Outcomes of Cognitive Behavioral Therapy (CBT) Interventions Provided by Unlicensed Professionals

Cognitive behavioral interventions are the most widely studied and evidenced-based
psychosocial treatment approaches for mental health and health related behavioral problems.
Despite their documented efficacy, there is a scarcity of licensed mental health
professionals who are available to treat patients with problems that would be amenable to
Cognitive Behavioral Therapy (CBT). While CBT interventions have a strong base in terms of
efficacy in randomized trials, effectiveness and dissemination studies are lacking in
comparison, and hence, these interventions are not reaching the patients in most need of
services. Complicating the problem further, insurance companies typically do not reimburse
for services provided by trainees who are not licensed. This is a public mental health
problem because it limits the degree to which CBT clinicians can be trained to deliver these
treatments, and a particular problem at MGH because referring providers do not have a place
to send their patient for CBT services, as trainees constitute a large portion of clinical
staff. To address this issue, the current study seeks to document outcomes of CBT
interventions delivered by credentialed but not licensed trainees. This information can be
used to guide policy and reimbursement guidelines for trainees, as well as promote the
ability to disseminate efficacious interventions. Information gained from this project will
be used to provide feedback to insurance companies, licensing boards, and mental health
community stakeholders regarding decision making re: reimbursement for care provided by
supervised trainees. Additionally, this may be used as a pilot study for a comparative
effectiveness study comparing trainees to licensed staff psychologists.

Inclusion Criteria:

- Patients presenting to the Behavioral Medicine Service are generally individuals with
an acute or chronic medical condition or medically related concern with or without an
associated DSM-IV psychiatric disorder, as well as adult patients who require
assistance with changing health or health-risk behaviors. Patients presenting to the
OCD program typically have obsessive compulsive disorder, body dysmorphic disorder,
Tourette syndrome, compulsive skin picking, or trichotillomania. Patients presenting
to the general CBT program typically have panic disorder, social phobia, generalized
anxiety disorder, depression, specific phobia, post traumatic stress disorder,
attention deficit hyperactivity disorder, or an eating disorder. Patients at any of
the programs have an identifiable behavior or behavioral pattern/ mood problem that
they would like to change.

- Age 18 or older

- Ability to provide informed consent and comply with the study procedures

- Ability to complete self-report questionnaires (either written hardcopy or
computer-based version) with adequate accommodation, if necessary

- Patients with a PCP at MGH, receiving specialty care at MGH, or employees of MGH.

Exclusion Criteria:

- Exhibit active suicidality (suicidal ideation with intent or plan) to the point that
more intensive treatment (i.e. acute hospitalization) is required.

- Active untreated and unstable bipolar disorder (i.e. stable bipolar disorder under
care of a psychiatrist is allowed).

- Psychosis.

- Mental retardation.

- Any condition that, after the baseline evaluation, is determined to preclude treatment
with cognitive behavioral therapy.

- Received more than 4 sessions of CBT for the target disorder within the past 3 years.