I, too, would like to welcome you to Washington and to this year’s State Leadership Conference, Psychology and Communities: Advancing Health, Building Resilience and Changing Behavior. This year’s theme is actually a direct continuation from last year’s Conference. Some of you may recall that during last year’s conference, entitled “Health and Behavior: Taking Psychology Back to the Future,” we discussed the increasing public focus that was being placed on the effects of lifestyle, behavior and stress on health and illness. We looked at how the “mind-body connection,” as it is often referred to by the public, was for the first time receiving mainstream media coverage. We highlighted psychology’s unique and central role at the intersection of psychological and physical health. We were reminded that a future health care system that relied on connections between behavior and health reaches squarely back into psychology’s past. What policy makers and the public were just starting to realize, psychology has known for years if not decades -- the research, the knowledge base, and technologies to change behavior in ways that benefit people’s health do exist. And, much of the research, the knowledge base and technologies are psychology’s work. We looked forward to a time when psychologists are recognized as the experts in behavior in a health care system increasingly reliant on the important role of behavior.

The public attention to the intersection of psychological and physical health has only continued to grow since then. A Newsweek cover story in October highlighted the link between stress, psychological health and cardiovascular health. A January New York Times series, “The Stealth Epidemic,” put a spot light on diabetes and clearly fingered the culprit for this epidemic as behavior -- faulty diet and inactivity. But, while these stories may be of interest to us, and validating of what we believe we have to contribute, they are certainly not new to us. Having begun last year to develop a direction and a vision for our profession to maximize our contribution where health and behavior is concerned, this year we must start to take steps toward implementing that vision. We must determine just how best to position psychology to capitalize on this opportunity. How do we accomplish the goal of enabling our profession to be preeminent for advancing health, building resilience and changing behavior? There is, of course, no one way to accomplish this goal; it will require flexibility, innovation, persistence and strategic resilience on our profession’s part. It will also require a change in the way the public behaves toward their health and health care. And, it may even require a change in the way we as psychologists do our work.

Central to the implementation of a vision for psychology, as always, is the community of psychology organizations and their leaders represented at this conference. Our leaders, and ultimately our organizations, must act as catalysts for the implementation of any vision we adopt for our profession. If change is required, we must know how to lead the change process. This raises a fundamental question of whether leading change is simply a variation of traditional leadership, or whether it is a qualitatively different kind of leadership. And, what is the role of those communities beyond the borders of the psychology community when it comes to creating change that better positions us as experts in behavior at a time when stock in behavior is rising? How do we collaborate with these other communities to achieve our goal? I will come back to these important questions in a few minutes.
Since last year’s State Leadership Conference, much has occurred. But most of what occurred -- good or bad -- pales by comparison to the enormity of what took place in Louisiana, Alabama, and Mississippi as a result of Hurricanes Katrina, Rita and Wilma. Homes and possessions were lost. Businesses were lost. People were lost, displaced or driven away. Psychologists lost their patients and their practices. Interns lost their training sites. Students lost their schools. A city was washed away. The only good news, if there was any, was that psychology was in a position to help. As has happened following other disasters, the APA’s Disaster Response Network was deployed by the Red Cross to the affected states and to states where victims where being evacuated. In addition to the DRN response, hundreds of psychologists supported relief efforts throughout the country in community shelters from Massachusetts to California. The Directorate also worked with SAMHSA to put psychologists who specialize in substance abuse on the ground where there was a need. All tolled, more than 1,000 psychologists offered disaster mental health support to evacuees and aided disaster responders in the months following the hurricanes. We shouldn’t forget, too, that many other component parts of APA contributed on behalf of psychology as well -- financial contributions, dues forgiveness, resource support to state associations and help locating new training sites, to name a few things.

Another step taken by the Practice Directorate to aid in the aftermath included a one-year Practice Assessment exemption for practitioners living or working in the affected areas of Louisiana, Mississippi, and Alabama. We also redoubled our efforts to engage in public education about building resilience in the wake of this national disaster. Although we had been planning to transition to mind-body health public education activities in the Fall, the pressing need for the resilience materials we had developed since the terrorist attacks of 9/11 led us to postpone that transition until later in the year. Specifically adapted resilience materials were disseminated by the Directorate through our DRN’s, other psychologists and directly to the public through the Help Center. Several state psychological associations have continued to implement programs to help evacuees transition from hurricane survival to building new lives. Some of these intermediate care programs will be featured at the Conference in a Monday workshop entitled “Beyond Immediate Aid: Bolstering Communities with Psychological Support Following Disaster.” It has been extremely gratifying to see our profession able to make such a tangible contribution to this real world need.

And, psychology’s work was not lost on the national media. Stories appeared on the CBS Evening News, CNN, a CBS special on the medical aspects of Hurricane Katrina, and articles were written in the Wall Street Journal, Newsweek, the Washington Post, and USA Today. In preparing for a piece about the emotional impact of the hurricanes on Larry King Live, even Dr. Phil called the Directorate and asked to be briefed about psychology’s activities.

While psychologists continue to help hurricane victims cope with life after this unprecedented disaster, our Mind-Body Health Public Education Campaign has been picking up steam. Video news releases were disseminated around the holidays to take advantage of interest in holiday stress and the perennial “New Years Resolution” story line related to being overweight. A heart disease video news release is now circulating as well. The airing of these three releases has, to date, collectively resulted in just under 8 million media impressions. The mind-body health public education toolkit is now available online and beginning to be downloaded and used by members for forums, seminars and workshops. Thanks to our public education campaign coordinators and to Ron Levant’s “Making Psychology a Household Word” initiative, with the particular help of Board of Directors member Ruth Paige in that initiative, we anticipate that more members than ever will engage in campaign activities. Since this is a grassroots campaign, maximum member involvement is key to its success.

Just two weeks ago as part of the campaign, we released the results of a public stress and mind-body health survey done in partnership with the National Women’s Health Resource Center and iVillage.com. The survey results seemed to hit a chord with the American public. The results, along with the campaign’s mind-body message, were the focus of a Good Morning America story, as well as local radio and print coverage literally around the country. The results were also presented at a press conference in New York to close to 30 reporters from media outlets ranging from Glamour, to Ladies Home Journal, to Newsweek, to the Wall Street Journal. To further the reach of the campaign’s messages, discussions are underway with Sesame Street, Time for Kids, MTV and Lifetime Television for future mind-body health campaign activity. And an agreement has been reached with MSN.com to provide campaign content to that web site, which receives over 85 million visits a month.

The Directorate’s educational efforts about the value of psychological services extend beyond the general public. The Psychologically Healthy Workplace Awards Program, with the outstanding work of your organizations and the efforts of our Business of Practice Network, has made great strides helping the business community appreciate the connection between the psychological health of employees and the organizations’ performance and productivity. Since last year’s SLC, five of you have added programs to bring the total of state, provincial and territorial associations with PHWA programs to 44. More than 250 winners have been recognized at the state level to date. Later today, the program will reach a new milestone when we inaugurate the annual National Psychologically Healthy Workplace Awards. We will also be continuing with our third annual Best Practices Honors which recognizes companies for particularly innovative or creative activities.

Educating policy makers about the value of psychological services is also a must, despite being a process that often takes a very long time. After close to a dozen years of effort, we finally succeeded in persuading Medicare that psychological and neuropsychological testing should be recognized as having a “professional work value” when reimbursements are calculated, that is, recognition of the psychologist’s time and effort in the testing process. Historically, Medicare officials had taken the position that since physicians did not do psychological testing, the service had no “physician” or professional work value. With this work value now included, reimbursements are increased as much as 122% for some services in some geographical areas.

But as this group knows more than most, changing policy is only half the battle -- implementation of the new policy is the other half. Implementation of the new reimbursement levels is, in this case, the responsibility of the Centers for Medicare and Medicaid Services, or CMS, the same agency that is so smoothly and seamlessly implementing the Medicare Prescription Drug Benefit into the country’s healthcare system. As some of you already know, it was CMS that required us to work with the AMA to develop a new set of CPT codes for testing services in order to implement the new professional work value. The new codes went into effect this past January yet, more than two months later, we are still awaiting clear instructions from CMS to its insurance carriers to accept the new codes. As a result, the success with which psychologists are effectively being reimbursed at the new levels is uneven, to say the least. Carriers do not yet understand, for example, that it is the psychologist who bills for the technician’s services, not the technician. Nor do they yet appreciate that the activities of supervised trainees are not the same as activities of the technicians. With the help of the APA’s Division of Neuropsychology, the National Academy of Neuropsychology and the Society of Personality Assessment, we have initiated a full court press to educate our members and, importantly, the insurance companies about the change. And, we are working with CMS to have the agency issue clear direction to its carriers. There will be a workshop Sunday morning entitled “How to Put the New Codes Into Action: Advocating to Insurance Carriers on Behalf of Psychology.”

Also on the Federal front this past year, we worked with our Federal Advocacy Coordinators and our very effective grassroots network to help stop the scheduled 4.4% decrease in Medicare reimbursement rates. We also worked to prevent weakening or elimination of Medicaid’s EPSTD program for children -- the Early and Periodic Screening and Diagnostic Treatment Services program. And we worked to prevent Association Health Plan legislation from wiping out many states’ protections for people receiving mental health services. Unfortunately, this latter piece of legislation is back again, and in a more muscular form which threatens to eliminate virtually all state level protections established through almost thirty years of work by psychology and the mental health community. Our Government Relations staff will be preparing you on this issue through the course of the Conference for your visits to the Hill on Tuesday.

One of the Practice Organization’s key legislative priorities for 2005, and one that many of you will recall as part of the Hill visits at last year’s SLC, was to secure funding for the Mentally Ill Offender Treatment and Crime Reduction Act. I am happy to say that with the help of champions Ohio Senator Mike DeWine and Ohio Congressman Ted Strickland, we were able to secure $5 million in funding for Fiscal Year 2006, a substantial increase over earlier funding for the mental health court program at a time when federal program budget cuts were the norm. We will again be working to gain funding for this program for the FY 2007, and you will hear more about that during the conference.

Despite continued bipartisan support in Congress for mental health parity, the effort remained stalled this past year. Important work, however, continued here in Washington as well as through our grassroots, to keep the parity flame alive. Long time parity supporters, New Mexico Senator Pete Dominici and Massachusetts Senator Ted Kennedy, remain steadfast and committed to the cause. We anticipate a strong parity bill will be introduced by them in the Senate next week, and we are optimistic that this will help turn that slow burning flame into the necessary blaze that results in discrimination against people in need of mental health services being outlawed once and for all. You will hear much more about this as the Conference progresses.

Before moving off the federal advocacy agenda, it is important to note that psychology’s political action capability continue to grow. The Association for the Advancement of Psychology and the APA Practice Organization collaborated to increase the number of psychologists contributing to the PAC, and to increase the number of dollars being contributed to it. But much more needs to be done to realize psychology’s political giving potential and to create the one-two punch with our grassroots advocacy efforts of which we are capable.

In the legal arena, activity continued in the federal class-action lawsuit against the nation’s largest managed care companies based on the Racketeer Influenced and Corrupt Organizations Act -- or RICO. You will recall that the suit alleges that the defendant companies conspired to reduce and delay payments for services provided by non-physician health professionals, including psychologists. In April of last year, the court gave final approval to the $11.5 million settlement offered by CIGNA, and in August, more than 4,000 psychologists received almost $2.2 million from that settlement fund. Serious settlement talks are now underway with other of the defendants.

As a testament to the length of time policy change can take to implement, this past year the California Department of Health Services finally issued regulations implementing the California’s hospital practice law in state hospitals and enforcing the 1990 California Supreme Court decision in CAPP v. Rank. This was accomplished through the efforts of California psychologist and Committee for the Advancement of Professional Practice member, Bill Safarjan, his Psychology Shield organization, the California Psychological Association and the Practice Organization. But never willing to give up the fight to protect what they see as their perceived turf, the state psychiatric association and psychiatric union sued DHS to block the regulations. Unfortunately, just last month, the court determined that DHS did not follow the required procedures when promulgating the regulations and ordered the Department to re-issue the regulations according to a different procedure. We look forward to this set of regulations, and stay tuned for the next round in what will certainly be a 15 rounder.

Speaking of psychiatry’s dwindling turf, nine states introduced legislation seeking prescriptive authority for appropriately trained psychologists this past year. While no state enacted a prescribing law, this was the highest number of states to actively work bills in any one year. Hawaii, Missouri and Connecticut have already filed bills for 2006, and at least two more are expected including Georgia and Tennessee, which is looking to build on its strong showing of last year. Hawaii’s bill, which would allow appropriately trained psychologists to prescribe in federally qualified health centers and other specified clinics in underserved areas, is already moving. It has passed the House Health Committee, a committee in which it did not succeed last year and, just this week, it passed the House Consumer Protection Committee albeit with some amendments. Of particular note has been the expressed support of the bill by HMSA -- the BlueCross/BlueShield company and the largest insurer in the state. It has also received the support of the medical directors of each of the community health centers in Hawaii.

Just as important as those states working to enact new laws, is the implementation and prescribing experience of the states with laws. New Mexico currently has three prescribing psychologists and Louisiana now has 30 “medical psychologists,” the designation for prescribing psychologists in that state. Significantly, well over 10,000 prescriptions have been written without incident.

Other state-level activities over the last year witnessed mental health parity laws enacted by Washington, Oregon, Iowa and South Carolina, bringing the total number of states with some form of parity to 41. Hawaii, Illinois and Maryland expanded their existing parity laws. In New York last year, the legislature reversed the governor’s budget proposal and kept psychology in its Medicaid program. And, Texas succeeded in having psychological services restored in the state Medicaid program.

Psychologists have successfully expanded their practice authority this past year in Colorado and Arkansas. In Colorado, the Colorado Psychological Association helped pass a law recognizing psychologists’ ability to perform competency-to-stand-trial evaluations in juvenile cases, and is currently working on companion legislation for adults. After much persistence, the Arkansas Psychological Association succeeded in revising their licensing law to allow the use of technicians by neuropsychologists. The new law established standards and requirements for psychologists’ supervision of technicians, set up education and training requirements for technicians, and limited the use of technicians to neuropsychological assessment. ArPA’s solution to this sometimes thorny problem of technicians can stand as a model for those other states grappling with the same issue.

While I have only been able to mention a handful of the many accomplishments which took place since the last SLC, all of the organizations represented here -- state, provincial and territorial associations, and APA divisions -- have done significant things this past year for our profession and for the public. While we have much left to do, I am confident that as a community we can do it. As a case in point of what we can accomplish together as a community, I call your attention to the Committee of State Leaders Diversity Initiative. This initiative, now in its seventh year and funded jointly by CAPP and the Practice Directorate, the Office of Ethnic Minority Affairs and by the SPTAs, has grown from 14 diversity delegates in the first year to the 36 delegates in attendance today. Most importantly, of the diversity delegates who have attended SLC, a growing number have taken on leadership positions in their organizations. With the elections of Arizona’s Evie Garcia, Utah’s Janice Pompa and Washington State’s Carla Bradshaw to the position of President-elect, this brings to 6 the number of Diversity Delegates who will serve in their organizations’ top spot. And many Diversity Delegates are now serving on their associations’ Board or committees as well. The success of this initiative has clearly not be a matter of what APA can do for your organizations or what your organizations can do for APA but, rather, it is a matter of what we can do together, what we can do as a community.

Perhaps some of you are thinking, “The Diversity Initiative is making a good contribution, but at the average pace of just under one new leader a year, how long will this take to achieve its goal?” For those of you who may discourage easily, I call to your attention Malcolm Gladwell’s The Tipping Point. Gladwell believes new ideas are like viral epidemics -- contagious and capable of spreading at one dramatic moment. Little causes can have big effects. Little things can make a big difference. Incremental changes or almost imperceptible changes at the margins accumulate. Ultimately, significant change happens, not gradually but at one dramatic moment when everything can change all at once -- the tipping point. And, for those of you who may be skeptical, I remind you of what our President, Dr. Koocher pointed out at the Council of Representatives meeting last month while remembering Rosa Parks. A single act of conscience by this one African American woman who, in 1955, refused to give up her seat on a bus became the tipping point for a wave of events that changed the nation.

So what is the epidemic of change for which we seek a tipping point? Simply put, it is twofold: a solution to our broken healthcare system, and a role for psychologists in that reformed system that appropriately values our services and enables our ability to provide those services. We are compelled to ask the question of how we can contribute to that tipping point, But, to first know how we can best contribute, we need to check in on how health care reform is progressing. Unfortunately, the answer is not so good. Just as we discovered last year, no good comprehensive health reform plan, or even an organized vision of one, has yet been able to emerge in response to recent years of turmoil in the country’s health care system.

Among the few visible so-called reform trends that can be found is the movement towards consumer-driven health care. This concept intends to better enable individual consumers, as opposed to employers or other third-party payers, to be better purchasers of their health services, not just the beneficiaries of services purchased for them by a third party. In theory, consumer-driven health care intends to produce an informed consumer of health care who will make smart purchasing choices based on quality and cost. It typically consists of a high deductible insurance plan, with the potential for a combined employer and employee funded health reimbursement account used by the employee to pay for services within that deductible. The Bush Administration continues to promote Health Savings Accounts -- a form of consumer-driven health care -- as one of its only vehicles for healthcare reform.

But adoption has not been what was hoped for. According to Mercer Health & Benefits Consulting, the number of consumer-driven plans grew by only 2% among small employers in 2005 -- the very population that was supposed to be most advantaged by the plans. The Mercer study found that the plans are more popular among jumbo employers with 20,000 or more workers, where 22% offer some form of consumer-driven health plan, up from 12% in 2004. But even in those companies, enrollment in the plans averaged only 8% of workers. A survey by the Employee Benefits Research Institute and the Commonwealth Fund found lower consumer satisfaction and higher out-of-pocket costs with consumer-driven plans than with more comprehensive health plans. Importantly, the study found that individuals with consumer-driven health plans were more likely to avoid, skip or delay health care because of costs than those in comprehensive plans. The study also found that few health plans of any type provide the cost and quality information sufficient to enable informed decisions, and it found very low levels of trust by consumers in the information provided by these health plans.

Another area where hope springs eternal for reforming health care is the adoption of information technology to create a more effective, more efficient and better integrated health care system. Despite the promise, one health commentator sums it up this way: “If the state of U.S. medical technology is one of our great national treasures, then the state of U.S. health information technology is one of our great national disgraces. We spend $1.6 trillion a year on health care -- far more than we do on personal financial services -- and yet we have a 21st century financial information infrastructure and a 19th century health information technology infrastructure…(T)housands of small organizations chew around the edges of the problem, spending hundreds of millions of dollars per year on proprietary clinical IT products that barely work and do not talk to each other. Health care organizations do not relish the problem, most vilify it. Many are spending vast sums on proprietary products that do not coalesce into a system-wide solution, and the investment community has poured nearly a half-trillion dollars into failed health information technology ventures that once claimed to be the solution. Nonetheless, no single health care organization or health information technology venture has attained anything close to the critical mass necessary to effect such a fix. This is the textbook definition of a market failure.”

An information-driven health system appears to be faring no better than a consumer-driven health system as a vehicle for reform. Nor, as we know, have attempts to administratively limit services or realign incentives done much to cure the woes of the current health care system. And until recently, little has been done in attempt to improve health as a means of improving the health care system. Efforts are emerging, however, to refocus on quality and, it is argued, move the system away from the historical obsession with costs. Tools such as pay-for-performance, evidence-based practice and outcomes measures are being touted as a potential remedy for the system’s problems. Pay-for-performance is most frequently described as an effort, initiated by payers, to realign incentives in health care services delivery so as to provide incentives for improving the quality of care. The major focus of the 100 or so current employer initiated pay-for-performance programs is to attempt to determine how well health professionals care for their patients and to reward the ones whose outcomes are best, usually with bonus pay at the end of the year. CMS has also been experimenting with pay-for-performance programs, and the Medicare law recently enacted by Congress barely escaped language requiring some type of pay-for-performance component in Medicare. At present, however, what constitutes a pay-for-performance program is far from standardized, or even clear. There is considerable confusion as to whether incentives should be provided in response to performance-based measures or clinical outcome measures. Some programs include measures of preventive services, such as cancer screening, mammography, and immunizations. Some include measures of care for such chronic diseases as asthma, diabetes, and cardiovascular disease, others do not. Many programs also use client satisfaction measures. Some incorporate utilization measures, such as percentage of generic drugs prescribed or medically unnecessary tests ordered. Some actually reward physicians for using various forms of information technology. Some attempt to incent performance and good quality, while others incent quality improvement.

For those wishing to hear more detail about pay-for-performance issues, there is a workshop on Monday morning entitled “Pay-for-Performance and Outcomes Measurement in Health Care: National and State-Level Developments.” For now, suffice it to say, although providing incentives for efforts to improve quality seems a good idea in concept, implementation will make all the difference. Depending on what performance is incented, a program can facilitate the delivery of quality care or actually impede it. Even the most helpful tool in the hands of those with less than helpful motives can become a weapon. If payers “incent” those who provide the least amount of care, pay-for-performance will be nothing more than the latest version of managed care. Even efforts to incent evidence-based practice is no guarantee. The result of an effort to incent an overly narrow approach reliant only on empirically validated treatments would be very different than an approach which integrates the best available research with clinical expertise in the context of patient characteristics, culture and preferences. This latter alternative is the definition of evidence-based practice which is now APA policy due to the efforts of many, but particularly Carol Goodheart who headed up Ron Levant’s evidence-based practice presidential initiative.

But, if improved health is, indeed, the goal, the impact of behavior on health and illness and the public’s growing recognition of this connection has great potential. One could imagine pay-for-performance incentives given to those health professionals who address health and behavior connections. To take it a step further, perhaps the health and behavior link has the potential to be the tipping point for dramatic change in the health system.

To remind us of what we know, behavior is integrally linked with the promotion of health or the opposite, the development of disease. The six leading causes of death in this country are related to behavior. According to the Centers for Disease Control, the obesity rate in America is approaching 30%, and 65% of the population is either obese or overweight. The stress survey we recently conducted found that those Americans most concerned about their stress level were more likely to smoke and use “comfort foods” but less likely to exercise than people not concerned about their stress level. Those that used food to cope with stress were more likely to report hypertension and high cholesterol, and were more likely to be overweight and obese. 43% of all adults according to one study were found to suffer adverse health effects from stress. People are finally beginning to understand what our CEO Norman Anderson points out in his book Emotional Longevity, having a good support system or an optimistic outlook can lead to better health and even longer life. To state the obvious, good health is all about behavior, everyday behaviors that can be learned. If improving health has the potential to solve many of the problems in our current health care system, and behaviors can improve health, it is not such a stretch to say that health care reform, then, is really all about behavior reform. The key question for us to begin to consider is what can we do to “tip” health care reform in this country?

It goes without saying, I hope, that the one thing we should do is assure that our skills as psychologists are honed to facilitate behavior change in those whose unhealthy behaviors are taking a toll. Knowing how to navigate the intersection of psychological and physical health is also key. The Sunday morning workshop on “Working at the Intersection of Psychological and Physical Health: Practical, Political and Training Considerations may offer some insights. I will not dwell on this particular point of “how to” any further here, although each of our organizations should look to have available continuing education support for our members.

The bigger question for today is how do we spread the word that health care reform is really about behavior “reform”? How do we persuade policy makers, that the solution to at least some of their biggest problems is right at our finger tips? How do we move employers and other payers to appreciate the cost to them of unhealthy behaviors and lifestyles so they are eager to pay for efforts to create healthy ones? And, how do we create the social epidemic, as Gladwell would call it, that flows from the single tipping point and leads people to literally demand healthy lifestyles; how do we create the epidemic that leads people away from feeling entitled to good health care and leaves them feeling entitled to good health.

Perhaps Gladwell, himself, can offer us some wisdom. Among his many metaphors, he describes Paul Revere’s ride as the most famous historical example of a word-of-mouth epidemic -- a piece of extraordinary news that traveled a long distance in a very short period of time, and which mobilized an entire region to arms. At first blush, it seems straight forward why this would occur. Revere was carrying news that no one could ignore -- the British were coming. But, on further inspection, there appears to be more to it than just a compelling message. Gladwell reminds us that at the same time Revere began his ride north and west of Boston, a fellow revolutionary named William Dawes carried the same urgent message to Lexington via a different route. Yet, few people from the towns Dawes rode through materialized for the battle the next day. Why did Revere succeed where Dawes failed? Gladwell concludes that Revere’s news “tipped” while Dawes’ did not because of differences between the two men, not the messages. Revere, according to Gladwell, was a “connector” -- someone who provided the link for collections of people who would not otherwise come together. It was his ability as a connector that enabled his message to succeed while Dawes failed. In Gladwell’s words:
“When Revere set out for Lexington that night, he would have known just how to spread the news as far and wide as possible. When he saw people on the roads, he was so naturally and irrepressibly social he would have stopped and told them. When he came upon a town, he would have known exactly whose door to knock on, who the local militia leader was, who the key players in the town were. He had met most of them before. And they knew and respected him as well.”

Gladwell also tells us that Paul Revere was a “maven” or someone considered to be very knowledgeable and, therefore, credible. What he never tells us, however, is that Revere was actually arrested by the British that night and later released without a horse to continue his now famous midnight ride. But that’s a story for another day. No matter the actual events of that April night in 1775, it is the lesson that is important here. A good message alone cannot succeed without the right people to carry it; a social epidemic depends as much on the people who support it as the idea which they spread.

Turning now back to our predicament, I would ask is there a Paul Revere among us? Or are we a group of William Dawes? Fear not, convening the right people to carry the message that “tips” and cultivating the support necessary for the message to spread can be well within our leadership skill set, although horseback riding is generally not.

But, what is the leadership that is required? Traditional leadership has often been described as tactical. Tactical leadership works best when the objective is very clear -- win a game, defeat the enemy, enact a piece of legislation. The people involved in the effort are being led in the execution of a plan. The tactical leader clarifies the goal, persuades others the goal is important, explains the strategies and tactics necessary to advance the goal and coordinates the activities of those involved. Traditional leadership is also typically leadership by virtue of a position at the top of a functional structure. But, in their book about leadership, Chrislip and Larson argue that this traditional leadership does not work well when collaboration among people or groups or communities is required. In their research on successful collaboration, they found another form of leadership with distinctly different roles and tasks -- they termed it collaborative leadership.

The typical tactical or positional leader works with a homogeneous group. A collaborative leader, on the other hand, must work with a mix of people, a range of stakeholders or different communities over which the leader holds no formal power or authority. Leadership must be exercised in a peer-to-peer context. The strategies for getting results in situations requiring collaboration are usually less clear because of the complexity of the problem, and the fact that different stakeholders typically have different interests in the outcome, at least at the start of a collaborative process. Additionally, collaborative leaders are more focused on promoting and safeguarding the collaborative process.

In a nut shell, according to Chrislip and Larson,
“Collaborative leaders challenge the way things are being done by bringing new approaches to complex public issues when nothing else is working. They convince others that something can be done by working together. They inspire collaborative action that leads to shared vision. They empower people by engaging them on issues of shared concern and helping them achieve results by working together constructively. Their credibility comes from the congruence of their beliefs with their actions. If they espouse collaboration, they collaborate themselves. They recognize that their ability to get things done must come from respect, since they have no formal authority. They keep people at the table through difficult and frustrating times by reminding them of the common purpose and of the difficulties of achieving results with other approaches. They ‘encourage the heart’ by helping to create and celebrate successes along the way to sustain hope and participation.”
While this brief tutorial on some variations of leadership can hardly do justice to the complexity of the leadership challenges we face over the coming year, it is intended to give us food for thought rather than a specific road map. When leading change is involved, that is, when we commit to a vision to do something that has never been done before, some believe there is no way to absolutely know how to get there. Robert Quinn, who has written extensively on leading change, describes the process as “building the bridge as we walk on it,” which clearly depicts the uncertainty we face. Should that metaphor cause some anxiety, perhaps you would prefer his alternative descriptions of what it’s like to lead change: “walking naked into the land of uncertainty” or, my personal favorite, “learning how to walk through hell effectively.” Clearly, leading change is not for the faint of heart.

In spite of any uncertainty or even adversity we may face, we must move ahead and build that bridge using the tools at our disposal. We start with solid psychological interventions that can effectively treat mental health problems and significantly influence physical health. To these core competencies we add our message that health care reform is really about behavior reform, or behavior change. We use the public education campaign to take that message to consumers, the Psychologically Healthy Workplace program to take that message to employers and our grassroots advocacy to take that message to policy makers. And, we use our leadership skills to collaborate within our community and with other key communities that surround us.

Moving out beyond our own psychology community, indeed beyond the health community, is critical. “Heads Up Kentucky” undertaken by the Kentucky Psychological Association, for example, was not just public education -- it was a way for psychology to tangibly move beyond its borders out into the community at large. The demonstration project under way at Geisinger Medical Center in Pennsylvania that we and the Pennsylvania Psychological Association initiated with congressionally appropriated dollars is not just a research study of psychological care integrated into the primary care of older adults -- it is a model collaborative care program that provides tangible benefits to the community. The demonstration project we are in the process of developing in school-based health centers is not just an effort to reduce childhood obesity -- it is an attempt to use psychology’s skills in a key role in the community.

There are many more community doors for us to knock on and people to awaken if we are to be remembered as Paul Revere rather than William Dawes. Participation by psychologists in the many civic groups and organizations any community has to offer provides critical connections within the community. Our profession no longer has the luxury of setting ourselves apart to observe, analyze and evaluate from a distance; we must be active participants in all our communities to accomplish our goals. Non-profit organizations, public service agencies, fraternal and service organizations and social, religious and cultural groups provide us the opportunities to actively participate.

Electing psychologists to office is another way to actively participate. We know what can happen when psychologists are elected to Congress and state legislatures. We are in the process of finding out what can happen when a psychologist is elected governor of a large Midwest state. And, when you attend the Monday morning plenary entitled “Connecting Psychology with the Community,” you will hear what can happen when a psychologist is elected to be mayor of his town.

Those of you who have been coming to this Conference over the years know that each year, I try to challenge our organizations and our leaders to take a next step forward, to move out of our existing comfort zone. In prior years, I have urged us to move beyond the narrow conception of ourselves as mental health professionals and see ourselves as comprehensive health professionals. Last year, I urged us to take that a step further to begin to see ourselves more as experts in behavior to maximize our impact and opportunity, not only where health and behavior are concerned, but anywhere we find problems of behavior. Importantly, this conception of ourselves is not intended to replace our practice as mental health professionals or as comprehensive health professionals, but instead to encompass and enhance it.

While we are clearly making progress, these prior challenges still remain. Our nation continues to suffer from debilitating and costly preventable health conditions in which behavior plays a critical role. It is not so grandiose to say, however, that we -- our profession and our organizations -- do have solutions to many of these problems. Which brings me back to the main idea of the day: we must do better at getting our message beyond the borders of our own profession. Others beside us need to know that we have solutions to some of the country’s most significant problems. And, we must do more to collaborate with others -- other professions and other communities -- if we hope to put those solutions to good use.

So my challenge to us this year is to continue to find more ways to spread the word; continue to work to trigger the tipping point that starts an epidemic of good health in this country. In recent years, we have made good progress getting out of our offices and into the community. Public education activities have helped with that. But let’s now take the next step. Consider forming a work group -- a subgroup of your Board, perhaps -- whose charge it is to identify as many possible leverage points in all possible relevant communities where psychologists could be participating and spreading the word. Civic groups, cultural groups, service organizations or even elected offices are all important places for psychologists to be. For each one of these places, determine what it will take to have a psychologist involved and see if you can find one of your members to work with you to get involved.

Some of you may already be doing this, but my challenge is to begin to do this in a more systematic way. Now let me be clear that I definitely understand how already overloaded your agendas are likely to be. I am not suggesting something that should be time and resource intensive, at least not immediately so. It is something that can build over time. I am suggesting that you survey your local landscape to see where and how psychology’s community network can be strategically expanded to further the spread of our message. Call it a community networking initiative, a community leadership initiative, or perhaps call it the Paul Revere initiative. But no matter what we call it, it will ultimately be the cumulative effect of our message, our collective persistent efforts to carry that message and our collaboration with communities beyond our own that enable us to succeed. If we can do these things, a dramatic change in health care may just be the country’s next health epidemic.