CRITICAL INVESTMENTS IN OUR NEXT GENERATION

The Institute of Medicine (IOM):  The Board of Children, Youth, and Families of the IOM will establish a Forum on Promoting Children's Cognitive, Affective, and Behavioral Health (C-CAB Health Forum).  This Forum will engage in dialogue and discussion to connect the prevention, treatment, and implementation sciences with settings where children are seen and cared for, including primary health care, schools, preschools and child care, social service and child welfare, juvenile justice, family court, military, and community based organizations, and to create systems that are effective and affordable in addressing children's needs.  A major goal of the Forum is to highlight and address gaps in the science of implementing programs and practices in the service of informing research, policy, and practice.  One necessary component of addressing implementation science is knowledge utilization of the end user or decision maker, which can be at the local, state, or federal level.  The Forum will address gaps in the science of implementation by convening a multi-sectorial group of representatives from academia, federal agencies, professional organizations, and philanthropy in an ongoing way, over three years.  This group of Forum members will decide on two workshop topics per year and work with the Academies staff to design the agendas and invite speakers and guests to participate.  Workshops can be designed to engage the users of research from state and local agencies as well as intermediaries who translate research for legislators and service providers.  Psychologist Kimber Bogard is the staff director for the IOM Board.  Those colleagues familiar with the philosophy behind President Obama's Patient Protection and Affordable Care Act (ACA) will quickly recognize how this IOM initiative nicely parallels the legislation.

            Earlier in the year, the Board issued an insightful report Confronting Commercial Sexual Exploration and Sex Trafficking of Minors in the United States, with psychologist Sharon Lambert serving as a committee member.  Every day in our nation children and adolescents are victims of commercial sexual exploitation and sex trafficking.  The report concluded that efforts to prevent, identify, and respond to this national tragedy are largely under supported, inefficient, uncoordinated, and unevaluated.  They require better collaborative approaches that build upon the capabilities of people and entities from a range of sectors.  In addition, such efforts will need to both confront demand and the individuals who commit and benefit from these crimes.  Supported by the Department of Justice, the report focused primarily on trafficking for purposes of prostitution, exploiting a minor through prostitution and survival sex – which is the exchange of sex or sexual acts for money or something of value.  The Committee based its deliberations on three fundamental principles: * These crimes should be understood as acts of abuse and violence against children and adolescents; *  Minors who are commercially sexually exploited or trafficked for sexual purposes should not be considered criminals; and, *  Identification of victims and survivors as well as any interventions should do no further harm to these unfortunate victims. 

            Numerous factors contribute to the general societal lack of understanding and awareness.  These crimes may be simply overlooked, as they often occur at the margins of society and behind closed doors.  Victims may not come forward.  And, those who routinely interact with victims and survivors may lack awareness or tools to properly identify and assist victims.  Accordingly, there is no reliable estimate of the incidence or prevalence of these crimes and many victims go without help.

The Committee proffered three fundamental recommendations and urged that those are involved and who genuinely care seek to leverage existing resources towards these objectives.  1.) Increasing Awareness – Many professionals and individuals who interact with youth -- such as teachers, health care providers, child welfare professionals, and law enforcement officials – are unaware that these crimes occur and often are ill-equipped in knowledge about how to respond to victims, survivors, and those at risk.  Developing, implementing, and evaluating relevant training activities on how to identify and assist these young victims is necessary.  Public awareness campaigns are needed, with a special focus on increasing awareness among children and adolescents to help them avoid becoming victims.  2.) Strengthening Laws, Improving Understanding, and Prevention -- Minors who are the victims can still be arrested, detained, and given permanent records as offenders.  Instead, they should be redirected from criminal or juvenile justice systems to child welfare systems or other appropriate agencies.  Sadly, individuals guilty of taking advantage of these children have largely escaped accountability.  There is an extremely limited evidence base related to these crimes, particularly related to areas of prevention and intervention, with much variability in quality.  Accordingly, the Committee called for implementing a national research agenda in order to:  * Advance knowledge and understanding of commercial sexual exploitation and sex trafficking of minors in the United States.  * Develop effective, youth-centered, multi-sector interventions designed to prevent minors from becoming victims and to assist victims.  And, * Form strategies and methodologies for evaluating the effectiveness of prevention and intervention laws, policies, and programs.   3.) Collaboration and an Information Sharing Platform is essential – No one sector, discipline, or area of practice can fully understand or respond effectively to the complex problems surrounding commercial sexual exploitation and sex trafficking of minors.  Therefore cooperation is essential.

IOM -- A nation that is unaware of these problems or disengaged from solutions unwittingly contributes to the ongoing abuse of minors.  If acted upon in a coordinated and comprehensive manner, those involved can strengthen the nation's emerging efforts to prevent, identify, and respond to commercial sexual exploitation and sex trafficking of minors.  Myth – Help is readily available for victims and survivors.  Fact – There are far too few services to meet the current needs.  The services that do exist are unevenly distributed geographically, lack adequate resources, and vary in their ability to provide specialized care.

Efforts at the State Level:  "In the Spring of 2012, in response to a request from the Governor's wife, the Anchorage-based Cook Inlet Tribal Council (CITC) President & CEO Gloria O'Neill dedicated staff time to work with service providers from various fields to develop recommendations for state action to address sex trafficking in Alaska.  As a former Congressional staffer and policy analyst for CITC, I was tasked to guide the group.  Federal and local law enforcement and state juvenile justice officials provided technical assistance.  Sex trafficking is an overwhelmingly complex issue that requires multi-sector awareness and response.  According to the literature, vulnerability, often caused by trauma, particularly child abuse and neglect, is a significant risk factor.  Alaska has very high rates of trauma in the general population.  Six trafficking cases have been prosecuted in Alaska; however, concrete action towards prevention, victims' services, and demand reduction have been stymied by the paucity of data and research.  Our group found there was sufficient national and international research and examples of action from other states to guide the development of a basic framework for action in Alaska.  The legislature, which had just strengthened the trafficking statutes and created a temporary task force on the topic, was ripe for input.  Our final product included a background report, a plan of action, and recommended statutory changes.  More than half of our group's recommendations were included in the State Task Force's report to the legislature, and some, such as a comprehensive approach to demand, and new funding for prevention and services were left out.  However, our work effectively framed the issue for policy makers and service providers in Alaska.  Recognizing our work and its impact, FBI staff has nominated CITC for the FBI Director's Community Leadership Award [Lisa Moreno, MSW]."

Because It Was the Right Thing To Do:  Reflections – "I don't remember much about the salary – in the mid-'70s we almost had psychologists paid on the same state schedule as physicians.  I believe the Director of the Department of Health did not really know the difference between psychologists and psychiatrists.  I also recall that his daughter was a psychologist.  At one point he ordered the state hospital to close one of the wards for patients for security.  The hospital did not want to do that.  I later called him to personally say 'thank you' since we were having trouble with the patients sent from the prisons and courts.  Apparently he was very grateful for the support and when the position came open as head of Mental Health he thought of me.  It went fairly well for almost two years when the hospital called me and told me not to renew the contract for one of the psychiatrists.  He was foreign trained and was messing up the medication orders.  So much so that another psychiatrist had to follow him to correct his orders.  I did not recommend the renewal.  A few days later the Director called me in and told me we had to renew the contract.  I told him the problem and explained we couldn't afford to do it.  I found out later that his family had given $20,000 to the Governor's election.  In any case, I told the Director again that the records were clear and my answer was 'no' and that just in case someone tried to change the records, I had taken a copy home with me.  I then walked out of the office and said to myself, 'I think I just resigned.'  I was right and the next week he appointed a psychiatrist to the position.  I was tempted, but never did ask my successor what he did about it.  I assume he renewed the contract.  Jobs like that are too closely related to politics for me.  I went back to my old job until '95 [Joe Blaylock, first psychologist to be appointed as the head of the Mental Health Division of the State of Hawaii]."  Aloha,

 

Pat DeLeon, former APA President – Hawaii Psychological Association – December, 2013

 

TRULY UNCHARTERED WATERS

As the nation's health care leaders anticipate the expanding implementation of President Obama's Patient Protection and Affordable Care Act (ACA), there have been increasing concerns raised at both the state and federal level regarding the availability of qualified health professionals to address the complex behavioral, mental health, and substance-use treatment demands that are expected.  Building upon the current Medicaid system, the ACA will provide for the largest expansion of mental health and substance-use coverage in a generation, with 32.1 million Americans gaining access to these services, while another 30.4 million currently with some coverage will gain federal parity protection.  Under the law, insurance offered in the new marketplace must cover a core set of "essential health benefits," which includes mental health and substance-use disorder services.  As we now move towards integrated systems of care (Accountable Care Organizations (ACOs) and Medical Homes, for example) a critical question surfaces: Does there exist today sufficient numbers of psychologists, doctors of nursing practice (DNPs), and other traditional mental health providers trained to fill this niche, or will other disciplines (such as clinical pharmacists, occupational therapists, or newly evolving behavioral health care providers) expand exponentially into this unchartered arena?  And, are our training programs even aware of the changing behavioral health care environment?

Creative Models:  Since early 2000, visionary and former APA President Nick Cummings has called for the development of an entirely new training model of Behavioral Care Providers, who would work side-by-side with the patient's designated primary care provider.  Today such a program is actively underway at Arizona State University/Mayo Rochester School of Medicine, granting the Doctor of Behavioral Health (DBH) degree and focusing upon the emerging field of integrated behavioral health.  The classes are all online, with individual supervision also online.  There is two-way internet capacity.  The program makes arrangements for field placements in each locale for each student.  They have had absolutely no difficulty in placing students, and over half the placements hired the students, upon their receiving their degree, to create or expand an integrated program in their system.  The Nicholas A. Cummings Doctor of Behavioral Health program has slightly over 300 students, with 19 full-time faculty and 37 part-time faculty.  It is online all over the U.S. with several students being abroad in England, France, Germany, Malaysia, and Dubai.  The students come together in Phoenix twice a year; each time for a week.  Five of the graduates are now CEOs of large health care systems.  Nick's title is appropriately "Founding Sponsor," reporting directly to the University President.  It is perhaps unique in combining evidence-based interventions for integrated behavioral health, behavioral entrepreneurship, and management and accountability for clinical and cost outcomes.  Nick recently received word from China that they now have an affiliation with Jinan University, the largest university in China, which is affiliated with 10 smaller universities in the region.  They will become one of the largest, if not the largest, in the category of U.S. universities applied clinical/management education and training programs in China.

At this year's Illinois Psychological Association (IPA) annual convention, under the Presidency of Beth Rom-Rymer, Keith Baird described his vision for Behavioral Care Providers.  "A consortium of behavioral care providers is forming in Illinois, Behavioral Care Management (BCM), aiming to become a large-scale organizer of behavioral care which will negotiate contracts with ACOs and others.  Our developing network will have psychiatrists, psychologists, social workers, licensed clinical professional counselors, marriage and family therapists, and addiction specialists working collaboratively to deliver a new healthcare product to the marketplace.  We aim to lower health care costs by providing ease of scheduling with our behavioral care providers.  We will offer prevention and wellness services to the 'lives' that we cover, as well as promote access to our ever growing internet library resources.  This is geared to reduce the occurrence of various healthcare problems.  In addition, 40 BCM providers are completing their certification in integrated behavioral care through the University of Massachusetts.  We will offer behavioral care solutions to patients with chronic medical conditions that have a behavioral component, such as type II diabetes, high cholesterol, high blood pressure, obesity, and other stress-related health issues.  We are also working hard to deliver competitive reimbursement rates to our providers for the traditional services of psychotherapy, psychological testing, consultation, and pharmacotherapy."

Interdisciplinary Training:  Although the ACA envisions interdisciplinary, integrative, and collaborative training and service delivery initiatives, at the operational level this is much more difficult to accomplish than one might imagine.  Breaking down historical educational silos takes time and high level administrative commitment.  Educational institutions may have "different tuition rates" for courses taught, for example, in law vs. psychology; and, different disciplines may be on different quarter or semester schedules even within the same health sciences center.  Overcoming such institutional barriers and resistance is definitely a challenge.  However, we can assure you that it is well worth the effort.  Since retiring from the U.S. Senate staff, I have had the pleasure of serving on the faculty of the Uniformed Services University of the Health Sciences (USUHS) of the Department of Defense (DoD) and fostering interdisciplinary training has become a high personal priority.  For ultimately, it will be in the best interest of the next generation of health care providers and their patients (i.e., "educated consumers").

A Personal View:  "I recently had the privilege to participate in a military deployment psychology course.  During this course, the majority of the students were psychologists.  This group dynamic was ideal to be able to communicate and get to know the unique psychologist role along with educating on my role, the psychiatric nurse practitioner.  As a student and professional it is vital to learn the different perspectives our colleagues have on the part psychiatric nurse practitioners play in the mental health arena.  Partaking in this course gave me insight on the need for educating our colleagues on what our scope of practice encompasses.  It also enabled me to put a different lens on and learn about the roles of the whole mental health team including psychiatrists, psychologists, and social workers.

"There were several topics discussed including the deployment experience, cultural considerations in the deployed environment, sexual assault, ethics, traumatic brain injury, provider sustainment, and more.  Each topic was of equal significance and essential to the military mental healthcare field.  A belief that exists embraces psychologists and social workers doing the therapy while the psychiatrists and nurse practitioners prescribe medication.  A part of this course was designed to teach a therapeutic modality, including cognitive behavioral therapy for insomnia and either cognitive processing therapy or prolonged exposure therapy.  This section validated that although nurse practitioners are able to prescribe medications, we are also able to do therapy.  More importantly, we learned how to do these therapies in the deployed environment.

"Another captivating topic discussed during this course was technology in the mental healthcare field.  Technology is constantly evolving and has become integrated in patient care.  As providers, we must stay up to date with technology to deliver the most comprehensive care to our patients.  We learned about virtual worlds to treat disorders such as posttraumatic stress disorder, and mobile apps to guide patients with relaxation techniques and deep breathing exercises.  The lines of which provider was able to deliver the best technological care between different mental health professionals were erased, and together we were taught a treatment option in providing the greatest care for our patients.

"I am looking forward to graduating and working with my mental health colleagues from every path of the academic world.  Being able to participate in a course designed for our fellow psychologists is an imperative step in working as a team.  This team will help provide the best care for those who defend this nation and their families.  We must be able to utilize every specialty and communicate efficiently within our field to deliver healthcare at its finest [Bethany Casper; Capt. USAF]."

            The IOM:  The Institute of Medicine (IOM) was established in 1970 to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public.  Acting under the Congressional charter granted to the National Academy of Sciences in 1863, it serves as an advisor to the federal government and upon its own initiative, identifies critical issues of medical care, research, and education.  This year psychology was extremely well served by the election of APA CEO Norman Anderson to this distinguished body.  This fall, the IOM Board on Children, Youth, and Families convened top experts from multiple disciplines to analyze the best available evidence on critical issues facing children, youth, and families today.  Considered perspectives were elicited from the biological, behavioral, health, and social sciences fields focusing upon the entire lifecycle of our nation's families.  Psychologists Gary Evans, Ann Masten, Pamela Morris, and former Sesame Street CEO David Britt serve on the board.  Kimber Bogard, also a psychologist, serves as staff director.

            Having worked on Capitol Hill for nearly four decades, one of the most intriguing presentations personally was that by the Director of the Washington State Institute for Public Policy, the nonpartisan research arm of the Washington State legislature.  At the request of the legislature, the institute provides detailed cost-benefit analyses on a wide range of public policy areas.  This would include, for example, legislative proposals to reduce crime, improve educational outcomes, reduce child abuse and neglect, improve mental health, and reduce substance abuse.  Express dollar consequences (costs and benefits) were assigned to various proposed preventive efforts, such as encouraging nurse practitioner home visits, over the lifetime of the program and its beneficiaries.  It reminded me of the Office of Technology Assessment (OTA) which from 1972 to 1995 provided a similar non-partisan perspective for the U.S. Congress.  The overarching theme for that segment of the meeting during which the institute director presented focused upon family based preventive interventions which reflected the critical role that the family unit can play as a key mediator for child health outcomes.  The overall panel:  * Examined science that highlights the effect of the family on child health outcomes;  * Assessed how family-based interventions could be brought to scale to sustain positive child health outcomes;  * Considered the implications of benefit-cost analysis of these interventions for public policy;  and, * Explored how the board could advance family focused science and evidence based policy to promote children's' health, safety, and well-being.  One of the underlying questions discussed was: How to "scale-up" those initiatives that were demonstrated to be effective in order to impact the largest possible beneficiary population?  An indication of the national impact the board's deliberations can have was the considerable publicity generated by the release of its subsequent recommendations addressing sports-related concussions in youth, from elementary school through young adulthood, including military personnel and their dependents.

            An Earlier IOM Report:  The critical contribution of interprofessional collaboration to quality care has been known for decades.  In 2004, the IOM released its report entitled Improving Medical Educationfor which psychologists Eugene Emory and Neil Schneiderman served as committee members.  "There are a number of compelling reasons for all physicians to possess knowledge and skill in the behavioral and social sciences.  Perhaps most important is that roughly half of the causes of mortality in the United States are linked to social and behavioral factors [citing HHS reports from 1993 and earlier].  In addition, our nation's population is aging and becoming more culturally diverse.  Both of these trends highlight the need for enhanced physician capabilities in the behavioral and social sciences."  The committee found that there was very little literature on either barriers to the inclusion of the behavioral and social sciences in medical school curricula or strategies that might be employed to overcome such barriers.  However, it was definitely felt that the importance of an institutional commitment to behavioral and social science instruction cannot be overemphasized.  That without a firm belief on the part of the medical school faculty and administration, that this knowledge and skill is an important part of a physician's education and training, their recommendations would be ineffective in producing change.

            The committee further noted that the then current structure of American medical education was adopted in the early 1900s and had not varied greatly since that time.  The basic sciences – anatomy, physiology, biochemistry, and microbiology – were introduced as a scientific foundation on which clinical practice knowledge and skills were built.  In addition, the introduction of clinical science in the context of a university constituted a significant shift from a community practice-based, apprenticeship model of preparation for careers in medicine to one in which clinical medicine was taught by full-time faculty in a university-owned or university-affiliated teaching hospital.  Over the years, however, shifts have occurred within the basic structure of medical education, including those related to learning techniques.  Today, one hears more and more, for example, about the movement from passive learning through lectures to more active learning utilizing problem-based curriculum and most recently, the increasing utilization of technologically oriented simulation models.

            Exciting Journeys:  "GOLEM HAUNTS HARVARD – There's nothing like a high school or college reunion to focus attention on the reality of aging.  I recently attended the 40^th reunion of the Harvard and Radcliffe Class of 1973.  Name badges were critical to identifying classmates whose 20 year old faces had morphed into those of older adults in the foothills of traditionally defined 'old age.'  Unease about the march of time was evident in aging-related joking by classmates about memory and diminished loss of physical vigor.  A class discussion about research on aging was well-attended and provoked informal discussions about what each of us might do to make our later years personally, financially, and socially meaningful.  As a geropsychologist with 35 years in the field of aging, I shared my own personal and professional perspectives on aging with my classmates that emphasized the resilience of most older adults in contending with late life challenges.

"Skepticism from my classmates about what was seen as an overly rosy view of getting older was not unexpected.  Social expectancy research well demonstrates that most individuals acquire negative expectations about the aged and aging throughout their lifetimes.  Negative expectations about old age can be self-fulfilling prophecies.  As a psychology undergraduate, I remember reading Robert Rosenthal's Pygmalion in the Classroom in which he documented that simply by telling teachers that they should expect good performance from a class of students, those students, in fact, subsequently evidenced good performance.  The 'golem effect' is that low expectations lead to low performance.  It would be sad if my classmates – who are among the best and brightest of their generation – lived their later years under the shadow of golem and deprived themselves of the satisfactions that the later years can bring" [Greg Hinrichsen, APA Congressional Science Fellow (2007-2008) served with U.S. Senator Ron Wyden].  Rod Hammond, former Director of the Division of Violence Prevention, Centers for Disease Control and Prevention (CDC), was recently elected to the Berkeley Lake, Georgia, City Council – "I am failing the retirement thing! (Smile)."  Aloha,

Pat DeLeon, former APA President – Division 42 – November, 2013

 

THE FUTURE DEPENDS UPON WHERE ONE STANDS

  The enthusiasm for the future which was so palpable among the Early Career attendees at our recent Honolulu convention was similarly evident within that subset of the approximately 325 participants this Fall at the Illinois Psychological Association (IPA) annual convention, "Advocating for Psychology and Our Community: The Time is Now."  There can be little question that the enactment of President Obama's landmark Patient Protection and Affordable Care Act (ACA) will bring unprecedented change to our nation's health care environment.  The law envisions educated consumers (i.e., patients) taking responsibility for their own health care, including capitalizing upon the advances occurring almost daily within the communications and technology fields.  We will gradually transform from a fundamentally illness-oriented approach to one which places a priority upon prevention, wellness, and data-based care that emphasizes holistic, interdisciplinary, and integrated services.  Educational institutions will have to carefully consider whether they are really exposing their students to healthcare information and experiences (e.g., nutrition, exercise, resilience, etc.) or are they merely reinforcing an illness-oriented status quo that is comfortable.

Building upon the current Medicaid system, the ACA will provide for the largest expansion of mental health and substance-use coverage in a generation, with 32.1 million Americans gaining access to these services, while another 30.4 million currently with some coverage will gain federal parity protection.  Under the law, insurance offered in the new marketplace must cover a core set of "essential health benefits," which includes mental health and substance-use disorder services.  Within this overarching federal framework, the implementation process now moves to the individual state level.  Historically, unfortunately, organized psychology has been less than enthusiastic about serving the Medicaid and Medicare beneficiary populations.  Change is always unsettling and takes time, often far longer than one might initially expect, especially fundamental change.  Today's practitioners will undoubtedly experience significant "pain" as the projected changes are steadily implemented.  The next generation, however, will thrive – as long as the field of psychology remains relevant and continues to attract "the best and brightest."  The ACA provides significant challenges and for those with vision, exciting opportunities.  Especially, we would suggest, for those with an underlying commitment for serving society.

IPA's Call to Action:  "Why am I such a strong proponent of advocacy for ourselves, as psychologists?  Because if we don't advocate for ourselves, who will?  We advocate for ourselves because we identify ourselves in the world as psychologists.  We as individuals feel more empowered when we stand up, publicly, and declare that psychologists can make a difference in the world: with our patients, in the business and corporate world, in community agencies, in the criminal justice and civil litigation system, in government, in medicine.  How do we advocate for ourselves?  We develop a statement of purpose and a rationale.  We talk to friends and colleagues and we sign up a core group of interested people, who will hopefully become a group of highly enthusiastic, fervently committed, deeply engaged, inner circle people!  We figure out a plan for implementation.  Why should we advocate for others?  Because we are not solitary figures in our world.  We depend on others and others depend on us.  Because we are compassionate in the face of suffering.  We advocate for others because, as we strengthen others, we strengthen ourselves.  Today, we help others.  Tomorrow, others help us.  Insularity is suffocating.  Personal gain only is short-sighted and limiting.  We live in an interdependent world where there is knowledge and richness in diversity and pallor in sameness.  Why must we advocate, now, for our community and our profession?  There is no time to lose.  Our national healthcare system is at a critical juncture.  Hundreds of thousands of new patients will join the state Medicaid rolls as of January 1^st.  Approximately 250,000 of them will be diagnosed with a mental illness.  Our mental health system is not equipped to care for these new patients.  We, as psychologists, can make a difference and it is up to us to be at the forefront of change in the ways in which mental health care is delivered in our state.  Obtaining prescriptive authority is a critical step.  Either we rise to meet the challenge of our society's healthcare crisis or we run the risk of getting swept away by the incoming tide of change.  There is no other time but now [IPA President Beth Rom-Rymer]."

The Illinois Psychological Association prescriptive authority legislation (RxP), after considerable open and public debate, passed their Senate by a vote of 37-10-4.  Their chief Senate Sponsor is Don Harmon, the President Pro-Tem of the Senate.  With their lobbyists, IPA's leadership made the critical strategic decision to spend the next 12 months educating psychologists and legislators around the state on RxP issues, rather than immediately press for a House vote.  Theirs is a two year legislative session.  As always, "we live in interesting times."

            The Educator's Voice:  "We don't hear nearly as much about RxP in APA as we once did.  I think the combination of a long lull in getting bills passed, combined with continuing criticism of RxP by what turns out to be a pretty tiny group, has taken some of the wind out of the sails.  Sometimes these days when we're talking about planning for the future of the profession, RxP feels to me a little bit like your crazy Uncle Alfred.  Everybody knows it's still around and going strong, but you're not supposed to mention it in polite company.  It's too bad, because instead we should be celebrating the accomplishments of our prescribing psychologists.  We have several who have been decorated by the military.  We have brethren who have joined the Indian Health Service (IHS) for the opportunity to work in truly disadvantaged communities.  We have prescribers in Federally Qualified Community Health Centers and in Cancer Care Centers, and who have been deployed to help in major disasters.  We should be proud of our 20+ year record as a prescribing profession, not making believe it's not there [Bob McGrath, Director of the Fairleigh Dickinson University Clinical Psychopharmacology and Integrated Primary Care programs]."

A Voice from The Past:  "Volunteering is a wonderful vehicle for professional and community service.  In retirement, the opportunities abound.  Volunteering has afforded me many opportunities to find satisfaction and fulfillment in giving back to others.  My experience volunteering in the community during my 'retirement' has given me a wonderfully fulfilling life outside of psychology.  In Columbia, South Carolina, I deliver Meals on Wheels, exercise special needs dogs at Howlmore Animal Sanctuary, and teach line dancing.  I have also coordinated group service opportunities through my church to persons who are homeless.  I was recently honored to be the first 'runner up' for a national volunteer award given by the Meals on Wheels Association of America.  I endorse Marian Wright Edelman's belief that 'Service is the rent we pay for living.'  It has made retirement 'golden' for me, and many others [Mike Sullivan, former NYSPA President and APA State Advocacy guru for 13 years]."  Aloha,

 

Pat DeLeon, former APA President – NYSPA – November, 2013

 

 

 

ACTIVELY ENGAGING ONE’S CONSTITUENCY

The Importance of Addressing Stigma:  One of the most consistent themes heard during today's policy deliberations surrounding the consequences of integrating behavioral health services within primary care is the potential for addressing the historical stigma attached to receiving mental health and/or substance abuse care.  There clearly is no quick and easy solution.  Senior colleagues might recall the almost universal silence associated with receiving a cancer diagnosis during their parents' time -- just a few decades ago -- prior to the significant advances in treatment which are heralded today.  The impressive pubic engagement efforts of the American Cancer Society, the Susan G. Komen Walks, Department of Defense cancer funding initiatives, etc. are relatively recent phenomena.  Perhaps during the coming decade the particularly debilitating barrier of stigma will also be successfully overcome; especially, we would suggest, with the unprecedented advances occurring seemingly daily within the communications and technology fields.  The Fiscal Year 2014 budget for the Substance Abuse and Mental Health Services Administration (SAMHSA) includes $13.6 million for an exciting Public Awareness and Support (PAS) initiative.

The Administration:  The rapidly changing healthcare environment, the critical role behavioral health plays in achieving national health status objectives, and advances in communications technology provide new opportunities to change the way behavioral health is viewed and services are delivered in the United States.  The unmet need for prevention, treatment, and recovery support services provides a vast untapped market for SAMHSA products and services.  Opportunities to prevent or intervene early to reduce disability and death associated with mental and substance abuse disorders are often missed.  The Departments of Health and Human Services (HHS) and Education are working to facilitate a national dialogue on the mental and emotional health of young people.  About 60% of adults experiencing a mental disorder did not receive treatment and nearly 90% of people who needed substance abuse treatment did not receive care, according to the 2010 National Survey on Drug Use and Health.  For children and adolescents, only about 1 in 5 receives the treatment they need for diagnosable mental health and substance use disorders.  Expenditures on mental and behavioral health and substance use treatment for children and adolescents alone approximate $12 billion annually. 

            By learning to recognize the signs and symptoms of mental illness and substance abuse, friends and family members can help their loved ones take action and seek care.  Trained health professionals can also work with patients and families to identify problems early.  By confronting fear and misunderstanding with facts, raising awareness about the effectiveness of prevention and treatment, and improving knowledge about when and where to seek help, SAMSHA can bring mental illness and addictions out of the shadows and help the nation achieve the full potential of prevention and treatment for mental illnesses and substance abuse.  The SAMSHA Office of Communications, through the Communications Governance Council (CGC), is charged with setting the strategic direction and policy for SAMSHA's public communication activities.  The CGC is working to assure research based approaches are used to influence behavior change for the sake of improving health, preventing injuries, protecting the environment, and/or contributing to the community.  Individual behavioral change involves five basic steps: knowledge, approval, intention, practice, and advocacy.  To employ the best communication practices and technologies that focus on creating and sustaining behavior change, SAMHSA is putting into place a new science-based life cycle approach for public education communications efforts.  The lifecycle provides a five step process for planning, creating, disseminating, promoting, and evaluating educational information produced and distributed by SAMHSA.

            SAMHSA's Public Engagement Platform (PEP) and Project Evolve, SAMHSA's web consolidation and modernization project, are funded through the Public Awareness and Support budget line.  These two initiatives provide the wide infrastructure required to advance Strategic Initiatives by engaging audiences in a meaningful way.  The internet is the primary way people engage with the government.  SAMHSA has prioritized the internet as a strategic business and communications asset and launched Project Evolve to consolidate and modernize SAMHSA's web presence.  Elimination of redundant web development efforts is a key objective for this project and the installation of a Web Content Management System will result in lower overall costs, greater efficiency, increased effectiveness, and improved service for visitors.  Related project activities include audience analysis, usability testing, and planning for the prioritized migration of information from other sites to a consolidated SAMHSA.gov.site.

            Consistent with the draft Federal Digital Strategy, the project is working to support the development of quality content and effective communications governance, and the use of modern communications platforms all to increase efficiencies in SAMHSA's web based communication efforts with the long term goals of improving customer satisfaction and achieving cost savings to the agency.  SAMHSA's PEP provides the agency's programs a consumer-oriented fulfillment system.  SAMHSA's online store (http://store.samhsa.gov) is it's most highly visible customer interface and works in concert with a call-in contact center, warehouse, email updates, exhibit program, and strategic partnerships to fulfill the publication needs of public and health services providers.  The various channels of communication managed by the Office of Communications generated more than 24 million customer interactions last year and enabled SAMHSA to gather data that illuminate the "voice" of SAMHSA customers and how well they are being served by the agency.

            Through its Knowledge Management System, SAMHSA integrates content, operations, and data collection and analytics on all PEP customer interactions.  These touch points annually include about 500,000 inquiries to the contact center; 143,400 publication orders; 21.3 million publication copies shipped; 1.7 million SAMHSA Store visitors; 530,000 PDF documents downloaded; 11.9 million email updates delivered; and 12,000 exhibit booth visitors.  SAMHSA's email update service has grown to nearly 193,000 subscribers.  PEP also distributes a bi-weekly electronic resource entitled SAMHSA Headlines that provides the behavioral health field with the latest news, upcoming events, resources, and a quarterly newsletter, SAMHSA News, that provides in-depth information on key SAMHSA developments and findings.

Just as Americans are aware of the connection between hypertension, stroke, and heart disease and accordingly take action to monitor their blood pressure they can become aware of the connection between mental and substance use disorders and physical health and take action to prevent and treat these conditions.  SAMHSA's PEP and new Web Program provides prevention, treatment, and recovery support programs the communication channels need to reach public and professional audiences with critical behavioral health information.

            The Public Awareness and Support Initiative (http://www.samhsa.gov/publicAwareness/) continues to be driven by research with SAMHSA stakeholders – including web-based public engagement strategies/platforms – and applies the communications and marketing principles of customer research and audience segmentation, message development and evaluation.  Because it is based on consumer needs and input, the Initiative is dynamic and continues to evolve based on the shifting landscape of communications technologies and government involvement with the public.  It strengthens the agency's role in "Supporting the field with Information/ Communications" by conducting and sharing information from national surveys and surveillance; vetting and sharing information about evidence-based practices (e.g., National Registry of Evidence-based Programs and Practices [NREPP]); using the Web, print, social media, public appearances, and the press to reach the public, providers (e.g., primary, specialty, guilds, peers), and other stakeholders; and listening to and reflecting the voices of people in recovery and their families.  The requested budget will aid SAMHSA's efforts to research the best methods of collaboration with its stakeholders, which will improve its messaging and marketing; and as a result, more accurately reflect the voices of people and families in recovery.

            Interesting Developments in Other Health Professions:  Being primarily located, by choice, in my "new career" in the Daniel K. Inouye Graduate School of Nursing at the Uniformed Services University of the Health Sciences (USUHS) (DoD), I have become increasingly aware of changes evolving within the broader health professions community.  I have been impressed by the continuing growth of dual degree opportunities involving Schools of Nursing and, for example, public health, business, informatics, law, religion (hospice care), as well as nursing's systematic efforts to fully implement the recommendations of the Institute of Medicine (IOM) report The Future of Nursing: Leading Change, Advancing Health.  This includes ensuring that professional nurses will be able to practice to the full extent of their education and training; achieve higher degrees of education and training through an improved education system that promotes seamless academic progression; be full partners in redesigning health care in the United States; and, requiring better data collection and information infrastructure for developing effective workplace planning and policy making.  In essence, our colleagues in nursing should be actively involved in playing a fundamental role in the transformation of our nation's health care system.  At the visionary Fall Semiannual Conference of the American Association of Colleges of Nursing (AACN), the participants were asked to develop the "capacity to wonder" how they might continue to make outstanding contributions to the nation.  Lt. General Patricia Horoho, the first woman and first ever non-physician military Surgeon General, urged the audience to "think differently" and "change the fundamental conversation," asking the Deans: "How much health is actually included in today's curriculum?"

This Fall, the Tri-Regulator Leadership Collaborative met to review issues of mutual concern and set an agenda of work for the ongoing collaboration between the Federation of State Medical Boards (FSMB), the National Association of Boards of Pharmacy (NABP), and the National Council of State Boards of Nursing (NCSBN).  The schedule of work agreed upon included: Preparation for a historic, joint meeting of the governing boards of each organization in February, 2014.  A proposed position statement on interprofessional team-based care for adoption by each organization.  Assessing the public protection issues related to practice between and among countries and other international issues related to the regulation of health care practice.  Encouraging regular dialogue between U.S. medical, pharmacy and nurse licensing boards, including facilitation of dialogue with board members of each respective organization.  And, Planning for the second Tri-Regulator Symposium to be held in 2015.  The FSME, NABP, and NCSBN formalized their advocacy partnership in 2011 with the creation of the Collaborative.  Together, their various state member boards regulate a combined 5 million physicians, pharmacists, and nurses in the United States.  Also this Fall, Rutgers University announced the establishment of a dual doctorate in Pharmacy/Medicine at the Robert Wood Johnson Medical School and Ernest Mario School of Pharmacy.  The new PharmD/MD program will be the first of its kind which "could become a model to better prepare the experts who will drive national health-care policy in the wake of the Affordable Care Act."  Those who enroll in the program are expected to take 10 years to obtain their degrees.

USUHS:  "At USUHS we have a health policy seminar dedicated to exposing students to the many professions that interface with public policy, such as psychology, nursing, and education.  The seminar features speakers who informally discuss their journeys to policy-related fields and how policy experiences influenced their career trajectories within military and civilian sectors.  Speakers discuss the different skills necessary to work within policy, including building interpersonal relationships, being persistent, and focusing upon the 'big picture.'  A recent speaker, Anthony Principi, twice serving as Secretary of the Department of Veterans Affairs, discussed his vision and rationale for the difficult decision to consolidate and restructure the VA hospital system in 2004.  Stephen Trachtenberg, author and former President of The George Washington University, shared stories from the perspective of a visionary university president, highlighting the successes and difficulties of working within the education policy system.  Another speaker, Clyde Hart, current communications director of the American Bus Association and former U.S. Senate confirmed Maritime Administrator and Capitol Hill staffer, encouraged students to take advantage of any opportunity to work on Capitol Hill, identifying it as the one place where he learned the most simply by listening and watching.  Since the class includes students in both psychology and nursing, we are able to engage in interdisciplinary dialogue related to many areas within policy.  Towards the end of the quarter, students are encouraged to do a field site visit.  Past site visits have included visiting the American Psychological Association (APA), the federal or state offices of Congress (my mother and I visited our local Congressman in Mississippi), and the Health Resources and Services Administration (HRSA).  Through the seminar discussions and field experiences, students are exposed to the ways policy impacts every aspect of our lives and how we will be able to utilize our knowledge, skills, research, and clinical expertise to inform policy decisions [Omni Cassidy]."

Although there are steadily increasing numbers of public policy courses and relevant texts being offered/published within schools of nursing, this is not the case within psychology's educational institutions.  Perhaps a relevant analogy -- Today psychology is progressing nicely on addressing the complex issues surrounding Telepsychology.  Yet, in 2003 the Kaiser Family Foundation reported that "About 80% of U.S. residents who use the Internet have searched the Web to seek out health information, and most say doing so helps improve their quality of care."  Psychology's next generation must become more responsive to the changing times.  Some definitely are: "We met at the 2011 APA Convention in DC at the Speed mentoring opportunity for students and Early Career Psychologists.  After much ambivalence, I'm finally taking the plunge.  My colleagues in the Indian Health Service (IHS) and Steve Tulkin have encouraged me to pursue RxP authority.  In January 2014, I'll start the Alliant University Postdoctoral Masters in Clinical Psychopharmacology program.  I do like to believe that you planted the seed those few years ago.  Wish me luck.  Thanks.  [Casey McDougall]."

The IOM Forum on Global Violence Prevention:  Our nation's Capital hosts many exciting policy discussions, which can be transformational.  A new summary brochure produced by the IOM Forum on Global Violence Prevention details the origin, operation, and accomplishments of the Forum.  Established in 2010, it has brought together global experts from all areas of violence prevention and mitigation to facilitate multisectoral dialogue and exchange on a range of cross-cutting global violence prevention issues.  Several times per year, the Forum convenes expert workshops that explore these issues and opportunities for advancing proven or evidence-informed prevention efforts.  Violence is a major global public health problem, with multisectoral consequences for business, law enforcement, and other sectors, the impact of which is borne not only by the victims, but also by families, communities, and societies.  In 2001, violence accounted for 45 million disability-adjusted life years lost, with low- and middle-income countries bearing the largest burden.  The exact costs of violence, which include adverse health outcomes, lost productivity and economic opportunity, community deterioration, and effects on the next generation, are difficult to determine, but there is little doubt that the direct and indirect costs are great.  As quoted by the Forum's co-chair Mark Rosenberg from the Taskforce for Global Health: "In most people's minds, violence is seen as unmitigated evil, something that we have had to live with since time immemorial, and not something that we can prevent."  Nevertheless, violence can be prevented.

The past quarter-century has witnessed a shift in thinking about violence – from the assumption that violence is inevitable to an emerging scientific understanding among many different stakeholders that, through effective approaches, prevention is possible.  Violence is complex, whether interpersonal, self-directed, or collective, and, when not prevented, fosters more violence.  Effective prevention requires cross-sectional approaches developed through dialogue and collaboration among researchers, practitioners, and policy-makers whose perspectives reflect different disciplines and experiences.

During its first three operational years, the Forum explored different but related aspects of violence in a series of public workshops.  The existence of linkages and common risk factors within types of violence, as well as between different types of violence, was a constant thread through all the workshops and related activities.  Understanding these relationships is critical to preventing violence.  The Workshop on Preventing Violence Against Women and Children, for example, found the following key themes.  * The value of research and interventions that address violence against both women and children rather than treating them as "siloed" types of violence.  * The intergenerational transmission of violence.  * The need to address gender norms and roles of men and boys as part of the solution.  * The research and intervention gap in low- and middle-income countries.  And, * The need for responses that are multisectoral and are cross-cutting fields of violence prevention.  This workshop was webcast globally, allowing for the inclusion of more than 300 remote participants in more than 20 countries.

Key themes from the Workshop on Communications and Technology for Violence Prevention were: * The ability of information and communications technologies (ICT) to facilitate cross-sectoral solutions.  * The potential of ICT as a platform for scaling up effective interventions.  * The need for new methodologies for effective evaluation of interventions utilizing rapidly changing ICT.  And, * The opportunity for ICT as a tool to better reach vulnerable populations and address health disparities.  Following the momentum of this workshop, one of the Forum's sponsors, the Avon Foundation for Women, partnered with the IOM in a global mobile- and Web-based app challenge: Ending Violence @ Home.  The challenge brought together individuals from the fields of domestic violence prevention and communication technologies, raising awareness about and helping prevent domestic violence against women and children.  This was a globally-issued challenge, and teams from both the United States and abroad entered.  The numerous submissions covered a wide array of innovative approaches to prevent violence at home.  The four winning submissions showcased three different approaches: changing cultural attitudes about violence against women, preventing dating violence on university campuses, and equipping health care providers to detect and prevent domestic violence.  Other workshops include: Social and Economic Costs of Violence, Contagion of Violence, Evidence for Violence Prevention Across the Lifespan and Around the World, and Elder Abuse and Its Prevention [www.iom.edu/globalviolenceprevention].  There is tremendous potential for the behavioral sciences to contribute to a healthier society.  Aloha,

Pat DeLeon, former APA President – Division 29 – November, 2013

 

INTEGRATED PRIMARY CARE

APA annual conventions are always inspiring, and Honolulu was exceptionally so.  Our next generation of colleagues clearly understands that the nation's health care environment is undergoing unprecedented change and, as former APA President Suzanne Bennett Johnson has noted: Medicine's recent paradigm shift from the biomedical to the biopsychosocial model is occurring with significant implications for psychology… providing opportunities and challenges.  President Obama's landmark Patient Protection and Affordable Care Act envisions patient-centered, interdisciplinary primary caresystems, capitalizing upon the tremendous potential for data-based measures of quality health care, inherent in the communications and technology fields.  Prevention, wellness, and holistic care will become the expected norm by educated consumers (i.e., patients) – with necessary modifications to our current reimbursement models.

            One policy development that has particularly impressed me has been the increasing commitment by our sister professions' educational institutions to actively engage local communities in their own health care.  This Fall, I visited our College of Pharmacy's annual health fair, held in a popular shopping mall on the Big Island of Hawaii.  152 Pharmacy students (in their white coats) with four faculty/community pharmacist volunteers, along with 68 community volunteers, served 372 participants; 159 receiving free health screenings and 133 entries in the "children's poster contest."  This was an exciting community event – all ages, entertainment, music, etc.  Psychology's graduate students could have made a significant contribution, addressing biopsychosocial issues such as smoking and substance-use cessation, relaxation techniques, and preventing the spread of HIV/AIDS.  This is the future!  NPR/ Kaiser Health News: "The state of Oregon is trying some experiments to bring different kinds of medical professionals under the same roof… in a primary care setting, where doctors often have to deal with stomach aches and migraines that end up stemming from mental, rather than physical, problems" – the vision of Robin Henderson, St. Charles Health System.

            Under the leadership of Kimber Bogard, the Institute of Medicine (IOM) Board on Children, Youth, and Families has proffered a number of meaningful agendas for colleagues to pursue that would make a real difference.  Following the recommendations of the 2009 IOM report on Preventing Mental, Emotional, and Behavioral Disorders Among Young People, the Board launched a Forum to advance an agenda on integrating prevention and treatment services that address children's cognitive, affective, and behavioral health in settings where they are seen and cared for.  These places include schools, community based organizations, primary care offices, and child welfare settings.  How to implement and scale up evidence-informed practices will be a focus of the activities of the Forum.  Professor Emeritus Michael Murphy, with his lifelong passion for public policy, undoubtedly would urge IPA to engage in implementing effective programs targeting child abuse and neglect.  Each year child protection services receive reports involving six million children, while many incidents go unreported.  The IOM notes since its last report two decades ago, there has been great progress in child abuse and neglect research; yet, a coordinated, national research infrastructure with high-level federal support still needs to be established.  Clearly there are significant long-term developmental and biological effects.  Adverse outcomes include depression, PTSD, poor physical health, and attention difficulties and delinquency.  Children age three and under are more likely to experience abuse and neglect.  Every experience is unique.  Almost half of all Americans will meet one or more clinical criteria for mental and behavioral health or substance abuse disorders in their life; the first onset usually in childhood or adolescence.  Lifetime prevalence may be as high as 37% by age 16.  Expenditures on mental and behavioral health and substance use treatment for children and adolescents approximate $12 billion annually.  Throughout the convention, there were numerous symposia highlighting effective family-based initiatives.  What will be the role of State Associations in furthering this important policy agenda?  Aloha,

 

Pat DeLeon, former APA President – Indiana Psychological Association – October, 2013

THE FUTURE HAS ARRIVED

   As President Obama's landmark Patient Protection and Affordable Care Act (ACA) is steadily implemented over the next several years, psychology has an unprecedented opportunity to provide proactive and visionary leadership.   At this year's inspirational APA State Leadership Conference, Katherine Nordal stressed the importance of psychology's active presence at the state level and effectively demonstrating to the public-at-large psychology's "value-add" to quality healthcare.  "At this time last year, the future of the ACA seemed uncertain.  Since then, we've had a Supreme Court decision that upheld the ACA and the November reelection of President Barack Obama.  The ACA has survived, and implementation of the largest expansion of the health care safety net will proceed.  The clock is ticking toward full implementation of the law and January 1, 2014 is coming quickly.  But January 1^st is really just a mile maker in this marathon we call health care reform.  We're facing uncharted territory with health care reform, and there's no universal roadmap to guide us.  The details of ACA implementation vary from state to state, and so do the key players.  I believe that if we are not valued as a health profession, it will detract from our value in other practice arenas as well.  So regardless of how we feel about the current state of our health care system, psychology must take its seat at the table and contribute to the solutions needed to fix our ailing system.  No one else is fighting the battles for psychology and don't expect them to.  Health care reform is a marathon – we're in it for the long haul.  New models of care and changes in health care financing won't take shape overnight.  We can't hope to finish the marathon called health care reform if we're not at the starting line.  Fortunately, many psychology leaders have embraced our call to action."

            Earlier this year I had the opportunity of attending the Alaskan Native Southcentral Foundation Nuka conference where former Centers for Medicare and Medicaid Services (CMS) Administrator Donald Berwick described the revolutionary magnitude of change coming to our nation's health care environment and the pain that today's practitioners will experience as their daily professional lives are inevitably significantly altered.  The underlying objective of the ACA is to foster a data-driven, patient-centered system in which priority is given to preventive, holistic, and wellness-oriented care and where state-of-the-art advances in communications technology will be effectively utilized.  Cross provider and cross patient population comparisons (i.e., a public health oriented approach) will become the norm.  Isolated professional "silos" will give way to coordinated systems of care.  If one reads through the statutory text of "ObamaCare" there are very few express references to psychology – and, very few (if any) actual limitations on our potential contributions.  The ACA represents a major expansion of our nation's "safety net" which has historically been the responsibility of Medicare and Medicaid.  Critical policy decisions are once again being made primarily at the state level.  If we are honest with ourselves, we must recognize that organized psychology has not been systematically engaged in addressing the pressing needs of these underserved beneficiary populations, nor in working collaboratively with other disciplines (such as Advanced Practice Nurses and Clinical Pharmacists) to foster interdisciplinary, patient-centered, integrated primary health systems – either clinically or within our training institutions.  These are the signature elements of the ACA and health policy experts appreciate that the various components (e.g., licensure mobility, comparative effectiveness research, and matching educational requirements to clinical needs) have been deliberated in a number of far-reaching health policy conferences and documents (including those sponsored by the Institute of Medicine (IOM)) over the past several decades.  Professional isolation (i.e., silos) may be comfortable, but must radically change.

Unprecedented Opportunities:  The ACA will provide for the largest expansion of mental health and substance-use coverage in a generation, with 32.1 million Americans gaining access to these services, while another 30.4 million currently with some coverage will gain federal parity protection.  Under ACA insurance offered in the new marketplace must cover a core set of "essential health benefits," including mental health and substance-use disorder services.  The coverage for behavioral health services must be generally comparable with coverage for medical and surgical care.  Ken Pope recently shared a similar perspective, noting that in 2009 public and private mental health spending totaled approximately $150 billion, more than double its level in inflation-adjusted terms in 1986.  Those criticizing the ACA for primarily political reasons might naively ask whether the nation or the Administration is really committed to this magnitude of change.  Early this year a Kaiser Foundation/ Robert Wood Johnson Foundation/ Harvard School of Public Health survey found that seniors (i.e., those utilizing the program) were most likely to report that Medicare is working well (80%) and that the majority of Americans (67%) believe that federal spending on improving health actually saves money.  This summer representatives from the 16 states that by then had elected to run state exchanges met with senior Administration officials in our nation's Capital.  According to Hawaii's Coral Andrews, they were very pleasantly surprised to hear President Obama himself join their conference call, requesting a personal briefing on the progress (and tribulations) they were experiencing.  Recently I was on a conference call during which Vice President Biden reached out to approximately 3,000 nurses seeking their leadership and active support for educating the public regarding the benefits of the ACA, under which 95% of uninsured Americans will see lower than expected health care premiums in 2014.  Also present were two high ranking Administration officials, the Administrators of HRSA (Mary Wakefield) and of CMS (Marilyn Tavenner), both nurses!  Opportunities always exist for those who are engaged, as Katherine Nordal proffered.  Now is the time to develop and promote creative initiatives that will actively integrate behavioral health within primary health care.  This is a major challenge.  However, with the expected U.S. Senate retirements, the next Chairman of the Senate Finance Committee, which has jurisdiction over Medicare and Medicaid (i.e., major components of ACA), will most likely be Senator Ron Wyden, a longtime friend of psychology and professional nursing.  Colleagues James Werth, Jr.; Greg Hinrichsen, and Mary Polce-Lynch served with Senator Wyden as APA Congressional Fellows.

Psychology's Future Really Depends Upon Our Next Generation:  "My introduction to Former APA President James Bray's vision of Speed Mentoring occurred several years ago at the APA convention in Toronto.  Like 'speed dating', the APA program is designed to offer graduate students and early career psychologists (ECPs) the opportunity to meet briefly with a number of renowned psychologists in a very compressed period of time.  I so happened to be talking with one of these renowned psychologists as he was walking to the invited event.  As we approached the registration desk, the event coordinator received a last minute cancellation from a scheduled mentor.  My colleague volunteered me as a last second (albeit un-renowned) fill in.

"In this program, mentors meet with 4 separate groups of no more than 10 'mentees' in an hour's time.  Each brief group encounter lasts approximately 12 minutes.  The discussions tend to be very lively and a surprising number of topics are covered in this fast-paced Q&A session.  Then the bell rings and the mentees move on to another station.  As the un-renowned, fill-in mentor, the students and ECPs were politely inquisitive as to who in the world I might be.  I told them that I worked at a major medical center within the Department of Defense where a psychologist was the chief of an independent Department of Psychology.  In addition to the traditional adult, child, and neuropsychology programs, I mentioned that our psychologists were also responsible for a chronic pain program (where a psychologist-nurse supervises the work of anesthesiologists, nurses, chiropractors, psychologists, acupuncturists, and massage therapists), a traumatic brain injury program (supervising physicians, nurses, and psychologists), and a behavioral telehealth program (supervising a dozen psychologists and psychiatrists providing health care exclusively via computer video).  I also mentioned that we had an APA-approved internship program, a post-doc residency program, and three APA-approved fellowship programs (child psychology, neuropsychology, and health psychology); the last offering a post-doctoral Master's degree in clinical psychopharmacology as an option.

"To a person, the students and ECPs were very surprised.  I was surprised, as well, that they had not heard of psychologists serving in these roles (yes, they knew we were members of multidisciplinary teams, but not leaders of these specialized programs.)  Nor had they heard of a clinical psychopharmacology degree (which would prepare them for state or DoD privileges in psychopharmacology) incorporated into a specialized fellowship program.  For many, the notion that we could deliver needed services to underserved and rural populations via telehealth was also a novel idea.  The ensuing questions and discussion focused on the role of psychologists as leaders in health care and the opportunities to expand our scope of practice.

"It was a great pleasure interacting with these young professionals and, to my own surprise and delight, I have been invited to participate in every subsequent Speed Mentoring event now held annually at the APA convention.  While there have been significant gains and losses for our psychology programs in these interim years, the students and ECPs at the Speed Mentoring event appear to find the unusual things we are doing at the medical center quite interesting [Ray Folen]."  Aloha,

Pat DeLeon, former APA President – National Register – October, 2013

 

TRAILBLAZERS FOR THE FUTURE

Our 121^st Annual APA Convention in Honolulu, Hawaii was truly exciting andprovided a timely glimpse into the future of psychology.  The energy and enthusiasm of the next generation was palpable, as was their appreciation for the critical importance of becoming actively engaged within our nation's healthcare arena.  The community mental health center movement had its beginning with the inspirational vision of President John F. Kennedy; the community health center movement was a feature of President Lyndon Johnson's Great Society, when psychologist John Gardner served as Secretary of the then-Department of Health, Education, and Welfare.  Over the years, almost all training and service delivery programs treated mental health and substance-use as fundamentally separate and distinct from physical health care.  Increasingly, however, enlightened clinicians and health policy experts (including the Institute of Medicine) have called for active integration, with the development of holistic, patient-centered clinical initiatives recognizing the critical importance of the psychosocial-economic-cultural gradient of care.

            The Times They Are A-Changin':  President Obama's signature Patient Protection and Affordable Care Act (ACA) will provide for the largest expansion of mental health and substance-use coverage in a generation, with 32.1 million Americans gaining access to these services, while another 30.4 million currently with some coverage gaining federal parity protection.  Under ACA insurance offered in the new marketplace must cover a core set of "essential health benefits," including mental health and substance-use disorder services.  The coverage for behavioral health services must be generally comparable with coverage for medical and surgical care.  Ken Pope recently shared a similar perspective, noting that in 2009 public and private mental health spending totaled approximately $150 billion, more than double its level in inflation-adjusted terms in 1986.  Perhaps most telling – listening to the Washington Redskins this weekend, two of their former quarterback commentators talked about the efforts of The Purple Heart Foundation to make readily available services for veterans suffering from PTSD and/or considering suicide.  They were talking to a mainstream audience, not to the professional journal readership.

Visionaries:  Oregon's health leaders have long been in the forefront of shaping our nation's evolving healthcare environment.  In 2002 the State requested a Section 1115 Medicaid waiver to develop an effective "safety net" for your most needy citizens, recognizing the need for holistic and "wrap-around" care.  Your 2009-2010 efforts to enact prescriptive authority (RxP) legislation, although not yet successful, places future generations in an enviable position to demonstrate their "value-add" in health care; at the St. Charles Health System Robin Henderson is demonstrating what psychology can contribute.  In 2011 the State established the Oregon Health Insurance Exchange Corporation which is increasingly becoming the implementing vehicle for ACA.  Earlier this summer representatives from the 16 states that have elected to run state exchanges met with officials from the Administration.  According to Hawaii's Coral Andrews, they were very pleasantly surprised to hear President Obama himself join their conference call, requesting a personal briefing on the progress (and tribulations) they were experiencing.  With expected retirements, the next Chairman of the Senate Finance Committee, which has jurisdiction over Medicare and Medicaid (i.e., major components of ACA), will most likely be Senator Ron Wyden, a longtime friend of psychology and professional nursing.  Colleagues James Werth, Jr.; Greg Hinrichsen, and Mary Polce-Lynch served with him as APA Congressional Fellows.  We would suggest, therefore, that those who does not appreciate the President's personal commitment to having all Americans have access to quality healthcare or who hope for Obama Care to be "defunded," simply have not been paying attention to the monumental importance of this national vision.

            Having retired from the U.S. Senate staff after 38+ years with Senator Daniel K. Inouye, I have become quite interested in what "senior colleagues" are doing.  This fall my wife and I will be visiting Oregon simply because we have never been there before together.  Oregon is the home of former APA President and health psychologist extraordinaire Joe Matarazzo.  It was a distinct pleasure to work closely with Joe as a member of the APA Board of Directors and over the years on behalf of health psychology.  Today, whenever I go to the Uniformed Services University of the Health Sciences (USUHS) (DoD) in my part-time capacity as Distinguished Professor, I particularly appreciate his vision in establishing their Department of Medical Psychology.  The local folklore is that four decades ago, while on the founding Board of Regents, Joe successfully convinced each of his fellow Regents to vote to establish the department, losing only the USUHS President's vote.  Oregon's vision has, and will continue to, serve the nation admirably.  Aloha,

Pat DeLeon, former APA President – Oregon Psychological Association – September, 2013

 

 

ONWARDS TO THE FUTURE

  As Steve Ragusea recently pointed out when agreeing to reinvigorate the Florida Psychological Association (FPA) prescriptive authority initiative (RxP), it has been quite a while since one of our state psychological associations successfully enacted RxP legislation.  Over the past decade a number of states have made considerable progress with both Hawaii and Oregon getting as far as having their bill ultimately vetoed by their Governor.  This year Illinois and New Jersey have made considerable progress, each having passed one of the Houses of their respective legislatures, and with both of their efforts remaining alive in their two year legislative cycles.  Patience, persistence, and personal presence will always be the key to ultimate success.  Collectively, how do we encourage our colleagues to keep inching forward at the state level until the next generation of psychologists believes that their profession has "always prescribed," as it has clearly been in the best interests of its patients?  Merely writing e-mails to each other simply does not work.

Prescribing colleagues in the Department of Defense (DoD) and the U.S. Public Health Service (particularly, the Indian Health Service) have clearly demonstrated that psychologists can learn this clinical skill and can apply it admirably.  And, it would be quite helpful in convincing those in administrative and policy positions to expand these important initiatives if our research colleagues would take a closer look at what has been accomplished, including the extent to which behavioral approaches might have been superior to utilizing medication.  For example, research in psychotherapeutic techniques has repeatedly shown Panic Attacks can be successfully treated in less than 10 sessions.  If prescribing psychologists are eliminating the long term costs of anxiolytics and antidepressants by using cognitive behavioral therapy, the monetary savings and reduction in human suffering would be demonstrably substantial.  Bob McGrath, head of the Fairleigh Dickinson psychopharmacology training program, estimates that there are currently 1750 psychologists who have completed their advanced RxP training and with 60 percent of psychotropic medications currently being ordered by primary care providers, there is a pressing societal need.  Incidentally, Bob was just voted Psychologist of the Year by his New Jersey colleagues – a well-deserved honor.

            The Department of Veterans Affairs (VA) is the largest employer of psychologists and Advance Practice Nurses (APNs).  Obtaining RxP authority within the VA would be a major breakthrough for psychology.  The VA serves approximately 49.3 million beneficiaries, constituting 15.5 percent of the nation.  It operates the largest Federal health care delivery system in the country, with 152 hospitals, 107 domiciliary residential rehabilitation treatment programs, 133 nursing homes, 300 Vet Centers, and 821 outpatient clinics.  It is estimated that 6.5 million patients will be treated in the coming year.  The VA has proposed utilizing its federal supremacy authority to establish a system-wide, national nurse practice standard which would allow these practitioners to function to the fullest extent of their training, pursuant to recommendations by the Institute of Medicine (IOM).  Under the leadership of Cathy Rick, then-Chief Nursing Services Officer, the new VHA [Veterans Health Administration] Nursing Handbook, provides APNs with the authority for independent practice, regardless of individual state licensure limitations, unless an individual VA facility limits their scope within that facility.  This visionary document has been "cleared" by the relevant legal authorities who will be reminding hesitant states about the federal government's supremacy powers within federal facilities.  Two underlying values enumerated are that the patient owns and drives their care based on the information available and that nursing interventions are based on the best available evidence and accepted standards of practice.

            Specifically the handbook proposes:  "Clinical nursing practice varies widely among the States.  To ensure safe and appropriate health care to the nation's Veterans, VA has standardized the elements of practice, within VA, for clinical nursing practice other than the prescribing of controlled substances, without regard to individual State Practice Acts.  This ensures a consistent standard of nursing care throughout VA's national health care system….  Under the Federal Controlled Substances Act… a health care practitioner may prescribe controlled substances only if the practitioner's State license authorizes such prescribing.  Accordingly, APRNs, including NPs, may prescribe controlled substances within VA only if they are authorized to do so by their State of licensure or registration and comply with the limitations and restrictions on that prescribing authority.  Where VA establishes elements of nursing practice that are more expansive or otherwise inconsistent with State practice standards, VA's practice standards control.  VA nurses must follow the VA nursing practice standards established in VA rules, regulations, and policies."

            Not surprisingly, medicine (the President-elect of the American Society of Anesthesiologists, who herself possesses a nursing degree and was trained as a nurse anesthetist), has expressed objections, based upon the commonly used "public health hazard" argument.  She said of the proposed policy:  "This document effectively eliminates the gold standard, physician-led, team-based coordinated care in anesthesiology.  The VHA intends this to be the policy for all its hospitals, superseding state law, where currently more than half of states require physician supervision of nurse anesthetists….  (L)ocal chiefs of anesthesiology will no longer have the authority to set policies they deem best for the patients they serve."  The proposal policies "raise significant safety concerns in our sickest population."  "The length and depth of training are dramatically different.  As physician anesthesiologists we trained for 12 to 14 years rather than 5 to 7.  Nursing education and training did not prepare me for the level of care needed in the perioperative environment when seconds matter."  Despite her statement, all of the objective evidence that we have seen over the years indicates that nurse anesthetists are extraordinarily safe, including a recent review of approximately 500,000 cases.  In rural America their services are crucial as they are the primary provider of anesthesia.

We were very pleased to learn that Heather Kelly, who for the past 15 years has addressed legislative and administrative issues for the Science Directorate regarding the importance of psychological research at the VA, NSF, and DoD, has now become the APA point person on their team effort on all military and veteran-related issues, including the clinical portfolio.  Obtaining RxP for interested VA employees will become one of her agendas.  Accordingly, the research that Steve Ragusea has proposed would indeed be most timely, as well as extraordinarily useful to Heather, in countering medicine's ongoing emotional "public health hazard" arguments against the expansion of non-physician scopes of practice and particularly, against RxP.  And, we should remember that obtaining RxP provides clinicians with the authority to modify or stop ineffective medication decisions.  Fred Frese, a longtime advocate for individuals challenged by chronic mental health issues, reports on a 7-year follow-up study published in JAMA-Psychiatry finding that individuals with schizophrenia who are on reduced or no doses of anti-psychotic medications do better than those on medications.  Other research Fred has highlighted suggests that those on antipsychotic medications live 15 to 25 years less than would be normally expected. 

            The Alliance for Health Reform:  One of the most enjoyable aspects of having retired from the U.S. Senate staff after 38+ years is that I have the time (and willing friends) to host a psychology-nursing health policy seminar at the Uniformed Services University of the Health Sciences (USUHS) (DoD).  Each week we invite a colleague who is, or has been, active within the public policy process to discuss their personal journey.  Recently Toni Zeiss addressed the class (generally 7 to 10 students and faculty) about her experience serving as the first woman and first non-physician to be appointed as Chief Consultant for Mental Health Services at the VA Central Office.  At our annual APA convention in Honolulu, President Don Bersoff presented her with a special Lifetime Achievement Award.  A previous guest was twice former VA Secretary Tony Principi.

Ed Howard, another speaker, and I used to work together when he was on the staff of then-Representative Spark Matsunaga, who was elected to the U.S. Senate in 1977.  Ed is currently the Executive Vice President of the bipartisan Alliance for Health Reform, which is chaired by Senators Jay Rockefeller and Roy Blunt.  Ed suggested that our nation's health policy experts might finally be appreciating the importance of mental health care to our nation's overall health care system and our citizens' quality of life.  Interestingly, Ken Pope has shared a similar view noting that in 2009, public and private mental health spending totaled approximately $150 billion, more than double its level in inflation-adjusted terms in 1986.  The Accountable Care Act (ACA) will provide the largest expansion of mental health and substance use disorder coverage in a generation, with 32.1 million Americans gaining access to these services, while another 30.4 million currently with some coverage will gain federal parity protection.

Highlights of the information which Ed presented:  *An estimated 26.2 percent of Americans ages 18 and older – about one in four adults – suffer from a diagnosable mental disorder in a given year.  * In 2008, just over half (58.7 percent) of adults in the U.S. with a serious mental illness received treatment for a mental health problem.  * Approximately 38,000 people committed suicide in 2010.  * Over 8.9 million individuals have co-occurring mental illness and substance use disorders.  Only 7.4 percent of these individuals receive treatment for both disorders, while 55.8 percent receive no treatment at all.  Minorities with mental health disorders have less contact with specialists.  More than half of disabled Medicaid enrollees with psychiatric conditions also had claims for diabetes, cardiovascular disease, or pulmonary disease.  People with mental illnesses and addiction disorders are at much greater risk than the general public for homelessness, poverty, poor nutrition, and lack of health care.

            The All Important "Bigger Picture":  Community Health  --  David Derauf, Executive Director of the Kokua Kalihi Valley (KKV) Community Health Center in Honolulu, Hawaii, recently shared with us the cogent observations of one of his medical colleagues:  "A few months ago, I was sitting across from Dr. Robert Jesse, Principal Deputy Under Secretary for Health in the VA, in a meeting when he asked a provocative question, 'Why is it when we talk about personalized medicine, we only talk about genetics?  Why wouldn't we talk about a patient's social circumstances and how we can 'personalize' medical care for them?'  He is totally right.  In this country, 50 million people are hungry, while 26 million have heart disease and 26 million have diabetes.  Those numbers cannot be mutually exclusive.  Many people with heart disease and diabetes must be hungry at some point each month, which has been shown to result in worse health and higher rates of health care utilization.

"Yet despite this knowledge, we do not typically 'personalize' healthcare to ask patients a simple two-question scale validated by Children's HealthWatch to detect food insecurity, even when we know they are at a higher risk based on their zip code and where they receive their health care.  Think for a second about the inefficiency of a doctor asking a woman to come back to the hospital each month to check her blood pressure when that woman regularly skips meals, worries about paying bills and potentially cuts her pills in half since she can't afford them?  Before we progress to expensive genetic testing to see if a patient processes drugs differently, wouldn't it be more 'personalized' and more effective to screen for a common modifiable factor like hunger, and then make sure eligible patients are getting all the food subsidy programs for which they are eligible?

"In many ways the VHA, the Nation's largest integrated health care system, already 'personalizes' its care in important ways.  It pays for Supportive Services for Veteran Families (SSVF), including help with job training and childcare, and it has begun to bring legal services onsite at VA facilities as part of medical-legal partnerships [such as with the University of Hawaii William S. Richardson School of Law] to address many civil legal needs that interfere with getting and staying healthy.  I look forward to a future when 'personalized medicine' means less high tech care, and more 'patient centered' inter-professional teams addressing the full spectrum of social determinants of health."

A "Retiree's" Journey  –  "A long time ago, ten years ago, I retired from the VA.  And time and technology are passing by me so quickly.  I can see it in my grandchildren, now starting college, who know so much more and can access so many things so quickly – compared to what I was like when I was graduating from high school.  I was typing only 40 words a minute by the time I left high school, compared to two of my grandchildren, one still in high school, who repair computers and design software and create computer systems for their prep-schools.  I stand in complete awe, as I work with Student Veterans, returning home from war, now enrolling in college.  How outstanding they were in combat and now how outstanding they are in college.  Like, what's happening now, as I consult with the Office of the Dean of Students at the University of Texas at Austin, in the Student Veterans Center.  I see first-hand the mastery of so many skills, so that Student Veterans are achieving so much….  Reminds me of my days as a teenager, attending a residential prep-school, adjacent to the UT Austin campus, 1947-1953.  I was awed by World War II combat veterans enrolling in college, worked with them as we nailed up signs for Lyndon Baines Johnson (LBJ) running for the U.S. Senate in the Democratic primaries of 1948.  World War II Student Veterans were awesome then, as OIF/OEF/OND Student Veterans are so now!  Plus, older veterans – Korean and Vietnam era – are retiring and returning to school!  There is so much more we must do to help veterans return to school.

"Sad, now, that political leadership has changed so much in Texas.  LBJ filled his politics with Pro-Life for living, improving education, enhancing health, helping businesses change from war to peace….  Nowadays, though, current Texas politicians are practicing Pro-Death.  Refusing federal dollars for healthcare already paid for by Texas tax-payers; refusing federal dollars for Education already paid for by Texas tax-payers, etc., etc.  It's Pro-Death in Texas and Pro-Life in Massachusetts… and all you have to do is compare the life expectancies in the State of Texas with that of the Commonwealth of Massachusetts.  Citizens are living much longer in Pro-Life Massachusetts than in Pro-Death Texas.  Similarly, it's not just life expectancies being shorter in Texas, it's also Infant Mortality is higher in Texas.  And, it's not only due to lack of healthcare in Texas… some portion of the higher death rate may be associated with greater use and excellent aims in using firearms and weapons here in Texas.  Sad.  But we can not focus on what is Wrong.  We must aspire to doing what is Right… [Walter Penk]."

A Personal Perspective  –  It is important for psychology remember its history as we focus on future agendas.  The Center for the History of Psychology, located at the University of Akron in Akron, Ohio, is a unique institution that cares for, provides access to, and interprets the historical record of psychology and related human sciences.  Under the leadership of David Baker, the Center houses a museum of psychology as well as the Archives of the History of American Psychology and provides a variety of educational programs for the public.  The Center houses and makes available the personal papers of more than 200 psychologists.  The collections include personal and professional correspondence, sound recording and moving images, artifacts, photographs, unpublished papers and presentations, and other kinds of material that tell the story of psychology.  The Center, a 501(c) 3 organization, is supported primarily through gifts from visitors, foundations, and other donors.  The gifts provide support for processing collections, creating exhibits, and providing public programming.  Individuals interested in donating materials should contact Cathy Fay [cfaye@uakron.edu].  Aloha,

Pat DeLeon, former APA President – Division 55 – September, 2013