APA Past President

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Pat DeLeon, APA Past-President

"Russ began the call by saying he would focus on two areas of Practice Directorate activity that highlight the need for us to be creative and resourceful in coming up with additional resources in order to carry on major parts of APA's practice agenda with the maximum effectiveness. These areas (include).... 2. the push for state laws granting prescriptive authority to appropriately trained psychologists. Russ stated that he was describing major initiatives already underway and currently being funded with a combination of: 1. Special assessment resources, 2. Additional voluntary contributions by members, and 3. State psychological association resources. However, he wanted to convey the EXTREMELY limited nature of all current financial commitments and resources. Russ described the anticipated future needs which he suggested required 'potentially more resources than are available to the entire discipline of psychology, never mind just the APA'....

"In the second area that illustrates the need for the profession to secure additional resources, Russ gave a progress report on prescriptive authority. As with (the first agenda), the prescriptive authority agenda is resource intensive. APA has tried to balance focusing resources on states with the greatest likelihood of passing legislation on the one hand and supporting burgeoning legislative agendas on the other. The following states have indicated that they will be introducing RxP legislation in 2001: Georgia, Louisiana, Florida, Texas, New Mexico, Connecticut, and Missouri. Illinois plans to introduce a prescriptive authority bill this Fall. Alaska, Montana, and Hawaii may introduce legislation, but have not firmly committed to doing so. Georgia, Louisiana, Florida, Texas, and New Mexico have communicated that they are variously working with their state association lobbyists, educating legislators and state officials, building relationships, raising money, and building grassroots networks.

"As of June, California is the only state with a currently active bill. The California bill was originally introduced to the Senate as a bill which would allow PDP (DoD) graduates, and graduates of comparable training programs to prescribe. Before being passed out of the Senate Business and Professions Committee, the 'comparable training program' language was removed. The bill must still pass through the Senate Appropriations Committee and the floor of the Senate before going to the Assembly.

"Over the past several years, CAPP has been providing significant funding to nine of these states. Two of the states that CAPP has given resources to are Georgia and Louisiana, which have consistently moved their legislation closer to passage each year. There are a couple of other states with less legislative history, that look like they could mount very credible campaigns in their legislatures. There was discussion by Board members and the invited Council Representatives following each of the topical briefings...." A report provided to the Board of Directors last December indicated that as of that date, APA had invested approximately $640,000 in the RxP agenda, not including the all important professional staff time.

The Larger Context Of Health Care - Over the years, we have noted that our colleagues oftentimes do not appreciate the extent to which professional psychology no longer represents an island unto itself (if it ever did), but instead has become an integral component of our nation's overall health care delivery system. We have no doubt that psychological practice will thrive in the 21st Century, not because we may want it to but because our behavioral and psychological expertise will bring "added value" to what educated consumers (e.g., patients) demand. DoD graduate and President-Elect of the Maryland Psychological Association, Morgan Sammons, reflects upon the potential impact for the prescribing psychologist of a recent U.S. Supreme Court decision: "A report prepared for the Kaiser Commission on Medicaid and the Uninsured and posted on the website of the Henry J. Kaiser Family Foundation (Rosenbaum, S., The Olmstead Decision: Implications for Medicaid) [www.kff.org] analyzed the potential implications of the June, 1999 Supreme Court decision (Olmstead v. LC) requiring community based service provision to persons with disabilities. Briefly, the unanimous ruling, known as the Olmstead decision, held that it is a form of discrimination to treat persons with disabilities in institutional settings when they could benefit from non-institutional treatments. The Court ruled that it was incumbent upon the states to provide proper community based treatment alternatives. The case involved two mentally disabled women who continued to be treated in institutional settings even after service providers had determined that their needs could be met in a less restrictive environment of care. One pertinent fact was that on one occasion, an attempt was made to discharge one of the plaintiffs to a homeless shelter, on the grounds that this represented 'community based care'. Another pertinent fact was that the state in question had an extremely long waiting list for community placement and had not utilized all available federal resources.

"The Court held that it was the duty of the state to provide necessary health care services in a non-institutional setting where the condition of the patient allowed treatment in a less restrictive environment of care. Although Rosenbaum in her analysis noted that the Court's decision was complex and that the process of implementation will be complicated and slow, there are several potentially significant implications for psychologists seeking prescriptive authority.

"Primary among these remains the access to mental health care in publicly funded community mental health services, where access and services have long been limited by budgetary constraints and inequitable patient:staff ratios. Waiting lists are long and the scope of services limited. Brief medication checks remain the order of the day in many such clinics.

"Could prescribing psychologists have a positive effect on this situation? Almost undoubtedly so. The addition of highly skilled psychopharmacologic service providers would not only speed entry into the system, but prescribing psychologists could also offer a range of behavioral and psychotherapeutic interventions that public health patients are not currently likely to receive. Prescribing psychologists would be a cost-effective alternative to traditional psychiatric services, inasmuch as psychiatrists in many states have been in chronically short supply in the public health system. In California, psychologists have proposed that psychologists certified to prescribe give back to the community in the form of periods of service in publicly funded clinics or underserved areas.

"Prescribing psychologists are, then, an alternative to be seriously considered by states mandated to implement the provisions of the Olmstead decision. By expanding the availability and scope of services to patients in the Medicaid and other publicly funded systems, prescribing psychologists will have an appreciable and highly positive influence not only on access to care, but the quality of care provided to sectors of the population that have to date been poorly served by traditional mental health service systems."

Devolution By Any Other Name - For those who are avid readers of the journal Professional Psychology, it should be clear from the thematic packages that Mike Sullivan and Randy Phelps have developed over the past several years, that the real action on health care reform, licensure mobility, and scope of professional practice activities has steadily evolved to the state and local level. While serving on the Board of Directors, Past APA President and current Chair of CAPP, Ron Fox, conceptualized a plan whereby Board contingency funds would be used to provide the Practice Directorate with flexibility to visit those states, on an informal basis, where fledgling interest had been expressed in the prescription agenda. Those of us on the Board often describe this strategy as one of Ron's most productive ideas. Since then, our Recording Secretary, Ron Levant, has effectively implemented Ron's vision. His report to the Board this February, in support of successfully requesting an additional $20,000 of Council contingency support:

"In June of 1996, the Board allocated $30,000 for 'strike force' visits by Practice Directorate staff to states needing assistance in moving their prescription privileges agendas forward. Six states received these initial site visits: Georgia, Illinois, Iowa, Louisiana, Nebraska, and Oklahoma. The response to these visits was universally positive, and these visits were considered to be an effective tool in supporting state efforts towards prescriptive authority for psychologists.

"During the August 1999 Board meeting, the Board allocated $4,100 of its 1999 contingency funds and recommended that the Council of Representatives allocate $16,000 of its contingency funds to support consultative site visits to stimulate the development of RxP activities in the states. The Practice Directorate, in consultation with CAPP and the Presidential Task Force on RxP, articulated criteria for determining which states should receive a consultative site visit. The criteria places an emphasis on states where the State Psychological Association leadership has shown great interest in RxP, but the membership could benefit from presentations designed to educate, generate enthusiasm, or channel member's energy into the most productive directions. The goal was to provide those states where momentum already exists, with extra help in moving towards introducing or advancing legislation.

"Although the funds were only available for the Fall of 1999, the Practice Directorate was able to implement seven (plus an additional two) consultative site visits - Montana, New Hampshire, Florida, Texas, Oklahoma, Tennessee, Maryland, New Mexico, and Connecticut. The leadership in each of the state associations visited have expressed unanimous appreciation for these site visits. The interest in more visits of this nature is high, as is the estimated potential benefit. DoD graduates have participated in several of the visits. The unique opportunity for open dialogue that this affords has been extremely beneficial in terms of altering opinions on the issue and perceptions of how psychopharmacology can be best integrated into psychological practice. A portion of the money was also used to commission a survey showing a county by county distribution of psychologists and psychiatrists in the United States. The information provided by this survey will be used to assist states in crafting their legislative strategy, and to bolster claims that prescriptive authority for psychologists is an issue of patient access to quality health care.... In addition, the states have expressed their desire for these visits to continue and the belief that they are critical to their prescription privileges agendas."

Subsequent observations - "Well, I think we got another impasse unstuck..... RxP people don't hold the real power in the association. No matter what they do to placate the powers behind the throne, it's never good enough.... The mediation hopefully got agreement on common ground to move forward. A small group of both sides will hash out details in a follow-up meeting later on.... Hopefully next time they'll be all a 'we', not 'us vs. them'." Within six months, members of that RxP task force - with the full backing of the Association President and President-Elect - met with the Speaker of the House and President Pro Tem of the Senate. "It went well and we're positioning ourselves to begin the process. We have a shot, but on the other hand, we may get blasted. We'll see."

Another State - "....I thought I should post a message to let you all know I have not died nor changed my profession to restauranteur. In Wyoming, the latest news is that the University of Wyoming School of Pharmacy has agreed to provide the training and has assigned preliminary instructors. The price will be very reasonable and the courses will probably begin next Fall (2000). It will involve self-study types of materials, followed up with didactic instruction from a session leader. It will be a series of certificates leading to an overall content mastery certificate. We are starting to get excited. During our conference, I think that having both Tim Duke (DoD graduate) do a brilliant presentation, followed-up by Pat had a one-two combination effect. I have spoken to several psychologists and some interns who were previously 'against' prescriptive privileges who are now 'for' the effort! We also discussed at our business meeting a fund-raising program to raise monies, some of which I hope to tap for use with the effort. Reading recent PEPTO discussions, I have asked our legislative committee to consider a bill effort in 2000 to help light more fires. We will devise a strategic plan for fund-raising and for educating legislators in the next year.... Keep on keeping on!" (Anton Tolman, WyPA President). For those interested in some of the specifics of the devolution process, check out the webpages Matt Nessetti recently brought to our attention. The description of the various state licencing boards' policy statements regarding discussions of medications with patients [www.mentalhealth madison.com/Documents/psychopharm_regs.htm], not to mention Matt's most innovative training module with DoD graduate Jim Meredith [www.nmhc-clinics.com/] are most impressive.

The Growing Impact Of Technology - Along with the educated consumer and policy decision-making evolving to the local level, the impact of technology upon our daily lives and profession practices will be the hallmarks of the 21st Century. At this Spring's Practice Directorate State Leadership conference, Marlene O'Neil, Executive Director of the Michigan Psychological Association, shared with me their exciting plans for alerting their membership to the tremendous advances occurring within the telehealth arena. Marlene Maheu was to be their invited speaker. Marlene's subsequent report - "The Michigan Psychological Association sponsored a morning workshop on 'Technology and the Delivery of Psychological Services: An Overview of Practical, Clinical, Legal, and Ethical Issues' in Detroit this March. The focus of my presentation was on how to develop a professional presence, products and services on the Internet, which keeping within ethical and legal requirements as a psychologist. Participation in professional listservs, developing websites, norming assessment tools, and interacting with patients was discussed in detail. The audience was enthusiastic about developing new practice development strategies using telecommunication technologies.

"On the above, I think we have a range of opportunities as psychologists, but the best vehicle for service delivery is through a company with enough staff to attend to all the legal, ethical, technical and clinical issues that must be addressed. It is very complex, and beyond the scope of training of any one psychologist at this point. Training is developing, however. I am developing a training program at the California School of Professional Psychology (CSPP) - post graduate, 46 hours course, starting this Fall.

"More specifically, the existing technology can support psycho-education but not psychotherapy. When we reach 15 frames per second of video conferencing abilities; have normed enough psychological tests online to differentiate between who can benefit from online treatment via video and who can not; after we have dealt with the multi-cultural and multi-lingual problems that are inherent to working with a worldwide audience; and we have completed enough research regarding all of these issues to make sure we are operating within a reasonable error rate, then we can go ahead and deliver psychotherapy as we know it via the net. Not before.... Until then, psychoeducation is the reasonable alternative....and there are many ways of delivering psychoeducation. If people want psychotherapy, counseling, or crisis intervention they can pick up the telephone and get it that way without all the limitations of dealing with e-mail....

"The afternoon session I offered the Michigan Psychological Association focused upon 'Clinical Perspectives on Etiology and Treatment of Cyber-infidelity'. The impact of increased anonymity and decreased privacy upon marital relationships was explored from various technical and clinical viewpoints. The results of an online survey with 2,500 responses to a questionnaire [published in selfhelpmagazine.com] were discussed. Definitions and ramifications of online romance upon marital partners and their children were explored in depth. An intervention model was presented for use both online and offline with patients who seek treatment for cyber-infidelity.

"The net is creating many ways for us to both enhance and encumber our lives. It allows us to do whatever we will do - only more easily and more rapidly. As psychotherapists, we must be informed and prepared to help people disentangle themselves from the problems they create with the Net. Most importantly, we must anticipate the problems that will be caused for our children by the Net. Sexuality and infidelity are closely aligned online - and so, we must be aware of what is happening in these arenas and help people enjoy the freedom to experiment safely, but also know how to help them when they get lost. When they get into trouble, we must be compassionate and wise enough to help them restore themselves to proper balance. For more information regarding the responses to the questionnaire, contact me at [drm@cybertowers.com].

A slightly different perspective from Ray Folen - "At Tripler Army Medical Center, in the Behavioral Medicine Service, we have biofeedback, weight management follow-up, neuropsychology, tobacco cessation and family therapy telehealth projects that are either up and running or in development. Basically, we are utilizing low bandwidth technology (<56K) to provide remote services. Using a single standard phone line, for example, we are able to establish a video conference connection that is of sufficient quality to meet our clinical needs. Using another phone line, we can run remote biofeedback equipment or monitor a remote neuropsych testing session. Rather than work with the ISDN, T1 and other high-end, high-expense, high-maintenance equipment, the materials we work with are typically low-cost and have minimal infrastructure requirements. Given that Tripler services parts of the world with very limited resources (50 percent of the earth's surface is our catchment area) keeping it low infrastructure is important. Even in the U.S., by the year 2003, 85 percent of the population will still have a telephone line as their primary means of communication. We believe that there is a lot of telehealth that can be done at 56K. Aloha,"

A Look To The Future - RxP Ahead: I must admit that I smile at the realization that it is only our colleagues in psychology who wonder Whether we will obtain prescriptive authority. For all others within the educational and health care arenas, the underlying question is not whether but When. Professional nursing, optometry, podiatry, and dentistry possess prescriptive authority in all states; nursing essentially autonomously in over a quarter of the states. The con- arguments are always the same. The opponents emotionally proclaim a "public health hazzard" and decry any profession that might suggest their training programs are comparable to (or perhaps superior to) medical school. And yet, from reviewing medicine' own literature it is clear that their lobbyists appreciate they are fighting an eventually losing battle.

[ApA Psychiatric News] - "Lobbyists Recount War Stories From Psychologist-Prescribing Fight. Psychiatrists in three Southern states have been able to fend off proposals to five psychologists prescribing bills. The lobbyists who helped deflect prescribing bills describe the legislative battles and their preparations for the next round. Psychiatrists and other Tennessee physicians let out an audible sigh late last year when a bill to grant psychologists the right to prescribe psychoactive drugs failed to make it out of committee in the state legislature. Unfortunately, the return of the prescribing proposal is 'inevitable and imminent' according to xxx, the Nashville lobbyist the Tennessee Psychiatric Association (TPA) hired to help it combat the bill. Speaking to about 200 psychiatrists at ApA's Joint Institute on State Legislative and Public Affairs in February.... 'We didn't see the bill coming and were unprepared.' She added, however, that state lawmakers supporting the psychologists' proposal were also unprepared 'for the firestorm that followed' the bill's introduction once opponents mobilized their forces. She said that the TPA is resigned to the fact that it will have to gear up for the same fight in the next legislative session, a task that remains especially daunting since psychologists can count several top leaders of the legislature among supporters of the prescription expansion. Another disadvantage opponents face is that legislators prefer 'to avoid confrontations' and may choose to do so here in light of support for the bill from their leaders. Last year, in the proposal's third appearance at the state house, the TPA and the bill's other opponents were unable to dissuade the chair of the State Senate's Health Committee, a backer of granting psychologists prescribing privileges, from appointing a 'study committee' on the issue, which highlighted its visibility and prominence on the legislative agenda.... Also troubling for the proposal's future is that the latest version of the bill was 'more credible' than earlier efforts as its advocates became more politically sophisticated....

"Georgia Success.... Xxx was one of the most active players in ensuring that psychologists in Georgia were not granted the right to prescribe psychoactive drugs. The lobbyist for the Georgia Psychiatric Physicians Association (GPPA) was still savoring the outcome of a prescribing bill that just the week before her address to the Joint Institute was withdrawn.... She too expected that the proposal was sure to surface in another legislative session, but noted that opposing it may be a more formidable task next time in light of two developments -- a prescribing-privilege bill about to be introduced on behalf of the state's advanced practice nurses and ill will between the state medical society and legislators stemming from a recent battle over optometrist prescribing.... To prepare for the next time a prescribing bill is introduced, the GPPA has implemented a sophisticated and expensive direct-mail campaign to the public centered around issues of whom they most want to be in charge of prescribing complex medications for them - physicians or health professionals who never went to medical school....

"Pessimism in Louisiana. Xxx of Louisiana made little effort to conceal his pessimism about the fate of psychologist prescribing in his state. The argument that seems to resonate most with Louisiana legislators is that 'no other state has it'.... Physicians dealing with the legislative process need to understand that 'while it may be hard to fathom why facts are not carrying the day,... for lawmakers things are rarely black or white'.... Despite all the effort and money psychiatrists and their allies will expend on convincing lawmakers that allowing nonphysicians to prescribe medications is a dangerous notion, repeating recent legislative victories is far from assured.... 'You may be right on this issue, but you still may not win.' The legislative campaign to obtain prescribing privileges for psychologists 'is a traveling circus and will appear at some time in your state'" Aloha.

Pat DeLeon, APA President - Division 42Web - April, 2000