Morgan T. Sammons, PhD, ABPP
In my clinical training I was often frustrated by the requirement to comment on both “mood” and “affect” in my patient evaluations. It’s not that I didn’t get the distinction. “Mood,” it was explained, was like weather, fickle and changeable but current; “affect” was climate, the more-or-less characterological outlook of a patient. (Since I worked predominantly on inpatient wards, the weather was usually stormy). But I usually argued that it was impossible for me to make a determination of “affect” on the basis of one short clinical interview. The requirement nevertheless stood, and after my supervisors deemed I’d successfully completed training, I moved on. Although the distinction still troubled me, I dutifully commented on both “mood” and “affect” in my clinical write-ups.
From time to time, it’s always useful for an organization to review is vision and mission statements. These are, after all, de rigeur in the modern organizational environment. Corporate and non-profit boards spend many retreats polishing vision and mission statements, usually with the assistance of expensive external consultants. After being carefully honed, most such statements generally reside unnoticed on an organization’s website and contribute little to its overall direction. But in the current political weather pattern, which promises to bring climactic change to American healthcare, I think that it is appropriate for us to re-examine our mission and vision to see if they will assist in charting the direction ahead. Hence the anecdote above. I’ve always thought a mission statement was like the “mood” of an organization – changeable, often in need of correction and frequently myopic, and the vision statement the “affect” of an organization – a more enduring and stable idea of what the organization is all about. Combined, both should guide an organization in shaping its response to internal and external challenges. And as I write this the external challenges are manifold.
American healthcare, and in particular American mental healthcare, is unquestionably in need of change. As we all know, Americans pay more per capita than anyone else in the world for health care that is less comprehensive and of lower quality than in most industrialized nations. The Affordable Care Act was extremely effective in expanding healthcare coverage to millions of Americans, an achievement that cannot be understated. To date, it has been less successful in controlling costs, although some welcome reductions have been seen. But the largest driver of American healthcare cost, at over $200 billion annually, is mental health. Cutting access to mental healthcare, as may happen if a block grant strategy is implemented by Congress, may save short-term dollars but will have deleterious and expensive ramifications for individuals as well as for state health and correctional budgets (emergency rooms and jails being ineffective, inefficient and often cruel venues for care delivery). Paradoxically, increasing spending in non-mental health areas may reduce mental health budgets, as the data demonstrate that when states spend more on certain supportive services (housing, educational and parental support) mental health morbidity and mortality, and therefore costs, go down. Unlike other areas of healthcare, where expensive providers and expensive technologies account for most costs, mental healthcare is low in both provider and technology costs. Our Achilles heel is fragmentation and lack of continuity. Artificially constraining access or further fragmenting health and social service delivery systems will do nothing to reduce mental health costs.
There is no easy fix. Solutions are long-term (e.g., expanding pipelines of mental health providers, ameliorating adverse childhood experiences, building and evaluating effective support systems) and structural (e.g., re-examining the scope of practice of all mental health providers; building payment schemes that are affordable to individuals and governments). In addressing these long-term issues, innovation and creativity have key roles, ideology should not. How can the Register use our vision and mission to contribute to innovative and creative solutions?
First, we must reaffirm that our vision encompasses health, not merely mental health. A more complete integration of mental health services into health service delivery will improve efficiency and reduce long-term costs. Second, we must understand that the challenge is global. Global research and global problem solving is required.
Our mission compels us to reaffirm the value of psychological services in healthcare delivery. To this end, we must redouble our efforts to ensure that health service psychologists’ contributions to patient improvement are more broadly recognized and appropriately compensated. We must demand change in outmoded education and training systems that restrict both the supply and qualifications of health service psychologists. We must expand the reach of our credentialing mechanism to ensure that all health service psychologists meet standard expectations for entry into the field and for maintenance of skills throughout their careers. Finally, I believe the Register has a leadership role not only in global psychology to ensure that training programs impart a universally recognized skill set for all those who call themselves health service psychologists.
Are these goals overaspirational and overexpansive? Perhaps, but during times of challenge organizations that expand their scope tend to succeed. Those that tread a narrow, inward looking path tend to become obsolete. To crib the motto of the British SAS during the Second World War, “who dares, wins.” It is time to dare.