Today's professional psychologists are pursuing a wide range of paths, Katherine C. Nordal, PhD, told participants at the 2016 State Leadership Conference.
"We have some incredible psychologists out in the field doing innovative things with group practice structures and integrated care systems," said Nordal, executive director for professional practice in APA's Practice Directorate and the APA Practice Organization. "And we also have psychologists who prefer to maintain their traditional fee-for-service practice model."
Expanding the practice spectrum for both kinds of practitioners was the theme of the 33rd annual State Leadership Conference, held Feb. 27–March 1 in Washington, D.C. Sponsored by APA and the Practice Organization, the conference brought together nearly 500 representatives of state, provincial and territorial psychological associations; APA governance and division leaders; members of the American Psychological Association of Graduate Students; early career and diversity delegates; and others.
In addition to participating in educational sessions and networking opportunities, participants made 320 visits to members of Congress and their staff on Capitol Hill to push for two key legislative priorities: urging members to co-sponsor the Medicare Mental Health Access Act and to enact comprehensive, bipartisan mental health reform legislation based on the Helping Families in Mental Health Crisis Act in the House and the Mental Health Reform Act in the Senate.
Exploring innovative approaches
At the meeting's opening session, three keynote speakers discussed the innovative ways psychologists are exploring their work.
The first, Nancy Breen Ruddy, PhD, vice president of patient engagement at McCann Health, in Mountain Lakes, New Jersey, targeted her advice based on where psychologists are in their careers. Late-career psychologists, she said, can probably continue to practice the way they always have. Mid-career practitioners may be able to keep earning a significant part of their income through direct service, although they may have to create more specialized niche practices or start collaborating with health-care professionals.
But early career practitioners and psychology trainees should be thinking about what else they can offer besides direct clinical care, Ruddy said. Examples of alternative services psychologists could provide include improving communication and relationships within organizations, creating and evaluating systems and supervising other clinicians providing direct clinical services.
"We have some answers the rest of the world needs, but only if we're flexible about where, how and to whom we provide services," said Ruddy. "The world needs psychology, but not just in 50-minute increments."
For keynoter Arthur C. Evans, PhD, that means taking a public health approach to psychology practice. As commissioner of Philadelphia's Department of Behavioral Health and Intellectual disAbility Services, he views the city's 1.5 million residents as his patients.
Getting entire populations the help they need means rethinking health care, Evans said. "People get sick, they go to treatment, we fix them and they leave well. That's the basic paradigm of our health-care system," he said. Evans noted that there are two major problems with that approach. Passively relying on people to seek treatment means most who need help don't get it. And the system's binary nature — you're either well and don't need help, or you have a diagnosis and do — means that prevention and health promotion aren't priorities.
Now that's starting to change, with reimbursement shifting from fee-for-service to incentives for keeping people well. That shift will bring opportunities for psychologists who are willing to explore interventions beyond psychotherapy and focus not on individuals but entire communities, said Evans. In Philadelphia, for example, mental health screenings out in the community invite residents to "get a check-up from the neck up." The city has also fought stigma by getting communities involved in painting murals on such issues as suicide and gambling.
Practitioners are also innovating when it comes to business matters. Take the management services organization that keynoter Geoffrey Kanter, PhD, is developing.
Now chief executive officer of Comprehensive MedPsych Systems in Sarasota, Florida, Kanter started his practice with four psychologists in 1998 and watched it grow to 107 multispecialty clinicians working in diverse settings. He then realized he could help other psychologists benefit from everything he has learned about setting up a business along the way. The organization he is creating will offer other psychologists a menu of management services, such as an encrypted email system, a Health Insurance Portability and Accountability Act compliance plan, clinical outcome measures, and discounts on office supplies and testing materials.
Helping psychologists with the non-clinical parts of running a practice will free them up to focus on the clinical parts, said Kanter. "This is a way to take individual practitioners and create a mega-group, but still allow them to maintain their independence and autonomy," he said.
Thriving in independent practice
Of course, not all psychologists want to make major changes in the way they practice — and they may not need to.
"There's always going to be a space for what we currently call private practice," said Ruddy. But, she emphasized, even traditional private practitioners may need to tweak their practices.
Ruddy suggested several easy ways private practitioners can stay relevant in a rapidly changing health-care system:
- Conduct a needs assessment, asking community members to identify the services they need.
- Give public talks with other health-care providers in your community, such as pharmacists.
- Do a better job of marketing yourself. "Psychologists tend to get pedantic," said Ruddy. Instead, focus on the take-aways. "What are the two things you want people to know about psychology before they leave?" she said. "Make those two points and spend the rest of the time schmoozing."
Helen L. Coons, PhD, president and clinical director of Women's Mental Health Associates, offered additional survival tips for psychologists who want to maintain individual or group practices in or outside the health system.
It's important for self-employed psychologists to diversify their income streams, Coons recommended. For her, that means a mix of clinical work from her collaborative care practice located in several health settings — still the bulk of her income — plus paid consultations from corporations, presentations around the world and continuing education for various professional and community audiences.
Another key strategy is to develop a niche practice, said Coons, whose own practice specializes in women's health and oncology and rotates to different medical practices all week. Collaborating with varied health providers is an obvious place to start, said Coons, citing both primary-care providers focused on internal or family medicine, pediatrics, obstetrics/gynecology, adolescent medicine and geriatrics as well as specialty-care providers in specialties as varied as gastroenterology, reproductive endocrinology, sports medicine, dentistry and physical therapy. Psychologists in individual and group practices may go on site to health settings, accept referrals under contractual agreements or both, said Coons.
And the opportunities for innovative and entrepreneurial work go far beyond health care, she said. "There is a range of niche settings out there that we're not capitalizing on," she said. Examples include working with banks, corporations, the media, private schools and law practices. Teri L. Strong, PhD, is another psychologist who has developed a niche practice. Founded in 2014, Strong Integrated Behavioral Health, LLC, in Eugene, Oregon, allows her to integrate behavioral health services with primary- and specialty-care services while maintaining an independent practice model. The practice also offers outpatient psychological services for those who need follow-up care, which is carefully coordinated with the medical clinics.
When the practice began, Strong had a contract with two primary-care clinics to provide a half day of psychological services at each. Within a month, the call for her services was so great she began hiring. With seven psychologists now on staff, the practice has developed service agreements with multiple medical clinics.
These clinics contract with her practice because Strong and her colleagues know how to provide effective, efficient services. They have long-term relationships with the medical community. And they are already contracted and credentialed with insurers, including Medicaid, Medicare and commercial insurance plans. "Most medical practices don't have the experience to hire, train and supervise mental health folks, so they welcomed our expertise in this area," said Strong. In addition, psychologists have specialized skills in developing systems, evaluating programs, training and other areas that medical personnel may not have, she said.
The rapid growth has been challenging, Strong admitted. "If you open a private practice, you'll be slammed," she said. "It's just so needed."
Serving the newly insured
The Affordable Care Act is spurring even more demand for services, said Monnica T. Williams, PhD, director of the Center for Mental Health Disparities and associate professor of psychological and brain sciences at the University of Louisville in Kentucky. By expanding Medicaid eligibility and offering subsidies for low-income consumers buying coverage through state-based insurance exchanges, the law has greatly increased coverage, said Williams.
But because many of these newly insured Americans have never received mental health care before, psychologists may need to adapt the way they practice. Williams and other panelists at a session on serving the underserved offered several suggestions:
- Fight stigma. Many of the previously uninsured come from communities in which seeking mental health care is frowned upon, said Williams, who has created a mental health program for refugees at the University of Louisville. But it's not just cultural norms that make people reluctant to seek help, she said. "Many are worried that if they talk about what's wrong, they'll be sent back to their countries," she said. "Or they're worried that their communities will find out."
Countering such attitudes can mean tweaking usual practices. If you're just reading items off a standard screening instrument, for example, you may miss signs of problems. "It might not occur to someone that a 40-year-old guy from Nigeria with five kids is not going to tell you he's having trouble," said Williams. Sometimes battling stigma can be as easy as a linguistic shift, said Amy S. Walters, PhD, director of behavioral health services at St. Luke's Humphreys Diabetes Center in Boise. Instead of calling herself a psychologist, for instance, Walters focuses on the behavioral health part of her work and has encouraged medical providers to do the same. "If they say, ‘We have this psychologist we'd like you to see,' the brakes go on real fast," she said. "But if instead they say ‘We have a behavioral health specialist on our team who can really help you …,' it's a whole different ball game."
- Attend to practical matters. Many of the newly insured are low-income individuals juggling multiple responsibilities. As a result, they may need accommodations that more well-off clients don't. Take child care, for example. "A lot of times families will bring their children with them," said Williams. "We can't interview a patient about their trauma if their 5-year-old is sitting next to them." Clients may also need language interpreters or help navigating public transportation systems to appointments.
Newly insured clients may also need help with practical matters in their own lives, said Jessica K. Floyd, PsyD, a psychologist with Abrams and Associates, LLC, and the Lourie Center for Children's Social and Emotional Wellness in Rockville, Maryland. Working with these clients entails more case management than psychologists are typically prepared for, said Floyd. Although Floyd's clinical work focuses on children, she'll step in if parents are having trouble accessing health care for themselves, reviewing paperwork and helping them figure out their options.
Psychologists also need to remember that therapy is probably something new for these clients, said Floyd. "They're not going to quite understand just sitting down and talking," she said. In addition to educating clients about therapy, psychologists should be flexible. "These clients aren't going to be on time, and they're not going to come to every session," she said.
- Be quick. Newly insured clients typically don't want to leisurely explore their issues, said Rita H. Billow, PhD, behavioral health director at the Northwest Community Health Center in Libby, Montana. "These are hard-working people who just want to get well and get back to work," said Billow. "They're not necessarily looking for a cure and they don't want to process family of origin issues; they just want to function and carry on with life."
Also keep in mind that even with insurance, clients can still have financial constraints. "Quite a few people I see just once or twice," said Walters. "They'll call and say, ‘I loved seeing you, but I can't afford the co-pay.'" Focus on the most salient problem and give clients tools they can use right away, she urged. "You may not have the luxury of eight to 10 sessions of cognitive-behavioral therapy," she said. "How can you teach them the basic principles in a very applied way that they can take out the door and start practicing?"