THE FOUNDATION FOR AN EXPANDED VISION (RxP History)

 Federal Involvement:  On November 30, 1984, at the Hawaii Psychological Association (HPA) annual convention, U.S. Senator Daniel K. Inouye urged the membership to amend their state practice act to allow them to independently utilize drugs where appropriate so that their "clients will be well-served."  After the Senator's challenge, the HPA Executive Committee agreed to pursue legislation which would study the feasibility of obtaining this clinical responsibility.  At that time there was little enthusiasm for the proposal within the psychological community and extreme opposition within the psychiatric community.  During the 1989 legislative session, hearings were held on eight separate bills.  A House Resolution was enacted "Requesting the Center for Alternative Dispute Resolution to convene a series of roundtable discussions."  Thus, Hawaii became the first state in the nation in which the issue of psychologists prescribing (RxP) was seriously debated.  Interestingly, their RxP legislation was ultimately vetoed on July 10, 2007 – more than two decades after the Senator's address.  In the 2015 legislative session, renewed HPA and grassroots interest resulted in their RxP bill passing the House of Representatives on March 10, 2015, by a vote of 23 yes, 13 yes with reservations, and 15 no.

            During Congressional deliberations on the Fiscal Year 1989 Appropriations bill for the Department of Defense (DoD) [P.L. 100-463], Senator Inouye included language which directed the Department to establish a "demonstration pilot training project under which military psychologists may be trained and authorized to issue appropriate psychotropic medications under certain circumstances."  Organized psychiatry raised considerable objections.  The following year the conferees stated: "the Department cannot ignore direction from Congress and therefore should develop such a training program…."  A DoD Blue Ribbon Panel was established, with Russ Newman representing APA, and recommended a two year fellowship, combing didactic and practicum activity.  To begin on time, two psychologists were initially assigned to the Army Physician Assistant program at Ft. Sam Houston Texas.

The Walter Reed/Uniformed Services University of the Health Sciences training program (PDP) began in the summer of 1991, and was closely monitored by the American College of Neuropsychopharmacology (ACNP).  ACNP concluded: "All 10 graduates of the PDP filled critical needs, and they performed with excellence wherever they were placed."  On June 17, 1994, Navy Commander John Sexton and Lt. Commander Morgan Sammons became the first graduates.  RxP training has continued in various venues, particularly in the private sector.  DoD and USPHS credentialing policies have been issued.  The seminal contribution of the DoD initiative is to affirmatively demonstrate that psychologists could be trained to safely prescribe in a cost-effective manner.  Interestingly, individual psychologists had been prescribing within the VA and Indian Health Service (Floyd Jennings) during this time period; however, without any formal organized training.

            APA Governance:  In 1989, under the leadership of Norma Simon, the APA Board of Professional Affairs (BPA) held a special meeting to explore this intriguing phenomenon.  BPA recommended: "focused attention on the responsibility of preparing the profession to address… needs of the public for psychologically managed psychopharmacological interventions be made APA's highest priority."  In August 1990, the Council of Representatives established an ad hoc Task Force on Psychopharmacology, chaired by Michael Smyer.  Its report concluded that practitioners, with combined training in psychopharmacology and psychosocial treatments, "could be viewed as a new form of health care professional, expected to bring to health care delivery the best of both psychological and pharmacological knowledge.  Further, the proposed new providers had the potential to dramatically improve patient care and make important new advances in treatment."  In August 1995, Council formally endorsed RxP for appropriately trained psychologists as APA policy and called for the development of model legislation and a model curriculum.  Subsequent Councils adopted these (1996); called for a national examination (1997); and formal APA recognition of Designated Postdoctoral RxP Training programs (2009).  APAGS adopted its Resolution of Support in 1997.  Bob McGrath estimates today there are more than 1750 psychologists who have completed their post-doctoral psychopharmacology training.

            State Legislation:  In March 1993, Indiana and in December 1998, Guam passed psychology RxP authorization legislation, although neither has been implemented to date.  In March 2002, New Mexico and in May 2004, Louisiana passed RxP legislation with John Bolter signing the first civilian script on January 20, 2005.  Elaine LeVine was the first female civilian prescriber.  More than a decade later, Illinois enacted its RxP legislation which was signed into law on June 25, 2014.  What is unique to Illinois is the decision to legislatively address the specifics of the required training (including at the undergraduate level) and its openness to incorporating RxP training at the graduate level.  Previous policy discussions had focused exclusively upon post-doctoral training.

            Future Challenges:  Although military and USPHS prescribing psychologists have provided quality psychopharmacotherapy services for more than two decades, there has been continued resistance within the VA and the federal Bureau of Prisons.  Ron Fox, former APA President: "As of December 31, 2013 when I was chair of the APA Insurance Trust, I can attest to the fact that prescribing psychologists do NOT have to pay higher premiums for professional liability insurance as the Trust deemed an increase unnecessary; and, because the Trust policy provides insurance to cover expenses related to licensing board complaints, I know that there have been no complaints or actions taken by state licensing boards regarding prescribing abuses by appropriately trained psychologists."  Along with enacting additional state practice laws, future challenges will include expanding to Federally Qualified Community Health Centers, state and local mental health clinics, and the evolving Accountable Care Organizations and Patient-Centered Medical Homes envisioned under President Obama's Patient Protection and Affordable Care Act.  Aloha,

Pat DeLeon, former APA President – Division 12 – April, 2015

 

HERE COMES THE JUDGE

  Perhaps it is due to growing up in a family where both parents were lawyers.  Perhaps it was serving as the first chair of the APA ad hoc Committee on Legal Issues (COLI).  More likely, it was profoundly enjoying Laugh-In.  For whatever reason, like former Division President Andy Benjamin, I have always been impressed by the commonality of interest between psychology and the legal profession.  The needs of psychology's patients often parallel those of the attorney's clients.  In 2008, the first Veteran's court was established in Buffalo in an attempt to seriously address this interface.  Former Massachusetts Psychological Association President and APA President Ron Levant heralded this transformative movement.  At the national level, APA and ABA cosponsor impressive conferences.  Another former APA President Don Bersoff, the association's first General Council, noted that by 2013, APA had submitted 147 amicus briefs, 58 of which were filed in the U.S. Supreme Court.  Why don't we hear about more state psychological associations working collaboratively with their local state bar associations?

            The FY' 2016 budget for the HHS Administration for Community Living (ACL) proposes to prevent, detect, and respond to elder abuse, neglect, and exploitation.  As the population of older Americans increases, these problems continue to grow.  Yet, there is no single set of national elder abuse prevalence data.  A 2004 national survey of State Adult Protective Service programs showed a 16% increase in the number of elder abuse cases from an earlier 2000 study.  Estimates are that 84% of all elder abuse incidents go unreported.  The most recent data suggest that at least 10%, approximately 5 million older Americans, experience abuse each year, many in multiple forms.

            The Administration reports extensive negative effects of abuse, neglect, and exploitation on the health and independence of seniors.  Older victims of even modest forms of abuse have dramatically higher (300%) morbidity and mortality rates than non-abused older individuals.  Adverse health impacts include an increased likelihood of heart attacks, dementia, depression, chronic diseases and psychological distress.  As a result, a growing number of seniors access the healthcare system and are ultimately forced to leave their homes and communities prematurely.

ACL envisions building a foundation and establishing best practices for States to expand and improve the protection of elderly individuals living in their communities and in long-term care settings; increase the information and technical assistance available; protect the rights of older adults and prevent their exploitation; and reduce health-care fraud and abuse.  Its Ombudsman Program relies heavily upon volunteers who make up the bulk of those who resolve resident issues.  The landscape is changing as individuals in need of long-term care services and supports increasingly choose to live in community settings.  Fortunately there is a growing federal awareness of the uncharted area of abuse, neglect, and exploitation of older adults and persons with disabilities.  These challenges must be effectively addressed.  We would rhetorically ask: What better topic for a joint conference or dinner discussion between our local state psychological and bar associations?  Aloha,

Pat DeLeon, former APA President – Division 31 – March, 2015

UNITED WE STAND, DIVIDED….

 The Critical Nature of State Associations:  Early on in my career I worked for the State of Hawaii Division of Mental Health at a time when state employees were being unionized.  Dues were an "expense" that I never regretted; for with the union, our collective voice was heard.  A very small, but illustrative example: When the inpatient psychiatrist was going away for two weeks, he pinned a notice on the bulletin board that I was in charge.  Upon his return, I submitted a request for a small amount of additional pay.  The head of the Division (a physician) took the position that a non-physician could nothave been in charge.  The union representative successfully argued that I was, in fact, in charge -- "See the pin hole where the notice was posted."  Several years later, psychologist Joe Blaylock was appointed Head of the Division of Mental Health.  As individuals, we may sincerely believe that our expertise is beneficial and serves society well.  However, the reality is that organized medicine has, over many years, consistently opposed any expansion of the clinical practice of all non-physicians, including their ability to serve in administrative or policy setting positions.  Without developing a cohesive collective voice, the past will all too accurately continue to predict the future.

The enactment of President Obama's Patient Protection and Affordable Care Act (ACA) heralds the beginning of unprecedented change in our nation's health care environment.  Former APA Congressional Science Fellow Sandra Wilkniss points out that the ACA provides one of the largest expansions of mental health and substance use disorder coverage in a generation.   She has also urged psychology to appreciate the magnitude of transformation occurring as the nation's health care system moves steadily towardsintegrated, interdisciplinary care – and thus away from its historical reliance upon fee-for-service, independent practice.  Data-based gold standard "best practices" will be tomorrow's expectation.

            I sincerely appreciate the 25+ years that I have been able to be involved in the APA governance and particularly the opportunity during my Presidency in 2000 to visit a number of smaller rural state psychological associations.  Nationwide, there are over 46 million citizens living in rural America who face ongoing challenges in accessing health care.  Rural America is where psychology can truly make a demonstrable difference in the lives of so many Americans.  Rural residents have historically struggled with issues related to access to care, recruitment and retention of health care providers of all disciplines, and maintaining the economic viability of hospitals and health care providers in isolated rural communities.  Rural residents have higher rates of age-adjusted mortality, disability, and chronic disease than their urban counterparts.  Interestingly, the goal of President Obama's "Improving Rural Health Care Initiative" is to build healthier rural populations and communities through evidence-based practices.  This is an important mission for which psychology and the other behavioral sciences can make a unique contribution.  Exciting opportunities exist for those with visionary leadership.

            A number of our colleagues do not seem to understand that as one of the nation's educated elite, they have a societal responsibility to become personally involved in effectively addressing society's most pressing needs.  Collectively, they do not seem to appreciate that through their own state psychological association, and at the federal level APA, they can have a profound impact upon the public policy/political process.  During my involvement within the APA governance, I came to deeply appreciate that our profession is only where it is today because of the efforts of the visionary leaders of the past.  Gene Shapiro, Nick Cummings, Suzanne Bennett Johnson, Bill McKeachie, and the late John Gardner (former Secretary of HEW under President Lyndon Johnson and President of Common Cause) to name just a few to whom we owe so much.  Today's challenge is for each of us to reach out to colleagues and convince them to join (and especially, to rejoin) the only collective voice they have – the Arkansas Psychological Association.  This is particularly true for our senior colleagues who thereby will have the opportunity to mentor the next generation.  During my early days with the Hawaii Government Employees Association (HGEA), I saw how effective this personalized approach can be.  This challenge is about the very future of the field in a dramatically changing world – it is not exclusively a practitioner, academic, or science issue.  It is about survival and addressing unprecedented change.  It is about setting achievable goals.  And it is, above all else, about taking advantage of new exciting opportunities.

            Telepsychology – A Future For Many:  The unprecedented advances occurring within the computer and technology fields continue to have a major impact upon all aspects of society including our economy, except, most health policy experts would proffer, the health care industry.  The ACA is dedicated to rapidly changing this in furtherance of targeting the critical health policy goal of accomplishing "the triple aim" -- i.e., improving the experience of care, improving the health of populations, and reducing the cost of health care.  Psychology is very fortunate that 2011 APA President Melba Vasquez possessed the vision to appreciate the significance of the advent of the era of Telemental Health/Telepsychology for the profession and for all of behavioral health.  Acknowledging the successes of pioneering colleagues within the Departments of Veterans Affairs (VA) and Defense (DoD) who have been particularly responsive to its exciting potential, she established in close collaboration with the Association of State and Provincial Psychology Boards (ASPPB) and the APA Insurance Trust (APAIT), a telehealth task force which systematically addressed a number of the complex issues surrounding utilizing this evolving technology.  In August, 2013 at our annual convention, Council passed their recommended Telepsychology Guidelines on the consent agenda.

Telemental health services were initiated within VA in 2004-2005, and under the leadership of Antonette Zeiss, the first psychologist to be appointed chief consultant for the Office of Mental Health Services, VA was soon leading the way for the nation.  In fiscal year 2013, more than 600,000 veterans accessed care using telehealth programs for a total of over 1.7 million episodes of care.  It is estimated that VA telehealth services are increasing by approximately 22% annually.  We are indeed most fortunate that one of the truly visionary leaders in this area is Steve DeMers, ASPPB Chief Executive Officer.  His colleagues Fred Millan and Janet Pippin Orwig have been working diligently with both nursing and medicine, as well as the Council of State Governments, to coordinate developing an innovative Telepsychology Licensure Compact.   The critical implementation steps will be at the state level until sufficient national consensus is ultimately developed justifying a federal approach.  Working out the details will become one of the Arkansas Psychological Association's priorities over the next several years.  "It ain't quite this simple, so I better explain just why you got to ride on the union train."  Aloha,

Pat DeLeon, former APA President – Arkansas Psychological Association – February, 2015

 

 

REMAINING RELEVANT – DEMONSTRATING VALUE-ADD

During the February, 2015 Council of Representatives meeting, Beth Rom-Rymer received a well-deserved Presidential citation from APA President Barry Anton.  It had been a decade since Louisiana's Jim Quillin, John Bolter, and colleagues were successful in persuading Governor Kathleen Blanco to sign HB 1426 into public law on May 6, 2004.  Describing the innovative Illinois law, Beth opined: "We believe that our law, Public Act 98-0668, that gives independent prescriptive authority to licensed clinical psychologists with advanced, specialized training in Clinical Psychopharmacology, is an incredibly important step forward in the provision of comprehensive, integrated mental health care for all Illinois residents.  The training, beyond the doctoral degree in psychology, includes seven basic science undergraduate courses; a Master's degree in Clinical Psychopharmacology with a capstone exam; and a series of nine medical rotations over a period of several months.  There is no 'conditional prescribing period' once the criteria for training and education have been met.  There are monthly collaborative meetings between the licensed prescribing psychologist and a physician of his/her choosing.  Psychologists and psychiatrists are now working, side-by-side in Illinois, to create training opportunities for prescribing psychologists and to provide high caliber healthcare to their patients.  We, indeed, are thrilled with this terrific success for the provision of comprehensive, mental health care by prescribing psychologists in Illinois."

            A Significant Shortage of Providers:  Morgan Sammons recently brought to our attention The Wall Street Journal article rhetorically asking: "Where Are the Mental-Health Providers?"  Noting that: "The shortage of mental-health providers in the U.S. has long been considered a significant problem.  But it is becoming more acute as people are encouraged to seek treatment, or find that they are able to afford it for the first time as a result of new federal requirements that guarantee mental-health coverage in insurance plans.   That's prompting a sea change in attitudes among mental-health advocates, who are starting to look at solutions that are broader than just training more psychiatrists."

Former APA Congressional Science Fellow Sandra Wilkniss points out that President Obama's Patient Protection and Affordable Care Act (ACA) provides one of the largest expansions of mental health and substance use disorder coverage in a generation.   She has consistently urged psychology to appreciate the magnitude of change occurring as the nation's health care system moves steadily towards integrated, interdisciplinary care – and thus away from its historical reliance upon fee-for-service, independent practice.

A similar perspective was expressed in this year's budget request for the Substance Abuse and Mental Health Services Administration (SAMHSA) which noted that addressing mental health and substance abuse is critical to the health of individuals and families.  Prevention, treatment, and recovery support services for behavioral health are essential components of health service systems.  Behavioral health remains one of America's most pressing needs, yet it is also one of the most undervalued and least-addressed.  The ACA, in conjunction with the Mental Health Parity and Addiction Equity Act, has the potential to create or enhance access to coverage for behavioral health services for 62 million Americans, nearly one-fifth of the nation's population.  The current behavioral healthcare infrastructure and workforce, however, will need additional capacity to absorb the influx of patients who now will have the coverage to seek treatment.  Behavioral health can, and should, be addressed as a public health issue by ensuring that the programs and policies focus on these tenets: Behavioral health is essential to health; Prevention works; Treatment works; and People Recover.  And, APA's Heather O'Beirne Kelley, who heads up APA's Military & Veterans Policy (MVP) team, has been working with various Veterans organizations in furtherance of the establishment of prescription authority (RxP) for appropriately trained and certified psychologists in the Veterans Administration (VA), matching that which DoD has granted for 17 years.  

            Invigorating Renewed Interest:  During Beth's consultations with an increasing number of state psychological associations which have developed renewed interest in the prescribing psychologist (RxP) agenda, as a direct result of her legislative success, she emphasizes that: "Prescribing psychologists will significantly increase the number of mental health professionals in Illinois who will be providing comprehensive, integrative mental health care.  The number of psychiatrists in Illinois is 1200 and dropping, as psychiatrists retire.  The number of licensed clinical psychologists in Illinois is 5,000 and rising.  At least 40 Illinois psychologists are currently in training in Clinical Psychopharmacology.  As Illinois graduate programs in Clinical Psychopharmacology proliferate, hundreds of psychology undergraduate and graduate students will be doing their training to become prescribers and the number of psychologist prescribers will exponentially increase."  Bob McGrath, Director of the Fairleigh Dickinson University RxP training program, estimates that nationwide 1,700 colleagues have already completed their advanced psychopharmacology training.

            Who will be the next generation of Prescribing Psychologists?  Two of Beth's protégés:

*  Karla Torres is an Early Career Psychologist who is Director of Behavioral Health and Pastoral Care at the Lawndale Christian Health Center, a Federally Qualified Healthcare Center (FQHC), that serves a largely Hispanic and African American population on the west side of Chicago.  This FQHC has had great difficulty accessing psychiatrists and has great appreciation for her training in clinical psychopharmacology.  She has almost completed her training for the M.S. degree in Clinical Psychopharmacology from Fairleigh Dickinson University and is looking forward to completing the other components of her training over the next few years.  She was one of the key psychologists who worked hard with legislators as the Illinois Psychological Association sought to pass their bill in 2013 and 2014.

*  Rosemarie Kugler is a civilian senior psychologist who is practicing on a military base just outside of St. Louis, Missouri.  She lived and practiced, most of her life, in the southwestern tip of Illinois.  She had taken all but one of the seven required science courses as an undergraduate over 40 years ago.  She completed her training in Clinical Psychopharmacology, from Alliant International University, just two years ago, and recently took the PEP.  She is hoping to do her series of medical rotations in a medical center setting and an FQHC in southern Illinois and become a prescribing psychologist as soon as possible.  Aloha,

Pat DeLeon, former APA President – Missouri Psychological Association – February, 2015

 

WAY UP NORTH

 Having worked with Hawaii's U.S. Senator Daniel K. Inouye for 38+ years, I have had the opportunity to visit Alaska on a number of occasions, including during my APA Presidential year in 2000.   Senator Inouye was a close personal friend of Senator Ted Stevens and over the years, I became impressed by the many similarities which existed between their two states, especially among the indigenous Native Hawaiian and Alaska Native populations.  In my judgment, the Southcentral Foundation health system, with Katherine Gottlieb as its President, is the finest health care system in the nation.  Similarly, the Cook Inlet Tribal Council, with Gloria O'Neill as its President, is a fascinating and highly effective human resources organization.  Both of these visionary institutions focus upon providing care and services to Alaska Natives and represent an unprecedented opportunity for psychology's next generation of indigenous providers – especially since their leaders respectively serve on the Board of Regents of Alaska Pacific University (APU) and the University of Alaska (UA).

            The Health Resources and Services Administration (HRSA) is one of the most important federal agencies for psychology, nursing, and the other non-physician health care providers.  It funds the all-important Federally Qualified Community Health Centers (FQHCs) network, which began under President Lyndon Johnson's Great Society Era.  And, it is the home of the Graduate Psychology Education (GPE) program, targeted to training colleagues to work with underserved populations.  The Fiscal Year 2016 GPE budget request would provide $7,916,000, noting that the demand for behavioral health services will grow as more individuals are covered under the President's Affordable Care and Patient Protection Act (ACA) and the Mental Health Parity and Addiction Equity Act.

At Alaska Pacific University, Bob Lane currently has one Native Alaska adjunct faculty member and one native student, as well as two additional American Indian students.  APU invites a number of guest speakers from the Alaska Native community and is actively seeking to make education more accessible in remote regions via blended classes and intensive weekend residencies.  The University of Alaska (UA) program has an Alaska Native Board of Elders to provide guidance to the faculty and students to ensure that the program is culturally relevant and designed to meet the needs of the Alaska Native population.  Jim Fitterling reports that before they even begin their doctoral training, all newly admitted students attend an intensive cultural retreat and sit literally, as well as figuratively, at the feet of these Elders.  UA has Native Americans as adjunct faculty, teaching courses such as Native Ways of Knowing.  The doctoral program has several graduates – including their first Alaska Native – working in the Alaska Native Health Corporations throughout the state, providing opportunities for telepsychology and telesupervision at distal sites in rural Alaska.  Interestingly, Rod Baker recently noted the Veterans Administration (VA) Office of Inspector General report found that psychology was one of their "largest staffing shortage" occupations – a finding definitely relevant to Alaska.

HRSA Administrator, Mary Wakefield: "HRSA is the primary Federal agency for improving access to health care by strengthening the health care workforce, building healthy communities and achieving health equity….  (T)he Health Center program will continue to play a critical role in the health care system by providing high quality, affordable and comprehensive primary care services in medically underserved communities even as insurance coverage expands."  The HRSA Office of Rural Health Policy was established in 1987 to serve as a focal point for rural health activities within HHS, including advising on rural policy issues, conducting and overseeing policy-relevant research on rural health issues, and administering grant programs that focus on supporting and enhancing health care delivery in rural communities.

Historically, rural communities have struggled with issues related to access to care, recruitment and retention of health care providers of all disciplines, and maintaining the economic viability of hospitals and other health care providers in isolated rural communities.  Nationwide, there are over 46 million citizens living in rural America who face ongoing challenges in accessing health care.  Rural residents have higher rates of age-adjusted mortality, disability, and chronic disease than their urban counterparts.  The goal for the President's "Improving Rural Health Care Initiative" is to build healthier rural populations and communities through evidence-based practices.  This will include the coordination of rural health activities within HHS and across the Federal Government.  The broad and non-categorical nature of HRSA's programs allows the office to focus funding on key emerging needs.

            HRSA's pilot rural family medicine residency training initiative, in which the first year of training takes place in urban-based locations and the second and third years of residency occur in rural locations, resulted in 70% of the graduates staying in rural practice after completing their training.  The telehealth grant program is expanding the use of telecommunications technologies within rural areas that link rural health providers with specialists in urban areas, thereby increasing access and the quality of healthcare provided to rural populations.  Telehealth technology also has been found to offer important opportunities to improve the coordination of care in rural communities.  The Office of Rural Health Policy plans to expand its work with the VA addressing veterans' access to rural health providers through the support of pilot programs that use telehealth and health information technology exchange to enhance services for rural veterans.  In addition, the Office is working with the VA Office of Rural Health on the implementation of the Veteran's Choice Act which allows rural hospitals and clinics to provide services to Veterans who reside more than 40 miles from a VA facility.   The Fiscal Year 2016 budget request for the Office of Rural Health Policy is for $127,562,000.

            This winter I had to opportunity to visit American Samoa for the first time.  Without question, this U.S. territory personifies rural America with all of its unique challenges and its indigenous population.  Rural American, however, also provides unprecedented opportunities for those with vision, persistence, and compassion.  The HRSA Pediatric-Emergency Medical Services (EMS-C) program was established back in 1984, following up on my daughter's use of a then-typical hospital emergency room.  In American Samoa I had the pleasure of meeting with those in charge of their EMS-C program.  It was a wonderful experience seeing how they can respond effectively to local crises, including those caused by natural disasters.  Most intriguing was their willingness to utilize their limited resources to address their most pressing needs.  For example, transportation itself can be quite a challenge for the elderly throughout rural America and thus the EMS-C personnel conduct home visits – thereby avoiding predictable future crisis calls to the LBJ hospital emergency room.  In our judgment, the $20+ million HRSA budget request this year for this national program is truly an outstanding investment in the nation's future.  Incidentally, during one of my visits to Alaska I had a similarly rewarding experience, seeing how your EMS-C staff were creatively responding to the overwhelming need for helicopter support from rural Alaska.  Those with vision and persistence do make a real difference in the daily lives of our citizenry.  Mahalo.  Way up north, to Alaska.  Aloha, 

Pat DeLeon, former APA President – Alaska Psychological Association – February, 2015

THE AGE OF AQUARIUS

Over the years, MPA has provided outstanding vision and leadership at the national level. During my tenure on the APA Board of Directors, I had the pleasure of working closely with future APA Presidents Norine Johnson, Gerry Koocher, and Ron Levant.  MPA members have chaired a number of the major APA policy boards and committees.  Having spent my undergraduate years in your state, I might admittedly be a little biased; however, it did not surprise me that it was the Massachusetts Nurses Association that ultimately convinced their national association to support the independent practice of Advanced Nurse Practitioners.  A number of underlying features of President Obama's landmark Patient Protection and Affordable Care Act (ACA) were undoubtedly inspired by Governor Romney's Massachusetts Health Care Reform legislation.  Collectively, you have a long history of seeing the "bigger picture."  And of course, Great Barrington is the home of Alice's Restaurant – in celebration of which Arlo Guthrie has embarked on the 50^thanniversary tour.

            Times do change.  The APA Council of Representatives has reconstituted its role in order to focus primarily upon major policy issues, and we understand from Dolly Sadow that the Council will be focusing upon "translating Science into Policy" as a mega issue.  The broader underlying issue will be developing Council as a policy making and disseminating body, rather than serving as a passive reactor to initiatives perceived as not of its own making.  How will Council facilitate policy initiatives that are consistent with APA's strategic plan and which speak to society's real needs? – that is the challenge ahead.  As perhaps a first step in this radical paradigm shift, during their February meeting Council heard directly from those who have spent their professional lives being engaged in shaping national policy.  Without question, this is an exciting evolution which will take time to effectively implement.

Reflecting upon our personal interest in policy development, several of us at the Uniformed Services University of the Health Sciences (USUHS) (DoD) recently reviewed the psychology literature on teaching health policy.  Last year, under Nadine Kaslow' s leadership, Council endorsed moving towards Competency-Based education, similar to that which almost all of the other health professions have embraced and which is a cornerstone of the ACA.  Whereas the study of health policy is, for example, a required competency within professional nursing and a priority of public health and social work education, we could find very few references to this notion within psychology.  There were, of course, articles on political advocacy (which in our judgment represents only a small subset of health policy) and an increasing number of social psychology experiments – with the plea that if only used by policy makers these could make a real difference.  However, the fundamental notion of educating future members of the psychology profession about the profession of health policy which possesses its own unique history, language, and nuances seems to be, at best, an afterthought.  Accordingly, Council's new vision truly does represent a major paradigm shift.

            Another graduate from one of the Commonwealth's finest institutions of higher education (albeit not from the oldest women's college in the nation), Heather O'Beirne Kelley heads up APA's Military & Veterans Policy (MVP) team which is working to support military personnel and veterans, their families, and their communities, as well as the psychologists who conduct research with and provide direct services to these populations.  Their priorities for this year range from funding for research at the Departments of Veterans Affairs (VA) and Defense (DoD), to provision of timely, high-quality mental health care in the service member and veterans communities, and establishment of prescription authority (RxP) for appropriately trained and certified psychologists in the VA, matching that which DoD has granted for 17 years.  [Personally, we continue to wonder why MPA has not made this a priority, especially following the impressive success in Illinois last year spearheaded by Beth Rom-Rymer, who incidentally was honored by President Barry Anton at the February Council meeting.]

In terms of research funding, the President's newly released FY'16 budget proposed a nice increase for the VA's intramural research program, so APA and the larger veteran community will support that request.  However, the Administration's budget also proposed a cut to DoD basic research, which the scientific and university community will urge Congress to restore in its annual appropriations process this spring.  APA supports military personnel in seeking and receiving high-quality, effective mental and behavioral healthcare throughout their careers – from enlistment/commissioning through pre-deployment, deployment, and transition to veteran status.  MVP advocacy efforts thus are particularly focused on garnering Administration and Congressional support for issues such as mental health screening and follow-up; access to care; suicide prevention; provision of TRICARE benefits; and supporting communities and other systems (including educational, health, and legal) in understanding and working with veterans.  Your former MPA Executive Director Elena Eisman, who has also served on the APA Board of Directors, picked a fascinating time to transition to our nation's Capital.  Aloha,

Pat DeLeon, former APA President – MPA – February, 2015

 

ALICE’S 50th ANNIVERSARY TOUR

 Having A Timely and Visual Presence:  One of the most exciting aspects of being personally involved in the public policy/political process, which definitely would include participating in the APA governance, is having the opportunity to listen to, and spend unforgettable time with, visionaries who are truly dedicated to their cause.  Psychologists often do not appreciate that they are among our nation's educated elite and as such, have a special responsibility to provide proactive leadership in addressing society's most pressing needs.  I was particularly fortunate to serve as APA President just prior to Norine Johnson's term.  Norine truly appreciated how the nation would benefit from psychology's calming presence right after the horrific 9/11events and with Rhea Farberman's steady guidance, passionately addressed the concerns of our nation's children and their families by engaging the media.

In the days and weeks following, APA, with Norine as its national spokesperson, was active with the news media to help the American public understand the traumatic effect the attacks would have on some individuals.  In the first three days, APA received 166 interview requests.  In one lead interview Norine was part of an hour long CNN special segment.  By mid-October, she had done a number of national interviews and over 2,000 APA members had been interviewed on both the 9/11 and the anthrax attacks.  At her behest, the Public Communications Office created a public information brochure containing advice on how to deal with trauma, what is normal traumatic response, and how to recover.  APA teamed with the Advertising Council and the National Mental Health Association on a public service announcement encouraging parents to talk with their children about the events of 9/11.  Norine also understood the fundamental changes gradually occurring within our nation's health care environment and worked tirelessly to have the APA Council of Representatives, and ultimately the full membership, include "promoting health" in our Association's bylaws.  As President Obama's Patient Protection and Affordable Care Act (ACA) is now being steadily implemented, Norine's vision of more than a decade ago is clearly coming to fruition.

            The Administration's Budgetary Priorities:  The Administration's Fiscal Year 2016 budget request for the Substance Abuse and Mental Health Services Administration (SAMHSA) is $3.7 billion, which includes an additional $103 million funding for its top behavioral health priorities – strengthening crisis systems, addressing prescription drug and opioid abuse, expanding the behavioral health workforce, and fostering tribal behavioral health.  The Administrator: "The impact of untreated behavioral health conditions on people, communities, and healthcare costs in the United States is staggering.  For example, costs for Medicaid enrollees with common chronic conditions and co-occurring mental and substance use disorders are two to four times higher than average Medicaid enrollees….  (A)ddressing behavioral and physical health issues together can reduce costs and improve overall health."

            SAMHSA's budget emphasizes that addressing mental health and substance abuse is critical to the health of individuals and families.  Prevention, treatment, and recovery support services for behavioral health are essential components of health service systems.  Behavioral health remains one of America's most pressing needs, yet it is also one of the most undervalued and least-addressed.  The ACA, in conjunction with the Mental Health Parity and Addiction Equity Act, has the potential to create or enhance access to coverage for behavioral health services for 62 million Americans, nearly one-fifth of the nation's population.  The current behavioral healthcare infrastructure and workforce, however, will need additional capacity to absorb the influx of patients who now will have the coverage to seek treatment.  Behavioral health can, and should, be addressed as a public health issue by ensuring that the programs and policies focus on these tenets: Behavioral health is essential to health; Prevention works; Treatment works; and People Recover.

            "It has been 50 years since President Kennedy first challenged government to do more for individuals with behavioral health conditions.  In recent decades, seeking behavioral health services has become more acceptable and the science that addresses these conditions has advanced….  Many people receive this treatment within the general healthcare system allowing the specialty behavioral health system to focus on the needs of people with the most severe illnesses and/or addictions.  However, even with expanded access to treatment, more than half of people with mental illnesses and 90 percent of people with substance use disorders do not get the services they need.  The nation can do better."

Norine's vision of her profession embracing its role within the nation's evolving health care system was most prophetic.  On a recent HRSA national advisory committee conference call it was emphasized that: "Mental health disorders rank in the top five chronic illnesses in the U.S.  An estimated 25 percent of U.S. adults currently suffer from mental illness and nearly half of all U.S. adults will develop at least one mental illness in their lifetime.  In 2007, over 80 percent of individuals seen in the emergency room (ER) had mental disorders diagnosed as mood, anxiety and alcohol related disorders."  We would suggest that integrated care will become the vehicle for psychology's expansion into the more generic health care environment of the next decade.

Being At The Table:  Heather O'Beirne Kelly heads up APA's Military & Veterans Policy (MVP) team, devoted to supporting military personnel and veterans, their families, and their communities, as well as psychologists who conduct research with and provide direct services to these populations.  Her priorities for the coming year range from funding for research within the VA and DoD, the provision of high quality mental health care in the Service Member and Veterans communities, and establishment of prescription authority for appropriately trained and certified psychologists in the VA, matching that which DoD has granted for 17 years.

            Voices For The Future:  It is similarly informative to reflect upon the views proffered by those colleagues who have expressed a willingness to run for the APA Presidency, which is actually a very small and select group.  Jack Kitaeff, a lawyer and former U.S. Army psychologist, expressed his deep and abiding respect for those who have put themselves "in harm's way" and feels that the issue of veteran's mental health should be of monumental importance.  He would press for psychologists to be trained in treatment regimens targeting post-traumatic stress disorder (PTSD), including prolonged-exposure therapy, cognitive-processing therapy, and cognitive restructuring.  Amazed by how many psychologists are not members of APA, or have never considered becoming involved in the governance, he would seek to actively attract colleagues back to the Association and demonstrate to members that "they are indeed valued."  He would also focus on addressing the chronic shortage of professional psychologists dedicated to serving diverse and marginalized communities (e.g., the poor, those with HIV, diverse family structures, and the workplace), as well as underserved regions of the country.  And finally, Jack called for psychology to remain scientific and affirmatively seek to avoid allowing its advocacy efforts to be driven by ideology rather than science.  Throughout these enumerated aspirations are a number of national policy agendas which could serve the profession admirably.  "And friends they may think it's a movement.  And that's what it is…." (Ron Levant, Opening Session, 2005).  Aloha,

Pat DeLeon, Former APA President – Division 42 – February, 2015