Welcome to the fall 2014 edition of The Register Report, the first published since I’ve taken over as the Executive Officer of the National Register. I hope you find it to be informative reading. You will notice a few changes in our formatting and content that I hope meets with your approval. First, as you know, the continuing education that comes with completing the exams associated with each article have always been a valuable Registrant benefit. It’s my intention to enhance this benefit in coming issues by making our content more topical and organized around a specific theme. As always, I’m grateful to Dr. George Stricker, who carefully reviews each article and composes our CE questions. I hope you’ll also notice that articles now have abstracts. Over time I’d like to move to a more journal-like format, while still keeping content as clinically relevant as it’s always been.
I’m writing this column from the vantage point of incredible optimism for the profession of psychology. Changes in parity legislation and the passage of the Affordable Care Act (ACA) have created extraordinary opportunities for clinical practitioners. The “bad old days” of managed care are quickly receding. In their place we have entered an era that not only emphasizes the importance of mental health as a component of comprehensive care but mandates that we provide such services to those who need them. Nevertheless, it is already clear that mental health may be lagging behind. A recent survey of Accountable Care Organizations indicated that less than 20% are currently offering the range of mental health services required by the ACA (Lewis et al., 2014).
But the fundamental question has changed. Rather than asking “how do we ensure the survival of psychology as a profession” we now must ask “how do we optimize the training and credentialing of psychologists to ensure that all Americans requiring services can benefit?” This is a very nice step in the evolution of the profession, but it won’t happen without our active advocacy and involvement. In order to find our place at the healthcare table, we must ensure that the training of psychologists equips them to function as full members of a healthcare team.
In my opinion, the National Register is admirably suited to this task. As one of the largest organizations in the profession and one that has a long history evaluating credentials of health service psychologists, we bring a wealth of information and expertise to the table. Our long history with licensing Boards and educational programs ideally positions us in taking an active role to make the modifications needed to train new generations of psychologists.
As all who are even slightly familiar with the ACA know, new professional skills are required to deliver mental health and substance abuse services in an integrated health care environment. To that end, I believe that it’s essential that the National Register not only work with academic and clinical training programs, but also with psychological organizations like APA and multi-disciplinary organizations like the Collaborative Family Healthcare Association (CFHA). The most recent meeting of the CFHA had a number of excellent presentations sharing in common four vital messages:
- Redefining academic and clinical training. Forty years ago, Al Wellner was prescient in establishing an organization that verified the credentials of psychologists working as health service providers. That has been our business since our inception. Much more recently, APA has taken steps to define psychology as a health service profession, and is in the process of revising accreditation standards to emphasize training as health service providers. The National Register has much to offer as we seek to recalibrate our training standards to meet the needs of a future generation of practitioners.
- Developing evidence based interventions for addressing common psychological problems. Chronic mental illness has long been observed to considerably shorten life expectancy, in some estimates by over 20 years. In the US, these dismal statistics are worsened by the fact that life expectancy in the general population lags behind that of many developing nations, a statistic largely driven by lack of access to appropriate healthcare in vulnerable groups and an inefficient, expensive, and fragmented healthcare delivery system. American healthcare expenditures are the highest in the world, at almost 18% of our gross domestic product. We are six percentage points ahead of our nearest competitor, the Netherlands, which comes in second at around 12% of GDP. Yet, the life expectancy for most Americans is the lowest in the developed world. In terms of life expectancy, America ranks 33rd out of 196 nations for men, and 35th for women. At the CFHA meeting, psychologist and Assistant Secretary for Planning and Evaluation of the US Department of Health and Human Services Richard Frank presented a compelling review of how expanding coverage and integrating psychological services can demonstrably assist in reducing overall costs and directly improving quality of life (Frank, 2014).
- Developing common outcome metrics. We must as a profession bring our skills in measurement and assessment to develop definitive measures to gauge the efficacy of psychological interventions. To do this, we must stop attempting to define collaborative care purely in terms of cost offsets. Clearly, savings are there, but they often don’t occur in rote or expected ways. We can’t quantify the benefits of collaborative integrations in strict monetary terms, and it’s important that we as psychologists educate policy makers about better ways to evaluate the benefits of integrated care. In the short term, it’s actually quite likely that costs versus “treatment as usual” costs may increase, for the simple reason that patients are getting the kind of treatment they’d needed but, because of antiquated models of service delivery, had been denied them. But evidence increasingly demonstrates that such investments are worthwhile. In their excellent conference presentation, Deborah Cohen and Russell Glasgow noted that integrated management of numerous common conditions - depression, panic disorder, tobacco cessation, alcohol misuse, diabetes, irritable bowel syndrome, generalized anxiety, chronic pain, and insomnia, among others – has been shown to improve patient outcomes (Cohen & Glasgow, 2014; Melek, Norris & Paulus, 2013). But as those authors emphasized, utilizing analytical tools designed principally to measure single-modality efficacy (i.e., the randomized controlled trial) will not reveal the complex, long-term benefits of integrated treatment. We as psychologists must help lead the way for researchers and clinicians in integrated care to employ more sophisticated tools to demonstrate the benefits of integrated care.
- Developing measurable competencies for working with other healthcare professions. It is quite clear that in addition to the profession-specific clinical competencies we must acquire, there is a set of overarching competencies that all professionals need to acquire to effectively work together. Work of the Interprofessional Education Collaborative Expert Panel (2011) separated such competencies into four domains: (a) values and ethics, (b) interprofessional roles and responsibilities, (c) interprofessional communication, and (d) teams and teamwork. How can we, as the Register, assist the profession in adopting a common understanding of competencies required to work in integrated healthcare delivery settings?
In a microcosm, each of the articles in this issue reflect the many challenges that we must address in order to become fully invested members of the American healthcare system. Dean Steve Smith’s article reviews the decisions rendered in the most recent term of the US Supreme Court. Of immediate interest to psychologists, the Court addressed issues pertaining to assessment of intellectual disability and provision of expert witness testimony. Also of significance were the Court’s decision on the privacy of electronic communications (of great importance in an era of telehealth) and affirmative action in higher education.
Dr. Erica Wise continues her excellent series of ethical vignettes, along with colleagues Dr. Prudence Cuper and fellow NR Board members Drs. Molly Clark and Sarah Shelton. Two of these vignettes deal directly with challenges experienced in working as a member of a multidisciplinary health delivery team.
Dr. Diana Concannon addresses another vital issue for the profession: How can we solve the ongoing shortage of accredited predoctoral internship sites? Solving this problem is critical if we are to be able to train psychologists in adequate numbers to meaningfully contribute to the US healthcare system. Dr. Concannon advocates for the consortial model of internship training as one that has the potential to train a greater number of interns while maintaining quality training standards.
Finally, Dr. Theo Burnes presents the many challenges of providing care to marginalized or disadvantaged groups. In his article on working with populations at high risk for HIV and related illnesses, he also focuses on current inequities in health service provision and identifies four themes for providers working with traditionally disadavantaged populations.
I trust you will enjoy and learn from this issue of The Register Report, and that it will serve as an accurate reflection of our organizational priorities. We have many opportunities in front of us, and I look forward to working with you to ensure that the National Register continues to make a meaningful contribution to the advancement of the profession.