Reflections from the Past, or Perhaps the Future?

Former APA President Reflects on the Past and Future of Psychology

Hourglass

Pat Deleon, PhD, Former APA President

For nearly four decades, I had the honor of serving on the staff of the late-U.S. Senator Daniel K. Inouye, retiring in the fall of 2011 as his chief of staff. During that time, I was actively involved within the governance of the American Psychological Association (APA) and served as its President in 2000. Over the years, we have observed many changes within the field of mental health, both from the “front line” and at the all-important health policy level. Perhaps the most significant of these changes has been external to any of the mental health disciplines – it is the gradual acceptance by society of the importance and appropriateness of receiving quality mental health care, in the same manner that it is now “all right” to openly discuss receiving treatment for cancer or diabetes. I cannot help but believe that a major factor in this evolution has been the extent to which our nation has become increasingly educated. My mother, for example, was the second female attorney in the State of Connecticut; her mother had considerably less formal education. Both of our children have advanced professional degrees – law and social work.

Changing The Direction: A little more than a decade ago, psychologist Barbara Van Dahlen established the non-profit organization Give an Hour, in order to effectively link-up those veterans, service members, and their families who desired mental health services with practitioners within their local community from all disciplines. At the time of the celebration of Give an Hour’s tenth anniversary, over 175,000 hours of free mental health care had been provided. It might be said that Barbara is on a mission (or crusade) to Change the Direction of how our nation views mental health – as is Bill Pohlad, the director of the moving film Love and Mercy, which highlights the struggles of Brian Wilson of the Beach Boys. He and Brian Wilson were present at Barbara’s moving celebration.  Does each of us know “The Five Signs” which Barbara constantly highlights?  We all should. President and Michelle Obama have publicly talked about their importance on several occasions.

Barbara has often stated: “We must change our culture if we are to succeed in saving lives and ending suffering. We must come to accept that mental health and mental illness are elements of the human condition – just as physical health and disease are.” Today we know that less than half of the veterans (23% to 40%) who are experiencing mental health problems are likely to seek professional mental health care for fear of stigma or other related barriers to care. The unprecedented advances occurring almost daily within the communications and technology fields – whether this is telehealth or health care apps – has revolutionized our practitioners’ ability to effectively address their potential clients’ concerns. And yet, we have learned that change often takes considerably more time than one would originally expect and further, that fundamental change can be quite unsettling to those who are vested in the status quo.

State Licensure Restrictions: State scope of practice laws should be carefully scrutinized to ascertain whether specific limitations on the scopes of practice of the various mental health disciplines actually address consumer protection or quality of care concerns, or do they, instead, represent historical efforts to protect the status quo and thereby prevent competition. Psychology and psychiatry proclaim that the doctoral degree represents their minimum standard for independent practice. And yet, few appreciate the policy significance of the fact that nursing, clinical pharmacy, and more recently social work, have also adopted the doctoral standard. It is estimated that today there are 150-200,000 advanced practice nurses, 19,000 of whom specialize in mental health. Nursing essentially has obtained prescriptive authority in every state, under differing conditions. And, there has recently been considerable Congressional interest in having the various federal health care systems increase their number of marriage and family therapists and physician assistants in a concerted effort to address demonstrated mental health provider shortages. One might wonder: Do the different mental health disciplines actually provide qualitatively different types of care?

Having had the opportunity to work over the past several decades with individuals who have made a real difference at the national level, it has become quite clear that sustainable change requires commitment at the local, individual-to-individual level, as well as responding to a national vision. This summer, the White House released its report Occupational Licensing: A Framework for Policymakers, which was prepared by the Department of the Treasury Office of Economic Policy, the Council of Economic Advisers, and the Department of Labor. Not surprisingly, issues surrounding the licensure of health care professionals were addressed throughout the report, including licensure mobility and the variations found in professional scopes of practice within the states.

“While quality can be defined in many ways and is often difficult to measure, the evidence on licensing’s effect on prices is unequivocal: many studies find that more restrictive licensing laws lead to higher prices for consumers.” “(S)ince each State sets its own licensing requirements, these often vary across State lines, and licensed individuals seeking to move to another State often discover that they must meet new qualifications (such as education, experience, training, testing, etc.) if they want to continue working in their occupation.” “Scope of practice has long been a particular focus in the health care context, in large part because of concerns about access to primary care. Current scope of practice laws for advanced practice registered nurses – nurses such as nurse practitioners (NPs) with master’s degrees or more – vary dramatically by State, both in terms of their substantive content and the level of specificity that they provide. But State-level evidence suggests that easing scope of practice laws for APRNs represents a viable means of increasing access to certain primary care services. Research finds that APRNs can provide a broad range of primary care services to patients as effectively as physicians.”

Given the growing national interest in addressing the extraordinarily high cost of health care – unfortunately, without what should be expected demonstrable positive clinical outcomes – is it not time to seriously consider adopting national licensure standards, as well as fostering interdisciplinary competence? These policy questions were raised in December, 1998 by the Pew Health Professions Commission. Fundamental change of this magnitude will undoubtedly require the dedication and commitment of concerned citizens who are no longer satisfied with the status quo.

An Exciting Opportunity: Psychology’s quest for prescriptive authority (RxP) can be said to have begun with the November, 1984 address by U.S. Senator Daniel Inouye at the Hawaii Psychological Association annual convention at which time he urged the profession to seek prescriptive authority. Since then, legislation has been enacted in Indiana, Guam, New Mexico, Louisiana, and Illinois; although several statutes are yet to be implemented. Bob McGrath, one of the original architects of psychology’s far reaching RxP training initiatives, estimates that two years ago there were approximately 1750 graduates of psychology’s training programs, with growing interest since the passage of the Illinois law this past year. The first two Department of Defense (DoD) prescribers, Navy Commander John Sexton and Lt. Commander Morgan Sammons, graduated in June, 1994. Over the succeeding two decades, they and their federal colleagues clearly demonstrated their clinical competence to utilize psychotropic medications. And yet, resistance from organized medicine and some psychologists continues; notwithstanding positive clinical outcomes.

Earlier this year, former USAF Prescribing Psychologist Elaine Foster shared her personal frustration: “After graduating from the DoD Psychopharmacology Demonstration Project (PDP) I served as a prescribing psychologist in the Air Force for over 20 years. I continued to serve our active duty military after retiring, again as a prescribing psychologist under contract with the Air Force. During that time, I prescribed for our veterans when we had space available at our military clinic…. If I walked across the hospital parking lot to our annexed VA clinic, I could no longer prescribe to that same patient I’d been prescribing to while he or she was active duty. The current VA restrictions are illogical…. Because New Mexico recognizes prescribing psychologists, I can now prescribe to our veterans, but only in New Mexico, and only through a third party contractor…. This just does not make sense and is a clear waste of federal funds.”One rhetorically wonders: Where are the collective voices of those psychologists who are themselves veterans?  Don’t they believe in their own profession and the importance of quality care?

Integration Of Mental Health Services: Another substantive change that we have observed over the years has been the growing appreciation at both the clinical and health policy level of the inter-connectedness of the “mind and body.” Historically, at the federal level this was reflected in the Community Mental Health Center movement initiated by the vision of President John F. Kennedy; whereas, the Community Health Center (FQCHC) initiative was an outgrowth of President Lyndon B. Johnson’s Great Society Era. Federal funding for these two important efforts (including the all-important training component) was housed in different elements of the Department of HEW/HHS and different reimbursement models were adopted under Medicare and Medicaid. Fortunately, signs of change are definitely evident — especially with the enactment of President Obama’s Patient Protection and Affordable Care Act (ACA). Although once again, seemingly rational changes will take longer to implement than one might anticipate – especially in the financial/reimbursement arena.

In 2006, the then-President of the Institute of Medicine (IOM) proclaimed: “(T)he link between mental and substance-use problems and illnesses and general health and health care is very strong. This is especially true with respect to chronic illnesses, which now are the leading cause of illness, disability, and death in the United States…. (I)mproving our nation’s general health and the quality problems of our general health care system depends upon equally attending to the quality problems in health care for mental and substance-use conditions…. (This) requires a fundamental change in how we as a society and health care system think about and respond to these problems and illnesses…. To this end, the Institute of Medicine will itself seek to incorporate attention to issues in health care for mental and substance-use problems and illnesses into its program of general health studies.”

Marc Lalonde, then-Minister of National Health and Welfare for Canada, noted in 1974: “Good health is the bedrock on which social progress is built…. For these environmental and behavioural threats to health, the organized health care system can do little more than serve as a catchment net for the victims. Physicians, surgeons, nurses and hospitals together spend much of their time treating ills caused by adverse environmental factors and behavioural risks…. The Government of Canada now intends to give to human biology, the environment and lifestyle as much attention as it has to the financing of the health care organization so that all four avenues to improved health are pursued with equal vigour. Its goal will continue to be not only to add years to our life but life to our years, so that all can enjoy the opportunities offered by increased economic and social justice.”

This fall, the U.S. Army Surgeon General Patricia Horoho met with our nursing and psychology health policy students at USUHS. As she has testified before the Congress, she emphasized: “Long term success in Army Medicine lies in our ability to effectively impact the ‘Lifespace.’It is in the Lifespace where the choices we make impact our lives and our health. We understand the patient healthcare encounter to be an average interaction of 20 minutes, approximately five times each year. Therefore, the average annual amount of time spent with each patient is 100 minutes; this represents a very small fraction of one’s life. It is in between the appointments – in the Lifespace – where health really happens and where we desire a different relationship with Soldiers, Families, and Retirees. We need to reach beyond the physical boundaries of our medical treatment facilities. In other words, we want to partner with those entrusted to our care during the other 525,500 minutes of the year where people are living their lives and making their health choices.” Without question, our nation’s health care system is steadily evolving in fundamental ways. Those with vision who specialize in mental health are facing unprecedented challenges and opportunities.

Aloha,

Pat DeLeon, former APA President – Center for Deployment Psychology – December, 2015