EVOLVING PERSPECTIVES

Fascinating Training Opportunities:  After having served on the U.S. Senate staff for 38+ years (i.e., the legislative branch), it is a wonderful experience to now have the opportunity to serve within a university system and specifically, the Uniformed ServicesUniversity of the Health Sciences (USUHS) of the Department of Defense (DoD).  Almost all of the USUHS students are active duty personnel, or have demonstrated a clear commitment for eventual federal service.  Recently, one of the nursing students informed me that she had already been in the military for 17 years.  To put it mildly, collectively, they are very impressive; as are the faculty.  Over the years, I have been impressed by the opportunities within the public sector to develop truly creative programs, especially within the federal sector with its considerable resources and broad responsibilities.  This past month I had the opportunity to visit theUSUHS National Capital Area MedicalSimulation Center with David Krantz, chair of the Department of Psychology.  We saw first hand their vision for psychology's training programs in the 21^st century.  A report from USUHS Professor Jeanette Witter:

            "The use of in vivo encounters with specially trained individuals, known as standardized patients (SPs), has become an established part of medical education in theUnited States.  SPs are professional actors, retired teachers, and laypersons trained to simulate specific challenges in outpatient, inpatient, and critical care settings.  The simulated patient encounters transition students from the classroom to real patient contact in safe environments.

            "The Department of Medical and Clinical Psychology at USUHS trains active duty military and civilian students to become the clinical psychologists practicing within the military and/or researchers in the field of medical/clinical psychology.  Since the inception of the clinical psychology program 17 years ago, it has trained approximately 40 doctoral level clinicians who have gone on to serve the military in a range of clinical and leadership positions.  One of the program's innovations has been to use SPs as a major component of the clinical training of the students, utilizing resources at the NationalCapital Area Simulation Center (USUHS SimCenter).  This medical simulation center is a world leader in the development and application of medical simulation programs for a range of disciplines and specialties.  In the clinical skills laboratory, consultation rooms are equipped with two video cameras and microphones to record the encounter.  An observation area at the center of the lab allows faculty and students to observe the encounters live or view digital recordings for subsequent analysis.

            "I currently direct the clinical skills courses in conjunction with Michael Feuerstein, the director of clinical psychology training.  In the first year of clinical training, students are trained to conduct comprehensive psychological assessments through academic and practical instruction.  They also receive instruction in the Foundations of Psychotherapy and Cognitive Behavioral Therapy.  Through the SimCenter, students simultaneously experience the practical application of the academic instruction they are receiving.  In patient encounters with SPs at the SimCenter, students learn how to conduct Intake Interviews, to utilize the techniques of Motivational Interviewing, to perform formal psychological evaluations, and to give feedback to patients.  They are observed in real time by teaching assistants and through videotape by their instructor, Clare Delabar, an adjunct faculty member and practicing psychologist, and they receive verbal and written feedback in supervision.  The ability to review their taped encounters allows the students to observe themselves and to see and hear the specific areas highlighted in supervision.

            "In the second year of clinical training, students begin their first practicum in the community and continue their academic and practical training in psychotherapy.  In the past two years, we have radically revised the approach to teaching psychotherapy in order to expose the students to a wider range of theoretical approaches and techniques.  Therefore in the second year of Clinical Skills Training, students take "The Art of Psychotherapy" with Leslie Cooper, another adjunct faculty member and a psychologist who works with cancer patients at Walter ReedNational Military Medical Center, the hospital with which USUHS is affiliated.  They are exposed to Humanistic Theory and Techniques with an emphasis on building rapport and listening to the patient's narrative.  Again they are able to practice techniques taught in this class with SPs at the SimCenter and to receive immediate supervision from advanced level students who serve as teaching assistants and from their faculty advisers.  Students are then instructed in Brief Dynamic Psychotherapy.  In that quarter students have the experience of conducting a course of Brief Therapy (6 sessions) using the techniques of Time Limited Dynamic Psychotherapy.  Finally, the students are instructed in Integrated Psychotherapy with Barry Wolfe, an adjunct faculty member with extensive experience in private practice in the community.  In an innovation begun in the current academic year, the three courses are linked through patient encounters with one consistent SP.  The students are introduced to the SP in Leslie's class by conducting an Intake Interview.  They then conduct a six session psychotherapy course with the patient in my class, followed by two sessions in Barry's class.  In total, the students see a single patient for nine visits with exposure to three therapeutic modalities.  This approach to training also allows advanced graduate students the opportunity to learn to supervise beginning clinicians in conjunction with the supervising faculty member.

            "The integration of hand-on-experience with didactic instruction in the risk free environment of the SimCenter allows the novice clinician to develop confidence and facility with the techniques of assessment and therapeutic intervention.  It affords the clinical faculty the opportunity to assess the students directly and to adapt instruction rapidly to the needs of individual students.  The realistic portrayal of the SPs, due to the skill of the actors and the training provided by the outstanding staff of the SimCenter, affords the students the opportunity to experience the challenges of clinical practice in a safe environment.  That the SimCenter reflects a realistic portrait of clinical work was highlighted by one student who is assigned in the Washington VA Hospital for his first practicum.  After a session in Brief Dynamic Therapy with the SP, the student, in supervision, stated: 'That's exactly the same session I had with a patient at the VA last Thursday and I didn't know what to do then either!'  With the amazing technology available to the students and faculty at the SimCenter, the student was able to receive immediate feedback on a session that had direct relevance to his experience working with 'real world' patients."

As organized psychology addresses the complex professional issues surrounding telehealth and telepsychology, we would hope and expect that the profession will learn from the actual experiences of our colleagues within the federal sector, and especially those in the VA.  Former U.S. Army Surgeon General (1996-2000) Ron Blanck, who is presently the Chair of the USUHS Board of Regents, noted over a decade ago that mental health/behavioral health professionals were the most frequent users of the Army's telehealth capabilities.  As with the visionary SimCenter, psychologists in academia and the private sector can definitely learn from our federal colleagues.  Our nation's health care environment of the future will be patient centered, feature interdisciplinary and/or integrated care, and affirmatively utilize the incredible potential inherent in the advances occurring with communications and technology fields.

A More Personal Perspective:  While transiting to a new career, I have become particularly interested in the views of respected senior colleagues who also decided to "retire." Gene Shapiro, visionary psychologist and now Professor Emeritus at Nova SoutheasternUniversity, whose U.S. Senate testimony resulted in psychology being included in the federal workers' compensation legislation:  "You asked for my thoughts on retirement.  Retirement for me was necessary but not what I desired.  My wife, Doris, needed full time help in ambulating and the drive to work, especially during rush and evening hours, became a bit frightening.  Having worked from the age of 15 to age 85, waking up without a productive goal to accomplish was difficult.  My background seemed to make retirement all the more difficult.  Having completed my B.S., M.S., and Ph.D. while I held various full time jobs, save a one year scholarship to Rutgerswhen I picked up 67 credits in the one year.  What I'm trying to say is that not working was something for which I was completely unprepared.  Fortunately, I had tennis to fall back on.  While my game is less than it was, I've been told it is excellent for my age of 92.  That keeps me occupied four mornings a week.  The problem is: What to do with the rest of the hours?  My Home Health Care Aide takes good care of Doris most of the time so I am reasonably free to do things, but what?  I found an area of interest.  Doris has been diagnosed with NPH and we have had some 'miraculous' (but limited) improvement with a very high dosage of Vitamin D.  Of course, it is impossible to pinpoint the Vitamin D effect.  I assembled a research team of very highly qualified neuropsychologists and developed a reasonable research design.  However, everyone has his/her other responsibilities and in spite of our good intentions the process is slow.  We haven't given up and will probably present the case history at the next APA convention.  My advice to everyone who asks me is: If you possibly can, never retire!"  Aloha,

 

Pat DeLeon, former APA President

AN IMPRESSIVE EVOLUTION

  On March 6, 2002, Governor Johnson signed New Mexico's HB.170 into public law, authorizing appropriately trained psychologists to prescribe.  On January 7, 2005, Mario Marquez applied for his "conditional certification."  In May 2004, Louisianafollowed suit and medical psychologist John Bolter wrote his first script on January 20, 2005.  Both the New Mexico and Louisiana State Psychological Associations had been working on their ultimately successful legislation for over five years.  When did psychology's prescriptive authority quest actually begin?  In 1984, U.S. Senator Daniel K. Inouye urged the Hawaii Psychological Association to seek this authority.  In 1972, visionary APA President, Nick Cummingsraised this possibility with his Board of Directors.  In August, 1995, the APA Council of Representatives formally endorsed prescriptive authority as APA.  By the end of 2008, Glenn Ally estimated that 200,000 psychotropic medication orders had been written by his Louisiana colleagues.  Today, now CSPP Dean Morgan Sammons postulates that between 800-1,000 colleagues have completed their formal psychopharmacological training.  The numbers are indeed impressive.

            With the passage of President Obama's landmark Patient Protection and Affordable Care Act (P.L.111-148), 32+ million Americans will soon have access to high quality, patient-centered primary care for the first time in their lives.  The President's vision calls for the utilization of the most up-to-date advances in communications and computer technology, an emphasis upon prevention and wellness care, and the steady development of comprehensive systems of care (Accountable Care Organizations (ACOs)) throughout the land.  Under previous Administrations, these would probably have been considered Health Maintenance Organizations (HMOs – President Nixon) and/or Managed Care (President Clinton).  Interdisciplinary care, comparison across diagnoses and patient populations, and reliance upon objective gold standards will increasingly become the norm.  The Administration is providing the States with sufficient flexibility to craft the health care environment which best fits their unique situations.  Within this broader policy frame of reference, I would suggest that psychology's prescriptive authority quest fundamentally represents an important evolution of the field into primary care health psychology.  And, I would also suggest that over the next decade there will be an increasing number of psychologists providing integrated care as employees in organized systems such as federally qualified community health centers (FQCHCs) and ACOs, rather than working in a traditional independent small practice or community mental health center.  Times are changing.

            As I reflect upon the professional literature over the past 25years, there have been consistent and increasing calls for the integration of mental health (now frequently called "behavioral health") services within primary care.  Whether one considers Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention(1979) or the Institute of Medicine reportHealth and Behavior: Frontiers of Research in the Biobehavioral Sciences (1982), the underlying message is very clear.  Primary care providers, with considerably less mental health training than psychologists, have been providing care for 60-80% of those with discernible mental health disorders.  Most practicing psychologists have been trained in a traditional mental health setting, pursuant to the community mental health center movement of President Kennedy' era, the psychological services organization of the VA, and/or university-based mental health clinics.  Collectively we have not been aware of the far reaching community health center initiatives of President Johnson's Great Society era, which represent the federal safety net for millions of Americans.

Those federal (and increasingly civilian) psychologists who do possess prescriptive authority have emphasized that their clinical skills are in definite demand and that their integrated skills have allowed them to clinically modify prescribed regimens of psychotropic medications more appropriately for their patients' benefit.  Within the Indian Health Service, pioneers such as Floyd Jennings prescribed with standing orders at the Santa Fe Indian hospital, New Mexico, during the mid-1980s, where quality assurance reviews of cases were quite positive.  In June 1994, APA President Bob Resnick attended the graduation ceremony for the first two Department of Defense psychopharmacology training graduates, John Sexton and Morgan Sammons. When one studies the literature for various subpopulations, such as the elderly, children, ethnic minorities, etc., the picture is again quite clear: psychologists with prescriptive authority provide the highest quality of care.

Although I have been involved in this movement over the years, it is impossible to predict with any sense of certainty which will be the next state to enact prescriptive authority legislation.  Will, for example, Hawaii andOregon be successful in overcoming their vetoed bills?  The numbers of psychologists completing their advanced training continues to grow.  As of the Fall of 2010, 276 graduates had been admitted to take the APA PEP (Psychopharmacology Examination for Psychologists) developed by the APAPO Practice Organization's College ofProfessional Psychology.  With the advances occurring in educational technology, I would expect that those on their clinical internships will soon have ready access to medication decision protocols.  Over the years, slightly more than one third of our State Associations have established task forces to coordinate prescriptive authority activities, with nearly a quarter having introduced relevant legislation.  Fundamental change always takes time; oftentimes, longer than one might initially expect.  Today, several of the States pursuing prescriptive authority, such as Arizona and New Jersey were initially considered to be among those that their leaders felt would be the "last in the nation" to undertake such action.

            Leadership changes, as does the nation's health care environment.  Looking over the Congressional landscape, it is evident that we will continue to see an increasing number of non-physician primary care providers adopting the doctoral level of training as their standard and expanding their scopes of practice to fully utilize their clinical expertise.  The right to prescribe medications by nurse practitioners and doctors of nursing practice, as well as by clinical pharmacists, for example, continues to mature exponentially across the nation and to be appropriate for their training.  They are calling for patients to have the freedom to choose the practitioner of their choice.  Sound familiar?

I am confident that psychology's leadership will appreciate the growing importance of proactive vision and action.  As the President of the Institute of Medicine has stated: "Dealing equally with health care for mental, substance-use, and general health conditions requires a fundamental change in how we as a society and health care systems think about and respond to these problems and illnesses.  Mental and substance-use problems and illnesses should not be viewed as separate from, and unrelated to, overall health and general health care (2006)."  Aloha,

 Pat DeLeon, former APA President

The National Psychologist – February, 2012