TIME FOR ACTION

     State Public Sector Initiatives:  Over the years that we have been involved with the prescriptive authority agenda (RxP), there has been remarkably little discussion regarding the possibility of colleagues working within State prison and mental health systems providing this important clinical service.  Fred Frese, a longtime advocate for psychology's increased involvement with individuals challenged by chronic mental health issues, recently reported 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.  As is the case with colleagues serving within federal institutions (i.e., the Department of Defense (DoD), Indian Health Service (IHS), and Department of Veterans Affairs (VA)), legislative restrictions on scope of practice issues frequently do not apply to public employees.  We understand from Glenn Ally that since the enactment of their RxP legislation on May 6, 2004, medical psychologists in Louisiana have had an increasing presence within their public mental health system.  Given the impressive and lengthy history of federal colleagues prescribing, we would hope that fostering state-based pilot projects would become a legislative priority for our State Associations.

During our recent Hawaii convention, we were very pleased to receive an update from Illinois RxP proponent Beth Rom-Rymer that in Ohio: "While, originally the Ohio RxP bill had been introduced as a small-scale demonstration project focusing upon the needs of the criminal justice system, legislative sponsors have urged us to introduce a full-scale RxP bill.  This bill will be introduced in the 2014 legislative session, with a promise of doing well (Michael Ranney)."  Those familiar with nursing's successful RxP quest over the years will appreciate the pivotal role that a small demonstration project in Ohio (when then-Dean Ron Fox was at Wright State University) evolved into a national success.

A New Era for Behavioral Health:  President Obama's Patient Protection and Affordable Care Act (ACA) provides the states with considerable flexibility to implement a program that is tailored to their unique needs and strengths.  Notwithstanding the current political climate, the political/policy experts that I am aware of do not seriously think that the ACA will be repealed or the newest phrase "unfunded."  Unprecedented change has come to our nation's health care system with an emphasis upon integrated, interdisciplinary, patient-centered care, utilizing communications technology to objectively develop data-based "gold standard" protocols.  The Administration has given a high priority to ensuring parity between mental health care and traditional physical health care, demonstrated by mental health and substance abuse services being among the ten "essential benefits" health insurers must provide under the state health exchange provision of ACA, which is to be implemented October 1, 2013.  Aloha,

Pat DeLeon, former APA President – Division 31 – September, 2013

LAND OF THE DINOSAURS ?

 Attending the annual APA convention has always been an exciting event -- seeing old friends, experiencing the enthusiasm of the next generation, and learning about new challenges.  This has definitely become "my gift to myself."  This year our 121st gathering was truly special, joining approximately 11,400 colleagues in Honolulu, Hawaii – home of psychology's first prescriptive authority (RxP) legislation.  One of the most memorable highlights was attending HPA's welcoming reception with former HPA President June Ching at the beautiful home of another former HPA President Tanya D'Avanzo, overlooking the ocean on the Windward side of Oahu.  Hawaii is truly special in so many ways.  APA President Don Bersoff, as well as a number of the Board of Directors, was able to attend.  Those of us who have decided to pursue careers in psychology are very fortunate – respected by society and possessing "interesting lives."  Accordingly, we have a special obligation to "give back to society."  Those who were fortunate to attend Don's Opening Ceremony not only were charmed by HPA President Darryl Salvador's Aloha greeting, they also were provided the opportunity to reflect upon how psychologists such as Jon Nachison (Stand Down), Toni Zeiss (VA), and Barbara Van Dahlen (Give an Hour) have lived a meaningful portion of their lives through public service, dedicated to improving the lives of those who have served our nation over the decades; i.e., Wounded Warriors and their families.  The inspiring Presidential programmatic initiatives, which were held throughout the convention, focused upon the resilience and the unique and pressing needs of military families, their loved ones, and those continuing to serve the nation with distinction.  Over the years, we have learned that the essence of all of the "learned professions" is possessing the vision and the willingness to seek a higher purpose – psychology is no exception.

            Since U.S. Senator Daniel K. Inouye called upon HPA to seek prescriptive authority in the fall of 1984, in order to better serve their clients, organized psychology has slowly but steadily advanced this legislative/clinical agenda.  In 1989 the Board of Professional Affairs (BPA) held a special retreat on this topic under the chairpersonship of Norma Simon.  And in 1995 the APA Council of Representatives formally endorsed obtaining prescriptive authority as APA Policy.  As a result of Senator Inouye's leadership during the Fiscal Year 1989 Department of Defense (DoD) Appropriations process, psychologists are prescribing today within DoD and the U.S. Public Health Service, as well as colleagues in Louisiana and New Mexico with John Bolter and Elaine LeVine being the first and first female outside of the federal sector legally prescribing.  Few appreciate, however, that both Indiana (1993) and Guam (1998) have also enacted authorization legislation although not implemented to date.

From our global health policy perspective, especially with the enactment of President Obama's landmark Patient Protection and Affordable Care Act (ACA), we fully expect that those who are comfortable with the present (regardless of their professional discipline and years of training) will soon find themselves obsolete.  Psychology and the behavioral sciences have much to offer to our nation's health care delivery system, but only if we collectively get involved in the public policy/political process.  As APA's Katherine Nordal graphically described at this year's impressive State Leadership Conference: "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.   Our practitioners increasingly will need to promote the value and quality they can contribute to emerging models of care.  I believe that if we are not valued as a health profession, it will detract from our value in other practice arenas as well.  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."  And a year earlier: "If we're not at the table, it's because we're on the menu.  And I quite frankly don't want to be on anybody's plate to be eaten."  Katherine also pointed out that psychologists make up only about one-sixth of the behavioral health workforce.  Thus, with general practice physicians consistently prescribing 60% of the psychotropic medications, RxP provides a real opportunity to demonstrate "value-add" to the health care systems of the future.

A Visionary RxP Trainer's Perspective:  Bob McGrath, who administers the Fairleigh Dickinson University (FDU) RxP training program, reports that: "We were saying 1600 colleagues have already completed their training a year ago.  Today I expect we are up to about 1750.  The pursuit of prescriptive authority in Illinois and New Jersey has resulted in an unexpected but exciting by-product, which is a dramatic increase in enrollments to the FDU psychopharm masters' program.  I'm pleased to say that we are about to start our largest class ever.  Even the possibility of passage in a more industrialized state has revealed a continued and even perhaps growing interest in psychopharm training.  I continue to believe we can only combat the mismanagement of medication – both its underuse AND overuse – if we can manage it ourselves.  I also maintain my belief that RxP should be the #1 advocacy agenda for the profession.  While other agenda items such as parity or identification as 'physicians' increase the potential for others to hire psychologists, only RxP enhances the motivation for others to hire psychologists.  Unfortunately, for too long a small group of naysayers have dominated the discussion.  I think it's time for us to celebrate the remarkable contributions of our prescribing psychologists, including a 20-year history without a single complaint or suit, decoration by multiple branches of the military, and a record of exemplary service in response to some of the great crisis events of recent years."  Those interested in the history of RxP would appreciate that Morgan Sammons and John Sexton were the first two DoD prescribing psychologists.  The RxP agenda is all about, and always has been primarily about, serving society and making psychological services more readily available for those who would clinically benefit from our expertise.  It has further been our observation over the years, as California Psychological Association practice leader Chuck Faltz has emphasized on numerous occasions, when CPA was active in pursuing RxP, the membership became meaningfully engaged and significantly increased their participation, both in numbers and financial contributions.  When CPA hit a hiatus, membership involvement slowed down dramatically.  At the Uniformed Services University of the Health Sciences (USUHS) (DoD), psychology and nursing are increasingly collaborating on developing integrated and interdisciplinary training modules.  Mark Skrade, President of the School of Professional Psychology at Forest Institute, continues to move forward on his vision for a joint PsyD-Advanced Practice Nursing or Physician Assistant dual degree program, with an emphasis on primary care.  Graduates of these programs will undoubtedly possess a rich appreciation for the nuances of ACA's integrated care.

New Horizons For Those With Vision:  A high personal priority of the NIH Director, the National Center for Advancing Translational Sciences (NCATS) was established at the National Institutes of Health (NIH) on December 23, 2011, with the mission to catalyze innovations aimed at enhancing the development, testing, and implementation of diagnostics and therapeutics across a wide range of human diseases and conditions.  By improving the process of translation, NCATS enables scientists in both the public and private sectors to develop drugs, devices, and diagnostics more efficiently for any number of diseases, ultimately accelerating the pace at which they are delivered to the patients who need them.  The NCATS budget document ($665.7 million) notes that there have been dramatic advances in our understanding of the molecular pathogenesis of disease in recent years, and by pairing this knowledge with advances in technology and with expert partners, NCATS is on its way to transforming the translational research process into an efficient and collaborative enterprise.  By focusing upon commonalities across diseases and organ systems, NCATS complements the work of other NIH institutes and centers as well as that of its pharmaceutical, foundation, and advocacy partners.

To date, NCATS has become a hub of innovation for translational sciences.  The Center has launched several major research initiatives, cultivated promising strategic partnerships, and established a presence at the NIH and in the community.  The milestones include: guiding an evolution of the national network of clinical and translational research institutions; overseeing an innovative grant program to create new tools for predicting drug toxicity in partnership with the Defense Advanced Research Project Agency (DARPA) and the Food and Drug Administration (FDA); and developing a breakthrough partnership program with eight pharmaceutical companies to find new uses for existing drugs.

NCATS supports the development, demonstration, and dissemination of a broad range of technologies, tools, and resources that facilitate collaborative pre-clinical testing and first-in-human clinical trial implementation.  Through its Clinical and Translational Science Awards, NCATS supports institutions across the country in their efforts to improve the quality, validity, generalizability, and efficiency of clinical and translational research.  The Research Electronic Data Capture (REDCap) system, a freely available powerful enterprise electronic data capture tool that is easy for investigators to use, provides capability for conducting clinical research studies quickly and securely.  Integrated clinical data repositories at supported institutions and policy agreements that allow searches across multiple institutional repositories facilitate clinical trial recruitment and hypothesis generation.  These tools are helping amalgamate supported institutions into a national network for observational and interventional trials.

In order for NCATS to meet its mission, the biomedical [and we would add behavioral] workforce must be sufficient in size and equipped with the requisite knowledge and skills for advancing the relatively new discipline of translational science.  NCATS supports a dedicated clinical and translational research training pipeline to ensure that our nation has the trained research team members needed to move basic research finding into the clinic.  Over 4,100 researchers have been trained so far.  These supported training programs incorporate nationally endorsed core competencies required for translational researchers, including the principles and application of translational science, collaborative team science, project management, and entrepreneurship.  Training competencies focused on therapeutic development are currently being developed.  NCATS is committed to increasing its support for accelerating the bench-to-bedside process.  In the coming year, NCATS proposes to greatly expand its successful drug repurposing initiative to encompass up to 100 rare diseases which currently have no treatment.  NCATS's highest priority is to advance the discipline of translational research by catalyzing the development of innovative methods and technologies that accelerate the development, testing, and implementation of diagnostics and therapeutics across a wide range of human diseases and conditions.  We fully expect that future budget documents will highlight NCATS's yet to be discovered interest in the mental and behavioral health fields.

            Retirement Perhaps, For Some:  "I appreciate your emails focusing on the major changes in health and different retirement patterns.  In my case they go together.  I work about half time as a contract psychologist with the Coast Guard Training Base-Petaluma Medical Clinic.  The base is an hour and a half north of San Francisco in the wine country and about a half hour from Bodega Bay on the Pacific where my wife and I live.  It's a great combination of environments.  I have completed my third year at the Coast Guard Clinic collaborating with a Coast Guard Physician(s) and Physician Assistant along with a dozen Health Service Assistants and additional Health Professionals.  I determined on starting here to find every psychology way to be helpful to these Coast Guard members and our Coast Guard patients.  So I have been able to make use of my broad background seeing patients/clients in universities, country hospital, USAF bases, public health, public agencies, a private in-patient clinic, as well as professional school contexts.  As I have worked here in consultation, short and long term psychotherapy roles, as well as in emergency triage situations, I thought how indebted I am to the psychologists from whom I have learned directly and indirectly, those researchers/theorists, and of course practitioners.  Then it popped into my mind: 'I belong to a noble profession,' experiencing being proud of being in our profession.  We would do well to describe our profession in this way to students and young psychologists.  We can get too lost in our disagreements and conflicts.  My best, [Rod Nurse]."  According to the National Park Service, Dinosaurs were a remarkably successful group of animals.  They lived on the Earth for 160 million years.  Their world and that of psychology has radically changed.  Aloha,

 

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

AN EVOLVING PERSPECTIVE

 During my years of service on the U.S. Senate staff, it was interesting to reflect upon how those committed to public service were truly fortunate to be able to focus upon developing programs that are effective, rather than exclusively being responsible for individual clinical outcomes, regardless of how personally satisfying that might be.  Increasingly, this broader perspective is now occurring within the private sector, particularly with the emphasis upon wellness, prevention, and integrated care fostered by the Patient Protection and Affordable Care Act (ACA) of the Obama Administration.  The hallmark of psychology's legislative success used to be whether there was an express mention of the term "psychology" in the underlying federal or state statutes; for example, authorizing the expertise of psychologists within the federal criminal code when issues of mental competence were being deliberated by the federal courts (accomplished at the request of the Reagan Administration, thanks to Bruce Bennett and former Hawaii Psychological Association President Barbara Porteus).  Today, there is an increasing emphasis upon whether the functions performed by psychologists are expressly recognized.  By definition, this approach reflects the policy recognition that the various behavioral health professions do significantly overlap in their expertise and raises the intriguing question of what is unique about their underlying training orientation that could/should be shared.  At the DoD Uniformed Services University of the Health Sciences (USUHS), I have been very impressed by the extent to which psychology and nursing, in particular, have been developing integrated and interdisciplinary oriented training opportunities.

            DoD Congressional Vision:  During this year's deliberations on its Fiscal Year 2014 recommendations for the Department of Defense, the House Appropriations Committee highlighted several issues of particular interest to public service psychology, especially when one appreciates that the underlying policy recommendations have relevance beyond that of any particular service (e.g., are relevant to those colleagues working within the federal bureau of prisons).  Under the Defense Health Program account (recommending $33.5 billion): "Mental Health Access For Servicemembers -- The Committee remains concerned with the ongoing stigma associated with servicemembers seeking assistance for mental and behavioral health issues.  The Committee encourages the Assistant Secretary of Defense (Health Affairs) and the Service Surgeons General to leverage all existing resources, within both military and civilian facilities, to provide comprehensive mental and behavioral health services to servicemembers and to continue efforts to reduce this stigma."

            The House Committee also expressed its support for the notion of Embedded Mental Health Providers, which was a visionary concept championed by Morgan Sammons when he was psychology specialty leader for the U.S. Navy.  "The Committee understands the tremendous toll exacted on all servicemembers and their families, including those in the special operations and National Guard and reserve communities, after more than a decade of war.  The Committee has always made the care of forces and their families its highest priority.  The Committee appreciates the focus that the Commander, Special Operations Command, has put on the psychological health and well-being of special operations forces and their families and recognizes the importance of providing support to this vulnerable population.  Further, the Committee recognizes the success of the embedded behavioral health program and fully supports its expansion to the special operations community.  However, the Committee believes that the mental health needs of all servicemembers, including special operators, are most appropriately addressed within the Defense Health Program by the Service Surgeons General to ensure the highest quality continuity of care for the servicemember.  Therefore, the Committee recommendation transfers $21,300,000 requested within the Special Operations Command operation and maintenance budget to the Defense Health Program to address the needs of the special operations community.  The Committee directs the Service Surgeons General to work with the Commander, Special Operations Command, to implement an embedded behavioral health program for special operations units during fiscal year 2014. 

            "The Committee also recognizes that National Guard and reserve personnel in states at high risk for suicide and dangerous behavioral health conditions need convenient access to mental health professionals for proper screening and care.  Onsite access to embedded mental health specialists during training assemblies has proven successful in overcoming geographical, stigma, and time barriers that might otherwise bar a member from similar services in an underserved community.  The Committee encourages the Secretary of Defense to work with the Chief, National Guard Bureau and Service Surgeons General to implement an embedded behavioral health program for National Guard and reserve component servicemembers in order to provide reserve component personnel with ready access to screening and treatment during unit training assemblies and urges the Secretary of Defense to robustly fund these programs."

            USUHS's Appreciation of the Future:  At USUHS, the Graduate School of Nursing doctoral program recently held its Wellness Boot Camp.  "We are all familiar with the scientific foundations of stress and the negative long-term effects of chronic stress -- whether the focus is research, clinical practice or health policy and program development.  The rigors of doctoral studies and professional life frequently result in marathon chair time, compressed sleep schedules and little time to exercise and plan healthy nutritional options.  These physical and psychological challenges can easily result in poor health habits that carry on well into professional careers.  A common complaint is that there is no time for self-care.  Ironically, the health goals of the collective international community are expressed in the World Health Organization's (WHO) goal, 'to improve equity in health, reduce health risks, promote healthy lifestyles and settings, and respond to the underlying determinants of health.'  The goals and objectives of the AMA, APA, APhA and ANA all share adaptations of this overarching goal.  Logically the easiest solution to improved health is through identifying risk factors, building protective factors and targeting preventive measures; however, the complexity of life outside of the research lab is replete with human emotions, behaviors, genetics and environmental factors.

            "The USUHS Graduate School of Nursing Ph.D. program recognizes the health risks associated with doctoral studies, values the health of its students and faculty, and practices prevention.  Because people are the most important investment, mitigation and prevention of stress-related conditions were the focus of our recent GSN Wellness Boot Camp.  Integrative health care and evidence-based modalities for self-care were addressed during the half-day camp.  The venue included didactic and experiential learning in the art and science of mindfulness meditation, progressive muscle relaxation, guided imagery, yoga, Reiki and laughter yoga.  Significant research relevant to military populations such as imagery rehearsal for post-traumatic nightmares, mindfulness-based stress reduction for healthcare workers and the use of complementary and alternative medicine in VA specialized PTSD treatment programs were highlighted.

            "Students and faculty attendees were able to network with the Senior Program Manager for Military Research, and the Optimal Healing Environment Program Manager of the Samueli Institute.  The latter provided a review of the physiology of stress and reminded the group that the simple act of three full breaths can change the physiology of both our breathing and our mind.  We were led through guided imagery exercises and provided research outcomes on the benefits of guided imagery for pain management in surgical patients, as well as in individuals with phantom limb pain.  The Walter Reed National Medical Center's therapeutic yoga instructor demonstrated supportive yoga poses that promote calm, concentration and relaxation, and are frequently used in the rehabilitation of Wounded Warriors.  Reiki master Jennifer Rawlings won over the crowd with a brief demonstration of Reiki on our doctoral chair, Dr. Penny Pierce.  The camp concluded with roars of laughter as my fellow USAF student Jackie Killian, a certified laughter yogi specialist, provided a preview of her doctoral research in the area of the physiological effects of laughter yoga complete with group exercises of purposeful and spontaneous laughter.

            "The take away from Boot Camp is a challenge for all of us.  As we continue to conduct research, incorporate finding into practice and design programs to reduce stress, prevent illness and promote resilience, we would each benefit from practicing these evidence-based mind-body modalities in our busy lives.  Perhaps the effects would not only be enjoyed by us but by our colleagues, families and patients.  It was particularly supportive to see Dr. Chip Rice, USUHS President, present that morning.  Our healthcare vision is evolving (Laurie Migliore, USAF)."

            The National Institutes of Health:  The National Center for Complementary and Alternative Medicine (NCCAM) is the Federal Government's lead agency for scientific research on various complementary health interventions and their potential role in integrative strategies for treating difficult health conditions and promoting better health.  NCCAM is committed to building the scientific evidence needed by consumers, providers, and health policymakers regarding the safety and usefulness of these approaches to improve health and health care.  The President's Fiscal Year 2014 budget request for NCCAM is $129 million, a slight increase over the previous year.  According to its budget justification, nearly 40% of Americans are integrating complementary health interventions into their health care and personal health practices, at an annual cost of $34 billion.  While decisions about the use of these interventions are sometimes made with the guidance of a professional health care provider, this is often not the case.  Furthermore, both consumers and providers are often confronted with limited objective information about the safety and effectiveness of these approaches.  To address these evidence gaps, NCCAM funds research across the continuum of basic, translational, and clinical research, guided by its strategic plan.

            A major focus for NCCAM is research related to chronic pain, an enormous public health problem that affects 100 million Americans and costs at least $635 billion per year in treatments and lost productivity, according to the Institute of Medicine (IOM).  Current drug-based treatment options are only partially effective and can have serious side effects.  Research exploring non-pharmacological approaches for treating chronic pain is a top Center priority.  In the past year, one supported study provided strong evidence that acupuncture may be helpful for chronic pain and another study suggested that spinal manipulation or exercise is more effective than medication for acute neck pain.  NCCAM will continue to support rigorous basic, translational, and clinical research to understand whether such interventions add value to existing approaches and to identify the biological mechanisms by which they exert beneficial effects.  A recent effort focuses on the use of complementary approaches to pain and symptom management in military and veteran populations.  This effort encourages collaboration between NCCAM-funded researchers, other NIH institutes and centers, and researchers at DoD and VA.

            NCCAM's intramural research program focuses on understanding the central mechanisms of pain and its modulation, with the long term goal of improving clinical management of chronic pain through the integration of pharmacological and non-pharmacological approaches.  Of particular interest are the mechanisms by which emotion, attention, placebo effects, and other such processes modulate pain or pain processing.  The program will be highly collaborative within the larger NIH neuroscience research enterprise.

            Research on the safety of natural products is another major priority, given the widespread availability and use of these products by the public.  One area of particular need is better scientific information about interactions between natural products and drugs.  The Center also remains committed to strengthening "real world" outcomes and effectiveness research that capitalizes on the reality that many complementary and integrative approaches are in widespread public use.  As such, NCCAM leads the development of the complementary health questions, which are included every five years in the National Health Information Survey conducted by CDC and the National Ambulatory Medical Care Survey involving interviews with 30,000 physicians.  Data from these two surveys is expected to provide the most current and comprehensive picture of the use of complementary and integrative health practices in the nation.   Finally, to help the public and practitioners make informed decisions about the use of complementary and integrative health interventions NCCAM disseminates its research findings, providing reliable, objective, and evidence-based information through multiple channels.  Aloha,

Pat DeLeon, former APA President – Division18 – September, 2013