Psychotherapy Bulletin 30 (3) Fall 1995

eo ocepys ‘OFFICIAL PUBLICATION OF DIVISION 29 OF THE AMERICAN PSYCHOLOGICAL ASSOCIATION Features In This Issue Knowledge Is Power Psychotherapy and Exercise Behavior Change The Family Life Cycle: Phases, Stages, and Crises Total Risk Management The Emotional Consequences of Therapeutic Misunderstandings The 1995 Beijing NGO Forum on Women, VOLUME 30 FALL 1995." Division of Psychotherapy of the American Psychological Association 1995 Officers and Committees oFFicers -MEMBERS-AT-LARGE aceon ED. Soy caben int ts New York, NY 10011 REPRESENTATIVES to APA COUNCIL, jean J. Rossi, Ph.D, 1995-1997 Stanley Moldavesky, P EDITORS of PUBLICATIONS —_Liaison to APA Committee on Intemational Relations in Peychatherapy Jour: atives to JCPEP Psy ST otherapy Bulletin Linda F. Campbell, Ph.D. Adethold Hall Olfice: 706 LIAISONS/MONITORS Administrative Liaison Mathilda B. Canter, Ph 4035 E. McDonald Dr. Representative o Interdivisional Phoenix, 8 Task Force on Health Care Reform Offi e0-2804 Arthur 1. Kovacs, PhD x 1821 Wilshite 401PSYCHOTHERAPY BULLETIN Published by the DIVISION OF PSYCHOTHERAPY AMERICAN PSYCHOLOGICAL ASSOCIATION 3900 East Camelback Road. Suite 200 Phoenix, Arizona 85018-2684 (602) 912-5329 EDITOR Linda Campbell, Ph.D. CONTRIBUTING EDITORS Medical Psychology David B. Adams, PhD. PS¥Column. Mathilda Canter, Ph.D. Washington Scene Patrick DeLeon, Ph.D. Practitioner Report Ronald F. Levant, Ed.D. Student Column Jack Wiggins, Ph.D. Substance Abuse Harry Wexler, Ph.D. Gender Issues Gary Brooks, Ph.D. Group Psychotherapy Morris Goodman, PhD. STAFF Central Office Administrator Pauline Wampler/Linda Reed Production Coordinator ‘Susan Rea PSYCHOTHERAPY BULLETIN Oficial Publication of Division 29 ofthe ‘American Psychological Assocation Volume 30, Number 3 Fall 1995 CONTENTS President's Message .... Editor's Column .. Student Column ... Washington Scene . Medical Psychology Finance . Practitioner Report ... Feature: Knowledge Is Power Feature: Psychotherapy and Exercise Behavior Change Feature: The Family Life oye Phases, Stages, and Crises . Commentary: My Agenda: Focus on the Older Adult .... eens Feature: Total Risk eee - Feature: The Emotional Consequences of Therapeutic Misunderstandings ..... reatare ie 12s baging NGO Sain on Women ce Professional Liability Fellows, «fe toaces 2 Gender Issues Reply Article... Letters To The Editor ..PRESIDENT’S MESSAGE Divided We Fall Stanley R. Graham Almost all of us have a stake in the marketplace where psy- chotherapeutic services are sold, If there is no market for services of psychologists there is less need for the training of psychologists and departments of psychology Would return to oné- tenth of their current size. Approximately 40,000. psychologists pay the assessment designated for mental health providers. If we, however, aad psychiatrists, psychologist, social workers, nurses, marfiage and family therapists, etc., we find ourselves the smallest part of 350,000 providers of psychothera- peutic services. Managed care organizations dealing with us individually have placed strictures ‘upon us, one by one, with litile effective resistance from the group as a whole. Even within the several divisions of APA, there are issues between us which absorb our attention and our energies and place constant roadblocks in the path of Peychologists retaining. their place nthe world. It'is no longer possible for us to practice in sheltered workshops. There is no security or stability left. In fact, we have been marked like the Kulaks during the Stalinist ter- ror to be exiled and eradicated. Unless we can form some protective structure which will allow us to continue to practice our profession, we will become a sub-profession or technolo- gy practiced by individuals much less educat- d and far less stable in their circumstances, We have indulged ourselves over the last decade in rhetoric about the value of our work and responsibility to our patients, which the managed care companies are forcing us to abrogate. [fully support our protests and public relations efforts, but we cannot expect public opinion to do what we will not do ‘ourselves. Given the nonprofit structure of APA and its vast diversity of function, itis not sur- prising that APA is relatively ineffective in dealing with multi-billion~dollar corporate entities intent on ignoring our voice. In truth, we are not the largest or strongest organization in mental health, and unless we work with all the other providers in the arena we are well ‘on our way to disappearing, Examining President Clinton's solution to reduce the cost of Medicare, we find that his primary focus is on curtailing the income of providers, While this may be worthwhile in certain areas, I feel that psychotherapists fees have already been diminished by managed care organizations below any respectable level. Frankly, it becomes meaningless for a person to invest nine to twelve years of study in order to make less that $25,000 a year. Unlike some of us, I had never believed that legislative action was our basic remedy. In truth, Thave never met a legislator who didn’t jlow at the thought of managed care since it Fras obliterated his responsiblity to provide funds by raising taxes or cutting fat, something which ro legislator does without great trepidae tion’ We truly need an organization, unfettered by the multiple goals of APA, capable of extending to and cooperating with all of our sister roviders so that we will not be dealt with one 3y one, Teliave we need a mult-dscipined organization that can represent the health providing professions in a that will allow us to exert leadership and cohesiveness so that managed care organizations cannot simply deal with the smallest part of us that are most fearful and submissive. Ifall providers said to their patients tomorrow, “I no longer take referrals from managed care organizations, but Tam willing to negotiate an appropriate fee for my services with you,” there would be no managed care organization the followin; week.” What is required is an organization o} the principal health providing organizations which could exert leadership in some defi tion of limits as to how far the individual practitioner can be diminished. Obviously, APA with all good intension, could not perform 4this function since the purchasers of services are free to choose social workers, psychologists, psychiatrists, counselors, ete. What is required is a pan-organization of providers which is able fo respond and say “your pro- posals are inadequate to our needs, and we cannot provide services on such terms.” The situation cries out for leadership. The divi- siveness that our professional organizations have practiced for so many years has allowed us to be swallowed by aggressive business people and the righteous cries of victimization do not cause a moment's pause in their depre- cations. Now more than ever the health professions require unity of purpose and effort before the managed care organizations destroy. our dignity as professionals and our security as human beings. The young people coming into the profession, withthe dearth of jobs and very tte opports. nity to initiate independent’ practice, have always been anxious to sign-up for managed care saying that something is better than nothing. The intense pressire_ of competion leaves many others needful of more hours and mote income. Nowhere has there been a voice saying, “don’t deal with those people.” Nowhere has there been an effort to guide the ‘most needful practitioners and provide some remedy for their vulnerability. What works in a free market is devastating to the young, the DI COLUMN vulnerable, and the proud. The so-called ma:- ket is not a free market when one side takes it or leaves it and the other side cannot. I'm sure that some wise people will ask “what will ha pen to usif we don’t submit tomanaged care?” My answer to that would be to use cooperation between professional organizations to form a national provider service that could compete successfully with managed care organizations (Graham, 1995). Within APA we must gain a greater commitment of concern for those who are vulnerable. Outside of APA, I think we have to call a halt to the color wars so reminiscent of summer camp. Remember, 350,000 professionals are roviding care. The managed care companies ‘ve divided us into 350,000 entities. “There has always been aneed and a purpose for all of us working in the field. The plan of amanaged care organization is to select the most submissive and malleable 15% or 20%, and then deny the rest can or should continue to deliver services. Whatever the difference is, the vast per- centage of mental health providers are resj sible individuals who strive to provide a standard of service. During this crisis we should aggressively reach out and form a col- lective organism of the several mental health professions capable of standing up to and dealing equitably with the managed care phenomenon. Clinicians and Researchers: A Working Alliance Linda Campbell Paychology has for many years aspired 10 a compatible working alliance between academic training/research programs and. practice. We know through observation of social and cultural phenomenon that nothing creates alliances as quickly and effectively as an external threat. Many psychologists perceive the changing practice environment (as affected by health care reform, managed care, policy changes affecting providers) as a threat to the practice of psychotherapy. This external threat to the practice environ- ‘ment can ironically be a great advantage to psychology in that we are far better prepared (through our scientist/practitioner training model) than any other mental health provider group (including psychiatry) to conduct research, interpret and implement research findings, and evaluate results. No other mental health profession at the training level or continuing education level pre- pares the professional in training to be compe- tent in the following: 1. Assessment (intellectual, personality, and increasing needs of special populations (LD, ADD] neuropsychology, forensics, child for evaluation of mental status of the client.2. Conduct a clinical interview and integrate the interview material with assessment to arrive at a diagnosis. 3. Utilize skills in understanding research methodology and how to interpret research findings in developing a treatment plan, 4, Implement fully the preferred treatment plan (with the current exception of prescription) because of the breadth of training in psy- shotherapy via extensive practica, intemship and post-doctoral requirements that only psy chology requires. 5. Conduct studies ourselves in our area of practice or to develop instruments to measure what we need to test out. Now most of u: would need refresher work, but the point that we were educated in statistics and measurement. No other mental health profession includes this training, 6. Lastly, we have the training and skills in program evaluation to evaluate our own work (also known as outcome study) No other mental health profession comes close to the comprehensiveness of training in psychology, wh a 5 ‘What is the incentive to take on this challenge If we can think in behavioral reinforcement terms for a moment, it is very clear why academics and clinicians have been marching to different drummers. They work in different reinforcement environments. Clinicians are reinforced by being perceived as effective and helpful by patients. Patients think that their quality of life has improved because of cognitive, behavioral changes that took place in therapy. This is what therapy is all about. Patients then refer others to the clinicians who are reinforced by knowing that they have made a positive impact in the lives of their clients and they receive more business for it. Now practice psychologists are being asked to empirically explain the improvements in quality of life. We can do it - we've just never had to prove it before, ‘The academic psychologists are reinforced by publishing empirically-based articles in scholarly refereed journals, acquiring federal funding, and being granted promotion and tenure (which is predicated on the first two reinforcers of publications and grants). Process and outcome studies can be a labyrinth under- taking in which unpredictable events can affect research design, method, timeliness, costs, and threats to validity linger every- where. Faculty who are on the promotion track may be reluctant to become involved in research projects that carry so much unpre- dictability. Researchers who are on a timeline for promotion often (a) do survey research using other academic program faculty or students, (b) do single subject /reaction time studies, or (c) through grants use VA or other cap- tive populations. What do we need to do? Conventional efficacy studies continue to be important in further investigating the critical factors in psychotherapy effectiveness. These studies must be presented in a more useful way for clinicians. Articles published in the academically oriented journals may be read primarily by academics and need not be changed. The findings in these studies, howev- et, can be very useful to clinicians. This is not to suggest that a psychologist in practice could not extrapolate meaning from the article if it were in hand, The need is for more publications that (a) report findings readily applicable to the practice setting, (b) provide outcome data ina format that allows practitioners to use the information in marketing, education, and communicating with various constituencies with whom practitioners work. New areas of research must be encouraged in clinical significance rather than statistical significance only. The outcome factors that are important to payers of psychological services are work productivity, lost days of work, tumover, job training costs, cost-effectiveness, and cost offset factors. Ifa statistically significant difference in outcome is not clinically significant, that is, does not result in an improve- ment of quality of life, work, or social/inter- personal skills, then itis irrelevant for practical Purposes. Professional psychology must develop publication venues for this research and value this research as we value research that seeks statistical significance. 6Psychology training programs should teach students how to conduct process/outcome research rather than requiring only that they be familiar with the existing literature. Currently, students in even the most rigorous training programs can complete a program with no hands-on experience in process/outcome research other than to study outcome findings for preliminary examinations. Training programs with in-house clinics must take the leadership. Further, even if programs profess to be training researchers and academics rather than practitioners, the responsibility is even greater. Academic training clinics are ideal sites for outcome projects given the community client population and the prescriptive control of therapeutic variables not afforded to ractitioners. Liaisons should be developed etween training programs and practice set- tings in the community andl with health care delivery representatives including insurance and managed care entities. Changing the reinforcers In order to accomplish the alliance between academic and practice psychologists and to achieve the needed changes, reinforcers must change. Already, reinforcers are changing for practitioners in that patient satisfaction is still necessary, but not sufficient. Practitioners could participate in larger scale data collection projects conducted by academic divisions of state associations or conceivably even by practice divisions of APA. Such a project would, of course, need funding, designated investiga- tors, and must meet other criteria necessary for rigorous research. There is a grand opportunity for state associations to bring together academics, clinicians, and management psychologists in developing ways 10 bring psychologists into collaboration. The point is that incentives for practitioners to collaborate with researchers are present. es, in reinforcers for academics could include the following: (a) the granting agencies ‘must encourage alliances between practice and academics through criteria for grants awarded. If granting agencies funding outcome studies encouraged the inclusion of practice sites and the collaboration with clinicians (much as they now include consumers), academic researchers ‘would willingly build in such a compliment. (b) The APA Accreditation Guidelines must encourage curriculum that includes teaching ‘outcome research methods, research in practice related areas, and the development of outcome research at clinical training sites for those programs that claim a scientist or scientist / practice model (@) Existing scholarly journals must acknowl- edge and include for publication, studies that identify ‘clinically significant. findings and must begin to value investigative results that advance’ the practice of psychology. This change requires a shift by some editorial boards of ara and other prestigious psychological journals. (a) There is a need for publications that pro- apie ae advance thes ence etiudngs cf behavioral change tho jotherapy as itis evidenced in practice: Tis means journals that will publish findings that have direct clinical and application relevance and journals that_will publish summaries, analyses, and reviews of findings presented in a marketing and/or applied format. The purpose of s information is to provide the practitioner with sound data to both guide and substantiate psy- chotherapeutic practices and to create new and innovative avenues for publication for acade- Perhaps both academics and practitioners, for the first time, have still different reinforcers, but very strong incentives to collaborate, Adapted rom a presentation atthe 1995 American Papel Ackaton Convention VOTE 10 FOR 29STUDENT CO! Incorporating Activism and Public Policy in Professional Psychology Graduate Education Delia Ojon, University of Florida ‘The status of health care and its delivery system in the United States has become one of the ‘most significant social issues in recent years. Feverish debate and increased political activity have followed efforts to reform the health care delivery system. Fortunately, one of the conse- quent effects of the health care reform issue Ras been a reevaluation of professional goals and activities as well as increased political activism and advocacy on the part of the pro- fessione most affected by reform efforts, For psychology, reforms in the health care delivery System Will bring rather drastic changes to the Way our profession provides its services, The traditional independent fee-for-service mode of service delivery will cease to exist. In the near future, health care in general and mental health care in particular Will be organized within a framework of limited benefits, tighter cost controls, provider accountability, and provision of services within a broader, more integrated delivery system (Broskowski, 1995). Unfortunately, the field of psychology has been slow to respond to the rapidly changing health care environment. However, the sur vival of our profession will ultimately depend ‘on how we answer the basic question of who will make the critical policy decisions that affect the manner and degree to which we provide psychological and behavioral health care. If we are to control our own professional future, our presence must be expressed and recognized when decisions regarding the provision and regulation of psychological services are made and when decisions that shape the nations’ social policies are being developed and evaluated. Our commitment to understanding and being actively involved in the policy process needs to be stronger and begin early in our professional development. Future training of psychologists will need to consider the changing health care delivery system and our role within this system. One of the key mechanisms for increasing our public policy activity i to incorporate this in our professional graduate training curriculum. Exposing students to critical policy issues in health care and encouraging research, analysis, and activism. in this area will ultimately ensure that the future needs of our profession will be addressed. Although most psychology graduate programs do.not off specialignion or an area of Concentration in public policy within the curriculum, there are a number of activities that interested graduate. students can become involved inn an individual level to increase their understanding of and involvement with Public policy fonetion both on a state and Rational level. ‘The American Psychological ‘Association (APA) offers a year long infern- Ship for prychology graduate students with the Publie Policy Orlice in Washington, D.C. Smident may also choose to develop areas of concentrated work or specialization in public poley through extadePartmental curriculum and coursework. Other activities individuals an become invoived with include working on the legniative and public policy comunitines oF the various State Srnaloiel Association volunteering to work with state leglladve nembers of substanuative committees within the slate legislature; working. with. various State agencies on policy issues relevant to psy- thologg: In addon, Jome states ofler org ised! Spportunities for individuals 1 intern with the legislature, state agencies, or the Governor's Office. I would like to share my own experience as a legislative intern with the Health Care Committee of the Florida House of Representatives. The Florida House of Representatives legislative Intern Program is a year long half-time internship which provides training and active participation in the legisla~ tive process and public policy formation. The: iptemship program provides an opportunity for individuals to gain valuable knowledge and experience in public policy analysis, development of legislation, and the overall legislative process. During my internship year, Twas assigned to the Health Care Committee of the House of Representatives. Some of the policy issues the committee primarily deals 8with include: managed competition joint ven- tures, public health, Medicaid, Emergency Medical Services, state health benefit pack- ages, matemal and child health, AIDS/HIV, health care fraud and abuse, professional licensure, health care work force/medical educa tion and training, certificate of need, medical malpractice, anti-trust, and rural health. My responsibilities included drafting bills, resolu- tions, and amendments, analyzing proposed legislation through research and investigation, ‘communicating this information to legislators in written and verbal form, and investigating constituent concems and drafting letters for members. During the interim legislative period I attended a number of short courses sponsored by the House of Representatives and the intership rogram. These courses were extremely help- fal in getting me oriented to the professional environment of the legislature. I also attended a number of special hearings during the interim. The most important activity I was involved in during the interim period was working on various Committee interim projects. I was involved on a project with two other staff ana- Iysts evaluating Floridas’ school health system. project looked at Full Service Schools and Supplemental School Health programs in Florida and the influence of health care reform on these programs. I also had an opportunity to develop my own research project. Since my background and interest area is in mental health policy, I decided to focus a project in that area and evaluate the effects of Florida’s, health care reform efforts on behavioral/mental health care. During the interim, [also had a number of other brief research assignments. ‘One project involved researching County tax hospital districts in Florida and another project explored organ donor programs in other states, ‘The 1995 legislative ses ture of anticipation, excitement and anxiety. began with a mix- The Capitol became transformed overnight, bussing with cellular phones, clean suited fob byists, and senior and freshman legislators. Given the change in the senate leadership with the November elections and the increased number of Republican members in the House, there was much anticipation about how this legislative session would play out. One of the biguest issues facing the health care committee what was to happen to the Florida Health Security Plan, the states’ major health care reform proposal. I worked on a number of bills during the legislative session. Probably the most interesting bill T worked on was a bill creating University Health Services Support Organizations. The bill allowed academic health centers at Florida universities to create not-for- profit organizations that would act as accountable health partnerships. Other bills T worked on included a bill creating a Prescription Drug Review ‘Commission to evaluate variations in the costs Of prescription drugs, a bill providing annual corporate income tax credits to private corporations providing contributions to preventa- tive _ cancer-screening procedures _ for low-income state residents not covered by insurance, and a bill limiting the amount hos- pitals and ambulatory surgical centers could charge for providing patients with copies of their medical records. Throughout the year I worked on a number of constituent letters for the committee. Members ‘would receive letters from constituents on cer tain issues and refer them to our committee for investigation and response. This was an extremely valuable experience because I had a chance to learn about a vast array of issues related to health care that were not necessarily “hot” public policy issues. Tt also gave me an ‘opportunity to see how the public interacts, influences, and is influenced by government. For each letier I worked on I found myself becoming invested in exploring the issue and finding some resolution. Although, in most incidents, the issue was quile complicated with no simple solution. The internship with the House of Representatives afforded me an opportunity to ‘meet and interact with a diverse group of people and to further my knowledge and understanding of health policy issues. The internship has been an extremely valuable experience for me and has solidified my interest in behavioral health policy. I have grown to understand the necessity of advocacy and having a voice and also the necessity of communi- caling the value and contributions of our profession. Through my experience, [have had an opportunity to more fully understand the setial policy-making process and also the necessity of increasing the visibility of psychologists to the public, to lawmakers, and to policymakers. References Broskowski, A. (1995). The evolution of healthcare: Implications forthe training and careers of psychologists. Professional Psychology: Reseach and Practice, 26, 136-162. 9WASHINGTON SCENE The Prescription Privilege Agenda~Onwards to the Future Pat DeLeon Dr. Pat DeLeon isa contributing alitor for the Peychatherapy Bulletin in the area of legal end lgistive issues. He is Past Presidan of Dizision 29 and a recon of the Distinguished Payciologst Aiand. Dr. DeLeon i the Recording Secetary of APA, The Department of Defense (DoD) Program: In our last column we noted that for the first time, the House Committee on National Security (formerly, the Armed Services Committee) had addressed the issue of military peychologists prescribing. If enacted into public law, not only would the House provi sion immediately terminate the innovative DoD training program (known as the PDP), it would also expressly prohibit those psychologists who had already graduated from the program from effectively utilizing their new clini- Cal skills, We would note, this latter prohibi- tion would be regardless of any adverse impact upon their patients. Without question, the House provision was (and still is) the most serious threat to the program’s existence since its inception, ‘As of this writing, the House and Senate Committees with” jurisdiction over the Department of Defense are still in conference and the fate of the PDP has not been decided. During the Senate “mark-up” the objection- able House provision was struck and thus it has become a conference item. Both professional associations are actively lobbying the conferees—for example, we have received reports of “letters to the hometown editors” of conferees opposing the project, written naturally by local psychiatrists. One of the House members is reported to have commented to a psychologist colleague that: ”..No other sec- Eon of the entire Defense bill = provoking as much activity... have not seen this much action in all my years.” The ultimate decision ‘will be made prior to the end of the fiscal year (October 1, 1995). The APA Practice Directorate, under the leadership of Russ Newman and for this struggle, Marilyn Richmond, has been working extraordinarily hard to maintain the DoD program. Their proffered policy argument stresses that: 10 "(Ihe PDP is a DoD demonstration project intended to increase access for military personnel to high quality mental and behavioral health care in a cost effective manner. Many military personnel are deployed in situations where both general medical and mental health services are limited. These individuals must often then seek mental health services from primary care physicians, who are not specifi- Eally trained in recognizing the indications for and actions of psychotropic drugs. The PDP seeks to address this problem by examining. the efficacy and cost-effectiveness of training military psychologists, who are already highly. trained health care professionals, to prescribe these medications.” “An intensive grassroots effort has been ongoing. since the Spring to save the PDP. Phonetrees were activated, letters faxed to Congressional offices and telegrams sent. In one State, calls were launched during the State Association's annual convention. And in another state even psychiatrists called in sup- ort of the project” Throughout the country psychologists visited key Senate and House Inembers’ aswell as their staffs, during campaign. Thanks to this incredible outpour- ing Of support the tide was tured in favor of continuing the PDP. The Senate Armed, Services Committee and the House and Senate Appropriations Committees all reported legis- fation without language terminating the pro gram. The Senate Appropriations Commitee, ip fact, included language stating that: (1) Committee supports the continuation of # program with fepresentation from each service and requests that the Department provide thet results and recommendations of that program! to the Committee no later than September 30, 1996. Paychology won the support of three out of “the ‘four relevant. Congressional Committees.” But that one is very troubling, An Insider's View—Continuing “Thoughts” From The Graduates: [Morgan Sammons} —"Not long ago, a seni InlutSy_peychologist opposed io tne idea Bae eee Bellows in this year’s. Poychopharmacolo Demonstration. Project (DPF. class. ienarked fo be ('paaphas) tht he hop She was enrolled fn kt Fellowship for ‘Sheet joy of leaming/ because that wasonly benefit she could hope to gain from the program. Events in the recent past have not Supported this prediction. In the past few months, both John Sexton and I have finally leared the lat bureaucratic hurdles and have jegun to implement the prescription skills we worked so diligently to acquire” “There was joy—and a good amount of in—in learning psychopharmacology, but I elieve the experience has benefitted us both immensely. Though our Fellowship experience has changed Our practice in many ways, curiously, many of these changes have been largely unrelated to the ability to prescribe. For example, I now strongly believe that all psychologists who practice in hospital or clinic set- tings, not just those who prescribe, must acquire fundamental know!- edge about basic physical parame- ters and their assessment via labo- ratory and physical, exams. ‘Acquisition of this knowledge will not tum us into junior physicians.” Ie will allow us to appreciate ll aspects of our patient's functioning and force us to pay more than mere “lip service’ to the ‘bio’ portions of the "biopsychosocial model we have embraced.” “Thave learned that my role as a consultant to other health care providers, most notably other sychologists, has been remarkably expanded. am able to’ provide information regarding ‘medications, their doses, interactions and side effects, to psychologists formulating treatment plans. My new understanding of how medications, psychoactive and otherwise, and medical illnesses and procedures affect my patients now allows me fo place their problems in a true biopsychosocial perspective. My role as a teacher has grown—during my doctoral tin: ing, and that of most other psychologists, knowledge of clinical _psychopharmacology ‘was acquired incidentally, without any type of formal instruction. What was once acquired ‘off the cuff’ can now be incorporated formally into training programs for interns and sti- dents, making them better informed, and therefore more able providers.” “"My role as an educator to patients has grown. 1 can instruct patients in the risks and benefits of pharmacofogical intervention and assist them in becoming educated consumers who ‘can make the best possible decisions regarding. their treatment options. My role as a student "There was joy-and a good amount of pain- in learning psychopharmacology, but I believe the experience has benefitted us both.” continues—as I strive to keep abreast of devel- ‘opments in psychopharmacology and, most ‘importantly, in techniques of integrating psychotherapy and pharmacotherapy and ‘accurately assessing the outcome.” “During our taining, John Sexton and 1 repeatedly stated our belief that the acquisition prescriptive authority would not change our identity as psychologists, but like any special- ‘would add new skills to our professional practice. We have seen this rediction amply born out. We have not some ‘pharmaceutical vending machines’ as some have predicted. We have become more comprehensive providers, able to provide a more complete ange of services when appropri- Ble, without disturbing the el cate therapist-patient relationship from which stems all positive change in psychotherapy. We would urge interested state and or local associations to invite John or Morgan to address their membership; we can assure the readership that “an interesting time will be had by all.” If there is any question as to whether organized psychiatry has noted the PDP, just read their literature—for example, their President's column: ”..he more you know about this program, the more outrageous, wasteful, and Shameful it becomes.” [May 5, 1995] The APA Council of Representatives Has Spoken! Historically, it has not been APA policy for the Council of Representatives to take a specific position on the appropriateness (er lack there of) of any particular cfinical (or for that matter, educational or research) technique instead relying upon the more generic policy guidance that pychologists should be sensitive to the potential limits of their training. Nevertheless, those concemed about the prescription priv lege movement have argued (sometimes quite vocally) that such a stance should be taken before any legislative or educational efforts are made. In their judgment, obtaining prescription privileges 1s qualitatively different, for example, than providing biofeedback care. Accordingly, during the New York City annual convention, in recognition of California’s ongoing legislative efforts, the Council of abRepresentatives voted by the necessary two-thirds margin to suspend the rules and take up Jerry Clark's new business. item. During the debate, which lasted approximately one and a half hours, motions to strike any reference to legislative advocacy and to require 2 post-doctoral focus were defeated, with the Council ultimately voting overwhelmingly to orenffirm as policy its 1886 acceptance ofthe following resolution: The practice of psychology encompasses the observation, assessment, Gr the alteration of Behavior and/or concon tant physiological functioning through behav ioral procedures. ‘The techniques eons effect such alterations include both physical as well as_ purely psychological interventions applied by psychologists operating within the limits of individual training and experience. “in taking this action, the Council specifically notes that the practice of paychology includes the use of physical as well as psychological interventions when such interventions are (a) in the consumer's interest, and (b) within the training, experience, and. competence of the attending psychologist. Specifically, this current action contemplates and supports ‘Association activities in seeking prescription privileges for psychologists. Such activities include, but are not limited to, support and assistance for the development of appropriate training curricula and training pro- Grams, support and assistance for legislative advocacy, ete “Council directs the Committee for the ‘Advancement of Professional Practice, the Board of Scientific Affairs, and the Board of ra iaie to, evelop comiculumy eyond the professional psychology core) an ‘Rodel legislation to implement the process of preparing psychologists to prescribe.” ‘Those of us who support the prescriptive priv- lege evolution owe a great debt of gratitude to California's visionary leaders— Jerry Clark, Elsie Go Lu, Chuck Faltz, Steve Olmedo, CPA President Helene Feldman, and, naturally, Rog Wright. Simply stated, without their leader ship, perseverance and dedication, we would never have progressed this far in such a relatively brief period of time. In reflecting upon this year’s advances, however, itis instructive to reflect upon the policy recommendations of the past. In 1981 current Ohio Psychological Association President David Rodgers published a proposed model psychology licensing act which Frould have provided individual sate licensing boards with the authority to allow psy- chologsts to prescribe. At that tine David specifically noted the probable controversial nature of prescriptive authority—talk about being ahead of one’s time! In this light, we would note a more recent arti- le published in the Ohio papers, entitled No {slation, in which the President of the Academy of Medicine of Cleveland expresses the view that: “It is premature to expand the scope of practice of APNs (Advanced Nurse Practitioners) or to grant them independent authority to prescribe drugs as proposed...until these nurse pilot programs have been critically and objectively evaluated.... Physicians recognize the important role ‘APNs play in healthcare. They serve ay vital ‘members of the health care team. Advance practice nurses are particularly important in the evolving integrated medical care system. Physicians support the proposition that APNs. Gan, provide needed services, to, patients Legislation, however, that would establish a nebulous practice of medicine without proper and safe protocols, done in the name of Cost-containment and access, is uncon scionable, High-quality care must be available to all citizens, regardless of setting and econ nomics... Its in the best interest of the patient that individuals who have not attended med= ical school, who have not passed the appropri= ate state licensure examination and who have! not successfully completed a rigorous resicien- cy traning program, practice In an. envio ment that is'safe and supervised. Practicin medicine is a privilege that is eamed an maintained through education, not legisla tion.” The readershi 4 thologist” for "APN, ublic health/public ‘hazard argument, an Ralize as Past-APA President Ron Fox kee on pointing out: “They (medicine) are simp! amazing, they do not change. They keep mak: ing the same old arguments...” Hopefully, we will lean; although its of inte est that this year the Association of State ani Provincial Psychology Boards has on its p gam agenda a DEBATE ented "Preseripi ivilees: Implications for the Practice Regulation of Psychology.” Hawaii's Ongoing Efforts Ray Folen reports: “The veterans of the Haw: 12Prescription Privilege Task Force were very pleased to be present at the annual meeting of the APA. The overwhelming vote of the Council in support of prescription privileges and its active encouragement of state level advocacy towards this goal was gratifying. We in the state association legislative trenches now have the support and endorsement of our national organization, something that will def- iutely help in the legislative intaives to fol low. “The APA resolution set the stage for the convention symposium on prescription privilege training models chaired by Glenn Ashkanazi of the University of Missouri A variety of models, remarkable more for their similarities than their differences, were presented by Hawaii, Missouri, California, Alberta and CADP task groups: The number of proposed didactic training hours ranged from 200-300. ‘Additional supervised experiences to follow the didactic training also were recommended in each model.” “Of particular interest was the prosentaion of the Alberta model by Louls Fagliaro (Ph.D, Pharm.D.), the author of more pharmacology books thant anyone else currently living in the westem hemisphere, He argued persuasively that, based on his many years of experience training health professionals, 200 hours of didactic training (100 hours through self-study) followed by several months of supervised experience, was more than sulfi- cient for psychologists to prescribe safely. ‘vJohn Sexton, one of the first two graduates of the PDP, reported on the proposed CAPP Task Force model of curriculum of approximately 300 didactic hours followed by a supervised experience. component. John, subsequenty indicated that a 250 hour model was possible. OF surprise to many was the fact that the appropriateness of a reduced didactic trainin model has also been recognized in the Dol program. This ‘training of the trainers’ initia- Everhas reduced didactic hours by almost 50%, down from a high of 1300 hours. “Hawaii and Missouri, probably as different as. two states can be, proposed very similar training models of approximately 200 hours (mixed classroom and self-study), followed by supervised experience. "Some modification, i expected in both programs, though, to tabk inline withthe et tobe Bnalized CAPE ‘model. Inall, there were more than 10 sessions at the convention on prescription privileges—an idea whose time has clearly come! “The Hawaii Prescription Privilege Task Force hat drafted legislation that wil be submitted at the opening of the 1996 legislative session in January, with a positive outcome expected this third go-round. In addition, the Hawaii prescription privilege training program, ‘Medication Management for Psychologists, is gett begin ths Fal ag soon as CAPP put tt final ‘seal of approval’ on a proposed model curriculum.” Reflections (One of the advantages (or perhaps challenges) ok working on Capitol Hills that one becomes systematically exposed to an extraordinarily wide range of information that frequently crystallizes one’s thoughts in ways that are totally unexpected: Our personal support for psychology obtaining prescription privileges Ealvanised in this fashion and, most secently, ‘We have gained an appreciation for the extent to which federal Medicare policy can signifi cantly impact traditional state retmburseinent lecisions. Psychology worked very hard to be recog- rived under Medicare. This was truly 2 major victory and has opened the doors for us to deemed one of the true health care professions. However, as our nation’s health care costs continue to escalate faster than any other segment of our economy, legislatures af both the federal and state Jevel ae strugging t find viable solutions. This past legislative session, the Hawaii legislature modified its Workers’ Compensation Act to directly link its fees with the Medicare Resource Base Relative Value Scale (Hawaii’s payments are now not to ‘exceed 110%), thereby resulting in a projected 40% reduction. We also are aware that University counseling centers are beginning to have to “justify” their existence in the face of ‘managed care competition. At times like this, it is unfortunately somewhat difficult to remember how meaningful our services can really be to society. Correspondence regarding this columm should be addressed to Dr. Pat Deleon, clo Senator Inouye, US Senate, Washington, DC 20510.AEDICAL PSYCHOLOC Non-disabling Disorders: Treatment of Chance vs. Treatment of Choice David B. Adams Dr. Adams is been a contributing eto to the Peyhotherepy Bulletin for nine yeas. He is a Fellow of the Actdemy of ychosomatic Medicine and sts on the Adesory Board ofthe Prescribing Psychologists Register. He serves on the edioiel board of multiple scientfc journal, is the author of greater than sixty articles and chapters on the interface betceen pay- chopathlogy and pathopiysology. Dr. Adams is the cncel, Alrector of Atlania Medical Psylology which consult to corpo rations regarding psychological factars affecting physical conditions and violence inthe workplace. Pathoplasticity There is pathoplasticity in the expression of mental disorder as there is variability in the expression of orthopaedic limitation, viral illness, sensory deficit or any other compromise to health, While the concept of individual differ. ences is often verbalized, itis infrequently used to further the understanding of the patient. It is an artifact of the irrationality of the human animal that everyone seeks to be unique, read- ay eecting most categorization processes, Ye that ‘same’ individual wishes their physical symptoms to immediately indicate a known diagnostic entity for which treatment is immediatel available. Thus, a_patient will While the concept Some will have bacteriologic complications to what would have otherwise been a self-limited viral illness, and others will zecover with no discernible sequelae. In effect, the concept of pathoplasticity conveys the realization ‘that even with the same disease process, no two patients are the same. However, pathoplasticity also implies that there will still be some commonalities, and ‘most humans, without training, can readily recognize the symptoms and signs of an upper respiratory infection, gastiis, muscle stain and a host of other mild health concerns. Such Giagnostic understanding is taught early im life- Children are taught to label their symptoms, and the media provides a host over-the-counter and otlter conservative mea sures to deal with symptomatic relief Ease Of Diagnosis An individual training to understand _m: anxiety or somatoform disorders, regardless the prevalence of such conditic ismore problematic If theresa exposure to information regar the latter disorders, the accept radiologic diagnostic, con- of individual is too often in the form of di Paychodiagnestc implications of Aiferences is often Paraging, humor on, theo personality assessment. verbalized, it is infre- motion for inpatient care on Major depression has often been referred to as the most common of all mental disorders; the “common cold” analogy is often used. While it is anticipated that there will be common symptoms in a. viral ‘upper respiratory infection, it is also expected that no two patients will have the precise symptomatology arising from the infection and not necessarily the precise course of the illness. Some patients will have gas- trointestinal complaints, some will have causalgia, and others may have diffuse muscu- loskeletal symptoms. The timeframe of recov. ery may vary between twenty-four hours for Some patients and several days for olhers 14 quently used to further the understanding of the patient. other, An individual, thereby, mi readily reach physiological ai educational maturity without capacity to recognize sympto and signs of mental disorder self or others unless those indi are s0 blatant as to obviate the being ignored. Sleep disord sexual dysfunction and some substance-t ed disorders lend themselves to read learned diagnostic assessment, skills ca by many people without formal training. It when the disorder is defined by a range symptoms, and within that range pathoplas ity of expression exists, that differential di nostic assessment becomes complex.Not all patients with major depressive disorder, acute stress disorder, or somatization disorder will have identical symptoms. While depressed patients must meet the current diagnostic criteria that differentiates between major depressive disorder, dysthymic disor der, and adjustment disorder ‘Ww ressed mood, not all patients diagnosed with major depressive disorder will have sleep distur- bance, significant weight change and for recur- rent thoughts of death. Indeed, far too many Individuals, with major depression are, not diagnosed because their symptoms include low energy, anhedonia, indecisiveness, agita- tion, and feelings of worthlessness that are not as readily observed (and which may be difficult for the individual to verbalize). There is variability in the expression of the disorder among individuals and even clinicians seeing the patient may interpret the symptoms as fatigue, boredom or situational “stress”. The later being especially problematic since the stress may be a result rather than a cauise of the symptoms the person is manifest ing. Disability Similarly, not all clinically depressed patients are equally impaired by their symptoms. It is more than theoretically possible for a patient to show significant Weight loss, manifest difficulty with sleep maintenance, display anhedonia and to feel worthless, guilt-laden and preoccupied with thoughts of death and fo remain undetected by either friends, family oF the health care system. To determine the level of disability a patient experiences from irritable bowel syndrome can, be a complex process. The presence of the symptoms themselves does not determine the functional capacity of the patient. Some patients will work while having a urinary tract, infection; others will fail to show for work for several days with even the mildest of upper respiratory tract infections. There is not a lin- ear relationship between all disorders and levels of disability. Hemiplegic patients, schizo- phrenic patients, and patients with metastatic disease can remain productive although limitations may need to be objecticely defined to insure productivity continues. Determining the level of disability manifest by an individual is not, in most cases, synony- Determining the level of disability manifest by an individual is not, in most cases, synonymous with determining diagnosis. ‘mous with determining diagnosis. To simply determine that a patient has bipolar disorder ‘or systemic lupus erythematosus does not create ‘an automatic disability determination. However, many psychologists respond as though determining that their patent has dysthymic disorder, ‘specific phobia, and/or hypochondriasis, or any of a myriad of other ps¥chological disorders, itself determines the disability level and functional capacity of the patient. Simply, diagnosis and disability are related determinations but are not identical determinations. To have someone in treatment for acute stress disorder does not mean that this patient is incapable of work or that the patient's best treatment needs are necessarily ‘met by equating diagnosis and functional inca pacity. Functional Incapacity In the diagnostic area. of health care referred to as disability deter- ruination we have an increasingly complex psychosotial economic problem emerging. If a patient is eligible for, or receiving, short term or long term disability benefits for the manifestation of symptoms and signs of mental disorder, can the psychologist remain scien: tically grounded and” base the decision as to the patient's disability on empirical measures? Will the doctor instead be (a) vulnerable to the complex countertrans- ference ues of wishing to assist the patient in maintaining viable income, (b) further disabling the patent by amplifying the patient's estimation of the impact of symptoms, (0) creating within the patient a concept of productivity eroded by a competing concept Sen ea ase extending a period of nonproductivity, inad- vertently creating additional family and eco nomic intricacies which are not then readily resolved? The salient concern for the doctor must be a combination of both scientific acumen and socioeconomic philosophy. The psychologist must determine early in practice: 1. the economic basis of society, and how it best survives 2. the concept of productivity of the individual and the level of self-accountability 153. the role of society in providing support for retum to productivity 4. the structure of a Society with members unable to serve a productive role 5. the need to insure that this Socioeconomic philosophy is consistently applied, understood by patients and is not vulnerable to the psychologist’s own economic strivings. of health ci increasing! The latter consideration, the economic aspirations of the doctor, are arguably the most roblemat, icf Ihe patient is Being seen only when determined to be dis- abled if funds aze avallable for sychological care only because of disability Seterminstion, and ithe patent wil leave the practice if seen as capable of return to work With restrictions, can the psychologist comfort ably and objectively determine thatthe patient is capable of full or partial duty release? In toto, the question which is increasingly being asked by concerned administrators of In the diagnostic area to as disability deter- ‘mination we have an psychosocial economic problem emerging. disability programs is whether a psychologist aces disability determination ugon scientifically determined _ psy- chopathological indices and true functional, capacity ‘concerns ox instead, whether the psychologist bases disability determination deci sions upon economic incentives related to a complex and competi- tive marketplace. If the lay public is to be expected to learn to recognize the symptoms and signs of the more common psychological disorders, then the psychologist must be expected to “recognize personal socioeconomic philosophies which may impact diagnostic decision ~ making. sare referred ly complex Correspondence regarding this column should be addressed to Dr. David B. Adams, The Medical Quarters, Suite 251, 5555 Peachtree-Dunwoody Ra., Atlanta, GA 30342, ‘We already have 500 signatures, but we need 200 ‘more signatures of APA members to present our application for a division to the APA Council, If you agree with us that there is a need for such a division and you would be interested in joining it, please sign below. Our purpose starting this divi- 1) To encourage US psychologists to meet and lear about psychologats in biker counines 2) To publish a bulletin for all members and associate members. 3), To assis Psychologists doing intercultural esearch to fet to bro ajcolgits nies cumin eae ibontén eis 4) To discuss psychological assessment and treatment ‘models as they’ are practiced and exchange ideas with linial psychologist abroad, 5) For those of our members who are travelling abroad: to find opportunities for meeting Psychologists tn the country they are visiting, © plan to give fetuses, OF workshops, Sign Up For Starting An International Division Of Psychology! 6 Tohear from psychologists abroad who ae interested in visting US universitcn want to give lectures or walk shops, oF ae looking for temporary placements 7) Tomake contact with psychologists when planning to attend conferences abroad orto he the “eontect person” for psychologists visting the US cami Steering Committee: LL. Adler; E.G, Beier; FM. Culberton; Hi David: FL. Denmark Tam an APA metber or fellow and wish to support the establishment of an APA division of ‘International Psychology, and agree to become a member of this new division upon its establishment. Print Name and Address Signatur Return to Ernst G. Beier, PRD. Dept. of Psychology, ‘University of Utah Salt Lake City, Utah 84112, Tel and) Fax 801 355 7501, 16FINANCE Economics of Psychotherapy and Psychopharmacological Training Jack G. Wiggins Dr, Wiggins isa Past-Presdent of APA and Dison 29. He is «1 memiber ofthe APA Finance Comte, Election Comittee, the College of Professional Peycology and the Investment Committee. He is also a member of the Council of Representatives. Dr Wiggins maintains a practice in Cleveland, hia. The APA Council authorized the development of curricula for prescriptive training at its August meeting. The Council decision ‘was not just the product of APA internal business. It is a global phenomena, Prescriptive authority for psychology is also being considered in Argentina, New Zealand and South Africa. This will impact both practice and research as well as the education of psychological psychotherapists. It will also affect the incomes of practitioners and ulti mately those of educators. This is an effort to examine some of the implications of this deci- In 1992 the American Psychiatric Association ‘commissioned a study of the financial impact of managed care on the practice of psychiatry. It was reported psychiatrists whose practices are based on psychotherapy would have incomes only 1/3 as much as those of doing medication case management. This finding should be alarming to psychologists. If doctor. ally trained psychologists have to compete with non-doctoral level counselors, psychologists’ incomes will be reduced unless they gain Prescriptive authority, This has been a Hard jact for many practitioners to accept. It is time we prepare ourselves to prescribe rather than protest marketplace decisions. Our task is to setve the public rather than preserve the status quo. It took nearly 20 years for psychotherapy to be a standard of graduate training. It must not take this long to obtain pre- Sefiption privileges if peychology isto remain part of the healthcare field The practice implications of prescriptive authority can be examined from Sturm and It is time we prepare ourselves to prescribe rather than protest marketplace decisions. Wells report that counseling rather than med- igation ‘reduces functional limitations ‘of essed patients. Yet, antidepressant med- Scaions used in conjunction with counsel enhances the effects of counseling by as muck a5 50%. They compared treatment outcomes of psychiatrists, general medical physicians, and other mental health specialists (mostly psychologists). They found depression could be treated effectively by the other mental health cialists at 70% of the cost of psychiatrists when appropriate antidepressant medications. were available. They also found that use of anti-anxiety medications actually increased functional limitations with depressed patients. The general medical doctor’s treatment of depression used psychopharmacological intervention and less than 3 minutes of counseling, Their treatment results were only about half as effective as the other two groups, ‘The cost of removal of one functional limitation was approximately $1000 for the combined treatment, while the cost benefits were a $2000 to $3000 increase in family income. The public policy implications are that when the combined treatment approach is used the tax revenues on these additional earnings offset the cost of treatment in approximately 3 years! Such a quick return on fnvestment would be onsidered a high yield or growth industry by The success rate of the combined psychotherapy-psychopharmacology approach of 68%, reported by Sturm and Wells, is comparable to those reported for psychotherapy alone. Wexler and Ciccheti reviewed three studies comparing success and failure rates of ay- chotherapy, psychopharmacology and the combined approach. They also analyzed the findings of five other studies comparing success and discontinuance of treatment’ rates where only two treatment methodologies were evaluated. Using very sophisticated statistical analyses they concluded that psychotherapy was more potent than psychopharmacology in 7 4pT Seog a Ey Sm aan Coal in Oa Erlning it peychology st and then in poy- Heute, Geren plats Ome chophatmacology. To accomplish this it willbe Reyer Cine Practice, 19) Te outa of New pecenyice pena to! Lene rmcirea a =e os ; ee federal agencies for training is. The rrespondence regarding this column should be a fo training Soman has established that psychol- Dr: Jack Wiggins, 7097 West 130th Stet, Cleelid, Ot ogists an be tained to use peychopharmaco- logical treatments successfully and safely. It is in the public interest to obtain federal and state Seciaie ee ee meet the needs for mental health of an under- served public. References Boll, PE, Digman, RH and McKenna, JP. Should Psychologists Obtain Prescription Privileges? A Survey of Family Physicians, Proessional Peycology: Research and Practice, 1985, Vol. 26: No. 4, 371-376 Kroenke, K and Mangelsdorf, AD._ Common Symptoms in Ambulatory Care: Incidence, Evaluation, ‘Therapy and Outcome, 1989, The American Journal of ‘Madiche, VOL. 86, 252-266, Sturm, P and Wells, KB. How Can Care for Depression Become More Cost-effective, Journal of the American Medical Assocation, Jan. 4, 1998, Vol. 273, 51-58. How to Reach Your Clients in a New Way De Jon Jnraton Dall based inkl peychologst is figling the gma often asada with payehosheapy in ‘an innovative way—and she needs your help. Her upcoming book, Lescns From the Other Side of the Couch, is &Col- lection of stoi writen by mental health professional iting various esos they have eared rom ther ches and hhow they applied them to their oven life. She would like to hear your story. Why should you take the time to write a lesson that you have learned? Dr. Johnston believes that, in this time of professional upheaval, now is the time to renew our intrest in what we know and, for the general publi, to create an interest in what we do. It also gives usa chance to reflect not only on the challenges our ellets presen, but also on the strengths and assets that many of our clients bring to the therapeutic process. ‘Whitten érom the therapist's perspective, each story will focus ona lesson you leamed from a client—whether itis an insight, behavior change, a coping strategy ora different perspective. She is looking fora diversity of stories, particularly storie that touch the reader's heart or promote behavior change in some way. ‘The story may be inspirations, ‘humorous, heart-warming, heart-wrenching, or educational. The lesson is up to you. If your submission i selected, you will be credited asthe author or contributor anda short biography on you and your practice will appear atthe back ofthe book. In addition, a portion ofthe book's proceeds will go to a mental health charity. “This books targeted to lay audience (please avoid professional jargon) and will consist of shot stores (between 300 ‘and 1500 words, approximately, 1 10 5 typed pages). The deadline for submission #s December 31. The submission ‘must not have been published or under current review by any other publication. An independent review process will setermine the final selection. Mail submissions to: Joni E. Johnston, P 3519 Dickason Avenue, Suite 100 Dallas, 1X 75219 Fax submissions to: 214-521-4791 (it rings six times before it picks up) For further information or sample stories, call: 214-521-7715Outcomes Measurement and Empirically Validated Treatments: What's All the Fuss About? Ronald F. Levant Ronald F. Levant, Ei.D., AB.PP, ise Member-At-Large ofthe ‘APA Board of Directors, He ‘was the Chair of the APA Committee for the Advancement of Professional Practice (CAPP) from 1993-95, an « member ofthe Board of Directors of Division 29 (1991-94). He iin Independent Practice in Brookline, Massacluselts, and Clinical Associate Professor of Peychology, Harvard Medical School (Cambridge Hospita). One thing is certain: We practitioners are going to have to become more knowledgeable about clinical science in order to understand, participate in and influence the dis- course that is swirling around us in regard to such issues as “Outcomes Measurement” and.“ Empirically Validated Treatments” (for exam- ples of recent writings on this topic, see: Barron, 1995; Division 12, 1993; Kovacs, 1995; Schlosser, 1995; Smith, 1995; Taylor, 1995; Wiens, et al, 1995).’ 1 will use this issue's column to do what I can to clarify some of the issues, It should be noted at the outset that these two concepts, while both arising from the same source — namely the long and venerable tradition of psychotherapy out. come research —have taken on somewhat dis- tinct meanings. “Outcome Measurement” is @ business term used in the health care industry to denote the assessment of quality of care. “Empirically Validated Treatments” is a polit cal term employed by the clinical scientist camp to advance its agenda of playing a larger role in determining the direction of professional practice Outcomes Measurement As the health care industry has consolidated over the past several years, the aggressive emphasis on cost control has brought about a realization among purchasers of health care that quality matiers tremendously, and that without some way to measure quality, it is Impossible to assess the value of competing 20 wit is clear that the outcomes of health care are going to be measured, and, further, that outcomes measurement is going to play an increasing- Ty important role in holding providers and health plans accountable, health plans. The existing industry standard, the Healthplan Employer Data Information Set (HEDIS), offered by the National Committee for Quality Assurance, is widely used by US. ‘corporations. HEDIS covers the waterfront in terms of health care, but yet from our perspective is limited because it devotes little attention to mental health, Recently a group of major employers and government ‘off cials, spurred by the Jackson Hole Group(of”Managed Competition” fame ), formed the Foundation for Accountability, ‘whose mission will be to improve upon outcomes assessment.’ This group is taking a disease-specific approach to measurement development, and includes depression among its initial 4 ~ 6 targets (Prager, 1995). Hence it is clear that the outcomes of health care are going to be mea sured, and, further, that outcomes measurement is going to play an increasingly important tole holding ‘providers and_ healt plans accountable. “What is not clear is hot this process is going to develop in regard t mental health, and to what extent its ultimat form will reflect an enlightened perspective o psychotherapy. Part of the problem is th American Psychology is in deep conflict abor ‘many facets of this Process, so that an enlight ened perspective, consensually shared amor practitioners of all stripes and clinical. scie lists, has yet to emerge. A central problem, on creating a lot of confusion at present, is matter of Empirically Validated Treatments Empirically Validated Treatments Under the leadership of David Barlow, Phi then President of APA Division 12 (Clini Psychology), a task force was constituted consider methods of educating clinical p: chologists, third party payers, and the putabout effective psychotherapies” (Division 12, 1993, p. 1). The Task Force Report proposed criteria for establishing efficacy, and published a list of eighteen “well-established treatments,” and seven “probably efficacious treatments.” Quite apart from the problems of standards of care and legal liability that this report may create for practitioners by fosterin, the illusion among third party payers and mal- ractice attomeys that only’ those treatments listed have validity (Kovacs, 1995), there is another serious issue there — and that is the matter of treatment manuals Treatment Manuals ‘The criteria proposed by the Division 12 Task Force rest on a particular approach to the assessment of the outcome of psychotherapy, namely the reliance on treatment manuals. In this approach, both assessment and treatment are fully specified and standardized, and reduced to a set of protocols. There is a certain face Validity to this approach, in that it fosters the specification of the treatment and facilitates-replication. Furthermore, there appears to be consensus among clinical scien- tists that the treatment manual approach constitutes the “state of the art” of psychotherapy research. Problems With Treatment Manuals However, the treatment manual approach con- tains serious problems, some of which are beginning to be discussed (Barron, 1995; Kovacs, 1995; Smith, 1995). First, there is the bias in favor of behavioral and other short-term approaches, which lend themselves to treatment specification and manualization. Thus it is no accident that the overwhelming majority of the _ eighteen “well-established treatments” published in the Division 12 Task Force Report are behavioral or cognitive-behavioral. Psychodynamic treatments weigh in only as “probably efficacious.” The Authors of the Task Force Report recognize this problem but attempt to solve it by urging psychodynamically-oriented clini- al researchers to become more like behavior- ists and develop more clearly specified treatments and mantuals. second al approa roblem is that the treatment manu- tends to focus on the treatment of wuthe treatment ‘manual approach tends to focus on the treatment of fairly delimited problems. fairly delimited problems. While this is under- standably necessary for research design purposes, it severely limits the generalizability of the research. The focus on delimited problems does not adequately represent the work of actual practitioners, who every day face much more complex problems, incfuding co- mor- bity of substance abuse with affective or anxiety disorders, other forms of dual diagnosis, and Axis II diagnoses. A third problem concems the old idiographic — nomothetic polarity. Practitioners tend to be idiographic:. They typically tailor their treatment based on an ongoing, often theory-dri ven assessment of the patient. Treatment manuals are nomothetic: ‘The manual specifies a particular protocol to be followed for patients With a particular diagnosis. Iti true that more sophisticated treatment manuals do allow for the individualization of treatment. However, there is little room for effective individual ization. Lam indebted to Persons (1991) for this insight. She has ointed out that outcome studies sased on treatment manuals typically use standardized, atheoreti- cal methods of assessment, such as the DSMCIY, and, further, tend to arate the assessment’ process form the delivery of therapy, thus making it impossible to individualize the treatment based on an ongoing, intervention-relevant assessment of the patient's problems. Finally, there is a subtle science-centric bias built in to the treatment manual approach, which is seen in the way that it fits the professional world of the clinical scientist, but does not take the world of the clinical practitioner into account. Professional status for the clinical scientist involved in psychotherapy research is customarily earned by accruing ications that evaluate the outcomes of a \eoretically-based treatment. This process is greatly aided by utilizing treatments that are Suiictently specified (i.e. inthe form of teat ‘ment manuals) that they’ can be implemented by advanced graduate students supervised by postdocs (or some variant thereof). However, the fruit of the researchers! labors is not useful to seasoned practitioners, who, unlike the graduate students following a protocol to treat a sharply delimited problem, tailor treatment based on ongoing assessment of their patients who often have multifaceted problems that are poorly captured by a DSM-IV diagnosis. Is it 21PRAC ONER REPOR’ Outcomes Measurement and Empirically Validated ‘Treatments: What's All the Fuss About? Ronald F Levant Ronald F Levant, EAD., AB.PP, ip Member-At-Large ofthe ‘APA Board of Directors. He ‘was the Chair of the APA Committee for the Adcancement of Profesional Practice (CAPP) from 1983-95, ana « member ofthe Board of Dirctors of Ditision 29 (2991-84). He i in Independent Practice i Broalline, Massachusets, and Clinical Associate Professor of Peychology, Harcerd Medical School (Cambridge Hospital. (One thing is certain: We practitioners are going to have to become more knowledgeable about clinical science in order to understand, participate in and influence the dis- course that is swirling around us in regard to such issues as “Outcomes Measurement” and ” Empirically Validated Treatments” (for exam- ples of recent writings on this topic, see: Barron, 1995; Division wit is clear that the outcomes of health care are going to be measured, and, further, that outcomes measurement is going to play an increasingly important role in health plans. The existing industry standard, the Healthplan Employer Data Information Set (HEDIS), offered by the National Committee for Quality Assurance, is widely used by US. corporations, HEDIS covers the waterfront in terms of health care, but yet from our perspective is limited because it devotes little attention to mental health. Recently a group of major employers and government off sials spurred by th Jackson Hole Group(of”Managed Competition” fame ), formed the Foundation for Accountability, whose mission will be to improve upon outcomes assessment. This group is taking a disease-specific approach to measurement devel- ‘opment, and includes depression among ‘its initial 4 — 6 targets 12, 1993; Kovacs, 1995; Schlosser, ‘ (Prager, 1995) 1995; Smith, 1995; Taylor, 1995; holding providers and P*8° 199°) Wiens, et al, 1995).” I will use this health plans Hence it is clear that the outcomes issue's column to do what I can to clarify some of the issues. It should be noted at the outset that these two concepts, while both arising from the same source — namely the long and venerable tradition of psychotherapy outcome research — have taken on somewhat dis- tinct meanings. “Outcome Measurement” is a business term used in the health care industry to denote the assessment of quality of care “Empirically Validated Treatments” is a political term employed by the clinical scientist camp to advance its agenda of playing a larger rolein determining the direction of profession. al practice. Outcomes Measurement ‘As the health care industry has consolidated over the past several years, the aggressive emphasis on cost control has brought about a realization among purchasers of health care that quality matters tremendously, and that without some way to measure gual, i is impossible to assess the value of competing 20 accountable. of health care are going to be mea~ sured, and, further, that outcomes measurement is going to play an increasingly important, role in holding providers and health plans accountable. “What is not clear is how this process is going to develop in regard to ‘mental health, and fo what extent its ultimate form will reflect an enlightened perspective on psychotherapy, Part of the problem is that American Psychology is in deep conflict about many facets ofthis process, 0 that an enlight ened perspective, consensually shared among practitioners of all stripes and clinical sciene| tists, has yet to emerge. A central problem, one! creating a lot of confusion at present, is th matter of Empirically Validated Treatments. Empirically Validated Treatments Under the leadership of David Barlow, Ph.D, then President of APA Division 12 (Clinic Psychology), a task force was constituted “t consider methods of educating clinical ps chologists, third party payers, and the pubabout effective psychotherapies” (Division 12, 1993, p. 1. The Task Force Report proposed criteria for establishing efficacy, and published a list of eighteen “well-established treatments,” and seven “probably efficacious treatments.” Quite apart from the problems of standards of care and legal liability that this report may create for practitioners by fosteriny the illusion among third party payers and mal- ractice attorneys that only’ those treatments Fisted have validity (Kovacs, 1995), there is another serious issue there — and that is the matter of treatment manuals. ‘Treatment Manuals ‘The criteria proposed by the Division 12 Task Force rest on a particular approach to the assessment of the outcome of psychotherapy, namely the reliance on treatment manuals, In this approach, both assessment and treatment are fully specified and standardized, and reduced to a set of protocols There is a certain face validity to this approach, in that it fosters the specification of the treatment and facilitates-replication Furthermore, there appears to be consensus among clinical scien tists that the treatment manual approach constitutes the “state of the art” of psychotherapy research. Problems With Treatment Manuals However, the treatment manual approach con- tains serious problems, some of which are Beginning to be discussed. (Barron, 1995; Kovacs, 1995; Smith, 1995). First, there is the bias in favor of behavioral’ and other short-term approaches, which lend themselves to treatment specification and manualization. Thus it is no accident that the overwhelming majority of the eighteen “well-established treatments” published in the Division 12 Task Force Report are behavioral ‘or cognitive-behavioral. Psychodynamic treatments weigh in only as “probably efficacious.” The Authors of the Task Force Report recognize this problem but attempt to solve it by urging psychodynamically-oriented clinical researchers to become more like behavior ists and develop more clearly specified treatments and manuals. yroblem is that the treatment manu- tends to focus on the treatment of second al approaé suthe treatment manual approach tends to focus on the treatment of fairly delimited problems. fairly delimited problems. While this is under- standably necessary for research design purposes, it severely limits the generalizability of the research. The focus on delimited problems does not adequately represent, the work of actual practitioners, who every day face much more complex problems, including co— mor- bity of substance abuse with affective or anxiety disorders, other forms of dual diagnosis, and Axis II diagnoses. A third problem concems the old idiographic— nomothetic polarity. Practitioners tend to be idiographic:. They typically tailor their treatment based on an ongoing, often theory-driven assessment of the patient. Treatment manuals are nomothetic: The manual specifies a particular protocol to be followed for patients With a particular diagnosis. Itis true that more sophisticated treatment manuals do allow for the individualization of treatment. However, there is lit- He room for effective individualization. 1am indebted to Persons (1991) for this insight. She has jinted out that outcome studies ased on treatment manuals typically use standardized, atheoreti- cal methods of assessment, such as the DSM-IV, and, further, tend to separate the assessment’ process form the delivery of therapy, thus making it impossible to individualize the treatment based on an ongoing, intervention-relevant assessment of the patient's problems, Finally, there is a subtle science-centric bias built in to the treatment manual approach, which is seen in the way that it fits the profes: sional world of the clinical scientist, but does not take the world of the clinical practitioner into account, Professional status for the clinical scientist involved in psychotherapy research is customarily eared by accruing publications that evaluate the outcomes of a theoretically-based treatment. This process is greatly aided by utilizing treatments that are Sulficiently specified (ie. in the form of treat- ‘ment manuals) that they can be implemented by advanced graduate students supervised by postdocs (or some variant thereof). However, the fruit of the researchers’ labors is not useful to seasoned practitioners, who, unlike the ‘graduate students following a protocol to treat a sharply delimited problem, tailor treatment based on ongoing assessment of their patients who often have multifaceted problems that are poorly captured by a DSM-IV diagnosis. Is it atany wonder that clinicians have been found to not highly value clinical research (Cohen, Sargent, & Sechrest, 1986). Where Do We Go From Here? During my tenure as Chair of the APA Committee for the Advancement of Professional Practice (CAPP), the Committee dealt with these issues as a co- sponsor (with BPA and BSA) of the APA Task Force on Guidelines for Psychological Interventions. CAPP argued that the template for developin, guidelines should be broad-based, and shoul. Tecognize as evidence both the findings that ‘emerge from clinical research and the clinical Judgement of experienced practitioners. CAPP vigorously argued against a narrow positivist approach in which te independent erable in treatment research is defied in terms of an overarching theoretical perspective, and oper- ationalized asa treatment manual, CAPD pro: posed instead’ an open view of the indepen dent variable, defined as the process of thera- Py as conducted by experienced and effective Practitioners. The template for developing uidelines that was recently approved by the “ouncil of Representatives reflect to a significant degree CAPP’s efforts to shape the doct- ment The Practice Research Network The Practice Directorate, under the aegis of both CAPP and BPA, is exploring the development of a Practice Research Network, which represents one version of an enlightened view of practice, defined in terms of what we as practitioners actually do. ‘The proposed sy tem will allow practitioners to compare their practice patterns with national data and facili- tate their demonstrating to third party payers and consumers the quality of their services. of the nominee's work. Division Of Consulting Psychology Of The American Psychological Association Call For Nominations: 1996 Harry Levinson Award For Excellence In Consultation ‘The Harry Levinson Award is given to an APA member who has demonstrated exceptional ability to in sate a wide range of psychological theory and concepts and convert that integration into applicatie by which leaders and managers may create more effective, healthy, and humane organizations. award, funded by the earnings froma trust fund established by Harry Levinson and administered by American Psychological Foundation will offer a check for $1,000. Nomination dossiers should inclide letter of nomination, the nominee's current resume or c-. and appropriate supporting documentati such as letters from colleagues or clients, publications, or other evidence of the significance and imp: The proposed network will be designed t accommodate a range of measures in order faithfully represent the complexity of both the patients’ problems and resources, and of the practitioners’ methods, while at the same tim Permitting the use by practitioners from Wide range of theoretical orientations (Taylor, 1995), This is one version of an approach to outcome measurement. There may be others. A always, I invite your responce to these ideas References Barron, J. W. (1998). Treatment research: Scie economics and polities. The Independent Practitioner, 15( 9496, Cohen, L. H,, Sargent, M. M,, & Sechrest, 1. (0986). "Use of psychotherapy research by profession psychologists. American Psycholegist, 412), 198-206 Division 12 (1993). Report of Task Force Promotion and Dissemination of Paychologi Procedures. Kovacs, A. “We have met the enemy and he is us ‘The Independent Practitioner, 15(8), 135-137, Persons |. B. (1991). Psychotherapy outcome s fies do not accurately represent current models of chotherapy. American Peychologit, £60), 99106 Prager, LO. (1995, July 24). Buyers flex muscles, ‘health plan quality measures. Anerica Medial News, Schlosser, B, (1985). Ivs outcomes assessment ti The independent Practitioner, 152), 87-89. Smith, E,W. L. (1995). A passionate, rat response to the “manualization” of psychothera Peyehothorapy Bulletin, 30(2), 36-40. Taylor, G.T. (1995). Outcomes project fers pro sion an important tool. Practitioner Focus, 8 (2) 1,19, Wein, A.N, Brazil, PJ. Fuller, K. 1, & Sotomot E. (1995). " The’ practitioners new weapon: Ds Poychotherpy Bulletin, 3002), 46-5 Correspondence regarding this colunms should be addressed Dr Ronald F Lent, 1083 Beacon Steet, Suite 3c, Broo MA (D146. 22“Knowledge is Power” Arthur L Kooacs ‘Dr. Koones las heen in independent practice for 36 yee. He ‘has just completed a term asa special consullant on healthcare reform appointed by the American Peycologcal Association's Comite forthe Advancement of Professional Practice and its Practice Directorate. He is a Fellow of APA's Divisions of Clinical Prychalgy, Peychotherapy, Independent Practice, and amily Peychology and is Past-President of APA's Division of Independent Practice an also of eur Division of Peychoterapy He currently holds the post of Founding Dean Emeritus, California Scho! of Professional Prychology, Los Angele. He formerly edited the journal Psychotherapy and now sees as & Imeniber of the editorial boards both of that journal and of Both [APA's Divisions of Independent Practice and of Peycotherapy have recognized his contributions by awarding him Distinguished Professional Contributions asad, and in 1990 heroasaerded an APA Presidential Board of Directors Citation fora creer of devoted service tthe Assocation. Dr. Kovacs has published numerous papers on professional issues, on te rate {f profesional practice, on paychotherapy and ont mates rela ed fo te education and training of psychologists 1 feel quite a sense of urgency to set forth the observations that follow, for the more colleagues I may be able to help understand the social forces whipsawing the ability of psychotherapists to do the work they have been trained to do, the better. Most who read these pages are kindred spirits, yearning to participate compassionately in the myriad dramas of yaman enlightenment that unfold in our consulting rooms. Yet too many now find themselves instead frustrated by current develop- ‘ments in the financing and regulation of care. Unless we can appreciate the nature of the pro- found cultural changes in how human dis-ease is being conceptualized by policy makers, by employers of large numbers of workers, and by those who own and operate the insurance industry, we are at perilous risk for findin ourselves obsolete. As I write these works, am reminded of a wonderful Gary Larson car- toon. Tt is the annual convention of the dinosaurs. ‘The chief dinosaur is at the podi- um. He is saying to the multitude assembled, “The climate is changing, and resources are getting skimpier. But thank God we have brains the size of walnuts!” Our calling is in serious trouble because of a series of “discoveries,” “scientific advances,” and governmental /economic policy decisions that by now have been unfolding for more than 100 years, ones that have interacted inexorably to create our current dilemmas. Hindsight is always wonderful; as I review these successive nodes of transformation, I ‘hope my readers will appreciate that the developments I will briefly describe have created the mosaic in which we are now enmeshed and for which there is little prospect for imme- diate relief. Please consider the following: In 1864, the role of the syphilis spirochete in attacking cortical tissue was discovered. For the first time, this appeared to the learned of the time to be a palpable demonstration that the correct solution to the age-old riddle of the mind-body problem was henceforth to assert the primacy of biology. The “breakthrough” was the modem beginning of what the Philosophers of science have always warmed as become the reductionist fallacy, a point of view asserting that the most “real” the most “scientific” explanations for any phenomenon can only be secured through the examination of variables, interactions, and mechanisms that are postulated to be occurring at some “under- lying” level. According to the emerging model now embraced by our culture and whose roots, are traceable to the study of paresis, all that fascinates us as individual, group or family psychologists is ultimately’ only controllable and understandable at the level of biology /physiology- The isues, context, and variables of concern to us and composing our orienting models are merely epiphenomena, ephemeral froth on the “real” currents running at much deeper and more “scientific” levels. Limuts of time and space preclude my present ing the conceptual arguments that demolish the reductionist fallacy, but I assure you that this view of the relationship between what has come to be enshrined as an important canon of present day “common sense” and as constitut- ing the “obvious” relationship between “mind” and “body” is thought of as absolutely invalid logie and a poor prescription for the 23building of science by the philosophers of sci- tn 191, Freud published The Pychoathology of Everyday Life. Using slips of the tongue, trivial episodes of forgetting, and other parapraxes, Freud asserted that there is an absolute conti- nuity between the mental mechanisms that underlay the most deranged human behavior and those mechanisms that lead to simple if annoying perturbations in the life of everyone. All problematic conduct is to be understood as being derived from the interplay between the arousal of inner conflicts, the use of the mechanisms of defense, and ‘the ego's need to protect itself from acknowledging in consciousness memories and imagery that could prove to be too painfully dis Grepant from images of the self supposedly needed by each of us to Sustain our adaptations, As the century of psychology has contin- ted to-ran ts course, then, most any behavior that the culture stig- ..the collected entries in the DSM IV remain a disguised set of moral prescriptions, an empty listing of conduct and mood shamans or to the priesthood for spiritu teaching, exorcisms, moral reeducation, some stich other interventions. Other trouble mortals have been given over to a culture's physical healers who did trephining, blood le fing, or some other physical intervention “cure the problem. And in many cultures, roles have been blurred or even combined that the spiritual and physical healers have been one and the same persons. In western traditions, deep divisions have ically existed over the relative roles of priesthood and physicians as those to be leg imaled for the custodianship troubled lives. With the discover of the mechanisms believed “cause” paresis, a grand tip ov took place, and the chief respor bility for the remediation of tro blesome lives was handed over the medical profession. Yet bankruptcy ‘of this | decisi remains apparent. The chief m ical guide to the universe of care matizes, that leads to experiences now the DSM IV. It poses as ol personal distress, or that causes MAF are fo De stigma: *scienttc.” “medical” diagnos dixomfort or concern to those tized as not valued by nomenclature. In reality, howev who share lives with certain per- ie cui the collected entries in sons has come to be labeled as a "mental disorder” No longer is anyone considered irritating, trou: lesome, or eccentric. We are all ill, There is not a single citizen in this nation for whom a “mental health professional,” were hhe or she asked to provide care, could not find an appropriate “diagnosis” inthe DSMIV and tuse the diagnosis to justify beginning “treatment” and asking that some third party payer come up with furids to make such “treatment” possible. Related to both of these developments, our culture has moved over the past 150 years to settle on its own fashion another dispute that exists in all cultures. In every time and place, persons emit deviant behavior, behavior that Wanders from the norms of conduct that the ems and supports y culture, then, sorts those persons who do not conform their behavior to the prescribe templates into two pies the bad and the mad. Bad persons are traditionally held responsible for their “unwillingness” to do what is expected, and pain of some kind is inflicted on them fo punish them for the errors of their ways. Mad persons, on the other hand, are considered much less responsible. Over the centuries, some have been tured over to 24 remain a disguised set of m: rescriptions, an emply listing Conduct and ‘mood that aze to stigmatized as not valued by culture, Please remember that everythi posted to the DSM IV appears there as a res Of votes having been taken. Does any’ think, however, that the American Ch Sociely takes votes on whether or not deoxs bonucleic acid is a complex hydrocarbs Does the International Astrophysical Soci take a vote about whether or not Ganymedi ‘a moon of jupiter and whether or not Jupit a planet orbiting the sun? Yet the Amer Psychiatric Association take votes on wh forms of non heterosexual relatedness are are not a disorder, whether certain mood. sitivities that may or may not accom, female menstrual cycles constitute a psy atric problem, and whether or not women’ are abused by male mates have some ki personality defect that contributes to abuse. Moral judgements and prescriptic those forms of culturally salient conduct experience that are to be esteemed or that to be stigmatized and stamped out cl require a consensual process as embodi the faking of votes. True sciences do not: ate in such a fashion,During World War Il, the US. government elected to take draconian steps to insure that there would be no runaway inflation created by a superheated economy running at full capacity around clock. Wage and price freezes were instituted. American corporations found themselves locked into intense battles to recruit and to retain sufficient workers to meet war production quotas, particularly since lar scale mobilization had drastically curtailed the yrotker pool, ‘The traditional device available for the purpose, paying larger wages to cap- ture workers loyalty, could not be used. Some bright corporate wizard had a very creative brainstorm, however. Maybe it would be possible to give workers “benefits” that were not “really” wages and were therefore exempt from wage and price controls, Chief among these was to be the provision of health care, for clearly both employers and workers alike had a vested interest in keeping employees healthy. The invention worked: the government looked the other way and agreed to allow corporations to deduct the provision of health care as a busifiess expense our nation became cursed with a set of renewed interest in matters physiological and neurological, By the present decade, then, the American public has become totally chemical- ly dependent, About 957 of the populace ligests some kind of psychoactive substance every week — if not every day (Ihave included so-called recreational, pharmaceutical, and illegal substances in this count). The common sense consciousness is that if one does not feel gait right, some chemical should be taken ‘olicy makers, the general medical profession, managed. care companies (MCOs), and the psychiatric profession all maintain that in excess of 100 million Americans have what amounts to some sort of “neuronal diabetes”, genetically based, and must therefore remain ‘on some maintenance doses of the equivalent of psychoactive “insulin” for their “condition” if they are to function optimally. Thus, our society has by now realized Huxley’s visions, so well set forth in Brave New World. The ingestion of soma by the populace hhas become the order of the day, driven by the enormous profits {© be made by the pharmaceutical companies and by the dynamics of Wage tates foe which govern, ecg ee eaten eee ee i ey Wee lent approval would be required tions that employers, are supported by these views, Wold elated pay tree on SE Baraat eee Pvt Hefshion onhtto. Roach ete a RE In this fashion, our nation became take care of the by practitioners without so-called cursed with a set of deeply hel “mental health” training: nurse convicons tat employers, in enlthneeds ofthe practitioners intemist, family quite a paternalistic fashion, ought aaron Practitioners, OB-gyns, etc!) to take care of the health needs of workers and that all required care should be provided as close to for free as union negotiators could manage. In the late 1950's, physicians in India discovered that extracts’ of the rauwolfia plant acted as a chemical restraint on the agitated behavior of deranged persons, From this simple beginning, the psychopharmacology revolution Begin, driven by the enormous profits that the drug companies began to garner. The profession of psychiatry, previously torn as was the general culture disputes about whether or not troublesome behavior required reeducation or Phystological intervention, closed ranks hind the latter point of view as the careers of most professors of psychiatry in the nation’s medical schools came to be funded by dru; ‘company grants for the purposes of doing fie trials on proposed new medications and by a By the 1970s, psychologists across fhe nation had two decades worth of experience struggling to secure social legitimacy’ for the profession and to carve out career paths applying emerging psychological perspectives to troubled human lives. "These struggles played out in battles to secure licensure and for inclusion in federal and state programs designed to bring care to the troubled. In the decade noted, a very fate- ful decision was made. The leadership of the profession elected in 1976 to declare that applied psychology was a “health care profession”, hoping thereby to increase its perceived status and potency, to secure health insurance reimbursement dollars as the funding base for the support of careers in psychology, and to defray the expenses of access to psy ological care for members of the general public. For a decade and a half, the self-declaration appeared to work miracles. Coverage of psy- 25chological services was included in first Medicaid and then Medicare. Gradually the Tnnurance companies fll inline, and state leg- Rlanaes passed freedom of choice bills open ing insurance coverage to psychologists. “The National Register of flealth Service Providers In Paychology was founded to aid insurance cris in Hentaying those colleagues, who (were “poorly trained? to "deliver health services.” Consumers responded enthusiastical- Wy career openings expanded exponentially the ‘profesibnal school movement appeared tm the acane and began to ain and broadcast into the nation's sommes the ere por ber of applied. paychologsts. suddenly. in demand, Aid the hembership of the American Peyehologieal Association went from about 50}000 to bver 100,000 during the 19 year pert ts huled Teainly by the avlabity of heath fteurance dollar supporting eareer options Soiree eee its euming our living froth fees Bid diecty by our clghts, but we Epted for the aptum of third party Payments instend By the early 1980s, corporate ‘America began to be alarmed. Stuck with traditions, many law and union contracts that co pelled industry to provide health Care to its employees ~ and stuck ‘with employee expectations that health care Ought to be freely available and cost little or nothing for the consumer ~ benefits managers suddenly found their insurance emium costs spiraling upwards Etadizaying rate’ Each year between 1975 and 1985, the costs of care jumped upward between 14 and 22%, even though the general inflation rate in the country only. varied between 3 to 5% over the same period. In truth, medicine is the only field in which tech- nology does not eventually result in cost sav ings but inexorably contributes to layers of Additional costs.An aging population cohort and the invention of even more intricate and costly surgical, medical and. pharmaceutical interventions has and will keep fueling cost increases. At the present time, 14% Of the nation's GNP is being spent on health caze (half of it being spent to keep people alive an verage of abeut/sit more months than they would live anyhow!). And these costs, since they are mainly laid upon corporate America, make it increasingly difficult for the nation to keep the prices of its goods and services down Please note that only 7% of all health costs are being spent on so- called mental health, and only 0.7% are being spent on outpa~ tient psychotherapy! to levels necessary to compete in a global economy. Please note that only 7% of all health costs are being spent on socalled mental health and only'0.7% are being spent on outpatient psychotherapy!. Yet becauise of our mind sets arid our self declarations that we are engaged in. "health care” as we sit with clients in our con sultation rooms ~ as well as the mind sets of ‘makers who believe that we are tre mental illness” ~ we who are in truth making of ourselves a pimple on the butt of the berser health care elephant are being dragged into an increasingly unpleasant future. ‘The elephant is now sitting on us. No politician is yet willing to advocate for on of the necessary elements critical for securing rational solution to health care costs: the s¥s tematic and thoughtful rationing of care Should an 80 year old alcoholic eligible to have his/her healt an provide a liver transplant Should everyone have the sar deductibles, or should the mo affluent be ‘expected to pay mo of the cost of their own care befo the insurance kicks in? Our so ety is not ready to tackle th {ssues, relief is not in sight, $0 co porate America has. successful done a very capitalist thing # past decade: it used its enormo political clout and purchas power to force professionals int Eweat shops. The message of present “managed care” innovi tion is quite simple: work for the compas bosses for the amounts they are willing to gi you and under terms and conditions they wi Impose, or lose your capacity to work. Heal care costs are at least beginning to be < tained, but the containment is coming as result of the design of piece work struct that drive the incomes of providers increa downward and by getekeeper regula that make it harder and harder for consum to have access to care. Managed care, in eff has litle or nothing to do with care, but ev thing to do with managing costs. Federal legislation currently treat HMOs businesses. Health care is not yet viewed critical utility as is electricity of telephone vice. And very big businesses HMOs other kinds of MCOs are, indeed. |The Targest in the nation together amassed overbillion dollars in profits last year and paid their CEOs obscene salaries. are practi- cally unregulated by either state of federal legislation, encouraged and allowed to be exam- ples of rugged capitalism at its best It is not foo much of a stretch to assert that the health care industry in this nation is presently in about the same state as was the meat packing industry when Upton Sinclair wrote The Jungle at the tum of the century. Let the consumer beware of adulterated products, and let the workers beware of inhumane working conditions. In August of this year, the legislative body of The "American Psychological "Association adopted a policy statement that it was in the interest of the society and of the profession that paychologists be granted preserbing pav= ileges by the various state legislatures and that the resources of the APA would be lent to support these efforts. In this fashion, the medical- lation of psychology is proceeding tits next stage of futility as the profession struggles to rearrange the: eck. chairs on the Titanic. Given the: statistics described above about who is cur- renily writing prescriptions for psychoactive medications and waren the ‘commitment of MCOs to find the feast expensive workers (0 Carry out approved interventions, there is-no profession Sf greater sisk as we spproach the lose of the century than is the profession of psychiatry. The managed care leadership has announced that there is a 75% oversupply of ssychiatrists in the nation at the present time. Fs chology does indeed win the endless bloody battles it will have to confront in order to prescribe, this development will not rescue the profession. MCOs have a vested interest in seeing to it that nurses and GPs do as much of the care as possible, and I believe that given, enough time, even counselors will eventually be given the right to prescribe for counselors will do it even’ more cheaply’ than will psychologists. What securing prescribing privileges will do forpsychology instead willbe to transform the protession’s identity and sense of mission - for the worse! How many psychiatrists currently spend much time to clients or attempt- ing any form of behavioral experiential intervention? As a profession, we are about to go down the same road. Yet marketing surveys. conducted in 1989 and again this year by the ‘American Psychological Association have been very unequivocal. There exists in this nation a large number of troubled persons who want help and who want someone to talk to. ‘They do not want to be given assembly line care, they do not want to be medicated, and they do not want to be hospitalized. They want wise, caring, continuing compassionate guidance, and they presently see psychologists 8S the preeminent care givers who meet these criteria. And we, as a profession, are about to throw that away, abandon our client base, and. join the march fo extinction. Having had my say about the social developments in which the lives of our clients and our lives as professionals have become embedded, what are the hopes for the future? Over the short term ~ the next ten years, say ~ nothing much better is going to happen. Indeed, the prospects are grim. Managed care will become increasingly onerous and toxic as the MCOs continue to attempt to raid each others’ contracts and engage in mergers and acquisition battles. More and more Americans will come to be covered by some form of managed care insurance. Providers’ incomes will continue to 0 down. Care will continue to be denied, Groups of providers will attempt to band together, creating provider networks and taking capitation risks. Some of these will flour- ish and make their professional shareholders quite rich. Most will fail. Large numbers of Poyghiatrists and psychologists will find it ard to survive. Many will Rave to leave theit professions. When enough members of the public have been damaged by the excesses of the MCOs’, however, things will at last begin to change: A significant number of us who love the work ‘we do will exit the “health care delivery system,” ret to an earlier and quite pre- ious identity a8 applied psychologists whose work has nothing whatsoever to do with “health service,” ignores the DSMIV and medications, and we will base our incomes instead con client fees paid out of pocket for consulta- tions about life textures and meaning. Legislators will at last begin to view MCOs as utiles and move to pass regulatory lgisla- tion that will strike a better Balance between cost reduction, consumer access to care, and quality of care. Debates on how to ration care will begin. The germ of the most powerful and necessary idea will begin to blossom at last in the national consciousness - that we must finally break 27

Psychotherapy Bulletin 30 (3) Fall 1995

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