Washington Update

Ronald F. Levant

Ronald F. Levant, Ed.D., A.B.P.P., is a Member-At-Large of the APA Board of Directors. He was the Chair of the APA Committee for the Advancement of Professional Practice (CAPP) from 1993-95, and a member of the Board of Directors of Division 42 (1991-94).

Psychology is currently at a historic crossroads, where taking one path could lead to serious problems, perhaps even our eventual demise as a profession, and taking the other could lead to our continuing evolution, which may result in the fulfillment of our potential to be the premier primary psychological health care profession.

Challenges to Psychology

Ten years ago, the major challenge to psychology was organized psychiatry, as we sought legislatively to expand our scope to include hospital practice. Over the last five years new threats have emerged with such profusion and force as to dwarf the challenges of a decade ago. The major challenges that I envision for the future are the growing problem of supply and demand, and the related problem of the industrialization of health care.

The Supply and Demand Problem in both Professional and Academic Psychology

The APA Council of Representatives is currently engaged in a process of examining the question of whether the field is training too many psychologists for too few jobs in traditional mental health care and the professorate. We have heard about how hard it is for new clinical graduates to get accepted as providers on managed care panels, and are therefore forced to work in low-paid fee-for-service jobs, if they can even get those. We have also heard that there are often 100 qualified applicants for a single tenure track academic job.

The Pipeline. To understand this problem I find it helpful to visualize the supply and demand issues in the workplace as a pipeline, and to identify the points along the pipeline as follows: (1) High school, where it is reported that 800,000 students take a psychology course annually, thus creating the base for a tremendous level of interest in psychology. (2) Community colleges, which are increasingly important educational institutions, seen by President Clinton (for example) as the vehicle for upgrading the skills of the workforce. (3) Four year colleges and universities, where psychology is still a very popular major, if not the most popular major. (4) Graduate education where the largest and most visible educational opportunities exist to be trained as mental health care practitioners. These opportunities include: (A) Masters programs in clinical, counseling, and school psychology and related fields such as marital and family therapy, mental health counseling, etc. (B) Freestanding professional school doctoral programs. (C) university-based doctoral programs in clinical, counseling, and school psychology. (D) internship training. (E) Postdoctoral training. (5) Following graduate school and post-graduate training the pipeline sharply narrows such that many people trained to be traditional mental health practitioners (i.e. providers of psychodiagnostic and psychotherapeutic services, usually in outpatient settings) report increasing difficulties in making a living. (7) Scientists face a parallel dilemma, where many academic psychologists trained for the most popular career path -- tenure track positions in universities -- have trouble finding such positions.

What do the data show?. A body of data is being assembled and reviewed by an APA Task Force to address the questions about supply and demand (see partial list of reports). I want to share some of this data with you, with the caveat that what I am going to say is based on a very preliminary analysis of a partially-assembled set of data, not all of which is as reliable and valid as we would want it to be. (1) First let's look at the production of doctoral psychologists. The total number of doctorates (including Ph.D., Psy.D., and Ed.D) has fluctuated quite a bit from 1987-1993, but overall has risen only 4%. However, the number of doctorates in clinical psychology has risen 43% over this period, and the number of doctorates in clinical psychology from professional schools has risen 93%. (2) Taking a longer view, the total number of doctorates produced over the period 1981-1991 has been steady whereas the number of masters produced has increased substantially, and is currently about three times the production of doctorates, close to 10,000 in 1991. In an even longer view, the production of masters has increased 600% from what it was in the 1960's. (3) What is the effect on employment? Here the available data indicate that unemployment is rising somewhat. However feelings of pessimism about job prospects are rising even more dramatically. Furthermore, over the 20 year period 1973-1993, there has been a dramatic shift in the employment settings and activities for psychologists away from academia and into service delivery. (5) Finally, what about income? The available data indicate that about half of licensed clinical psychologists have reported reductions in net income of 18% on the average, and that academic salaries have not kept pace with inflation.

Changes in the Health Care Industry

Let's turn now to a discussion of changes in the health care industry. The major factor involved in the supply and demand problems is the industrialization of health care. In the past decade we have witnessed the transformation of health care from a cottage industry to something approaching an oligopoly. This increasing concentration of the industry has resulted in ever- larger health care corporations competing for greater market share by aggressively driving down costs using techniques such as standardization and automation. In this process psychological services are being re-defined as commodities that can be provided by increasingly less-well-trained caregivers, providing crisis intervention-type services, based on treatment manuals, perhaps even monitored by computer programs and supervised over the Internet. In this context, some leading psychologists (Cummings, 1995) and managed mental health care executives have asserted that there is an oversupply of mental health providers, and that as many as 50% of us will be forced to leave the field. If medical necessity is narrowly defined, psychotherapeutic treatment aimed at the restoration of functioning, and treatment episodes limited to a handful of sessions, then there may be too many providers, particularly the more highly trained psychologists.

But this view violates what is known about psychotherapy, which was recently confirmed in the Consumer's Union survey of 4,000 readers' experiences with emotional problems, reported in Consumer Reports (1995). The study found that respondents benefitted greatly from psychotherapy and that longer term treatment provided better results than short term treatment. Interestingly, patients whose length of therapy or choice of therapist was limited by managed care did worse. The study has certain limitations, including a non-random, self-selected sample, and reliance on self-report, but I have argued elsewhere (Levant, 1995), the standard psychotherapy outcome research methodology (known as efficacy research) trades off fidelity to the actual treatment situation for rigor. The Consumer Reports study (a good example of what is known as effectiveness research) does just the opposite: It is a large scale study of psychotherapy as it is actually experienced by consumers, with some limitations in rigor. Since both types of studies have their limitations, we stand to learn more about the actual effects of psychotherapy when we combine the results of randomized controlled treatment trials with studies of consumer experience and satisfaction; and when we do that psychotherapy receives particularly strong empirical support and it becomes quite clear that psychotherapy is being drastically downgraded in the current marketplace.

These changes create serious problems for psychologists. Although it is not the focus of this column, I do want to mention that the APA Practice Directorate has a four pronged strategy in place over the past few years to address these issues, which includes legislative approaches (which recently resulted in the Domenici-Wellstone Parity amendment), litigative remedies (such as the New Jersey suit against MCC for its policy of no-cause dismissals of psychologists from its provider panel whom they feel are not "managed care friendly"), initiatives to improve the leverage of psychologists in the market place (such as the outcomes management project currently being conducted with the Department of Defense), and a $6 Million dollar public education campaign to enhance the public's image of psychologists.

Opportunities for Psychology

Primary Care Psychology also has tremendous opportunities at this time to embark on a course of evolution that could lead to its becoming the premier primary psychological health care profession. To visualize this potential one must break out of the medical mind set for a moment, and reflect on a few facts about health care: (1) Seven out of the ten leading causes of death have significant behavioral components (Kovacs, 1994); (2) 50-70% of all visits to primary care physicians are for problems with a psychological origin; (3) The vast majority of people receiving mental health treatment are cared for by professionals with minimal specific training in mental health, a problem which is even worse in underserved and rural communities. A case could be made that health care should be reorganized so that psychologists serve as primary caregivers at the gateway to the health care system, functioning to diagnose and treat the more prevalent psychological problems, and referring to medical physicians when indicated. Those unwilling to go this far could probably agree that psychology should at least be a major part of the primary health care team.

What would qualify psychology for this role? Simply put, I believe that we have superb qualifications for this role. We are a doctoral level profession; we have the most extensive training in behavioral and mental health of any profession; we have outstanding skills in assessment, based on our traditional foundation in psychological testing; and although there are numerous variations and some conflict on this theme, we still are very strongly influenced by the Boulder scientist-practitioner model. In fact I believe that the science-practice dialectic is one of our greatest assets. The connection between science and practice enhances the possibilities for a science-based practice and for a clinically- relevant science. This important connection is something that we alone of all of the health care professions can uniquely claim.

Supply and Demand Revisited

To revisit the supply and demand problem in this context, the field may be training too many psychologists for too few jobs in traditional mental health care (as evidenced by the reductions in income and increases in pessimism among new doctorates discussed earlier). However it may also be the case that we do not train sufficient numbers of psychologists for jobs in potentially more promising areas. The most promising of course, in light of the comments that I have made about our potential to become the premier primary psychological health care profession, is health care psychology broadly defined -- including gero-psychology, neuro- psychology, pediatric psychology, onco-psychology, cardiac rehabilitation, etc. In addition, opportunities are growing in fields such as forensic psychology, business and industry consultation, and family psychology (including premarital counseling, divorce mediation and counseling, custody evaluation, parent counseling and education, domestic violence prevention and intervention). As noted earlier, scientists face a parallel dilemma, where many academic psychologists trained for the professorate have trouble finding positions. Attempts are being made to develop alternative career paths as applied scientists. Many of these new roles look very similar to the roles I just described for practitioners.

Coda

Scientists and practitioners must come together, united under a differentiated and integrated strategy that protects the whole of psychology and all of its component parts. Because only then can we guarantee that our limited resources will be used wisely, and that we will have a fighting chance to survive as a profession. To invoke Winston Churchill's famous warning: "we must take change by the hand before it takes us by the neck."

As always, I welcome your thoughts and comments on this column.

References

Consumer Reports. (1995, November). Mental health: Does therapy help? pp. 734-739. Cummings, N., (1995). Impact of managed care on employment and training: A primer for survival. Professional Psychology, 26, 10-15.

Kovacs, A. (1994). Personal communication.

Levant, R. F. (1995). Outcomes measurement and empirically validated treatments: What's all the fuss about? The Psychotherapy Bulletin, 30(3), 20-22.

Partial List of Reports on Supply and Demand

American Psychological Association, Education Directorate and Research Office (1996). Final report and recommendations of the APA work group on the impact of managed care and changes in the health services delivery system on the education and training and continuing education of professional psychologists. Washington, DC: Author.

American Psychological Association, Practice Directorate (1996). The Committee for the Advancement of Professional Practice (CAPP) practitioner survey results. Washington, DC: Author.

American Psychological Association, Education Directorate (1996). Final report of the BEA Task Force on Education and Training for Professional Psychologists. Washington, DC: Author.

American Psychological Association (1996). Final report of the APA Presidential Task Force on Education and Training for Work in Organized Delivery Systems. Washington, DC: Author.

APA workforce database: Employment reports currently available include: Doctorate employment survey, salary survey (1995), faculty salaries in psychology.

Fox, R. E. (1994). Training professional psychologists for the twenty-first century. American Psychologist, 49, 200-206.

Frank, R. G. & Ross, M. J. (1995). The changing workforce: The role of health psychology. Health Psychology, 14, 519-525.

Humphreys, K. (1996). Clinical psychologists as psychotherapists, History, future, and alternatives. American Psychologist, 51, 190-197.

Kohout, J. L. (Draft). Demographic characteristics of psychologists and supply/demand issues: United States. Washington, D.C.: American Psychological Association, Research Office.

National Science Foundation (1988). Profiles: Psychology: Human resources and funding. (NSF 88-325). Arlington: National Science Foundation.

Jeff McKee
Saturday, April 25, 1998