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WASHINGTON UPDATE
Onward to the Future: Professional Psychology Evolves In this column I would like to share some thoughts regarding the major features that stand out as professional psychology evolves into future roles. First of all, we need to redouble our efforts to shape the changing marketplace for professional practice. The changing marketplace for psychologists and psychological services is without doubt the single most important issue for professional psychology today. The industrialization of health care has turned psychotherapy into a commodity, which seriously shortchanges the consumers of mental health services and drastically reduces the numbers of psychologists-psychotherapists who can earn a living in practice. In response, organized psychology and individual psychologists have developed a broad range of initiatives to maintain and enhance the importance of mental health services in the nation’s health care system. These initiatives at times seem to be (in Stan Moldawsky’s memorable phrase) “turning the tide on managed care.” They include legislative and litigative actions undertaken to contain the abuses of managed care, such as the Patient’s Bill of Rights legislation and suits such as New Jersey Psychological Association’s no-cause termination lawsuit against MCC Behavioral Care, Inc. and the California Psychological Association’s lawsuit against Aetna U.S. Healthcare. The recent trend of attorneys with track records in tobacco litigation developing class action suits against managed care companies is a very encouraging sign. In addition, some psychologists have moved to create leverage for psychological services in the marketplace. Capitalizing on our inherent strategic advantages in being the best trained and most research-oriented mental health profession, some psychologists are creating data-driven integrated health care delivery systems that could compete very effectively with managed care companies. Second, there is a growing recognition of the importance of psychologists being involved in matters of public policy. Psychologists’ role in public policy is expanding. We now have psychologists who serve as state and federal legislators, as public administrators, and on public commissions at the local, state and national level. We need to keep public policy issues at the forefront of professional psychology, because I believe that professional psychology’s future hinges to a large extent on our ability to respond to important public health and societal needs. To quote from the APA Task Force on Envisioning, Identifying and Accessing New Professional Roles: Psychology must aggressively pursue its appropriate leadership position in the public arena as the foremost authority on human behavior. As a cultural force, psychology has much to contribute in the area of public policy but psychology’s voice has not been as influential as it might be. Psychology and psychologists must develop ways of communicating more effectively with society by moving the science presented in APA’s journals out into the public arena. Third, and no less important, is the evolving nature of professional practice. The scope of psychological practice is expanding and diversifying into new areas — areas where the distinction between applied scientist and professional practitioner begins to blur — such as health psychology (and its related aspects such as psychology in primary care, psychoneuroimmunolgy, and applied psychophysiology), neuropsychology, rehabilitation psychology, forensic psychology, feminist psychology, child and family psychology, multicultural psychology, geropsychology, business and industry consultation, and psychopharmacology. In addition, public sector care is very recently being seen anew, as an area rife with possibilities for an expanded scope of practice, such as in the correctional systems, and in the federal (VA), state, and community mental health centers, which serve those with long-term mental illness. Two of the most important issues for the future of professional psychology arise from the evolving nature of professional practice: the redefinition of psychology from specialty mental health care to primary health care and the expansion of the scope of practice of psychology to include psychopharmacology. As a specialty profession of mental health care, we deal primarily with the people who self-identify as having psychological problems and who have access to a mental health specialist, which is just a fraction of those who need psychological services. As a primary health care profession we would be able to serve the much larger group of people who do not have access to mental health care or who do not identify their problem as psychological. To grasp this potential, please consider a few facts about health care: (1) Seven out of the nine leading causes of death have significant behavioral components; (2) At least 50% (and maybe as much as 75%) of all visits to primary care medical personnel are for problems with a psychological origin (including those who present with frank mental health problems and those who somaticize) or psychological component (including those with unhealthy lifestyle habits such as smoking, those with chronic illnesses, and those with medical compliance issues); (3) The vast majority of people receiving mental health treatment are cared for by medical professionals with minimal specific training in mental health. The Cartesian worldview, which separates mental health from physical health, is breaking down, and as a result psychology has a tremendous opportunity to evolve into a premier primary health care profession. At the very least this would put psychologists on the front lines of health care, working collaboratively with physicians and nurses. The more visionary — if less probable — perspective is that health care should be reorganized so that psychologists serve as primary caregivers at the gateway to the health care system, functioning to diagnose and treat the more prevalent psychological problems, and referring to medical physicians when indicated. Psychology has been very slow to get on the bandwagon of primary care, and it is time for us to wake up and smell the coffee. Nurses and primary care providers of every stripe are there already: They view treating mental illness as part of their scope of practice. For example, I was in Tampa yesterday for a meeting of the Florida Psychological Association’s Legislative and Public Policy Board and next to our small room in the hotel was a huge room filled with hundreds of nurses, dentists, primary care doctors, acupuncturists and the like, who were taking a day-long workshop on psychotherapy of anxiety disorders. At the point that I decided to eavesdrop they were discussing exposure therapy. Needless to say the presentation was at a technician’s level and I was horrified to think that these folks will go out and begin applying these techniques with their patients. With regard to expanding the scope of practice to include psychopharmacology, the prescription privilege agenda has the capacity to dramatically accelerate the evolution of professional psychology, and to move us closer to fulfilling our potential of being a premier primary health care profession. The Department of Defense Psychopharmacology Demonstration Project graduates who are now prescribing have recently demonstrated through the USGAO report of 1999 that not only will properly trained prescribing psychologists NOT be a public health hazard as psychiatry has ignominiously claimed, but also that such psychologists will do an outstanding job at psychodiagnosis and at expertly combining psychological and pharmacological treatments. Division 42’s First Annual Practice Development Conference, which this year focuses on collaborative practice between psychology and dentistry, is a very positive step in the right direction. We need to continue to identify new opportunities for practice and provide guidance on how psychologists can access these opportunities. In my view the basic question that needs to be addressed is: How do new or established psychologists access new professional roles in anything approaching the numbers with which psychology moved into the role of outpatient psychotherapist in the 1970’s and 1980’s? Addressing this critical challenge includes the need to make new practice patterns more accessible to general practitioners, as well as the need to identify viable new marketplace opportunities and to assist psychologists in accessing opportunities that suit their expertise and interests. For example, how does a psychologist with appropriate education and training set up a practice in health psychology? How do they get referrals? How many are doing this? So too, in the care of those diagnosed with long-term mental illness in the public sector, new pathways to practice are clearly needed which might include the development of postdoctoral retraining programs in psychological rehabilitation and level II psychopharmacology, legislative and regulatory advocacy to change state Medicaid laws and regulations that limit or exclude psychologists from the care of the seriously mentally ill, and entrepreneurship to develop psychological delivery systems in those states that have privatized mental health care. Similar questions could be posed with reference to other new areas of practice. In regard to training, I think the education and training community needs to be challenged to respond not only to present-day marketplace concerns resulting from the industrialization of health care (which some are doing — e.g., Widener University’s joint Psy.D./M.B.A. program), but even more importantly to future concerns such as the evolution from specialist to primary care and psychopharmacology. We have not even begun to grapple with the training issues involved in the evolution to primary care, which, if taken seriously, might involve the revamping of the curriculum such that the generalist predoctoral training would be in health psychology, and mental health (perhaps in some specialized form such as the psychology of long-term mental illness) would be one of the postdoctoral specialties available. Last but certainly not least, we need to enhance science-practice collaboration. For one thing, the APA Science-Practice Task Force wrote of the need for practitioners to identify clinically-immediate problems for scientists to investigate. Secondly, with the increased emphasis in NIMH on “effectiveness” research, which studies psychological interventions as they are actually implemented, opportunities for practitioners and scientists to create practice-research networks are greater than they have been in a long time. As always, I welcome your thoughts on this column.
Ronald F. Levant, Ed.D., A.B.P.P., is Recording Secretary of the American Psychological Association. He was the Chair of the APA Committee for the Advancement of Professional Practice (CAPP) from 1993-95, a member of the Board of Directors of Division 42 (1991-94), and a member of the APA Board of Directors (1995-97). He is Dean, Center for Psychological Studies, Nova Southeastern University, Fort Lauderdale, FL, E-mail: Rlevant@aol.com |
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| Ronald F. Levant, Ed.D. | |||||
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