Advocacy: Looking Back Upon the Future

Reflections: At our Toronto convention, I had the pleasure of listening to former APA President (and now, Division 42 President) Ron Fox reflecting upon the importance of professional psychology affirmatively addressing society’s pressing needs. Presidential perspectives are unique. The past often is prologue for the future. Ron is, of course, correct and over the holidays, I have been reflecting upon how little I (and undoubtedly many colleagues) really know about our profession’s past. The catalyst for my musings is an outstanding publication by Ludy Benjamin and David Baker (Director of the Archives of the History of American Psychology) entitled: From Seance To Science: A History of the Profession of Psychology in America. Today’s critical policy issues existed decades ago; for example, the interrelationship between the public sector and private practice. Some highlights:

This book tells the story of psychologists who sought and seek to apply the knowledge of their science to the practical problems of the world. In 1917, 25 years after the founding of APA, the membership of the association numbered 307. Of that total, only 16 members (about 5%) were engaged primarily in the application of psychology outside of universities. For the first half century of American psychology, those psychologists engaged in college teaching and research outnumbered their colleagues in practice. That picture, however, changed dramatically after World War II. Today it is estimated that there are 117,260 psychologists in the United States. Among that number, approximately 75,000, or about 64%, are employed principally as psychological practitioners.
In 19th-century America, “having your head examined” was big business, largely due to the enterprising efforts of two brothers. Having your head examined meant phrenology, certainly the best known of the applied psychologies of the 19th century. Combe adhered to the categorization of 35 faculties as described by Spurzheim. In describing the basis in 1835 for his practical phrenology he wrote: “Observation proves that each of these faculties is connected with a particular portion of the brain, and that the power of manifesting each bears a relation to the size and activity of the organ. The organs differ in relative size in different individuals, and hence their differences of talents and dispositions.” What phrenology offered was not only the cranial measurement that identified the talents and dispositions but, more important, a course of action designed to strengthen the facilities and bring the overall complex of emotional and intellectual faculties into a harmony that would ensure happiness and success. This was practical phrenology, that is, phrenology applied. No doubt there were unsavory characters in the business, as one would find in any of the contemporary professions. But there were also many whose motives were about helping. We have described the 19th-century practices of phrenology, physiognomy, mesmerism, spiritualism, and mental healing as prescientific applied psychologies. The practitioners in these disciplines used the knowledge and mythology of mind and body and fashioned it into a helping profession, thus offering many of the same services that are today provided by professional psychologists.
Witmer’s clinic was a decade old before other universities began to adopt his model of psychological services, but by 1914 there were psychology clinics at 19 universities in the United States. Leta Hollingworth was an early advocate for the psychological study of women and women’s issues. Clinical psychologists could also be found in the justice system.
Clinical psychologists had been around psychotherapy in a variety of settings such as state hospitals and child guidance clinics, and they had been using psychotherapy in university counseling centers since the 1920s. A few psychologists, trained as psychoanalysts, had even developed private practices as psychotherapists as early as the 1920s. But the door was largely opened by the military, which allowed psychologists to be put to the test as psychotherapists. Once opened, psychiatry found it impossible to close. [Those of us supportive of psychology’s evolution towards prescriptive privileges (RxP-) have to smile.]
The number of doctorates awarded by professional schools has grown substantially. By 1993, professional schools awarded the same number of doctorates in clinical psychology as those earned in traditional university settings, approximately 1,150 from each. By 1997, professional schools were graduating twice as many clinical psychologists as their traditional counterparts. [The previous year, Dorothy Cantor presided over our Toronto convention as the first professional school graduate to serve as APA President.] All of this information points to the immense growth of professional psychology, but especially of clinical psychology in the past 40 years. [“Clinical psychology” was used in the early-1900s to represent a broad range of activities best described as “applied” psychology.]
Developments that will have a considerable impact on the profession include prescription privileges. What is clear is that the prescription train for psychologists has already left the station and it does not appear that it can be stopped by forces inside or outside psychology. The acquisition of these privileges will be a reality in the near future in most states. How that will change the profession of psychology remains to be seen, but change it will.
The secret to the future of the profession of psychology is really no secret at all. It resides in the doctoral training programs that have produced psychologists for more than 100 years. The profession will continue to thrive as long as what is learned in those programs has applicability to the world’s behavioral problems. And of those, there is no shortage. [I strongly urge the readership to read this book. Collectively we must remember the lessons of the past, as we strive to face the challenges of the 21st Century. We are after all, one of the nation’s learned professions.]

Societal Focus: The Institute of Medicine (IOM) recently issued a report entitled: Reducing Underage Drinking: A Collective Responsibility which, I am very pleased to note, involved at least four psychologists as committee members – Joel Grube, Bonnie Halpern-Felsher, William Hansen, and Jan Jacobs. LaTonya Wesley was also listed as representing APA. Clearly, this is an area in which psychology and the behavioral sciences can make a significant contribution. It is where we can provide proactive leadership. Prevention is the key and it is an issue which is definitely important to society. In so many ways, this is exactly the type of endeavor which Ron called for in his Toronto address. Highlights:

By the time children are seniors in high school, about 30 percent are drinking heavily at least once a month. And 40 percent of full-time college students and more than 36 percent of other young adults (ages 18-22) report heavy drinking. The best available estimate places the annual social cost of underage drinking at $53 billion, far exceeding the costs of youthful use of illegal drugs. The patterns and consequences of youthful drinking are closely related to the overall extent and patterns of drinking in society, and they are affected by the same factors that affect the patterns of adult consumption. Substance abuse prevention is typically targeted on young people themselves – to persuade them to abstain and try to keep the dangerous substance out of their hands. At the center of the committee’s strategy, however, is the judgment that parents and adults must be the main target of a strategy to reduce and prevent underage drinking.

Alcohol use by young people is dangerous, not only because of the risks associated with acute impairment, but also because of the threat to their long-term development and well being. Traffic crashes are perhaps the most visual of these dangers, with alcohol being implicated in nearly one-third of youth traffic fatalities. Underage alcohol use is also associated with violence, suicide, educational failure, and other problem behaviors. The younger the drinker, the worse the problem. Moreover, frequent heavy drinking by young adolescents can lead to mild brain damage. More youth drink than smoke tobacco or use other illegal drugs. For many children, alcohol use begins early, during a critical developmental period. In 2002, 19.6 percent of eighth graders were current users of alcohol. Among each older age cohort of high school students, the prevalence, frequency, and intensity of drinking increases. Yet federal investments in preventing underage drinking pale in comparison with resources targeted at preventing illicit drug use, which can be 25 times higher. Although it is illegal to sell or give alcohol to youths under the age of 21, they do not have a hard time getting it, and they often get it from adults. More than 90 percent of twelfth graders report that alcohol is “very easy” or “fairly easy” to get. When underage youth drink, they drink more heavily and recklessly than adults. They report that they “usually” drink an average of four and a half drinks, an amount very close to the threshold of five drinks typically used to define “heavy drinking/binge drinking.”

A key role in any national response to this problem must be played by parents who set models of drinking behavior for their children and who can affect the conditions under which their children have access to alcohol products. And, of course, youths themselves make important decisions – not only about their own drinking, but also about how they view the drinking of their friends and peers. Nationally, there are signs that public attention to underage drinking is increasing and that the public recognizes the need to address the problem more aggressively than has thus far occurred. One recent survey reports that there is almost universal recognition of the problem, with 98 percent of adults polled indicating they were “concerned” about teen drinking and 66 percent expressing that they were “very concerned.”

In contrast to anti-tobacco and anti-drug efforts, the task of developing a strategy for preventing and reducing alcohol use among young people faces an uncertain public policy goal. A strong cultural, political, economic, and institutional base supports certain forms of drinking in the society. Within this policy context, the message to young people, as well as adults, about alcohol use is both subtle and confusing. The message to young people is “wait” or “abstain now,” rather than “abstain always,” as it is with tobacco and illegal drugs. It is a youth-only rule and its violation is often viewed as a rite of passage to adulthood.

The committee reached the fundamental conclusion that underage drinking cannot be successfully addressed by focusing upon youth alone. Youth drinks within the context of a society in which alcohol use is normative behavior and images about alcohol are pervasive. They usually obtain alcohol – either directly or indirectly – from adults. Efforts to reduce underage drinking, therefore, need to focus on adults and must engage the society at large. The preeminent goal of the IOM recommended strategy is to create and sustain a broad societal commitment to reduce underage drinking. Such a commitment will require participation by multiple individuals and organizations at the national, state, local, and community levels who are in a position to affect youth decisions – including parents and other adults. The nation must collectively pursue opportunities to reduce the availability of alcohol to underage drinkers, the occasions for underage drinking, and the demand for alcohol among young people. [Given the considerable ongoing controversy within the readership regarding the relevance and appropriateness of health policy experts increasingly insisting upon “evidence-based” practice, it is particularly interesting that the IOM report makes numerous references to utilizing only targeted “evidence-based” education interventions.]

Training: Dick Dubanoski, Dean of the College of Social Sciences at the University of Hawaii, has taken psychology’s involvement within the public policy arena one step further, by providing “hands on” experience for his faculty and graduate students. The Legislator-in-Residence Program was established in 2002, in order to foster dialogue, explore issues, and initiate collaboration between State of Hawaii legislators and members of the academic community. The program is a natural for the College (where psychology is located) because so many of the issues facing our community today are related to the social sciences. The residency is one semester in duration, affording both the legislator and the university community the opportunity to study issues from various perspectives and in greater depth. Prior to the Legislator-in-Residence Program, the relationship between the university and the legislature could be described as an “on-call” relationship – one contacted the other only when one needed the other. This program has helped to create a proactive partnership, one that will flourish well beyond the semester in residence. The ongoing dialogue will result in a more informed position for the legislator, which translates to better policy-making for the benefit of Hawaii’s citizens and a keener understanding of the legislative process by the university, and particularly, its students. The College intends to continue to fund the program. We believe that the university and legislators, in partnership, have tremendous contributions to make towards public policy issues that will enhance the quality of life in Hawaii.

Technology: In another far-reaching report, Patient Safety: Achieving A New Standard For Care, the Institute of Medicine (IOM) noted that in October, 2001 the Department of Health and Human Services established the Consolidated Health Informatics (CHI) initiative to articulate and execute a strategy for the adoption of health care interoperability standards for federally operated and funded health care. Since the federal government represents more than 40 percent of the nation’s health care expenditures, there should be little doubt that these standards will become a powerful vehicle for eventually implementing national standards, in a manner similar to the manner in which Medicare has, over the years, directly impacted all of inpatient care, including private sector reimbursement decisions. The federal government’s initial focus is upon the electronic exchange of clinical health information; i.e., the establishment of a national Health Information Infrastructure. IOM’s vision:

immediate access to complete patient information and decision-support tools for clinicians and patients and
capturing patient safety information to design even safer delivery systems (including data-based “quality” standards). Presently, on average, patients receive only about 55 percent of those services from which they would likely have benefitted while half of that which is provided is “unnecessary.” Patients (i.e., consumers) will continue to become increasingly involved in their self care and disease management, and will gradually insist upon the capacity to utilize a personal health record and engage in electronic communication with their health care provider.

The IOM strongly believes that patient safety is indistinguishable from the delivery of quality care and that the discovery of new knowledge redefines what constitutes “best practice” in a specific clinical area. A key challenge that is amenable to standards development is translating clinical practice guidelines into a format that can be shared across applications and organizations. The magnitude of proposed change is unprecedented. Presently, only a fraction of hospitals have implemented comprehensive electronic health record systems (EHR) and although more common in ambulatory settings, they exist in only 5-10 percent of physician offices, with much variability in their content and functionality. Nevertheless, change is definitely coming. England’s health care system is instituting a $17 billion technology program, wiring every hospital, clinic, and doctor’s office in order to place the health records of its 50 million users on a central database. The Department of Defense (recall Ludy and David’s book) recently announced the award of contracts to provide ongoing support for current and future Military Health System (MHS) information technology programs, totaling approximately $8 billion over a ten year period of time. The stated objective is to provide MHS, its components, and the Department of Veterans Affairs with the ability to issue individual task orders for services, equipment, materials, and facilities to design, test, and operate MHS technology systems and systems components. Today, most providers practice, at least in part, outside of large institutions. The potential expense involved for the independent practitioner can be considerable – some systems can run $50,000 or more. Accordingly, the American Academy of Family Physicians is presently negotiating computer availability for its members. And, Russ Newman reports that the Practice Directorate is evaluating electronic records products for potential offering on their portal.

The next step for APA may very well involve convening those of our colleagues who have become technology expects from their experiences in the public and private sectors to systematically explore how psychology will ultimately interface with the (r)evolution occurring within the communications and technology fields. Common clinical data standards are critical to establishing a national health information infrastructure. While progress is being made, significant issues remain which ultimately will require national leadership, notwithstanding an historical lack of federal coordination in the establishment of national standards. Professional psychology must be continue to be proactive and not passively wait for these critical decisions to made by others – our very future depends upon it. Aloha,

Pat DeLeon is a former APA President.

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