Interprofessional Collaborative Practice: One of the fundamental tenants of President Obama's Patient Protection and Affordable Care Act (ACA) is that quality care requires respectful collaboration among the various health care disciplines. Our colleagues in pharmacy have been on the cutting-edge of this evolution with the Departments of Defense (DoD) and Veterans Affairs (VA), under the leadership of Toni Zeiss, affirmatively demonstrating its contributions. The National Alliance of State Pharmacy Associations (NASPA) convened a workgroup to build upon relevant recommendations from the National Governors Association (NGA), emphasizing the importance of alignment with pharmacists' considerable education and training. They took the approach that rapid innovation in education, training, technology, and evidence-based guidelines necessitate a collaborative practice framework that is flexible and facilitates innovation in health care delivery, especially at the practice level.
Give An Hour – An Inspirational Vision: Earlier this year I had the opportunity to attend the launch of Give An Hour's new initiative, The Campaign to Change Direction, which focuses upon how our nation views and talks about mental health/behavioral health issues. First Lady Michelle Obama was the keynote speaker with active participation from the highest level of leadership within DoD and VA, as well as numerous Wounded Warriors. A national public awareness campaign has been launched featuring Mrs. Obama. On July 21, 2015, while addressing the Veterans of Foreign Wars (VFW), the President himself urged all American to learn the five signs that may mean someone you know is in emotional pain and might need help: Personality Change, Agitation, Withdrawal, Poor Self-Care, and Hopelessness. Currently 18% of Americans have a mental health condition and 90% of those who die by suicide have a mental disorder. If one remains until the very end of the film Love & Mercy, one will see that as a nation we are finally moving towards viewing emotional issues in the same manner as physical ailments as the First Lady urged. Barbara Van Dahlen, Ph.D., President and CEO of Give an Hour, credits her inspirational vision to her young daughter's concern 10 years ago about how the nation has historically treated (or forgotten its responsibility for) homeless veterans. Immediate family members do have a major impact upon our life journeys.
An Interesting Aspect of the Hoffman Report: Having been interviewed by David Hoffman and one of his colleagues, I made a special point of carefully reading, and admittedly re-reading, the entire 542 page document. Since my 2000 APA Presidential term, I have been away from the governance feeling that it is time for our next generation. I can understand how the process might have unfolded. I learned many of the specifics enumerated in the report for the first time. My sincerest congratulations to Past-President Nadine Kaslow for being willing to pursue this independent review which, in my judgment, was an act of true courage. Personally, I could never condone torture in any fashion, a conviction I am confident that the vast majority of our colleagues strongly support. One vividly remembers the messages passed on by one's grandparents – "Those were your relatives whom you see hanging for public display." My wife and I were on the National Mall participating in the unfortunately small anti-war demonstration the night before the President acted. These are very important issues for all Americans. Although lengthy, I would strongly urge everyone to read the entire Hoffman report – there is much to be learned which must never be forgotten.
The report describes psychology's long history of involvement with the Department of Defense (DoD). During World War I, on the day that Congress declared war on the German Empire, APA President Robert Yerkes convened a meeting of a group of psychologists to discuss how psychology could assist in the war effort. A special meeting of APA's Council established 12 committees to assist the government in addressing psychological problems, including committees on the psychological examination of recruits; psychological problems of incapacity, including those of shell shock; and, recreation in the army and navy. One of the largest endeavors undertaken with the assistance of psychologists in support of the war effort involved the administration of tests to assess potential recruits. The Army administered a battery of tests similar to the Binet-Simon intelligence scale to more than 1.7 million recruits to attempt to differentiate between potential recruits who were unsuitable for service, those who would be suitable privates, and those who could serve as officers. During World War II, the effort to assess potential recruits expanded and by 1945 more than 13 million people had been screened. A number of prominent psychologists also developed an intensive program designed to assess the suitability of a candidate seeking to serve in the Office of Strategic Services (OSS), which had been created by President Roosevelt as the agency responsible for intelligence collection, espionage, subversion, and psychological warfare. Psychologists' participation in the war effort led directly to the creation of the modern APA. Throughout the Cold War, psychology had a close relationship with the military.
The G.I. Bill strengthened the profession of psychology both by expanding enrollments in institutions of higher education and by allowing some returning soldiers to train to become psychologists and join APA. The military also drove a major expansion in infrastructure supporting clinical psychology. Over time, the military and the VA created a demand for psychologists to care for soldiers and veterans with mental and emotional problems. Psychology had an important influence on the development of military doctrine regarding interrogations. Beginning in at least 1956, the military forbade the use of tactics it deemed coercive in interrogations.
Quoting Directly From The Report: "The very substantial benefits APA obtained from DoD help explain APA's motive to please DoD, and show that APA likely had an organizational conflict of interest, which it needed to take steps to guard against. DoD is one of the largest employers of psychologists and provides many millions of dollars in grants or contracts for psychologists around the country. The history of DoD providing critical assistance to the advancement and growth of psychology as a profession is well documented, and includes DoD's creation of a prescription-privileges 'demonstration project' in which psychologists were certified to prescribe psychiatric drugs within DoD after going through a two-year training course…."
"The APA Board also asked three sub-questions…. The third sub-question was 'whether any APA action related to torture was improperly influenced by government-related financial considerations,' including grants, contracts, or prescription-privileges policy for military psychologists. As described above, the substantial financial benefits in the form of employment, grants, and contracts that DoD provided to psychologists around the country had a strong influence on APA's actions relating to the PENS Task Force (and therefore 'relating to torture'), since preserving and improving APA's relationship with DoD (including the benefits to psychology that flowed from it) formed an important part of the motive behind APA's actions. We did not find that APA was motivated by a specific contract or grant, or that APA itself actually received any substantial grants, contracts, or other payments from DoD during this period. The financial motivations for APA related to the substantial benefits that flowed from DoD to the profession of psychology."
"As for the prescription-privilege program, we found that APA believed that this program has provided a very substantial benefit to psychology and APA, because obtaining prescription privileges in order to better compete with psychiatry was one of APA's leading priorities for many years. DoD's 'demonstration project,' created in 1991 and in place through 1997, which was initiated principally by Pat DeLeon (APA President in 2000) and his boss, Senator Daniel Inouye (D-HI) and his Chief of Staff, psychologist Pat DeLeon (APA President in 2000), allowed psychologists to have prescribing privileges in DoD and other federal locations, and created a two-year certification program that could be recognized by a state that authorized properly-certified psychologists to have prescription privileges like psychiatrists. Approximately ten psychologists were trained and certified through the DoD demonstration project, including Debra Dunivin. The demonstration project thus served a crucial unlocking function for psychology and APA, since it established the legitimacy of a prescription-training program outside of traditional medical school, thus providing a strong answer to the traditional critique from psychiatrists that the only way to be trained in prescribing psychiatric medications was to graduate from a traditional four-year medical school."
"We do not believe that by 2005, APA officials were realistically seeking or expecting anything further from DoD on the topic of prescription privileges. Nor do we believe that APA officials actually worried that a failure to curry favor with DoD would cause DoD to reverse course on prescription privileges by, for instance, disallowing previously-certified psychologists from continuing to prescribe medication when they treated DoD personnel. Thus, we do not believe that the prescription-privileges issue was a significant 'financial consideration' for APA in taking the actions it took in 2005."
"Nevertheless, it is clear to us that the way in which DoD had supported psychology in crucial ways in the prior years, including through the prescription-privileges program, played a fundamental role in APA feeling motivated to curry favor with DoD. This was less of a function of APA seeking something concrete with regard to a specific contract or program (like prescription privileges), but more of a function of APA knowing very concretely how willing and able DoD was to provide large-scale support to psychology as a profession – now and perhaps in the future in unknown ways. This was support that APA did not want to risk jeopardizing by taking a position that was at odds with what APA perceived as DoD's clearly stated preferences within the PENS process."
On pages 83-85 of the report, the authors provide a comprehensive overview of the DoD "demonstration project" (PDP). "In 1999, the U.S. General Accounting Office ('GAO') found that PDP graduates were well-integrated into the Military Health Service, that they held positions of responsibility and treated a broad spectrum of patients, carrying patient caseloads that were comparable to those of psychiatrists. It found that most of the graduates had been granted independent status, which allowed them to operate with only the same level of review as psychiatrists at their locations. The GAO further found that the graduates were evaluated as good to excellent, both by their clinical supervisors, and an outside panel of psychiatrists and psychologists, and found no evidence of quality problems in their credential files. However, the GAO also found that the PDP program was more costly than the Department of Defense's traditional mix of psychiatrists and non-prescribing psychologists, and stated that the impact of the program on combat readiness was minimal at best." We would strongly urge all psychologists to carefully review the entire Hoffman report. You may agree or disagree with its conclusions; clearly, reasonable colleagues do. Nevertheless, it is a fascinating document. "Which You Can Use To Change The World." Aloha,
Pat DeLeon, former APA President – Division 29 – August, 2015
