by Pat DeLeon, former APA President – Hawaii Psychological Association

One of the fundamental objectives of President Obama’s Patient Protection and Affordable Care Act (ACA) is to fulfill the “triple aim” — that is, to improve the patient experience of care (including quality and satisfaction); improve the health of populations; and reduce the cost of health care. Former APA Congressional Science Fellow Sandra Wilkniss points out that the ACA provides one of the largest expansions of mental health and substance use disorder coverage in a generation and further, includes mental health in the “essential benefits” provision of the law. She has also urged psychology to appreciate the magnitude of transformation occurring as the nation’s health care system moves steadily towards integrated, interdisciplinary care – and thus away from its historical reliance upon fee-for-service, independent practice. On a recent HRSA national advisory committee conference call it was noted: “Mental health disorders rank in the top five chronic illnesses in the U.S. An estimated 25 percent of U.S. adults currently suffer from mental illness and nearly half of all U.S. adults will develop at least one mental illness in their lifetime. In 2007, over 80 percent of individuals seen in the emergency room (ER) had mental disorders diagnosed as mood, anxiety and alcohol related disorders.”

Reflecting upon the actions of the APA Council of Representatives this February, Bob McGrath, director of Integrated Care for the Underserved of Northeastern New Jersey at Fairleigh Dickinson University and their clinical psychopharmacology program, is hopeful that recent changes in the rules governing the accreditation of health care programs in psychology will ultimately move psychology towards interdisciplinary training and thinking like health care providers. “I’ve long thought the Accreditation Guidelines and Principles that governed accreditation practices for doctoral programs, internships, and postdoctoral programs for many years was more about making a psychologist who was a health care provider than about making a health care provider who was a psychologist. Where training in History & Systems of psychology was mandated, there was no expectation that a licensed psychologist would have received any training in interdisciplinary collaboration, pseudo-psychological physical disorders, psychopharmacology, health policy, or substance abuse. An unanticipated consequence was reinforcement of our isolation from the rest of health care. The new Standards of Accreditation aren’t a radical reformation of the principles of training – when do psychologists ever do anything radical? – but in specifically referring to psychologists as ‘health care providers,’ they are an important evolutionary step in the process of integration into the larger health care system. Given the changes set in motion by the ACA, changes that will have both positive and negative consequences for the profession, our ability to compete in the health care marketplace in the future may well depend upon our becoming more of a part of that system.”

One of the most exciting related developments at the Uniformed Services University of the Health Sciences (USUHS) (DoD) has been the concerted effort by the leadership of the medical and clinical psychology and doctor of mental health nursing practice (DNP) training programs to jointly utilize the university’s simulation laboratory with its professional actors. Recently the “patients” demonstrated symptomology of considerable anxiety, depression, and manic-like behaviors while the nursing and psychology graduate students conducted initial intake interviews, which were subsequently critiqued by colleagues and faculty from both disciplines who had monitored the interactions through observation portals and/or on closed circuit video-equipment. Later this semester, it has been proposed that both disciplines will engage in psychotropic medication work-ups for the actor-patients. Historical professional silos are steadily disappearing.

The Journey Continues: “It starts with an idea. U.S. Senator Daniel K. Inouye had an idea in November, 1984 while addressing the Hawai’i Psychological Association’s (HPA) Annual Convention. Then, somebody or an organization implements that idea. The DoD in 1992. Indiana passed limited permissive authority in 1993. There is a groundswell of support: APA Council adopts prescriptive authority as national policy and a high priority agenda item in 1996. Entrepreneurial visionaries understand that the future of psychology will lie in the training of hundreds of psychologists in the foundational science, clinical psychopharmacology, 1996. Indeed, psychologists flock to the training. As many as 1,000 psychologists were being trained in large ballrooms and lecture halls, from New York to California. The Territory of Guam passed a prescriptive authority bill in 1998! Then, New Mexico became the first state to pass a comprehensive RxP bill into law in 2002! Not wanting to let a golden opportunity slip away, Louisiana quickly passed its comprehensive bill in 2004! Both states’ laws became effective January 1, 2005. John Bolter became the first male civilian prescriber and Elaine LeVine became the first woman civilian prescriber.

“After so much success, the naysayers, both within psychology and outside psychology, began to mount ferocious, adversarial campaigns. Some psychologists retreated. Other brave Generals mounted formidable campaigns in Hawaii and Oregon, only to be turned back as they were about to stand atop the summit. Years went by. Many whispered that the Movement was dead. Or, maybe, there never was a Movement; it was all just a nice dream, even a mirage. Yet, psychologists were still prescribing. Well, an anomaly. Times have changed and parents told their children that that’s just not going to happen anymore. 2012, 2013, rumblings were heard from the middle of the country. Illinois psychologists were scoring victory after victory, even as organized medicine was engaging them in full hand-to-hand combat. On May 30th, 2014, the smoke was clearing. Was it possible that the psychologists were the ones who were left standing? Cries of joy and jubilation rang out across the land! And anger. Why couldn’t this bill look like all the others? We don’t recognize this stranger. Send him back! But the Illinois Governor swooped in on his white horse and signed that bill into law. No sending him back now! At lightning speed, the Illinois psychologists channeled their energies into sculpting this amorphous, complicated, comely figure into something familiar and, at the same time, unique, exotic, complex. Lo and behold, the most foreign of the adversaries crossed the river, embraced their former enemies, and joined them in song. The ground was shaking. In the distance, drums were rolling. Babies were awakening. First one state, then another, started to get ready for the next battle. The scent of victory permeated the air. The wolves could be pushed aside. The Grizzlies could be tamed.

“Hawai’i, Idaho, California, Arizona, North Dakota, Wyoming, Texas, Nebraska, Minnesota, Michigan, Indiana, Ohio, Florida, Virginia, Maryland, New Jersey, Pennsylvania, Ontario (Canada) were rising up. Calls were made; conferences were scheduled; planes were flown in and out; conversations, speeches, rallies, testimony. The airwaves were chattering. There was purpose, intention. Serious-minded people were saying serious things. No more was it something to be made fun of. We could touch it again. It didn’t go away. It never did. And it will grow and grow and become something that only a few could imagine in November, 1984. But the whole world can see it now.” (Beth Rom-Rymer received a well-deserved Presidential Citation from Barry Anton at the February council meeting.) Aloha,

Pat DeLeon, former APA President – Hawaii Psychological Association – March, 2015