Wave of the future: Partnership between eye care and psychology

(Image credit: ©loreanto/AdobeStock)

The Embedded Behavioral Health Service is described as a “unique and innovative psychology service” in the Ophthalmology Department at the Massachusetts Eye and Ear (MEEI), Boston, in collaboration with its down-the-street neighbor, the Department of Psychiatry at the Massachusetts General Hospital.

Ethan Lester, PhD, a clinical psychologist at Mass General Brigham, director of the Embedded Behavioral Health Service, and a rehabilitation clinician at Spaulding Rehabilitation Hospital, Boston, described for Ophthalmology Times® how this partnership works.

A unique pairing

The collaboration between psychology and ophthalmology began in 2019, Lester said. MEEI’s Ocular Trauma Service runs under the care of the chief resident, and as such is a focal point for interface with ophthalmology residents. Considering this, a faculty member and chief resident envisioned that both patients who suffered ocular trauma and residents would benefit from the addition of a psychologist to the clinic.

The thought was that a program related to wellness and emotional wellness was related to medical training. After 2 years, this scenario grew into a full service, at which time the Low Vision and Vision Rehabilitation Clinic at MEEI embraced the clinic as a pilot that then evolved into a full service.

This unique clinic provides short-term, skills-based therapy with the specific goal of “helping patients cope with the challenges associated with low vision and other visual impairment,” according to Lester. Patients are scheduled for therapy every other week for about 3 months.

Currently, the support is short-term because of limited resources, ie, the Department of Ophthalmology has one full-time psychologist to service a large patient population, and the skills-based aspect of therapy concerns psychology protocols that are common to ophthalmology patients that include identify, stages, role adjustment, functional changes related to vision loss, and grieving for lost vision.

“The short-term nature of the care allows us to be as effective as possible in as short a period of time as possible to facilitate extending care to more patients and giving patients the ability to function without having to engage in weekly therapy,” he said.

In addition, once it becomes clear that a patient has achieved the maximal benefit from interaction with the clinic psychologist, there is potential for referral to other resources in other outpatient settings or community referrals to address a major depression, trauma, and substance issues.

Patients who are not clinic candidates are those who present with an active psychotic disorder or active substance abuse that would counteract therapy.

Patients have the option of meeting with clinicians in person on a biweekly basis or virtually – in fact about 90% choose phone or Zoom meetings to eliminate the challenges associated with traveling to in-person evaluations.

Measuring success

Lester and colleagues are currently developing a formalized assessment of patient outcomes. “We are piloting this in inherited retinal diseases in the coming year,” he said.

First, an initial screening inventory of emotional distress would be undertaken using the Patient Health Questionnaire 9 and the Generalized Anxiety Disorder screener.

Interestingly, he pointed out, a challenge that clinicians face is that not all patients who want to participate in skills-based therapy would have clinical levels of distress that meet the threshold of clinical distress. Lester and his team are currently working to quantify the true clinical impact of the service on a problem that might not be a clinical issue but a reactive issue to vision loss.

While the psychologists rely on patient reporting of stress, the teamwork between the services comes into play here.The ophthalmologists in the trauma service and optometrists in the vision rehabilitation service who initially refer patients to the service are instrumental in the documentation of the patients’ emotional stress, such as tearfulness during sessions or observed anxiety during follow-up, which in some cases can be under-reported or masked by patients.

Emphasizing the link between psychology and vision rehabilitation

“The natural place for a psychology or counseling service in an ophthalmology or optometry department is in vision rehab or a low vision clinic. Typically, a patient was assessed and received a recommendation for use of devices, technology, or techniques; consultation with a behavioral or mental health consultant would help them use those resources. The goals of vision rehab, psychology, and psychological counseling are aligned and the link is a natural fit,” Lester explained.

“Ophthalmologist and optometrists are becoming more aware of the value of this Embedded Behavioral Health Service that allows for rapid and tailored access to mental health professionals who really understand this patient population. In a very busy medical setting such as a city hospital or practice, referring patients to an outpatient psychology or psychiatry service can result in waiting listing of patients for 3 or 4 months. In our setting, the patient meets with an optometrist one week and then they have a follow-up call with a psychologist the following week,” Lester commented.

Ethan Lester, PhD

Ethan Lester, PhD

E: elester@mgh.harvard.edu

Dr. Lester is director of the Embedded Behavioral Health Service, Massachusetts Eye and Ear, Boston. He has no proprietary interest in this subject matter.