Recognize Barriers and Shatter Them

Pat DeLeon (former APA President) July 2016 PostShattered window with sun

The Extraordinary Vision of Give an Hour

This Summer several USUHS nursing colleagues and I had the opportunity to attend a special Give an Hour symposium titled Veteran Wellbeing: Bridging the Divide, held at The National Press Club in Washington, DC.  Among the presenters were Dr. David Shulkin, VA Under Secretary for Health; Brian Duffy, Senior Vice Commander-In-Chief of the Veterans of Foreign Wars; Andrea Inserra, VP at Booz Allen Hamilton; and Kana Enomoto, Principal Deputy Administrator of SAMHSA.  Earlier that day the VA released its comprehensive analysis of Veteran suicide rates, examining over 55 million records, which sadly concluded that in 2014 the number of Veteran deaths by suicide averaged 20 per day.  Since 2001, the nation’s adult civilian suicide rate increased 23%, while Veteran suicides increased 32% during the same time period.  After controlling for age and gender, the risk of suicide for Veterans was 21% higher than for non-Veterans.  One positive note — since 2001, the rate for those who used VA services increased by only 8.8% in contrast to a 38.6% increase for those who did not access VA services.  And yet, APA reports that only 40% of Veterans who screen positive for serious emotional problems seek help from a mental health professional and that female Veterans are particularly likely to suffer from mental health issues.

Those presenting that morning discussed the critical importance of creating effective partnerships – with the VA, with the Veterans’ communities, and with the private sector.  They called for developing awareness and appreciation for Veterans representing Strategic Assets to their local communities.  The Under Secretary was extremely supportive of integrating behavioral health within primary care, establishing a Center for Compassionate Innovation; and increasing the availability of Complementary Medicine, including the use of Service Dogs.  Having attended several Give an Hour events, one could sense a changing culture – a growing willingness to openly address the “hidden wounds” of our nation’s longest armed conflict and thereby rejecting the stigma that has surrounded receiving mental health care.  Most importantly, one could sense a growing understanding that in order to address the mental health needs of those who serve, we must address the barriers that prevent all Americans from seeking and receiving proper care.

Under Barbara Van Dahlen’s passionate leadership, Give an Hour has already facilitated over 192,000 hours of free mental health care donated by clinicians of all disciplines to our nation’s military, Veterans, and their families.  She is slowly developing enthusiasm within our State Psychological Associations with impressive success in New Hampshire and Wisconsin specifically around the Campaign to Change Direction, the national initiative that Give an Hour launched in 2015 focusing on changing the culture of mental health in America.  Recently, several mayors have expressed their interest in working with her on this important cultural agenda.  Most impressively, The First Lady and President Obama have personally been outstanding champions of all Americans learning the key components of Change Direction, the Five Signs of emotional suffering — Change in Personality; Agitation; Withdrawal; Lack of Personal Care; and, Hopelessness.  Just like we all know the signs of a heart attack, all Americans – civilians, service members, and Veterans – can learn the signs of emotional suffering.  The critical question: Is YOUR State Psychological Association Involved?

Evolving Competition Targeting Consumer Demands

During our tenure on the APA Board of Directors, Bruce Overmier and I would rhetorically wonder: “Why was APA in the accreditation business?”  The answer, of course, was to ensure quality education.  After rotating off the Board, I heard from various professional schools that the accreditation standards were considerably more restrictive than appropriate, especially given their underlying community-service mission.  I also heard that it was very difficult to incorporate health policy and relevant field experiences into the curriculum, notwithstanding how important this body of knowledge might be to the future of the profession.  Undoubtedly all involved have the best of intentions.

One of those professional schools recently reported that the new Standards of Accreditation, which will go into effect in January, 2017, are friendlier and more manageable for programs such as theirs which facilitates a health center/integrated care internship.  It will be interesting to see the impact of the expectation that all programs will send 50% of their interns to APA accredited internships.  Nevertheless, I remained somewhat uncomfortable that there has not been any viable alternative to the APA standards which clearly do impact state licensure and employment requirements.  Perhaps it is my legal background that suggests that competition per se is an important value that has served the nation admirably over the years and has often fostered unexpected beneficial changes in the status quo.  For example, the battles which psychology and nursing face in expanding their “scope of practice” are really all about competition — although they are frequently fought under the guise of “ensuring quality care.”

Alan Kraut, a longtime friend and colleague, is now the Executive Director of the Psychological Clinical Science Accreditation System (PCSAS) which recognized its first program in 2009 and today accredits 30 clinical training programs in the U.S. and Canada.  PCSAS has been recognized by the Council of Higher Education Accreditation and VA recognition has now been approved.  Alan has always possessed a broader vision and consistently has stressed the importance of applying clinical science in ways that are highly effective in improving public health.  Few appreciate that when he was working for APA, he was instrumental in hosting professional psychology’s initial Black Tie fundraising dinner at our annual convention in Los Angeles.  The recipient that year was U.S. Senator Daniel K. Inouye.  Alan reports that even in the few days since the VA has recognized PCSAS, he has received a number of new inquiries from clinical programs around the nation asking about their new accreditation process.  He is now in discussions with DoD and the USPHS and, as should be expected, efforts are also underway to modify state psychology licensing laws and implementing regulations.  A viable alternative to APA accreditation seems to be finally emerging; one which Bruce suggests could well be viewed as “supplementary” rather than “competitive.”

Former VA senior psychologist Bob Zeiss shared with us the VA’s revised Qualification Standards governing psychology hiring.  The VA is the largest employer of psychologists and nurses and their new standards recognize PCSAS and Canadian Psychological Association accreditation.  In addition, ABPP status can now be used in lieu of an accredited internship, offering a viable workaround for those who failed to recognize the importance of an APA accredited internship while in graduate school.  The basic requirements for employment as a VA psychologist are prescribed by P.L. 96-151 [at the request of the late-U.S. Senator Daniel K. Inouye].  These include a doctoral degree in psychology from an accredited graduate program in psychology with a specialty area consistent with the assignment for which the applicant is applying.  Or, having a doctoral degree in any area of psychology and, in addition, successfully completing a respecialization program including an approved internship, accredited by APA or CPA.  For those who might have completed an internship that was not accredited at the time, board certification by ABPP will satisfy this requirement.  Under Bob’s leadership – and continuing under that of his successor Kenneth Jones (Director of Associated Health Education) — the annual number of psychology post-doctoral training positions increased from 52 to 440, with the expectation that these numbers will increase further as a result of the Mental Health Expansion Initiative during the 2017-2018 academic year.  Currently in the public rulemaking process, already generating over 69,000 comments, VA is proposing to “increase veterans’ access to VA health care by expanding the pool of qualified health care professionals who are authorized to provide primary health care and other related health care services to the full extent of their education, training, and certification, without the clinical supervision of physicians.”  In many ways, the VA is on the cutting-edge of our nation’s 21st century health transformation.

The Implementation Process (RxP)

“Perhaps the most gratifying part of implementing our Illinois law is seeing and hearing the excitement of our undergraduate and graduate students as they envision themselves as full spectrum healthcare providers: prescribing psychologists.  Their eyes shine with delight at being the pioneers of their generation, creating paths of learning and practice for others to follow.  Our young students understand the frustrations of patients who need to wait for months to see a psychiatrist or who have no options but to consult primary care physicians who often don’t accurately identify the psychological disorders and are reluctant to prescribe psychotropic medications.  Our next generation of psychologists readily see themselves as healthcare leaders who will easily integrate medical as well as psychological and behavioral health information about their patients and will be able to create new and more effective healthcare modalities for clinic, hospital, community mental health, prison, nursing home, and medical settings.  While senior psychologists continue to debate the ‘pros and cons’ of RxP, our progeny immediately grasp the potential and are immersing themselves in their preparations to take their place in the vanguard of the modern healthcare environment” (Beth Rom-Rymer).  [The Good Girl’s Guide to Policy Advising – Tracey Koehlmoos].

Aloha,

Pat DeLeon, former APA President – Division 42 – July, 2016