2008 APA Survey of Psychology Health Service Providers
Daniel Michalski, Tanya Mulvey, and Jessica Kohout
APA Center for Workforce Studies
|Module A:||Doctoral Internship|
|Module C:||Client Complexity and Provider Revenue|
|Module D:||Information on Telepsychology, Medication and Collaboration|
Pursuant to the revised Recognition of Health Service Providers as passed by the APA Council of Representatives, “Psychologists are recognized as Health Service Providers if they are duly trained and experienced in the delivery of preventive, assessment, diagnostic and therapeutic intervention services relative to the psychological and physical health of consumers based on: 1) having completed scientific and professional training resulting in a doctoral degree in psychology; 2) having completed an internship and supervised experience in health care settings; and 3) having been licensed as psychologists at the independent practice level” (APA, 1996).
In order to identify psychologists providing direct services in the United States, this study sampled doctoral-level APA members identified as trained in a Clinical, Counseling or School subfield and eligible for licensure; and non-APA members holding a professional license in psychology from at least one state licensing board or agency. The study also included nonmember psychologists. At this time, state licensing boards provide the most complete (comprehensive) option for identifying psychologists who are not members of APA. Yet, state licensing boards do not report information on the specific training settings (degrees or internships) for licensees nor does APA collect data on internship settings of its membership. While not all participants in this survey meet the formal APA definition of HSP, the sampling criteria provide a reasonable approximation and do capture a representative sample of all psychologists licensed to provide direct services.
For purposes of an operational definition, survey participants throughout this report are referred to as Health Service Providers (HSPs).
This survey had both an online version and a paper version. All online participants received base questions on: demographics, education, licensure, employment and clinical practice information. The online survey contained four modules (A, B, C and D) in order to lessen the total number of items to which participants were exposed. Participants were randomly assigned a set of module questions to which to respond by way of branching. As such, an approximately equal number of participants responded to each module in the online survey. The modules included the following categories: A —Doctoral Internship; B —Insurance; C —Client Complexity and Provider Revenue; and D — Practice Information on Telepsychology, Medication and Collaboration. (See Appendix B for a copy of the online survey instrument with the four modules.) The paper instrument included a truncated version of the base questions from the online survey. The demographic items were more concise; only including gender, race/ethnicity, year of birth and disability status. Degree subfield, licensure and theoretical orientation were not asked in the paper version. The client complexity and revenue questions from module C were included in the paper instrument and asked of all individuals in the sample since these topics were of particular interest. (See Appendix A for a copy of the paper survey instrument.) In order for nonrespondents to be tracked, each of the survey forms was marked with a randomly selected unique six-digit ID number.
In August 2008, a cover letter with a link to the online survey was emailed to a group of 34,000 APA Members with valid email addresses and identified as Health Service Providers; that is, trained in or currently working in a clinical, counseling or school setting or performing a direct human service work activity. Nonrespondents received up to three email reminders with a link to the online survey approximately one week apart. Participants that contacted the Center for Workforce Studies requesting a paper survey were mailed instruments in November 2008. In November 2008, 8,000 paper surveys were mailed to a random sample of licensed non-APA member psychologists residing in the United States. An additional 2,000 surveys were sent to a subgroup of APA members without email addresses and identified as Health Service Providers. Participants from the email sample were also sent a hard copy of the survey if requested. Non-respondents to the paper survey received one postcard reminder about a month later in December 2008.
Given the exploratory nature of this study, only proportions and frequencies were reported; no distinction between members and nonmembers is implied beyond descriptive convenience in this report. Data and results from three of the four the modules mentioned above were disseminated prior to publication of this report and can be found linked at the top of this page. Results from the final module, Client complexity and Provider Revenue are included as part of this report but were not previously released.
Demographic and Educational Characteristics
Table 1 summarizes the general demographic and educational characteristics of survey respondents. The median age was 55, the mean age was 53 (SD=12.08), with nearly half of respondents (47 percent) over the age of 55. Less than one tenth of participants were under the age of 35.
Similar to the 56 percent identified as female among APA members (APA, 2009) and among those paying the APA Practice Assessment (APA, 2008), nearly three fifths (58 percent) of survey respondents were female.
Three percent of participants were of Hispanic/Latino origin and 2 percent of respondents were Caucasian/White and Hispanic/Latino. One percent was of Latino/Hispanic ethnicity and multiracial. At least 2 percent of APA members were Hispanic (APA, 2009).
Respondents by race, 2 percent were Asian or Pacific Islander; 3 percent African American/Black; and 3 percent multiracial and not of Hispanic/Latino origin. One percent indicated another race and less than 1 percent were American Indian or Alaskan native. In contrast, at least 2 percent of APA members were Asian or Pacific Islander; at least 2 percent were African American/Black; and less than 1 percent each were multiracial or American Indian (APA, 2009).
The proportions of race and ethnicity for survey participants varies in comparison to the proportions reported by the full APA membership and those APA members paying the special assessment. Substantial nonresponse to race and ethnicity questions by the membership in the APA Directory Surveys does not reflect true representation but can be used to report at least counts for these groups.
Ninety-one percent of respondents selected Heterosexual as their sexual orientation; 3 percent preferred not to answer; and 7 percent identified as Gay, Lesbian, Bisexual or Other. Five percent indicated that they had at least one disability.
Approximately four fifths of respondents held a psychology PhD degree; PsyDs represented 18 percent and EdDs 3 percent. These data vary in comparison to the 72 percent of APA members reporting a psychology PhD degree (APA, 2009) and the 75 percent of Assessment payers that held a psychology PhD degree (APA, 2008). Fourteen percent of APA members and 16 percent of Assessment payers held psychology PsyD degrees. Proportions of EdDs were consistent at 3 percent across each population discussed.
Table 2 shows health service providers’ employment status. More than two thirds (68 percent) of respondents were working full time while a quarter were working part time. Less than one percent each was either: completing postdoctoral work; not working, but seeking work; or not working, but not seeking work. Slightly more than 2 percent were retired but indicated that they were providing limited health services in retirement or offering pro bono service.
Table 3 reveals that a plurality of respondents (62 percent) was employed in one work position and nearly one third (31 percent) were working two positions. Less than one tenth (7 percent) of respondents worked three positions.
Table 4 breaks out the primary and secondary work settings for psychology health service providers. As expected, the most prevalent primary and secondary work settings were private practice (46 percent for each). Within this group, most respondents were located in individual private practice, 36 percent and 37 percent respectively. The proportion of Assessment payers in individual private practice was higher at 51 percent (APA, 2008). This result may be attributable to the fact that early career health service providers (seven years post doctorate degree) are exempt from the Assessment and also may not have the training (license) or resources to enter private practice settings at the start of their psychology career.
Those working in hospital settings accounted for 12 percent of primary work settings and 6 percent of secondary work settings. Within this setting category, general hospitals (public and private) and VA medical centers were most prevalent representing 70 percent of primary work settings and 81 percent of secondary work settings
A number of respondents identified other human service settings (e.g. clinics, counseling centers, rehabilitation facilities) as their primary and/or secondary work settings (11 percent each). Managed care settings, including health management organizations (HMOs) and independent practice associations (IPAs) or preferred provider organizations (PPOs) were less prevalent at less than 1 percent each. However, within managed care settings, community mental health centers (CMHCs) were the most frequent at 4 percent of primary work settings.
Sixteen percent of respondents selected an academic work setting (university; four-year college; medical school; or other academic) as their primary employment setting, while 22 percent of those indicating a secondary position were employed in academic settings. These results were similar to the employment profile of Assessment payers that reported 15 percent as employed in an academic work setting for their primary employment (full-time-employed only) (APA, 2008).
In schools and other academic settings, 3 percent were working in elementary and secondary school settings or district offices as a primary location while just under 3 percent claimed this as a secondary setting.
While private practice settings were the largest category for primary and secondary work settings, substantial proportions of HSPs were found in organized health care settings and higher education as mentioned above. In comparison to past profiles of Assessment payers, slight increases to organized health care settings were apparent. For instance in 1999, 8 percent of Assessment payers indicated human service settings as their primary employment setting compared to the 11 percent found in this study (APA, 1999).
Business, Government and other settings represented less than one tenth of primary or secondary work settings, at 7 percent and 9 percent respectively.
Table 5 analyzes type of primary and secondary work positions for psychology health service providers. Direct human service work was most prevalent for both primary and secondary positions at 73 percent and 63 percent, respectively. Faculty positions accounted for 11 percent of primary positions and 19 percent of secondary positions. Respondents also reported administration of human services at 9 percent of primary positions and 6 percent for secondary positions.
Table 6 examines the number of hours spent on selected work activities for the primary and secondary settings of psychology health service providers. Direct client patient care reflected the highest mean number of activity hours in primary work settings (22 hours; SD=12.58) and in secondary work settings (10 hours; SD=12.04). Within primary work settings, participants reported an average of 13 hours (SD=12.52) spent in a typical week completing basic or applied research. Similarly, an average of 7 (SD=7.09) hours per week are spent on basic or applied research in secondary positions. Fifteen percent of those that selected direct client patient care as a work activity of their primary position also reported at least one hour per week dedicated to basic and/or applied research. This indicates that a number of HSPs primarily engaged in direct services also maintain active links to scientific research.
Table 7 breaks out the typical number of weekly work hours for health service providers reporting full-time employment. For respondents employed full time in one position (primary) the median number of weekly work hours was 40 with an average of 44 hours (SD=7.42). The range extended from 31 hours (the threshold for full-time employment as described in the survey) to a maximum of 80 hours. For those working full time in 2 positions, the median number of weekly work hours in the secondary position was 10 hours with an average of 11.2 hours (SD=7.45). The range for work hours in the secondary position extended from 1 to 55. Outliers indicating hours greater than the maximum values reported above were excluded from analysis.
Current Focus and Work in Psychology
Table 8 reports psychology subfields representing areas of current focus and work for health service providers. Respondents could select multiple options. Clinical was the most prevalent selection accounting for 58 percent of responses. Child clinical accounted for nearly one fifth of responses or 19 percent. Of the remaining subfields, only behavioral, counseling and health psychology had proportions greater than 10 percent: 12 percent, 14 percent, and 11 percent respectively. These data vary from the current major subfields reported by APA Practice Assessment payers. Whereas, child clinical pulled 19 percent of responses in this study, only 5 percent of the Assessment payers indicated that option. Sixty-two percent of Assessment payers also selected clinical as their current major field, while 58 percent selected this option on the 2008 APA Psychology Health Service Provider Survey. These variances may represent shifts that occur during a psychology career and ways in which psychologists define their current work. Furthermore, because respondents could select multiple options in this particular study, respondents may have felt compelled to select the maximum number of subfields they felt represented their work as a health service provider. Conversely, the profile of Assessment payers does not capture this broader view of psychologists’ current focus and work as it represents degree field and current field as reported by the APA Directory.
Table 9 reveals that 95 percent of participants in the study were licensed for professional practice by at least one state licensing board/agency. The remaining 5 percent included psychologists working in settings not requiring professional licensure, those training to sit for licensure exams, or those in retirement. Additionally, 40 percent of those not licensed for professional practice worked in academic settings; 16 percent in hospitals; and 11 percent in business, industry, or government. Only online respondents were asked the questions pertaining to licensure.
Table 9a expands on the licensure status asked in the previous item. Ninety-four percent of participants indicated that their licenses were active when surveyed. Less than one percent held provisional licenses and 4 percent indicated that a license was not applicable to their situation. As mentioned above, these respondents may work in settings or performing activities not requiring a license.
Table 9b indicates that participants were licensed an average of 17 years (SD=10.73) and their time of licensure ranged from less than 1 year up to 60 years.
Table 9c breaks out the years that respondents were licensed into ranges. Nearly one fifth were licensed for less than 5 years. Yet the majority of participants (56 percent) have been licensed for professional practice between 11 and 30 years and 12 percent have been licensed for more than 31 years.
Table 10 examines the degree subfields held by respondents to the online survey. Similar to Table 8, clinical, counseling, and child clinical subfields represented the highest proportions of responses. Although respondents could select multiple options, participants tended to select fewer options than they did when attempting to explain their current work in psychology. While their doctoral study may have focused in a particular subfield, as the psychology career progresses, health service providers may expand upon their original knowledge base to encompass other subfields.
Provider Caseloads and Practice Characteristics
Table 11 explores the average time spent providing psychological services to selected age groups and populations. By age groups, adults comprised an average of 65 percent of respondents’ practice time. Combined, children and youth represented 26 percent of average time spent by HSPs providing direct service. Only 9 percent of average HSP practice time was dedicated to adult clients over the age of 65. By practice category group, services to individual clients or patients accounted for the highest average proportion of practice time, 74 percent. Families (related individuals treated as a unit) averaged 9 percent of practice time. Community prevention services accounted for 1 percent; the smallest average practice time among the practice category groups.
Table 12 examines client caseloads by average time spent on providing services to selected gender and race/ethnicity groups. By gender, women accounted for a slightly higher average percent of time from psychology practitioners: 54 percent versus 46 percent for men. More than one quarter of average time spent providing psychology health services was dedicated to racial or ethnic minorities. The overwhelming majority of practice time was provided to Caucasians.
Table 13 reports descriptive statistics for the number of clients belonging to underserved populations treated during a typical month by health service providers. Only responses that included at least 1 client were included in the analyses and the few responses that reported values greater than 300 were excluded. Low-income clients were treated by 69 percent of respondents with an average of 16 clients per month (SD=20.95). Clients with disabilities were reported by almost two thirds of respondents (63 percent) with an average of 12 clients treated by practitioners (SD=20.05). Fifty-eight percent of providers treated an average of 10 seriously mentally ill clients in the last typical month. Slightly more than half (5 percent) of respondents indicated that they were treating at least one Gay/Lesbian/Bisexual client with an average of 4 clients seen in the last typical month (SD=5.85). Undocumented immigrants constituted only 8 percent of clients treated by survey participants with an average of 6 clients per month (SD=8.11) contrasted to other immigrant populations that were treated by 26 percent of respondents but also with an average of 6 clients per month (SD=12.55). The high maximum values may represent some clients receiving treatment in group therapy settings, yet this should not be viewed as detracting from psychologists’ outreach to recognized underserved populations.
Table 14 analyzes the types of clinical issues for which treatments were provided by survey respondents. A strong majority of practitioners provided service to clients with Axis I disorders (91 percent) and 78 percent indicated this was a focus of treatment and an average of 50 percent of their caseload (SD=29.85). Adjustment disorders were treated by 70 percent of providers and 53 percent reported these as the primary focus of treatment and 14 percent of their overall caseload (SD=17.47). Clients faced with no particular mental or health diagnoses were treated by 13 percent of respondents and constituted 6 percent of the treatment focus. An average of only 2 percent (SD=8.79) of respondents’ caseload was devoted to those without mental or physical health diagnoses.
Tables 15 and 16 examine the primary theoretical orientations utilized by psychology health service providers. Only online survey participants were asked this question. Nearly 2 of 5 respondents indicated a cognitive/behavioral orientation (39 percent). Psychodynamic/Psychoanalytical and Integrative orientations accounted for 16 percent and 15 percent of responses respectively. Those indicating an “Other” orientation accounted for 6 percent of responses, and the most prevalent write-in specification offered was an “Eclectic” orientation. When theoretical orientation was analyzed by degree type (Table 16) the patterns remained relatively consistent. One exception was that larger proportions of PsyDs when compared to PhDs or EdDs indicated that they utilized an Integrative orientation in their provision of psychology health services.