clinical psychology

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Current Issues in ClinicalCurrent Issues in Clinical
PsychologyPsychology
Lecture 8Lecture 8

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PROFESSIONAL REGULATIONPROFESSIONAL REGULATION
 New issues of professional competenceNew issues of professional competence
 New questions in publicNew questions in public
 Professional regulation: an attempt toProfessional regulation: an attempt to
protect public interestprotect public interest

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CERTIFICATION:CERTIFICATION:
 A relatively weak regulationA relatively weak regulation
 Provides some guaranteeProvides some guarantee
 Involves examination or a reviewInvolves examination or a review
 Attempt to protect publicAttempt to protect public
 Does not prevent anyoneDoes not prevent anyone
 Often the result of psychiatrists’ lobbying againstOften the result of psychiatrists’ lobbying against
psychologistspsychologists

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LICENSING:LICENSING:
 A stronger form of legislationA stronger form of legislation
 Defines title & training as well as professionalDefines title & training as well as professional
activitiesactivities
 Laws are designed to prevent the use of termLaws are designed to prevent the use of term
“Therapist” by imposters“Therapist” by imposters
 APA’s model act for licensure (1987), (1992 new)APA’s model act for licensure (1987), (1992 new)
 Summary of common licensing requirements:Summary of common licensing requirements:

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Summary of Typical Requirements for LicensureSummary of Typical Requirements for Licensure
 EducationEducation
 ExperienceExperience
 ExaminationsExaminations
 Administrative RequirementsAdministrative Requirements
 SpecialtiesSpecialties

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Issues Regarding LicensingIssues Regarding Licensing
 Licensing & Certification: topics of intense professionalLicensing & Certification: topics of intense professional
interestinterest
 Some consider them invalid measures of professionalSome consider them invalid measures of professional
competencecompetence
 Licensing should be designed to protect public, not theLicensing should be designed to protect public, not the
professionalsprofessionals
 Kane says: Licensing safeguards against poor practiceKane says: Licensing safeguards against poor practice
 Academic clinicians say licensing violates academicAcademic clinicians say licensing violates academic
freedomfreedom
 To date, licensing is the only method to protect the public.To date, licensing is the only method to protect the public.

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AMERICAN BOARD OF PROFESSIONALAMERICAN BOARD OF PROFESSIONAL
PSYCHOLOGY (ABPP):PSYCHOLOGY (ABPP):
 American Board of Examiners in ProfessionalAmerican Board of Examiners in Professional
PsychologyPsychology: 1947: 1947
 Shortened toShortened to American Board of ProfessionalAmerican Board of Professional
PsychologyPsychology (ABPP):(ABPP): 19681968
 Offers certification in different areas of psychologyOffers certification in different areas of psychology
 Oral examination, case handling, and previous recordsOral examination, case handling, and previous records
are evaluatedare evaluated
 Five years' postdoctoral experienceFive years' postdoctoral experience
 More rigorous requirementsMore rigorous requirements

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NATIONAL REGISTER:NATIONAL REGISTER:
 Used by insurance companiesUsed by insurance companies
 FirstFirst National Register of Health ServiceNational Register of Health Service
Providers in Psychology:Providers in Psychology: published inpublished in
19751975
 A kind of self-certification, includes only paidA kind of self-certification, includes only paid
subscriberssubscribers

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Issues ofIssues of
MANAGED HEALTH CAREMANAGED HEALTH CARE
• 1970s: freedom-of-choice laws for psychologists
• Dramatic changes in Health Care: 1980s and 1990s

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 Arguments between physicians &Arguments between physicians &
Psychologists for conducting psychotherapyPsychologists for conducting psychotherapy
 By 1983, 40 out of 50 states allowedBy 1983, 40 out of 50 states allowed
insurance reimbursement for psychotherapyinsurance reimbursement for psychotherapy
 Typical reimbursement:Typical reimbursement: 50 to 8050 to 80 percentpercent
 Treatment plans hadTreatment plans had no inputno input from insurancefrom insurance
companiescompanies

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 Changes in private, fee-for-service practice:Changes in private, fee-for-service practice:
Late 1980sLate 1980s
 Health Care costs rose dramatically due toHealth Care costs rose dramatically due to
new technological improvementsnew technological improvements
 Medical education & physician salaries alsoMedical education & physician salaries also
rose.rose.
 Health care costs by 1995: overHealth care costs by 1995: over 1,000 billion1,000 billion
US $US $ == 15% of GNP15% of GNP

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Diagnosis-Related GroupsDiagnosis-Related Groups ((DRGDRGs)s)
 1983: Congress passed legislation1983: Congress passed legislation
 Payment was determined by diagnosisPayment was determined by diagnosis
 Patients were categorized intoPatients were categorized into diagnosis-diagnosis-
related groupsrelated groups
 AimAim: to provide a more cost-effective way of: to provide a more cost-effective way of
treatmenttreatment

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Health Maintenance Organizations (HMOs)Health Maintenance Organizations (HMOs)
 Comprehensive health services including mental healthComprehensive health services including mental health
services within one organization.services within one organization.
 Monthly membership feeMonthly membership fee
 All services for a fixed fee (No Additional Cost)All services for a fixed fee (No Additional Cost)
 Patients do not have a choice in selection of care providerPatients do not have a choice in selection of care provider
 Providers get a yearly salaryProviders get a yearly salary
 The HMO must be profitableThe HMO must be profitable

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Preferred Provider Organization (PPO)Preferred Provider Organization (PPO)
 A compromise between traditional fee-for-service &A compromise between traditional fee-for-service &
HMO style of health careHMO style of health care
 A network of Health care providers (can includeA network of Health care providers (can include
clinics & hospitals also)clinics & hospitals also)
 Professionals of PPO panel must treat a memberProfessionals of PPO panel must treat a member
patient on discounted ratespatient on discounted rates
 Authorized services with permission from insuranceAuthorized services with permission from insurance
companiescompanies

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Impacts of ManagedImpacts of Managed
Health Care on ClinicalHealth Care on Clinical
PracticePractice
Evaluation of HMOs & PPOsEvaluation of HMOs & PPOs

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 No freedom of choiceNo freedom of choice
 Survey: 17,000 HMO patients were dissatisfiedSurvey: 17,000 HMO patients were dissatisfied
 Managed Health Care requires thatManaged Health Care requires that
psychologists compromise professional ethics topsychologists compromise professional ethics to
contain costs.contain costs.
 In the words of Bertram Karon, "What startedIn the words of Bertram Karon, "What started
reasonably is becoming a national nightmare“.reasonably is becoming a national nightmare“.

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Some hidden benefitsSome hidden benefits::
 Inter-disciplinary collaborationInter-disciplinary collaboration
 More accountabilityMore accountability
 More use of empirically validated treatmentMore use of empirically validated treatment
approaches & brief, problem-focusedapproaches & brief, problem-focused
treatments.treatments.

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Issue ofIssue of
Prescription PrivilegesPrescription Privileges

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 Psychologists conduct research onPsychologists conduct research on
psychopharmacology of behavior, but do notpsychopharmacology of behavior, but do not
have prescription privilegeshave prescription privileges

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Opposition from other ProfessionsOpposition from other Professions
 Both theBoth the American Medical AssociationAmerican Medical Association and theand the
American Psychiatric AssociationAmerican Psychiatric Association go against it.go against it.
 1995 survey of 400 physicians showed strong1995 survey of 400 physicians showed strong
oppositionopposition
 They claim that aThey claim that a medical degreemedical degree is necessaryis necessary

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Opposition from within PsychologyOpposition from within Psychology
 Distraction from traditional focus on psychologyDistraction from traditional focus on psychology
 Psychologists would become "junior psychiatrists"Psychologists would become "junior psychiatrists"
 Practical problems: increased influence of pharmaceuticalPractical problems: increased influence of pharmaceutical
companiescompanies
 Need for professional boundariesNeed for professional boundaries
 Clinical psychology’s Identity as a unique health professionClinical psychology’s Identity as a unique health profession

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RationaleRationale
 A broader area of interestA broader area of interest
 Autonomy of clinical psychologists as healthAutonomy of clinical psychologists as health
service providersservice providers
 DeLeon (1988): Ethical duty to meet society’sDeLeon (1988): Ethical duty to meet society’s
needsneeds
 To serve under-served populationsTo serve under-served populations

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Pros and Cons ofPros and Cons of
Prescription PrivilegesPrescription Privileges

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Pros:Pros:
 These arguments were discussed in a 1995 interviewThese arguments were discussed in a 1995 interview
with the executive director of thewith the executive director of the Practice DirectoratePractice Directorate
of theof the American Psychological AssociationAmerican Psychological Association..
 Wider variety of treatmentsWider variety of treatments
 Potential increase in efficiency and cost-effectivenessPotential increase in efficiency and cost-effectiveness
of careof care
 A competitive advantage in the health care market-A competitive advantage in the health care market-
place.place.
 Natural progression to be a "full-fledged" health careNatural progression to be a "full-fledged" health care
professionprofession

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Cons:Cons:
 De-emphasis of "psychological" forms ofDe-emphasis of "psychological" forms of
treatmenttreatment
 A conceptual shift may occurA conceptual shift may occur
 May also damage clinical psychology'sMay also damage clinical psychology's
relationship with psychiatry and generalrelationship with psychiatry and general
medicinemedicine

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Prescription Privileges:Prescription Privileges:
Implications for TrainingImplications for Training
 19921992: APA has started supporting efforts to: APA has started supporting efforts to
train psychologists in pharmacologytrain psychologists in pharmacology
 Additional course requirementsAdditional course requirements
 Additional faculty requirementsAdditional faculty requirements
 More admission-taking difficulties for studentsMore admission-taking difficulties for students

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ConclusionConclusion
 A hotly debated current issue concerns the pursuit ofA hotly debated current issue concerns the pursuit of
prescription privilegesprescription privileges for clinical psychologists.for clinical psychologists.
 The American Psychological Association has recently endorsedThe American Psychological Association has recently endorsed
this pursuit, as have several of its highest-ranking officials.this pursuit, as have several of its highest-ranking officials.
 Many others remain either neutral or adamantly opposed toMany others remain either neutral or adamantly opposed to
obtaining prescription privileges.obtaining prescription privileges.
 The decision to pursue these privileges will have far-reachingThe decision to pursue these privileges will have far-reaching
implications for the role definition of clinical psychologists, theimplications for the role definition of clinical psychologists, the
training they require, and their actual practice.training they require, and their actual practice.

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 Psychologists wanting to provide independentPsychologists wanting to provide independent
in­patient carein­patient care
 Physicians have generally opposedPhysicians have generally opposed
 AA 19781978, legislation in California allowed, legislation in California allowed
psychologists to obtain medical staff privilegespsychologists to obtain medical staff privileges
 Approximately 16 % clinical psychologists haveApproximately 16 % clinical psychologists have
obtained full medical staff privileges in the U.S.obtained full medical staff privileges in the U.S.
 A dangerous trend for psychologists !!A dangerous trend for psychologists !!

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Issues in Private PracticeIssues in Private Practice
 Increased number of private practitionersIncreased number of private practitioners
 Two thirds = 35 to 40 %Two thirds = 35 to 40 % are in privateare in private
practicepractice
 47 %47 % increase since 1973increase since 1973
 But this trend will reverse due toBut this trend will reverse due to ManagedManaged
Health Care systemsHealth Care systems

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 Russ Newman:Russ Newman: director of the Practicedirector of the Practice
Directorate ofDirectorate of APAAPA
 Master’s­degree holders as alternative toMaster’s­degree holders as alternative to
clinical psychologistsclinical psychologists
 Less emphasis on long­term insight­orientedLess emphasis on long­term insight­oriented
psychotherapypsychotherapy

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Recent Trends in Private PracticeRecent Trends in Private Practice
 Fee­for­service private practice: a thing of theFee­for­service private practice: a thing of the
pastpast
 Changes in training programsChanges in training programs
 APA Working GroupAPA Working Group ((19971997) summary of) summary of
conclusions: training needs for future practicingconclusions: training needs for future practicing
psychologistspsychologists

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ConclusionConclusion
 Clinical psychology: Growth & ChangeClinical psychology: Growth & Change
 Contributions in assessment, treatment, research,Contributions in assessment, treatment, research,
teaching, and consultation as well as a betterteaching, and consultation as well as a better
understanding of human behaviorunderstanding of human behavior
 Attained increasing independence as a respectedAttained increasing independence as a respected
disciplinediscipline
 Unfortunate trend toward Managed Health CareUnfortunate trend toward Managed Health Care
 Intensified competition for available job positionsIntensified competition for available job positions

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 Multidisciplinary group practices,Multidisciplinary group practices,
 Brief, problem­focusedBrief, problem­focused
 Emphasis on demonstrating effective treatmentEmphasis on demonstrating effective treatment
outcomeoutcome
 Client satisfactionClient satisfaction
 Flexibility in adapting to changesFlexibility in adapting to changes
 A fascinating and exciting endeavor to helpA fascinating and exciting endeavor to help
individuals, groups, and societyindividuals, groups, and society
The FutureThe Future