Mental health professions vie for position in the next decade

The three major mental health groups seek out their own niches as the health-care market continues its evolution.

By Rebecca A. Clay

Psychologists will expand their scope of practice. Psychiatrists will return to their medical roots. And social workers, already flourishing under managed care, will further strengthen their position by conducting research to show just how effective their services really are.

Those are the predictions of health-care forecasters and leaders in each field who discussed with the Monitor where they see these often-competing disciplines heading over the next decade as the health-care marketplace continues to evolve.

Here?s what the experts had to say.

Psychology

One of clinical psychology?s greatest challenges will be marketplace consolidation, which is decreasing the need for mental health providers, says Ron Finch, EdD, director of the Health and Welfare Division at the professional services consulting firm Coopers & Lybrand LLP in Atlanta. Just half a dozen companies already cover most of the 140 million Americans in managed behavioral health-care plans, he points out. Over the next five or six years, he says, the market will pare down redundancies in provider networks.

But don?t be alarmed, say Finch and other forecasters. The good news is that there will be plenty of new opportunities once the market settles.

'If psychologists focus only on mental health assessment and psychotherapy, then, yes, there will be too many psychologists,' says Russ Newman, PhD, JD, executive director for professional practice at APA. 'But psychologists have a lot more to offer in addition to mental health services.'

New trends in psychotherapy reimbursement will help psychologists overcome their reluctance to part with tradition, says health-care analyst Monica Oss, president of the behavioral-health consulting firm Open Minds in Gettysburg, Pa.

Managed-care companies and health-care purchasers are starting to restrict reimbursement to psychotherapy sessions related to diagnosed mental disorders, for instance. That means psychologists may be increasingly likely to find themselves denied reimbursement for sessions devoted to helping patients find meaning or happiness, says Oss.

Instead of clinging to the traditional model of solo psychotherapy practice, she says, psychologists should brush up on business skills such as marketing and product development. They should follow social work?s lead and learn to work as part of interdisciplinary teams. They should come together in networks that offer one-stop-shopping solutions to a wide range of problems. And, she emphasizes, they should seek new outlets for their talents.

Health-care settings offer an obvious starting point, says Oss. According to Coopers & Lybrand, people with mental and addictive disorders are more likely to seek help from general medical practitioners than from mental health specialists. As a result, there?s enormous untapped potential in working with primary-care and other medical providers.

To enhance psychology?s ability to move into health-care settings, APA points to research demonstrating that integrating psychological services into physical care improves clinical outcomes and lowers costs for patients with diseases such as breast cancer. Now APA is exploring the possibility of a demonstration project that would show how psychology could do the same for people with cardiovascular disease and with short-term disabilities.

Psychologists should also draw on their training as skilled behavioral problem-solvers, Oss and other prognosticators advise.

Psychologists could partner with employers eager to boost productivity in the workplace, for instance. They could move into consulting in the legal arena, working on everything from child-custody cases to sanity evaluations to services for the ever-growing population of incarcerated individuals. They could work with nutritionists to help people stick to weight-loss plans. They could even work to predict, prevent and pick up the pieces after ethnopolitical warfare?a priority of APA President Martin E.P. Seligman, PhD.

'Psychology?s future will depend on not doing exactly the same thing we did in the past but to branch out to other needs,' says Seligman, a psychology professor at the University of Pennsylvania.

For Seligman, psychologists? quest for prescription privileges is representative of this expansion of psychology?s scope of practice.

'Prescriptive authority is a perfectly natural extension of psychologists? role as complete providers,' he says.

Psychiatry

Such efforts to expand psychology?s scope of practice outrage many psychiatrists. A recent action alert from the American Psychiatric Association?s director of government relations, for example, warned members of the 'organized psychological prescribing privileges vampire.'

And while psychology works to broaden its scope of practice, psychiatry sees narrowing its focus as the key to success in coming years.

'Psychiatry has to stay true to its medical roots,' says Rodrigo A. Muñoz, MD, president of the American Psychiatric Association and clinical professor of psychiatry at the University of California in San Diego.

Plummeting reimbursement rates and exciting advances in diagnosis and treatment will encourage psychiatrists to move away from psychotherapy and into settings where their medical training will give them greater returns, Oss predicts.

That?s already happening, says Muñoz. Although he emphasizes that patients benefit from both psychopharmacology and psychotherapy, he says it?s more important for psychiatry to put its efforts into neurophysiology.

Not all psychiatrists are happy with this increasing emphasis on neurophysiological diagnoses and treatments.

In his farewell column in Psychiatric News, for instance, Immediate Past President Herbert S. Sacks, MD, lamented the death of psychotherapy within psychiatry. Some psychiatry departments don?t even bother to teach psychotherapy anymore, he points out. Although he acknowledges that advances in neuroscience and psychopharmacology have brought relief to many patients, the shift to a purely biological stance worries him.

'A Weltanschauung (world outlook) which elevates evidence-based science and does not integrate it with clinical wisdom will lead us into a cul-de-sac,' he cautioned. 'In the worst-case scenario, our humanistic, intuitive and aesthetic sensibilities will give way to formulaic approaches to the treatment of the mentally ill.'

Other psychiatrists warn of a precipitous drop in the number of U.S.-trained medical students seeking psychiatric residencies. Although the number of psychiatric residents has remained constant over the last decade, the percentage of U.S.-trained medical graduates choosing psychiatry has declined by 40 percent, according to the association?s 1996 National Survey of Psychiatric Practice. Only 3.2 percent of U.S.-trained residents now choose psychiatry?the lowest percentage since 1929. Alarmed by an influx of foreign-trained residents, the profession is now working to enhance recruitment efforts targeting U.S.-trained students.

Social work

Social work, on the other hand, is booming. According to Open Minds? research, visits to social workers have soared from 5 percent of total visits under fee for service to 56 percent under managed care. (By comparison, psychologists? percentage of visits rose from 10 percent to 33 percent under managed care; psychiatrists? percentage plummeted from 85 percent to 11 percent.)

Indeed, social workers now provide more than half of the nation?s mental health services, says the National Association of Social Workers (NASW).

Such figures are attracting even more people to the field. The number of students enrolling in social work programs is on the rise among both young people and those seeking a second career. In fact, the Bureau of Labor Statistics predicts that the number of social workers will swell by 34 percent by 2005.

Social workers are poised to be the winners in the mental health-care market of the future, says Oss. With both payers and consumers unsure about the differences between psychologists and other providers, she says, they?re opting for lower-cost alternatives. Social workers? training and theoretical emphasis on patients? environments also prepare them well for work in the increasingly popular home- and community-based treatment settings, she says.

But social workers aren?t resting on their laurels, even as they celebrate the profession?s centennial this year. Differentiating the discipline from others and proving its value are urgent, say the profession?s leaders.

'We must demonstrate that social work is effective,' NASW Executive Director Josephine Nieves, PhD, told students at Long Island University earlier this year. 'Hard data?are essential, and soon, or we risk losing out to professions with more rigorous research standards.'

Adopting a more international focus is another priority, says NASW President Josephine A.V. Allen, PhD, ACSW, director of the undergraduate social work program at Cornell University. The exchange of information among social workers from all over the world will be key in helping U.S. social workers provide culturally competent services to a population that includes increasing numbers of immigrants and people of color, she says.

Social work must also intensify its historical commitment to advocacy on behalf of its clients, says Allen, who is also an associate professor of policy analysis and management at Cornell. She hopes other mental health professionals will help.

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