Cover Story

You don't need to look into a crystal ball to see professional psychology's future. Trends that will shape the discipline's future have been taking form for many years and continue to evolve.

Key among them is growing demand for and use of integrated, comprehensive health services that blend health and behavior, prevention, health promotion, and disease management, marketplace observers say. Policy-makers are looking to these areas for solutions to the nation's health-care problems, and monies finally are being appropriated to support these efforts (see page 66). Psychologists are positioning themselves to take advantage of changing practice opportunities.

Increasingly, practitioners are offering services beyond traditional psychotherapy and assessment by expanding into emerging practice areas (see page 56). Early career psychologists in particular are applying their broad skills and expertise to a mix of professional activities (see page 62). In his column on page 51, APA Executive Director for Professional Practice Russ Newman, PhD, JD, further explores these and other trends affecting the practice of psychology.

Even as practice opportunities evolve, there remain persistent challenges within the U.S. health-care system. Barriers persist in accessing quality care. In fact, an estimated 45 million Americans have no health insurance, according to 2004 data from the U.S. Census Bureau. In addition, data from the Center for Studying Health System Change show that health-care spending continues to escalate, and consumers are now bearing more of the financial burden of care.

Many who need treatment for mental health disorders, often in the nation's swelling minority and aging populations, still aren't getting adequate care, according to analyses by the U.S. Public Health Service and World Health Organization (WHO). That shortfall takes a toll not only on individuals, but on their families, employers and communities and ultimately, on the health-care system as patients only enter treatment after problems have snowballed, WHO data also suggest.

In light of such challenges, many see the health-care system beginning to embrace more consumer-centric approaches to health services delivery. For example, health-care futurist Jeff Goldsmith, PhD, an associate professor at the University of Virginia Medical School, predicts that health consumers will gain access to broader provider networks along with more information to help them make choices about their health care.

The limits of market-driven health care

A look at recent history helps elucidate that potential future. Newman and economic analysts such as Robert Kuttner characterize the evolution of the U.S. health-care system in recent decades as involving efforts to create a system where free-market forces control health-services delivery. Yet given their unique characteristics, Newman says, health-care services are not affected by market forces the same way as are other products and services.

In most markets, the same person decides whether to purchase a product or service, pays for it, and derives a benefit. Market distortions result when someone other than the consumer, such as a third-party payer, chooses to buy the service and pays for it. As a result, Newman observes, a free-market approach to health care has not worked.

Fundamental changes are welcomed by those who have questioned the nation's free-market approach to health care.

In "Everything for Sale: The Virtues and Limits of Markets" (Knopf, 1997), economic analyst Robert Kuttner argues that some domains, including health care, are inappropriate venues for the laissez-faire economics that dominate American life.

"Much of the recent history of health policy in the United States has been a hapless effort to bring 'market efficiency' and 'pro-competitive reform' to a sector that is inherently extra-market," Kuttner writes. He flags the explosive growth of managed care as a hallmark of the nation's market-driven health-care system.

"Market enthusiasts fail to tabulate all the costs of relying on market forces to allocate health care," Kuttner concludes. Among the costs he cites are fragmentation of the health-care system, underinvestment in public health and the "assault on the norms of service and altruism."

Cost trends

Health-care cost trends continue to shape the course of health-services delivery. Experts say the growth of the third-party payer system and the rise of managed care in the past several decades stemmed from spiraling health-care costs. In 1970, the nation's health-care costs accounted for 7.0 percent of the gross domestic product (GDP), but that figure had jumped to 13.4 percent by 1993. Since then, even with the dominant role of managed care with its focus on cost containment, health-care costs rose to nearly 15 percent of GDP in 2002.

Costs went up most rapidly in 2000 and 2001, says Paul Ginsburg, PhD, president of the Center for Studying Health System Change. According to the center's research, spending per privately insured American grew 7.4 percent in 2003, compared with 9.5 percent in 2002 and 10 percent in 2001. While acknowledging that the rate of increase in costs is still high, the center notes this is the first significant slowing of spending in almost a decade.

Still, health-care expenditures continue to increase faster than the rest of the economy, and individual, out-of-pocket spending on health care has risen faster than personal income. As employers face rapidly rising insurance premiums, many have responded by increasing patient cost-sharing, such as co-payments or deductibles. "There's certainly a lot more in the way of patient cost-sharing," says Ginsburg.

According to the 2004 Annual Employer Health Benefits Survey, released by the Kaiser Family Foundation and Health Research Education Trust, employee contributions to health insurance premiums increased 57 percent for single coverage and 49 percent for family coverage from 2001 to 2004. During the same period, workers' wages rose 12 percent.

While such cost-shifting is unwelcome news for consumers, futurists such as Goldsmith anticipate a growing role for consumers in health-care decision-making. That represents an opportunity for psychologists to educate consumers about the value of psychological services, he says.

"If people are going to be paying more of the bill with their own money, they're going to be looking for value for their money," says Goldsmith. "There are whole hosts of people who want to dialogue with mental health providers, and that's the essence of what you do."

The technology factor

Industry observers note that past attempts to decrease health-care costs have relied heavily on decreasing use of services by increasing administrative activity. Yet costs have continued to spiral.

Many now point to the Internet and new information technologies as offering a means of cost containment through reduced administrative activities and expenses. APA's Newman points out that electronic claims processing and record-keeping, along with the Internet's capacity to speed information dissemination to consumers, and make them better informed in the process, are among the possibilities for creating a more efficient and less costly health-care system. He says psychologists will need to be able to use information technologies to participate fully in the health-care system.

Federal law is boosting that imperative: The Health Insurance Portability and Accountability Act (HIPAA) calls for standardization of electronic health-care transactions in an attempt to streamline administrative processes and decrease the costs associated with paying for health services. HIPAA is widely expected to help fuel a drive toward greater application of technology by health-care professionals, says Newman. Although experts like Goldsmith and Ginsburg have yet to see any cost impact from the HIPAA rules, they anticipate increasing technology use and decreasing costs down the road.

Growing demand, unmet needs

In addition to cost and technology trends, patterns in health-services supply and demand are also shaping the health-care system.

Available data suggest that more consumers are entering treatment for mental health disorders such as depression that are associated with significant symptom severity and impaired functioning. That's good news, Newman says, since it reflects less stigma and fewer obstacles to access.

At the same time, many are concerned about inadequate treatment and unmet health needs. According to the World Health Organization Mental Health Survey Consortium in 2004, barely half of Americans with the most severe mental health problems and a minority of those with moderate problems get treated.

In the case of depression, a major epidemiological study published in 2003 in the Journal of the American Medical Association (Vol. 289, No. 23), and led by Ronald C. Kessler, PhD, professor of health-care policy at Harvard Medical School, found that only 57.3 percent of Americans with major depressive disorder had received any type of treatment in the preceding 12 months. No more than 21.6 percent of depressed individuals received treatment that met minimal standards for adequacy. This suggests that over three-quarters of people with depression in the United States are getting no treatment or inadequate treatment.

Many of those who are receiving treatment that isn't considered adequate are being given antidepressant medications without monitoring or follow-up. Indeed, even as more people with mental health disorders are treated, they're more likely to get a prescription than they are to receive psychotherapy, found Mark Olfson, MD, and colleagues in a study published in 2002 in the Journal of the American Medical Association (Vol. 287, No. 2).

And medication is not necessarily what consumers want. Numerous studies, including one on post-traumatic stress disorder by Lori Zoellner, PhD, published in 2003 in Behavioral Research Therapy (Vol. 41, No. 8) and one on panic disorder by Holly Hazlett-Stevens, PhD, published in 2002 in General Hospital Psychiatry (Vol. 24, No. 5), have found that consumers with a variety of disorders prefer psychological interventions rather than pharmacological ones if they have a choice.

Changing demographics

Yet another significant trend is the growing diversity of the consumers psychologists will treat. One part of that increasing diversity is the increase in racial and ethnic minorities.

"Minority populations are growing faster because of slightly higher birth rates on the one hand and new immigration on the other," says demographer Jorgé del Pinal, PhD, assistant division chief for special populations statistics at the U.S. Census Bureau.

The Hispanic population is growing especially fast, says del Pinal, and has now surpassed the African-American population. East Asian populations Cambodians, Thais, Vietnamese are also expanding rapidly.

These growing minority populations will need more mental health providers who speak their languages and understand their cultures, observers say.

"While there's been an increase in the number of minority psychologists, it's nowhere near keeping up with trends," says Melba J.T. Vasquez, PhD, an independent practitioner in Austin and president-elect of the Texas Psychological Association.

Psychologists need to understand cultural differences, says Vasquez, who helped create the Guidelines on Multicultural Education, Training, Research, Practice and Organizational Change for Psychologists adopted as APA policy in 2002. The guidelines were published in 2003 in the American Psychologist (Vol. 58, No. 5) and are available online.

"Psychologists can pathologize cultural differences if they don't understand them," she says.

Vickie M. Mays, PhD, a professor of psychology and health services at the University of California, Los Angeles, agrees.

Even a notion as basic as "family" may vary enormously from culture to culture, says Mays. Migrant workers, for example, may have families here and at home. They may live in multigenerational households as relatives migrate to join them. They may even live in single households with multiple families, having created a social network that functions as family.

Diversity is growing even within minority populations themselves, Mays adds, noting that California is experiencing an influx of Salvadorans in addition to the Mexicans who have been the area's traditional immigrants. Immigrants are also fanning out to suburban and other areas where they haven't gone before, she notes.

That means more psychologists are working with minorities or new minority groups for the first time. That in turn can mean a lack of cultural familiarity, linguistic ability and culturally appropriate services. Often there's not even research to turn to on such questions as how adolescents will navigate identity issues given their growing reluctance to classify themselves as a single race or any race at all.

"Psychology has a lot of catching up to do," says Mays, noting that multiculturalism should be a mainstream focus for all psychologists rather than a special interest issue. She suggests a two-pronged approach. "We need to recruit more minority psychologists, but we shouldn't make it their burden to diversify psychology," she says. "We should diversify psychology and then let them enhance it once we've got some basics there."

Another important trend is the aging of our society, experts say. "The leading edge of the baby boomers will start hitting 60 next year," says del Pinal. "As they get older, the shift in population is going to be dramatic."

That shift will have major implications for psychology, says psychologist Sandra L. Shullman, PhD, who directs the Columbus, Ohio, office of the Executive Development Group and is a member of APA's Board of Directors. Psychologists will need to be trained more routinely in assessing and working with issues important to older adults, such as maintaining independent functioning and managing chronic disease, as they will represent an increasingly important focus of services, she explains. To assist psychologists in this regard, APA published its Guidelines for Psychological Practice With Older Adults last year in the American Psychologist (Vol. 59, No. 4); they are also online.

Previous generations of elders haven't felt comfortable expressing a need for mental health services, says Shullman. "The boomers are a much more psychologically minded group," she explains. "Their needs, in both quantity and quality, are going to be very different from those of the senior generations we've had up to now."

All these demographic shifts demand a parallel shift within psychology, she adds.

"We have to stop treating demographic issues as 'special populations,'" Shullman says. "We have to start thinking about them routinely as we're solving problems and making plans."

Rebecca A. Clay is a writer in Washington, D.C.