123
Ta
ble
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tal
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skil
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ills
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-man
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ack
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team
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mar
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sin
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cro
ss-c
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skil
ls
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ltat
ion
is
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rces
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mo
nit
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ng
Adm Policy Ment Health
123
with patients when treatment is considered more broadly
than just a specific intervention applied only to patients
with a specific diagnosis.
Cross-Cutting Common Factors Skills
‘‘Common factors’’ are aspects of mental health treatment
that influence outcomes but are not particular to any spe-
cific therapy or diagnosis—they are found ‘‘in common’’
across therapies within and across conditions (Lambert and
Ogles 2004). Common factors include (1) client charac-
teristics (motivation, hopefulness, and expectations about
treatment); (2) therapist qualities (theoretical orientation,
training, and expectations); (3) change processes (interac-
tions that shift decisional balance or re-frame situations);
(4) treatment structures (the therapist’s ability to focus on
the client’s emotions, thoughts, and beliefs) and (5) the
therapeutic relationship (therapeutic alliance, engagement,
and transference) (Bickman 2005; Grencavage and Norcross
1990). By one estimate, in adult psychotherapy, common
factors account for as much as 30% of the variation in out-
comes, while the specific treatment itself accounts for about
15% (Lambert and Barley 2002).
Therapeutic alliance, broadly defined as the affective
bond between the provider and patient, and the agreement
of the two on the goals and processes of treatment, may be
among the most important common factors. Stronger alli-
ance has been found to increase the likelihood that patients
follow through with mental health treatment (Weiss et al.
1997) and, like the common factors as a whole, is associ-
ated with improvements in outcomes independent of the
specific treatment modality (Krupnick et al. 1996).
We propose that all primary care staff can learn skills
that target those common factors amendable to change
within the time and resource constraints of primary care.
Specifically, we propose that primary care staff can use
skills that impact certain client characteristics (for example,
increasing patients’ hopefulness, motivation to change, and
expectations that treatment will help), change processes (for
example, encouraging patients to try new behaviors),
treatment structures (for example, focusing on patient’s
beliefs and attitudes), and therapeutic relationships.
The common factors skills included in the framework
are derived from the psychotherapy literature and from
trials of trainings that sought to enhance the ability of
primary care providers and other office staff members to
communicate with patients about mental health problems.
Roter et al. (1995) randomized primary care physicians to
receive training in either ‘‘emotion-handling’’ skills or
‘‘problem-defining’’ skills or be assigned to a control
group. The ‘‘emotion-handling’’ skills taught physicians to
ask patients about their feelings, actively listen and talk
less, follow-up on signs of emotional distress, express
empathy, and compliment patients on their efforts to
address their mental health concerns while reassuring them
that doing so was appropriate. The ‘‘problem-defining’’
skills, which we map on to the common factor areas of
focusing on the patient’s beliefs and attitudes, taught
physicians to (1) elicit the full spectrum of patient concerns
by resisting immediate follow-up of the patient’s first
expressed concern, ask about other problems or concerns
using open-ended questions (‘‘anything else?’’), and pri-
oritize concerns at the outset of the visit; (2) delineate the
patient’s problem by starting with open-ended questions,
use facilitative questions to help the patient tell the story in
his or her own words, and assess the effect of the patient’s
problem on psychosocial functioning; and (3) seek to
understand the patient’s perspective by probing for the
patient’s understanding of his or her health problem while
clarifying expectations for the visit. Physicians were able to
master the skills taught in the trainings with both actual and
simulated patients. Trained physicians, particularly those
who received the problem-defining training, improved their
ability to identify and treat patients’ emotional problems.
Six months after the initial visit, patients who visited a
trained physician had greater reductions in their emotional
distress than those who visited physicians in the control
group. Moreover, physicians who took part in the trainings
were able to integrate new skills into routine care, and
visits with trained providers were not significantly longer
and did not result in a higher number of return visits
compared with physicians in the control group.
In a second trial that built on Roter and colleagues’
work, pediatric primary care physicians and nurse practi-
tioners were randomized to receive training in seven
clusters of skills that addressed their own expectations
about mental health visits as well as patient expectations,
change processes, treatment structure, and building a
therapeutic relationship. The clusters included: (1) Time
management (managing rambling or long lists of concerns
and prioritizing concerns); (2) Problem solving (using
techniques derived from solution-focused therapy); (3)
Managing negative affect (anger within the family and
anger directed toward the provider); (4) Agenda setting
(eliciting the full set of concerns, engaging children and
parents in discussion, promoting turn taking among family
members); (5) Problem formulation (seeking a common
understanding of the problem); (6) Advice giving (asking
for permission to offer advice, offering choices, and
exploring treatment preferences); and (7) Managing resis-
tance (not pushing back, agreeing on goals, asking per-
mission to provide more information) (Wissow et al.
2008b). Participating clinicians adopted some but not all
of the skills, but uptake of skills, as well as change in
overall interactional style with patients, was associated
with improvements in parent-rated child mental health
Adm Policy Ment Health
123
functioning and youth-rated mental health symptoms
6 months after the initial visit, controlling for the receipt of
other mental health services (Wissow et al. 2008b). Similar
to primary care interventions for adult depression (Wells
et al. 2007), the training was particularly effective at
improving the mental health functioning of Latino and
African American children and youth, perhaps because it
helped to address culturally-specific attitudes toward
treatment (Brown et al. 2007c). Moreover, mothers of
children with mental health problems who visited a trained
provider experienced significant improvements in their
own mental health symptoms—an important finding given
the negative impact of maternal mental health problems on
child mental health (Weissman et al. 2006). The effect
sizes of the training were similar to those of more complex
‘‘collaborative care’’ interventions that provide training on
the use of diagnosis-specific protocols and realign staff
roles to provide support and ongoing care (Asarnow et al.
2005). However, the population of focus for this trial was
heterogeneous with respect to parent and child/youth
mental health problems, potentially representing a broader
public health impact.
Finally, a pilot study adapted the 7-cluster primary care
training described above for use with MAs orienting patients
and obtaining their chief concerns in a pediatric practice
serving a largely Latino population (Brown et al. 2011). The
study found that after the training MAs were able to improve
their patient-centered interactions with families and parents
independently reported a greater likelihood that they would
discuss psychosocial concerns with them.
These trials built upon earlier communication trainings
for physicians that were not specifically focused on mental
health but used similar techniques and achieved similar
results. One such training, sponsored by the Society of
General Internal Medicine in the early 1990s, found that
physicians randomized to receive a training in which they
learned patient-centered interviewing techniques by inter-
viewing patients and receiving immediate feedback from
their colleagues were able to ask more open-ended ques-
tions, more often asked patients for their opinion of treat-
ment, and gave more biomedical information. Patients who
visited physicians who received the training disclosed more
psychosocial information and demonstrated fewer signs of
emotional distress during the visit (Levinson and Roter
1993). Other trainings have been developed to successfully
teach physicians empathetic communication skills and to
manage stressful clinical encounters, particularly encoun-
ters that involve strong negative emotions such as anger,
sadness, or fear (Platt and Keller 1994).
The proposed framework expands on these earlier trials
by suggesting that all members of the primary care team,
not just physicians, can learn some common factors skills.
MAs, care coordinators, and even receptionists and office
staff may particularly be able to use a subset of the skills to
capitalize on their existing job functions and relationships
with patients. Below we describe these skills and how they
relate to the role of each member of the primary care team.
In this list, we have taken the common factor-related skills
and re-arranged them to suggest a minimum set for each
category of primary care staff member:
Basic Communication and Interpersonal Skills
Basic communication skills, necessary for all members of
the primary care team, include the ability to interact with
patients in a warm, friendly manner that promotes trust,
genuineness and positive regard for the patient’s con-
cerns—common factor clinician interpersonal skills that
promote self-actualization and self-direction in treatment
(Cormier and Nurius 2003). Such interpersonal skills are
useful during interactions with all patients but they may be
especially helpful during interactions with patients who
have mental health problems since they may require special
encouragement to disclose concerns and engage in care.
These skills are the foundation for improving therapeutic
alliance and enhancing patient’s hopefulness, expectations
that treatment will help, and willingness to engage in
care—all important common factors in treatment.
Simple, non-verbal actions such as making eye contact
and smiling are related to improvements in patients’
satisfaction with care and adherence to treatment
(Marcinowicz et al. 2010; Mast 2007; Roter et al. 2006).
Receptionists can employ these skills when explaining the
purpose of paperwork and billing procedures and directing
patients to the next steps of the visit. Positive interactions
with receptionists might signal that primary care is a wel-
coming place to share concerns and receive help. MAs and
providers would use these skills while gathering health
information, setting the agenda for the visit, and agreeing
on the nature of problems and goals for treatment.
Primary care staff may require skills to defuse conflicts
and respond to stressful patient encounters that involve
anger or frustration directed to the staff. For example,
patients may appear frustrated at wait times or because
some authority (for example, family members or school
personnel) may have pressured them into the visit. In such
situations, staff can use communication skills that express
their empathy and reassurance that primary care can help.
The importance of empathetic communication is described
in more detail below.
Identification of Mental Health Problems
Primary care staff can identify mental health problems at
various stages of the visit using different approaches. Some
practices may implement routine screening using paper and
Adm Policy Ment Health
123
pencil or computerized questionnaires. These tools are
most often distributed by clerical staff at the time a patient
registers for care or by MAs as they ready patients for
provider visits. Although not the focus of this paper, the
use of mental health screening tools is complex, and the
various staff members involved must have skills, depend-
ing on their role, to introduce the tool, assist with admin-
istration, and discuss the results (Klinkman et al. 1998).
Providers in particular require skills to reconcile conflicting
screening results if information is gathered from more than
one informant, such as a parent and child/teen (Foley et al.
2005; Jensen et al. 1999) or parent and teacher (Brown
et al. 2006; Youngstrom et al. 2003; Thuppal et al. 2002),
as each informant can contribute meaningful but quite
different information. Moreover, providers must under-
stand the limits of any particular instrument and how these
instruments differ from other ‘‘screening’’ methods, such as
haematocrits or tuberculosis tests.
In addition to formal screening, primary care staff has
opportunities during their routine encounters with patients
to use some common factors techniques to identify mental
health problems. For example, receptionists could learn to
identify signs of distress (for example, patients who are
tearful or extremely anxious), interact calmly and empa-
thetically with such patients, and relay their observations to
clinical staff. MAs discuss the reason for the visit and ask
about health and functioning in the course of their inter-
actions with patients, providing an opportunity to identify
mental health problems. Mental health problems are,
however, rarely the chief complaint because patients may
not perceive primary care as an appropriate place to discuss
mental health concerns (Lopez-Stewart et al. 2000) or they
may report physical symptoms indicative of mental health
problems. There are several strategies that MAs and pro-
viders can use to overcome such barriers to identifying
mental health problems. First, patients must have an
opportunity to express their full list of concerns at the
outset of a visit to avoid the discovery of mental health
problems late in the visit, which decreases provider effi-
ciency and does not allow enough time to address the
problem (Marvel et al. 1999). Asking closed-ended ques-
tions and interrupting the patient after his or her expression
of the first concern results in failure to establish the
patient’s agenda, whereas asking simple, brief open-ended
questions (for example, ‘‘Anything else?’’ or ‘‘Tell me
more.’’) allows patients to express their full list of concerns
and requires, on average, only 6 seconds more (Marvel
et al. 1999). Such simple inquiry is non-intrusive, creates
opportunities for follow-up questions, and can more than
double the odds that mental health problems will be dis-
closed (Robinson and Roter 1999). Second, MAs and
providers should have skills to identify verbal and non-
verbal clues (for example, depressed affect, nervousness,
unexplained loss of weight, etc.) of mental health prob-
lems. This requires active listening to identify vague terms
that require further probing or exploration. This type of
vigilance and probing targets changes in the treatment
structure common factor by taking steps to fully understand
the patient’s emotions, thoughts, and beliefs that may be
indicative of mental health problems.
Responding to Mental Health Problems with Empathy
and Setting the Agenda
Once a potential mental health problem is disclosed or
suspected, MAs and providers need skills to respond with
empathy and reassurance that primary care can help.
Simple statements of empathy and reassurance decrease
patients’ anxiety and improve satisfaction with care
(Wasserman et al. 1984). Conversely, a dismissive
response may miss opportunities for intervention. Empa-
thy, or the ability of a clinician to relate to the patient’s
experience and express a sense of understanding, also
results in the development of stronger therapeutic alliance
(Ackerman and Hilsenroth 2003).
MAs may be able to promote the disclosure and dis-
cussion of mental health problems as they ‘‘prime’’ patients
for their visit. In addition to empathetically encouraging
the patient to discuss mental health concerns with the
provider, MAs can help the patient formulate an agenda for
the visit and increase the patient’s expectations and hope-
fulness that discussing problems with the provider will
help. The skills to target these patient common factors
could be derived from ‘‘patient activation’’ interventions,
which seek to increase the patient’s participation in the
visit and positive expectations for treatment outcomes.
Patient activation typically consists of helping the patient
formulate questions to ask the provider, reviewing current
treatment, and asking about treatment goals (Harrington
et al. 2004). One of the most frequently cited studies of
patient activation, carried out with adult ambulatory
patients, found that coaching patients to ask questions led
to more active participation in visits and improved clinical
outcomes (Greenfield et al. 1985). Although not referred to
as such, patient activation is a common practice in mental
health care, where it is better known as ‘‘role induction’’ or
‘‘empowerment’’ (Walitzer et al. 1999). MAs could help
patients think about how to explain the mental health
problem to the provider (for example, describing the con-
text of the problem occurs, how long has the problem been
present, etc.) and can help the patient think about what to
ask the provider and what type of help he or she would like
to receive during the visit. Providers require skills to
confirm the patient’s agenda for the visit and expectations
for treatment.
Adm Policy Ment Health
123
Developing Shared Understanding of Mental Health
Problems
The patient and provider must share a common under-
standing of the problem to develop a useful treatment plan.
This may involve gathering contextual information about
the problem, asking for clarity about terms or phases used
to describe the problem, and identifying underlying sources
of the problem, which may include poverty, stress, or
physical health conditions. Providers can use techniques
such as repeating back the problem and asking for
confirmation.
Assessing Willingness for Treatment and Developing
Treatment Goals
Once a mental health problem is identified, the provider
must assess the patient’s willingness to participate in
treatment. Such an assessment of readiness includes
understanding the patient’s perceived need to take action,
hopefulness that treatment will help, and interest in hearing
the provider’s recommendations (Bohart 2000). Providers
must be cognizant of whether or not the patient was
coerced into treatment and, if so, must remain neutral to
reinforce therapeutic alliance. An assessment of readiness
for treatment should not necessarily be tied to a specific
intervention, but rather should focus on actionable steps
that can lead to improvements in functioning. Patients vary
in their beliefs and attitudes about mental health problems
and treatments, which necessitates that providers commu-
nicate their respect for patient preferences while providing
education about the potential benefits of treatment options.
Providers should express hopefulness that treatment will
help to target changing patient expectations—a common
factor that improves outcomes.
Overcoming Barriers to Treatment
MAs, care coordinators, and providers can use communi-
cation skills that help patients overcome barriers to treat-
ment. Patients may benefit from help overcoming practical
barriers including poverty, insurance limitations, or inad-
equate child care. Connections between primary care and
community resources are essential to help patients over-
come such barriers. Patients may have attitudinal barriers
to treatment that could be addressed by increasing expec-
tations that treatment will help, as well as education about
treatment options. The skills to overcome attitudinal bar-
riers could be derived from motivational interviewing or
enhancement techniques that target common factors.
Therapists who use motivational enhancement techniques
work to reduce ambivalence and help the patient identify
behaviors or feelings that are barriers to achieving his or
her goals. A key component of motivational enhancement
involves ‘‘rolling with resistance,’’ in which the therapist
avoids direct confrontation of the patient’s unwillingness to
participate in care but instead helps the patient identify
more appealing behaviors consistent with his or her goals.
We do not suggest that primary care staff would neces-
sarily become proficient in the use of motivational
enhancement techniques. Rather, some of the basic skills
and attitudes incorporated in motivational enhancement
therapies could encourage patient change processes—a
common factor that influences outcomes.
Broad-Based, Brief Interventions for Major Symptom
Clusters: Skills Derived from ‘‘Common Elements’’
At the next level of the framework, primary care staff can
employ skills derived from the ‘‘common elements’’ of
mental health treatments. ‘‘Common elements’’ refers to the
shared features of different evidence-based treatments. For
example, 86% of evidence-based treatments for child and
adolescent depression include a child psycho-education
component, and 71% employ some type of problem solving
and cognitive coping skills; 92% of evidence-based psy-
chosocial treatments for attention and hyperactivity prob-
lems establish tangible reward systems for the child and
83% encourage parental praise of child behaviors and ‘‘time
out’’ strategies (Hawaii Evidence Based Services Com-
mittee 2004; Jensen et al. 2005; Hoagwood et al. 2001).
Not only do evidence-based treatments for the same
disorder share common elements, but some treatments for
specific diagnoses have a positive impact on other diag-
noses. For example, treatments specifically targeted to
panic disorder have a positive impact on co-morbid anxiety
disorder and depression (Barlow et al. 2004). For some
treatments and disorders, it is difficult to determine if this
‘‘spillover’’ in the treatment effect is the result of under-
lying similarities in the disorders or the treatments for the
disorders. Nonetheless, such findings suggest that treat-
ments for some mental disorders may have more similari-
ties than differences.
Mental health treatment in specialty settings often
begins with the process of identifying fine diagnostic dis-
tinctions among disorders on the assumption, sometimes
validated, that these distinctions are therapeutically
important. Such a process is difficult within the time con-
straints of primary care visits and providers’ lack of diag-
nostic training; primary care staff also lack time to learn
and deliver multiple, narrowly targeted, mental health
treatments (Daleiden et al. 2006). Further, not all patients
are receptive to highly structured mental health treatments,
particularly treatments involving psychiatric medications
(Pyne et al. 2005; Bussing et al. 2005; Brown et al., 2007c).
The framework proposes, instead, that primary care staff
Adm Policy Ment Health
123
could learn a core set of treatment skills derived from the
common elements of evidence-based treatments rather than
having to learn separate protocols for each specific disorder
(Moses and Barlow 2006). These common elements skills
would be broadly applicable to groups of patients with
similar symptoms and could be flexibly applied to accom-
modate varying patient treatment preferences. Such skills
could be used in immediate response to specific mental
health concerns rather than waiting for a diagnosis, or
while a diagnosis is pursued (Wissow et al. 2008a).
We are unaware of any package or curricula of common
elements skills for primary care. Common elements train-
ing has not been extensively tested in primary care, but
evidence of its effectiveness has been found in outpatient
mental health treatment settings. One variant of a common
elements approach is the Brief Consultation and Advisory
(BCA) treatment approach for child and adolescent mental
health problems, in which therapists (referred to as ‘‘con-
sultants’’) use brief problem-solving techniques to quickly
assess the parent’s perceptions of the causes of their child’s
difficulties, understand expectations for treatment, and
determine what actionable steps could meet those expec-
tations and resolve difficulties (McGary et al. 2008; Hey-
wood et al. 2003). A central goal of this approach is to
empower parents to feel that they can do something to help
themselves or their child (Heywood et al. 2003). In one
study, families randomized to receive BCA treatment
demonstrated greater improvements in child mental health
symptoms and parent stress than those receiving treatment
as usual 6 months after the initial visit (McGary et al.
2008). In our training for pediatricians and nurse practi-
tioners, we incorporated some common elements including
problem solving skills (derived from solution-focused
therapy) and managing anger within the family and anger
directed toward the provider (derived from family therapy).
As mentioned above, providers were able to use the skills,
particularly anger management skills, which resulted in
improvements in patient outcomes (Wissow et al. 2008b).
Table 2 summarizes common elements of evidence-
based treatments for child and adolescent mental health
problems (Hawaii Evidence Based Services Committee
2004). A task force of researchers and clinicians system-
atically reviewed the efficacy and effectiveness of evi-
dence-based treatments for child and adolescent mental
health problems and identified the ‘‘clinical ingredients’’ of
treatments using a structured coding manual that detailed
55 different clinical techniques and procedures. We pro-
pose that pediatric providers may be able to learn just a few
of these techniques to develop a ‘‘toolbox’’ of skills that
could be applied to children with certain symptom clusters.
For example, a provider could offer brief education on
establishing a reward system and using ‘‘time out’’ tech-
niques to a parent of a child who demonstrates hyperactive
symptoms. The parent could begin to use these techniques
while diagnosis is being pursued.
For adult anxiety and depression—two of the most
prevalent mental health problems in primary care—
researchers have identified three elements common to
evidence-based treatments: (1) altering cognitive appraisal
(helping patients develop a realistic appraisal of whether a
negative event will occur and a realistic understanding of
the consequences of that event); (2) modifying emotion-
driven behavior (helping patients identify behaviors that
are initially rewarding but ultimately reinforce disorder),
and (3) preventing emotional avoidance (helping patients
identify behaviors that prevent positive and negative
emotional experiences) (Moses and Barlow 2006). Applied
to the example of a patient with symptoms of anxiety
disorder manifested as a fear that her family is in danger,
the provider could apply skills to counsel the patient to (1)
consider whether the fears are justified (altering cognitive
appraisal), (2) suggest that the patient attempt limiting
persistently calling relatives to check on their safety
because such behavior only reinforces the anxiety (modi-
fying emotion-driven behavior), and (3) suggest that the
patient focus attention on immediate tasks and engage in
meditation and relaxation techniques (preventing emo-
tional avoidance). Again, the patient could begin using
these techniques while diagnosis and specialists help is
pursued.
Table 2 Common elements of evidence-based treatments for child
and adolescent mental health problems (Hawaii Evidence Based
Services Committee 2004)
Mental health problem Four elements common to
evidence-based treatments
(% of treatments for which
element is present)
Anxious or avoidant behavior Exposure (97%)
Modeling (44%)
Cognitive/coping (39%)
Relaxation (31%)
Attention and hyperactivity
problems
Tangible rewards (92%)
Parent praise (83%)
Parent monitoring (83%)
Time out (83%)
Depression or withdrawn
behavior
Psychoeducation for child (86%)
Cognitive/coping (71%)
Problem solving (71%)
Skill building/behavioral rehearsal
(64%)
Disruptive behavior Tangible rewards (89%)
Commands/limit setting (73%)
Time out (70%)
Parent praise (68%)
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123
Evidence-Based Treatment for One or More Specific
Conditions
Although less severe mental health problems may respond
well to common factors or common elements treatment
alone, there are some patients for whom a reasonable
diagnosis of a disorder can be made fairly easily, par-
ticularly depression and ADD, and these patients would
likely benefit from beginning an evidence-based treatment
protocol immediately. In addition, if the practice adopts a
‘‘stepped care’’ model (Katon et al. 2001), it may want to
follow-up with patients who have received less-specific
treatment or for whom a diagnosis or level of severity has
become clearer over time. Primary care practices will
vary in the extent to which they can offer evidence-based
treatments for specific conditions, depending on the needs
of their patient population, the availability of specialists
in the community, and the existing skills of the primary
care team. For the more common mental disorders such
as anxiety and depression, this may take the form of
cognitive or behavioral interventions administered over
time by a member of the office staff (Katon et al.
1995).
In some communities, primary care may also become a
resource for patients with more severe disorders. In those
communities, any mental health care may be too distant to
access, or available services may not include the ability to
supervise the psychopharmacologic aspect of treatment or
their somatic side effects. Thus, some primary care prac-
tices may find it necessary to acquire skills to monitor
relatively severe illnesses such as bipolar disorder and
schizophrenia, though in collaboration with a psychiatric
consultant that the patient sees periodically either in person
or via telemedicine.
Identify when Evidence-Based Treatments are Needed
Providers should be able to recognize common diagnosable
mental health problems for which there are well established
evidence-based interventions and to identify patients who
are functioning so poorly that immediate mental health
consultation is indicated. If a specialist is needed, the
provider should be able to communicate the necessity of
referral and have processes to assist the patient follow
through with referral. As mentioned above, MAs and care
coordinators can play a role in identifying the severity of
problems through screening or communication during
routine encounters. Specialists can also help primary care
staff determine when the severity of a problem has
exhausted the resources of primary care or there is a need
to move immediately to a diagnosis-specific treatment
protocol.
Use of Basic Formulary
Providers and care coordinators should be familiar with
medication formularies for common mental disorders.
While there is an ever-expanding number of psychotropic
medication available, there are, in fact, only a few that
meet criteria for use by generalists as first-line treatments.
These criteria include a long track record of safety, simple
administration that does not require therapeutic monitoring,
and relatively few side effects (Riddle and DosReis 2011).
Primary care providers may want to prescribe some of
these medications but they need skills to communicate with
patients about their risks and benefits, how they influence
expectations for recovery, and the helpfulness of other
supportive therapies. Some primary care practices would
rather a mental health specialist prescribe psychiatric
medications but can support monitoring side effects and
improvement.
Monitor and Coordinate Care
In addition to monitoring the use of medications, primary
care providers and care coordinators should have skills to
monitor patient functioning. Providers should be able to
communicate the necessity of regular specialty follow-up if
it is needed and be able to help with monitoring for signs of
relapse and side effects. Care coordinators familiar with
health and social service systems can help connect patients
to resources that may ameliorate many of the life stressors
that underlie and compound mental health problems
(Dietrich et al. 2004). With adequate training, MAs may be
able to help monitor care through regular phone calls to
patients or even home visits in some communities. As
mentioned above, providers, care coordinators, and MAs
may be able to use common factors skills (for example,
empathetic communication) and skills derived from moti-
vation interviewing (for example, managing resistance to
treatment by exploring other options) to sustain therapeutic
alliance, encourage patients to follow-through with treat-
ment, and overcome barriers to treatment.
Discussion
The framework presented here provides a conceptual
foundation for thinking about the clinical skills primary
care staff and the specialists who support them can use to
increase the mental health treatment capacity of primary
care. The concepts in this framework are derived from a
broad and diverse literature. Policymakers and leaders in
health and mental health services have focused much
attention on reforming delivery systems and health insur-
ance to better integrate physical and mental health services.
Adm Policy Ment Health
123
We hope that the ideas presented in this paper will stim-
ulate further dialogue, training, and research focused on
what types of mental health treatment skills primary care
staff and specialists need to effectively function and have
the largest impact on patient outcomes in a more integrated
service system.
Next Steps in the Development and Application
of the Framework
The framework presents training goals at a conceptual level
but there is a need to further operationalize the specific
skills. As mentioned, common factors trainings have had
some success in primary care but there is a need to better
understand which common factors are the mechanisms
most strongly associated with outcomes. Likewise, a
common elements approach has been used in specialty
mental health treatment settings, but there is a need to
identify and package common elements into training for
primary care staff. Finally, primary care staff need educa-
tion in the use of well-tested evidence-based treatment
protocols and medications for common diagnosable mental
disorders.
As a starting point to advance the concepts presented in
this paper, there is a need to better understand the extent to
which existing mental health and communication training
for primary care staff and mental health specialists include
the skills in the framework. We are unaware of a curricu-
lum for primary care staff or mental health specialists that
includes training in common factors, common elements,
and evidence-based treatment, but there are trainings that
include some of these skills that could serve as a founda-
tion for developing a more comprehensive curriculum
targeted to each member of the primary care team. Such a
curriculum must efficiently package practical skills that can
be used within the time limitations of primary care visits.
Ongoing health care reforms may provide opportunities
to disseminate, test, and refine the skills included in this
framework. Demonstration programs sponsored by SAM-
HSA and other agencies that seek to integrate physical and
mental health services could incorporate the skills pre-
sented in this framework. Such programs may provide
opportunities to conduct research to better understand how
different common factors and common element skills
function independently and in concert with changes in
organizational structures and reimbursement mechanisms
to affect outcomes. There is also a need to understand how
the use of skills included in this framework are comple-
mentary to other models of integrated primary care and
mental health services, including ‘‘collaborative care’’ and
‘‘stepped care’’ models (Asarnow et al. 2005; Bower et al.
2006; Katon et al. 2001). Given that many of the common
factors and common elements skills in the framework are
derived from other therapies from specialty mental health
treatment settings, there is a need for research to under-
stand how these skills affect outcomes in primary care for
specific diagnoses and across symptoms clusters. There is
also a need to understand to what extent primary care staff
can use the skills with some degree of fidelity and what
amount of adaptation for different staff and settings is
necessary.
Dissemination of these skills requires that training is
acceptable and accessible to primary care staff. Training
could take the form of brief in-person or web-based sessions
that minimize interference with patient care and allow for
staff to practice skills and receive feedback. The trainings
conducted in the aforementioned trials (Roter et al. 1995;
Wissow et al. 2008b) required approximately 4 h, broken
up into shorter sessions during which providers engaged in
didactic learning, role play, and practice with simulated
patients. In both studies, physicians and nurse practitioners
were receptive to the training, perhaps because it was
delivered during the workday and allowed them to practice
their skills and receive feedback. No single model of
training is likely to work in all primary care settings; rather,
a range of training models and methods that are effective
under different circumstances may be needed. Looking
beyond the existing workforce, schools of medicine and
nursing may be able to efficiently offer more substantial
mental health training using brief but comprehensive cur-
ricula that contains common factors and common elements
skills along with selected evidence-based treatments.
The adoption of this framework may require that mental
health specialists take a different orientation to supporting
primary care staff. Mental health specialists may benefit
from opportunities to learn how primary care functions.
Health plans and service systems could bring more mental
health specialists and primary care practices together under
the same organizational and financial umbrellas to facilitate
such learning opportunities.
If training in the skills included in this framework
proves effective, there may be opportunities to create
flexible treatment guidelines and algorithms that could
overcome some of the constraints of diagnosis-specific
treatments in primary care.
Acknowledgment This work was supported by National Institute of
Mental Health grant P20 MH086048.
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