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The 21st Century – Unlimited Opportunities

Advocacy

Pat DeLeon, Ph.D., J.D.

If the truth be known, I genuinely enjoy the opportunity to occasionally share with the readership what I readily admit is fundamentally a public policy perspective. And, I very much appreciate Steve Ragusea’s constant urging to: “Keep the message short and focused”. Yet, there are so many exciting developments occurring within our nation’s health care and educational arenas that are directly relevant to our field. It is extremely hard to choose. We should never forget that psychology is one of the “learned professions”. As such, our behavioral science expertise is highly relevant to solving many of society’s most pressing problems. Equally importantly, collectively we have a very real societal obligation to provide proactive leadership. This is the mark of a maturing profession and for many of us, it is also the essence of the prescriptive authority (RxP-) agenda. Above all else, we share a sincere belief in the importance of quality education and being responsive to changes evolving within our areas of expertise – notwithstanding the fact that in so doing, we might be pursuing paths where those who came before us, no matter how competent and how well intended, never tread. As our parents learned after World War II, with quality education one is only limited by one’s vision.

The RxP- Agenda Marches On:

I am confident that former APA President (soon to be Division President) Ron Fox is serenely smiling at the recent Washington Post front page story: “For Psychiatrists, a Bitter Pill in New Mexico – Law Giving Psychologists Right to Prescribe Medications Spurs a Battle With MDs.” In the early days of the RxP- movement, long before it was politically popular within psychology, Ron traveled across the country discussing this issue with the grass roots membership. As Recording Secretary of APA, during his Presidency, and as Chair of CAPP, he steadily mentored the next generation about the importance of controlling their own destiny and having the wisdom to trust their clinical expertise. I have no doubt that but for Ron’s extraordinary leadership, we would never have come so far, so fast. And, society would not be as well served. The Post article is most interesting:

“In his annual report to the nation’s psychiatrists in May, the medical director of the American Psychiatric Association rallied America’s psychiatrists ‘to stop this plague from spreading across the nation.’ (He) was not referring to bacteria, a virus or a brain disease like Alzheimer’s. The ‘plague’ was a victory by psychologists in New Mexico, who recently won the power to write prescriptions for such psychiatric drugs as Prozac – an authority generally limited to psychiatrists and other MD’s. A new law, which takes effect today, makes New Mexico the first state to give prescription-writing authority to psychologists – talk-therapy experts who are not MDs. Observers say New Mexico’s precedent could be the beginning of a fundamental change in how mental illness is treated across the nation, vastly increasing the number of patients receiving psychiatric medications. Studies show that many people with mental illness do not receive treatment, even as many others are given psychiatric pills they do not need.... This trend has been propelled by a new understanding of the biological basis of mental illnesses, a shift in research and insurance priorities towards drug treatment, and immense marketing efforts by the pharmaceutical industry. Research has shown that many patients with mental illnesses do best when given a combination of medicines and talk therapy. For psychiatrists and psychologists, the New Mexico law and the precedent it has set across the nation have meant a brutal and expensive battle....

“Psychologists who fought for the New Mexico law accuse psychiatrists of trying to protect a fiefdom. ‘A large part of it is a question of turf,’ said psychologist Elaine LeVine, who advocated passage of the New Mexico law. ‘It is the kind of power that comes with having a unique possession of a certain turf.’ The psychiatrists retort that the New Mexico law was a ‘cynical, economically motivated effort’ on the part of psychologists to obtain insurance reimbursements for treating patients with medicines. It is not at all clear how much business psychologists will take away from psychiatrists. Indeed, the vast majority of prescriptions for psychiatric medications are already being written by non-psychiatrists – primary-care physicians and other MDs prescribe most of these pills....

“The American Psychological Association has made the issue a major priority. Russ Newman, the association’s executive director for professional practice, said that organized psychiatry had long opposed the growth of psychology, having raised fears about psychologists’ ability to provide safe inpatient and outpatient psychotherapy in earlier times. ‘They are opposed to another profession that would be in competition with them and expose consumers to greater choice.’... (DoD psychopharmacology graduate John) Sexton estimates he has treated some 2,000 patients with various mental illnesses, from mild depression to bipolar illness and psychosis. He said that the training has helped him be a better care provider, even though he uses medicines sparingly. In an informal study, where he compared his own treatment against that provided by two psychiatrists, he found that the doctors trained in medical school prescribed medications to 61 percent and 68 percent of their patients. He prescribed medications to only 13 percent of his patients.... ‘A psychologist who prescribes will more likely do psychotherapy and then use medications sparingly and as an adjunct to talk therapy.... This is a good idea. Many of us feel that too many people put things in their bodies to escape pain in life, emotional or physical.’... At a session on the issue at the recent convention of the American Psychiatric Association, a surprisingly wide range of views emerged....”

Our New Mexico colleagues continue to have a sustained impact. Mario Marquez was recently on a local New Mexico radio show, affirmatively reaching out to the public. Elaine: “The Inside Scoop on the NPR Interview – I received a call from NPR Monday morning after the New Mexico RxP- law was reported on the front page of The Washington Post. The initial call was from an assistant to Robert Siegel of ‘All Things Considered’, asking for information. The assistant explained that they would be reviewing a number of bills that went into law on July 1st, 2002, and they wanted to have a little information about our Bill. Apparently, that initial interview was sufficiently compelling that the aide then asked me if I could be available for a direct interview with Mr. Siegel. A 15-minute interview was taped several hours later. It was apparent from the questions he asked me that these had been formulated partly by my conversation with his aide, and also from other sources. Interestingly, he asked a number of relatively provocative and confrontational questions. For example, he asked if the New Mexico law would mean, that in the future, if there were a lack of orthopedic doctors in a state, the state would allow chiropractors to complete that work. I think that it is very interesting that despite the more provocative nature of some of the questions, Mr. Siegel and the rest of the NPR staff chose very positive aspects of the interview to air on ‘All Things Considered.’ I would like to believe that we ‘won them over’ with the truth of our argument. Hopefully, we will be seeing more and more reporting that speaks to the sincerity and value of our efforts.”

Long time professional psychology advocate and mentor, Tommy Stigall, that very evening reported: “Driving home from the drug store a few minutes ago, I happened to tune in to National Public Radio just in time to catch an interview with Elaine LeVine, chairperson of the New Mexico prescription privileges committee. She was a most articulate and effective spokesperson for the RxP- movement and the profession of psychology. I found the interviewer to be well-informed about the issues and respectful and friendly toward his guest.... It felt good to hear our profession presented in such a positive light to a national audience. Congratulations once again to Dr. LeVine, her New Mexico colleagues, and all who had a part in this achievement.” Sir Ron da-Gray – Congratulations, Sir.

Psychology On The Front Line – Strengthening Resilience In Our Communities:

Over the years, perhaps the most exciting events hosted by APA have been the Practice Directorate’s State Leadership Conferences. The 19th held this year was no exception with over 530 colleagues in attendance from across the nation. Our sincerest congratulations to Chair Bill Safarjan and, of course, Mike Sullivan. Organized psychology’s response to September 11th was clearly on everyone’s mind. Russ’s inspirational keynote provided a clear vision for the future and touched a number of us very deeply as we paused to reflect upon why we had chosen psychology as our profession. Given what our nation had just undergone, it was important for all present, when the lights were low, to silently appreciate the relevance of what APA had accomplished over the years and the critical importance of our having developed a credible public presence. Mahalo.

[Russ Newman] “I, too, would like to welcome you on behalf of the APA Practice Organization to this year’s State Leadership Conference.... Without question, we and the entire nation have faced unprecedented challenges over the past year. While not the only challenge we faced, but by far the biggest, the terrorist attacks of September 11th have had a profound effect on us all – as individuals, as a profession, as a community and as a nation. We have all been touched in some way by these events, some more than others. Some of us have lost colleagues, friends and love ones; all of us have lost an innocence. I do not believe it is a melodramatic exaggeration to say that life in this country will never really be the same again. One look at the armed military vehicle with gun sights aimed, 24 hours a day, at the entrance to the highway that runs next to the Pentagon will tell you that.

“Far from simply being victims of the attacks, however, Psychology rapidly mobilized to become a valuable part of the response. I am proud to say that our profession has been able to make a significant contribution – and continues to do so – in the aftermath of the terrorist attacks. The extent of our profession’s contribution was not just the result of being trained to respond to psychological trauma, but also because we have been working together for years now, to build an infrastructure that enables us to reach beyond our offices, beyond the therapy and consulting rooms, and to deliver psychological services out in the communities where it was desperately needed....

“In the professional psychology advocacy arena, perhaps there is no better example of an advancing front line than the efforts underway to secure prescriptive authority for psychologists. Last year during this Conference, I announced to you that the New Mexico Psychological Association had just been the first state to have a prescription privileges bill successfully voted out of a full legislative chamber when it passed the New Mexico House. But as we know, the Senate did not take the bill up before its session ended. This year, I have the great pleasure of announcing what many of you already know, that... (t)he law currently awaits the Governor’s signature – the very person responsible for the bill even being heard during this special session of the New Mexico legislature. Let’s hear a round of applause for the great work of the New Mexico Psychological Association. Special commendation goes to Elaine LeVine... and Mario Marquez for their energy, their leadership, their persistence and, of course, their resilience in this emotional roller coaster-like effort.

“On a side note, if you have any doubt about the current state of mind of organized psychiatry as a result of this development, you need only look at the depths to which they have sunk in their effort to derail the legislation. ‘You wouldn’t do it to a dog, so why would you do it to your child?’ asks the little ApA in an ad in the Sante Fe newspaper. ‘Those who care about animals insist that the people who treat them be trained in animal medicine’ the ad continues, ‘(so) why would you trust someone not trained in human medicine to prescribe medicine for you and your family?’...

“But to return to the forest and away from the trees for a moment, some see HIPAA [the Health Insurance Portability and Accountability Act of 1996] as the critical start down a road of healthcare reform which seeks to replace a fragmented state-by-state approach to regulating health care with a federally-driven, more integrated approach to regulation. Federal mental health parity and the patient’s bill of rights are also credited with signaling that the realities of the currently ill-conceived U.S. health insurance marketplace are finally coming into focus. One medical economist... paints the picture well....
“Once an ardent supporter of a pure free market fix to the ills of the nation’s healthcare system, (he) now sees the necessity of certain broad regulatory solutions for those things we can no longer expect the marketplace to fix. Not only do I think his new direction makes eminently good sense because it’s essentially the same direction I’ve been advocating since 1995, I also think it makes good sense because it takes into consideration the real complexity of our healthcare system, the complexity of its dysfunction and the realization that there is no singular simple solution to its problems.... (F)or healthcare to be characterized by choice, continuity, affordability and quality, massive simplification of the system must be brought about....

“(M)any believe – and I am among them that with the right combination of regulatory reform and information technology, the future of healthcare includes a truly informed consumer with real power to make choices and no meddling managed care administrative middle men. Speaking of information technology, the Practice Organization has continued the development of an enhanced information technology infrastructure that we believe will enable us to provide more effective and more efficient services to the practitioner community, as well as to all of your associations. In particular, we are building an Internet-based practitioner portal where practitioners will be able to come for information relatively customized for their area of practice and their interests. They will be able to connect with other psychologists and communities of similar interest and will be able to find a wide range of practice management tools and practice enhancement materials as well. Should there be any doubt of the necessity of enhanced information technology for us to continue to be effective in the 21st Century, one need to only look at the post-anthrax Congress where the use of e-mail and on-line posts has dramatically accelerated in the wake of anthrax laced snail mail....

“Whether it’s coping with the loss of a family member, maintaining a positive outlook in the face of a life-threatening illness, dealing with a job loss or having the wherewithal to carry their family through tough times, many people have a difficult time explaining what gives them their inner strength. In psychology, this inner strength is called ‘resilience’, and it’s a characteristic that can indeed be learned. Getting this message out to the public is the necessary next step in developing psychologists’ role as guides for the psychological journey to find meaning in tragedies past, and to develop resilience against challenges yet to come. In this vein, I am pleased to announce today that we have recently agreed in principle with cable television’s Discovery Health to join forces in the production of a documentary on resilience and self-discovery. This documentary is scheduled to be first aired on September 11th, 2002, the one year anniversary of the terrorist attacks.... We believe this effort to educate the public about resilience is consistent with APA President Phil Zimbardo’s planned initiative to help the public see how psychology makes a significant difference in their lives. It also dovetails quite nicely with Board Member Ron Levant’s newly formed Task Force on Promoting Resilience in Response to Terrorism which intends to put state of the art material on developing resilience into the hands of practitioners.... The time has come for our profession to move to the next level as a result of what has been experienced and learned since the terrorist attacks. Perhaps never before have people been so open to the very psychological processes about which we are expert. Perhaps never before have people been so interested in taking the psychological journey for which we are uniquely trained to act as guides. And perhaps never before has the help we have to offer seemed so mainstream and so much a part of the new ‘normal.’... (W)e, now more than ever before, have both an opportunity and a responsibility to make a contribution to the most significant issues of our time. But in order to do so, we must restrain our own individual self-interest and put aside our professional differences so that we do not inadvertently shirk our responsibility or squander this opportunity. We must come together as a psychology community like never before if we are to effectively help strengthen resilience in other communities. I am confident that we can do this. I am confident that our profession will rise to this occasion. Many are counting on us.”

The Supreme Court Of The United States – ATKINS v. VIRGINIA: Held by a vote of 6- 3 that: “Executions of mentally retarded criminals are ‘cruel and unusual punishments’ prohibited by the Eighth Amendment.... Those mentally retarded persons who meet the law’s requirements for criminal responsibility should be tried and punished when they commit crimes. Because of their disabilities in areas of reasoning, judgment, and control of their impulses, however, they do not act with the level of moral culpability that characterizes the most serious adult criminal conduct. Moreover, their impairments can jeopardize the reliability and fairness of capital proceedings against mentally retarded defendants. Presumably for these reasons, in the 13 years since we decided Penry v. Lynaugh, the American public, legislators, scholars, and judges have deliberated over the question whether the death penalty should ever be imposed on a mentally retarded criminal. The consensus reflected in those deliberations informs our answer to the question presented by this case: whether such executions are ‘cruel and unusual punishments’ prohibited by the Eighth Amendment to the Federal Constitution....

“In the penalty phase, the defense relied on one witness, Dr. Evan Nelson, a forensic psychologist who had evaluated Atkins before trial and concluded that he was ‘mildly mentally retarded.’ His conclusion was based on interviews with people who knew Atkins, a review of school and court records, and the administration of a standard intelligence test which indicated that Atkins had a full scale IQ of 59....

“A claim that punishment is excessive is judged not by the standards that prevailed in 1685 when Lord Jeffreys presided over the ‘Bloody Assizes’ or when the Bill of Rights was adopted, but rather by those that currently prevail.... ‘The basic concept underlying the Eighth Amendment is nothing less than the dignity of man.... The Amendment must draw its meaning from the evolving standards of decency that mark the progress of a maturing society.’... In 1988, when Congress enacted legislation reinstating the federal death penalty, it expressly provided that a ‘sentence of death shall not be carried out upon a person who is mentally retarded.’... Much has changed since then.... It is not so much the number of these States that is significant, but the consistency of the direction of change. Given the well-known fact that anticrime legislation is far more popular than legislation providing protections for persons guilty of violent crime, the large number of States prohibiting the execution of mentally retarded persons (and the complete absence of States passing legislation reinstating the power to conduct such executions) provides powerful evidence that today our society views mentally retarded offenders as categorically less culpable than the average criminal.... The practice, therefore, has become truly unusual, and it is fair to say that a national consensus has developed against it. [See Brief for American Psychological Association et al. as Amici Curiae].

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