Twenty years ago, psychologists were fighting to be recognized as independent mental health professionals. The Medicare program and hospitals were the primary battlegrounds. In fact, I came to the APA in 1986 largely due to my own experience of being denied the ability to independently treat patients in Ohio hospitals.
Fresh out of law school, I saw an opportunity at the APA to implement "judicial advocacy"--the use of the courts as a complement to legislative advocacy. A few well-chosen lawsuits had the potential to move psychology's agenda forward, particularly in hospital settings. California and the District of Columbia had laws to enable psychologists' practice in hospitals, yet professional autonomy was elusive even in those jurisdictions. In retrospect, it's hard to say whether we "chose" the case of California Association of Psychology Providers v. Peter Rank or if it was forced upon us. Either way, CAPP v. Rank was an important step for professional autonomy, both for what it established and what it prevented.
Despite a California hospital practice statute authorizing psychologists to practice independently in hospitals, the state's Department of Health Services (DHS) issued regulations requiring that psychiatrists supervise psychologists' practice in hospitals. A group of self-respecting psychologists who refused to accept second-class citizenship banded together to form the California Association of Psychology Providers (CAPP) and sued to have the DHS regulations declared invalid. The case went up and down the appellate ladder on procedural issues for a number of years and finally settled in the appellate court for a decision on the merits.
The court of appeals' decision was big trouble. Although the court opined that psychologists could practice independently within the scope of their license, it continued on to unduly limit that scope. It said that psychologists' scope of practice did not include the treatment of disorders with organic causes or disorders treatable through organic means. What started as a simple declaratory judgment to invalidate the offending regulations turned into a case that threatened to set the profession back by at least a decade. The California Supreme Court, however, saw the error in the appellate court's logic. With arguments provided by California CAPP, the California Psychological Association and the APA Practice Directorate, the Supreme Court overturned the lower court's decision. The opinion made it clear: Psychologists could independently admit, diagnose, treat and discharge hospital patients. Psychology took a big step forward.
Two decades later, our profession continues to fight--continues to need to fight--to assure our ability to practice unimpeded. But, the fight is not so much about the authority to practice in a particular setting, although ironically California psychologists are still fighting to implement the CAPP v. Rank decision in state hospitals. The battle today is much more complicated. It's more about economics, market share and controlling our professional destiny in the marketplace than it is about "turf battles" and supervised practice.
The anticipated addition of a national health reform effort over the next few years will be a double-edged sword. While it will bring the battle into sharper focus with a chance for some relief, it will add a level of politics to the picture that may cause other dynamics to pale by comparison. It is tempting, even seductive, to believe a single-payer health system will fix the country's health-care woes and psychology's troubles in one grand stroke. I do not believe it will be that simple. Too much is at stake for too many competing interests.
If I were continuing at the helm of the Practice Directorate, I would continue to argue that our profession needs to be more flexible, more diversified, more business smart and more strategically resilient. There is a fight for autonomy under way today, but it is to become independent from third-party payers rather than from psychiatrists. It is also a fight for new business and new business models with multiple streams of revenue, rather than a fight with just insurance and managed-care companies over reimbursement rates. This is the fight for autonomy that psychology needs to win in order to control our destiny. Lawsuits and legislation will help, but the battle is bigger. It requires constant efforts to educate the public, including employers and decision makers. Additionally, it requires a strategic business approach to delivering psychological services that, unfortunately, most of us are not trained for in graduate school. The Practice Directorate has been building the necessary programs the last two decades to do just that, with an eye toward the next two decades.
It has been an honor and a privilege to have served the profession, APA and the practice community these past 20 years. I look forward to finding new ways to contribute and new ways to fight for our profession's future.
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