Roles for Psychologists in the 21st Century Research Paper

Psychology’s Vision

As one of the learned professions, psychology possesses very few external constraints upon its ability to effectively expand its scope of influence.Within the health care arena, for example, professional psychology has been extraordinarily successful over the past several decades in incorporating into its domain any clinical functions that it has pursued, notwithstanding the concerted opposition of organized psychiatry (e.g., the authority to independently diagnose and treat, regardless of the locus of service; DeLeon, Rossomando,&Smedley, in press). Within the educational arena, the essence of the national dialogues championed by the Reagan, Bush, Clinton, and most recently the G.W. Bush administrations has been psychological issues (e.g., lifelong learning and the appropriate role of standardized testing). The authors have been personally involved in the public policy arena for a considerable period of time, and from our collective perspective, we are confident that as our nation enters into the twenty-first century we shall see a continued expansion of psychology’s influence into a wide range of public policy areas. In fact, we fully expect that psychology’s vision will ultimately become the defining factor in shaping a number of future national debates (DeLeon, VandenBos, Sammons, & Frank, 1998). However, we are also all too aware that it is impossible to predict with any sense of certainty the specifics of what will come to pass.

Blueprint for Change

Whenever professional psychology (or any other discipline, for that matter) has evolved from the status quo, it has been our observation that there have been several underlying systemic principles involved. Perhaps the most important has been that the profession’s leaders have possessed a clear vision of where they wanted to evolve, including a substantively solid rationale. Unanimity of opinion among the general membership has never been required; nor, in all candor, should it even be expected. Change is always unsettling, and one soon finds that there are highly vocal individuals who remain personally vested in maintaining the status quo. Second, timing is extraordinarily important, both within the profession and external to it. To succeed, there must be a critical mass of dedicated colleagues who share the vision of the leadership. However, it is equally important that the proposed changes ultimately fit into a broader societal perspective. To be meaningful and to flourish, the way an individual profession seeks to evolve must be fundamentally consistent with related developments external to it. For psychology, the past decade has seen a virtual explosion of scientific knowledge within the mental health and broader behavioral health arenas. Even more recently, there have been unprecedented advances within the computer and technological arenas (including a growing appreciation for the applicability of telehealth). Third, it is impossible to overemphasize the extent to which those within a profession desiring change must be willing to be patient and persistent. Rarely do substantive modifications in laws, administrative regulations, or educational priorities occur the first time proposed. A clear and understandable rationale for the proposed change, including a distinct public policy foundation, must often be first articulated. It is especially important that this proposed change make conceptual (e.g., intuitive) sense to those who are not personally aware of the nuances of psychology’s expertise. It is as if one must first create a visual image of why the change will naturally occur. Fourth, within both the legislative and administrative arenas, those who are ultimately in a position to prioritize proposed modifications more often than not have a fundamental budgetary (rather than programmatic) background and orientation. Finally, those seeking change must become attuned to, and proactively address, the perceptions of other organizations (e.g., interest groups) that eventually will be affected by the envisioned modifications—particularly those groups that at first consideration might seem to be only tangentially relevant to the immediate policy discussions.

The Maturation of the Profession of Psychology

When President Carter signed Executive Order no. 11973 on February 19, 1977, thereby establishing his landmark President’s Commission on Mental Health (1978), there were approximately 59,900 members and affiliates of the American Psychological Association (APA). That same year, the state of Missouri became the last state in the nation to license or certify practicing psychologists. A decade later (1988), the Committee for the American Psychological Association of Graduate Students (APAGS) was established by the APA Council of Representatives. Over the years, psychology continued to be one of the most popular undergraduate majors. As we enter the twenty-first century, the comparable APA membership numbers have grown to 155,000, with APAGS possessing 59,700 members. These are very impressive numbers, and they speak well for the future of the profession. Stated slightly differently, within the public policy arena, psychology’s collective voice will be heard.

At the same time, however, we feel that it is important to emphasize that psychology is a relatively young profession and that, in particular, its members are only in the beginning stages of appreciating the importance of their personal involvement in the public policy (e.g., political) process. Although the discipline of psychology dates back to the founding of Wundt’s laboratory in 1879, it was on September 21, 1970 that classes began at the first independent professional school of psychology—the California School of Professional Psychological (CSPP; Street, 1994). This was to be the era of the Doctor of Psychology degree (PsyD), the first program being launched in the Department of Psychology at the Universityof Illinois at Champaign-Urbana in 1968. There can be little disagreement that the paradigm shift to the professional-oriented PsyD degree represented a fundamental change in psychology’s self-image and underlying mission. Today there are 48 accredited PsyD programs, most of which are within professional schools that graduate 58% of all clinical students (P. Nelson, personal communication, September 5, 2001).

Along with the increasing emphasis on professional psychology (e.g., clinical rather than experimental), the field has also seen the gradual development of “hands-on” public policy training initiatives. In 1974, Pam Flattau served as the first APA Congressional Science Fellow, under a program established in conjunction with the American Association for the Advancement of Science (AAAS). Today, over a quarter of a century later, approximately 125 colleagues have had the opportunity of serving on Capitol Hill (or in the administration) as APA or Robert Wood Johnson Health Policy Fellows or in other similar national programs. These farsighted and dedicated individuals have experienced first hand the excitement of personal involvement in the public policy process, with many subsequently returning to academia or public service dedicated to encouraging the profession’s increased public policy involvement. During their service to Congress or the executive branch, fellows learn about public policy development by participating in its formation. Fellows typically serve as legislative assistants (LAs), with all of the duties thereof, including meeting constituents, “staffing” senators or representatives in committee meetings and hearings, drafting legislation, writing speeches, and attending debates and votes on the floor of the House and Senate. Recent fellows have worked on the development of such legislation as mental health parity, the National Health Service Corps, patients’ bill of rights, rural mental health, and psychology’s participation in graduate medical education funding (to name a few).

Initially, APA focused only on providing this experience for recent doctoral graduates; as the program matured, however, a concerted effort was made to attract more senior fellows as well.The APA fellows have included individuals from almost every psychological specialty area, including several who also possessed degrees in law (Fowler, 1996). The Robert Wood Johnson Foundation fellowship and several of the other congressional fellowship programs select mid-career professionals who show promise to be leaders in their respective fields. Additionally, more senior fellows are better able to use their fellowships to learn about and to influence policy. Congressional offices typically feel fortunate to recruit an accomplished professional and appreciate the experience that more senior fellows bring to policy debates. Senior fellows are usually given responsibility for developing or augmenting their senator’s or representative’s policy in the fellows’ general area of expertise (e.g., mental health, health care, education).

Over the years, we have been very impressed by the increasing numbers of individual psychologists who have gravitated to positions of high-level public policy responsibility. During the era of the Great Society, John Gardner served as secretary of the Department of Health, Education, and Welfare. Psychologists have served as departmental assistant secretaries, subject to U.S. Senate confirmation; director of a National Institute of Health (NIH), as well as of other federal research institutes; head of the federal Bureau of Prisons; commanders of federal health care facilities; and chief state mental health officials. Former APA President Dick Suinn served as mayor of Ft. Collins, Colorado.

In the 107th Congress (2001–2002) three psychologists were elected to the U.S. House of Representatives, and 12 psychologists served in the various state legislatures. Within university administrations, our colleagues have served at all levels of responsibility. In the private sector, psychologists have been owners and administrators of the entire range of health care facilities. Psychologists’ expertise as clinicians is independently recognized throughout the judicial system and under all federal and private reimbursement systems. Moreover, psychology’s graduate students are supported under almost every federal training and service delivery initiative. One could suggest that collectively, psychology has done very well in insuring that the profession can fully participate in initiatives that have been conceptualized, and ultimately crafted, by other professional disciplines. The underlying unanswered question is whether professional psychology has matured sufficiently to establish its own programmatic agenda via the public policy process.

Systemic Changes Within the Health Care Arena

As we have indicated, over the past several decades there has been a gradually increasing awareness of the importance of the psychosocial, environmental, and behavioral aspects of health care for both individual clinical concerns (e.g., the impact of stress upon heart disease) and for more generic populationbased concerns (e.g., adverse ethnic health disparities or the incidence of family violence). From a psychological perspective, this concerted focus on behavioral (e.g., nonbiological) events represents an extraordinarily fertile ground for proactive interventions. The relevant scientific knowledge base is rapidly increasing. However, we would rhetorically ask: What is the availability of psychological interventions? To what extent have our nation’s health delivery systems, the allimportant reimbursement mechanisms, and society’s fundamental definition of “quality of care” actually incorporated psychological (e.g., behavioral science) expertise? In our collective judgment, this will be one of the profession’s major challenges for the twenty-first century.

Historical Perspective

In a historical context, the Lalonde report of 1974 effectively laid out the broad parameters for the health policy discussions of the 1990s and the twenty-first century. The Canadian minister of national health and welfare intuitively recognized the extraordinary impact educated consumers would ultimately have, as well as the critical importance of systematically seeking objective (e.g., data-based) programmatic goals. Interestingly, throughout his report and the subsequent policy documents that we will reference, mental health care per se was specifically noted by the highest level of health policy experts. Minister Lalonde prophetically noted that

Good health is the bedrock on which social progress is built. A nation of healthy people can do those things that make life worthwhile, and as the level of health increases so does the potential for happiness. The Governments of the Provinces and of Canada have long recognized that good physical and mental health are necessary for the quality of life to which everyone aspires. Accordingly, they have developed a health care system which, though short of perfection, is the equal of any in the world. . . . For the[se] environmental and behavioral threats to health, the organized health care system can do little more than serve as a catchment net for the victims. Physicians, surgeons, nurses and hospitals together spend much of their time in treating ills caused by adverse environmental factors and behavioural risks. . . . It is therefore necessary for Canadians themselves to be concerned with the gravity of environmental and behavioural risks before any real progress can be made. There are encouraging signs that this concern is growing; public interest in preserving a healthy environment, in better nutrition and in increasing physical recreation has never been higher. (Lalonde, 1974, pp. 5–6)

In most minds the health field and the personal medical care system are synonymous. This has been due in large part to the powerful image projected by medicine of its role in the control of infective and parasitic diseases, the advances in surgery, the lowered infant mortality rate and the development of new drugs. This image is reinforced by drug advertising, by television series with the physician as hero, and by the faith bordering on awe by which many Canadians relate to their physicians. The consequence of the traditional view is that most direct expenditures on health are physician-centered, including medical care, hospital care, laboratory tests and prescription drugs. . . . (O)ne finds that close to seven billion dollars a year are spent on a personal health care system which is mainly oriented to treating existing illness. (Lalonde, 1974, pp. 11–12)

The Minister went on to state that “When the full impact of environment and lifestyle has been assessed . . . there is little doubt that future improvements in the level of health of Canadians lie mainly in improving the environment, moderating self-imposed risks and adding to our knowledge of human biology” (Lalonde, 1974, p. 18).

Five global strategies were proposed:

1. A Health Promotion Strategy aimed at informing, influencing, and assisting both individuals and organizations so that they would accept more responsibility and be more active in matters affecting mental and physical health.
2. A Regulatory Strategy aimed at using federal regulatory powers to reduce hazards to mental and physical health and at encouraging and assisting provinces to use their regulatory powers to the same end.
3. A Research Strategy designed to help discover and apply knowledge needed to solve mental and physical health problems.
4. A Health Care Efficiency Strategy, the objective of which would be to help the provinces reorganize the system for delivering mental and physical health care so that the three elements of cost, accessibility, and effectiveness are balanced in the interests of Canadians.
5. AGoal-Setting Strategy, the purpose of which would be to set, in cooperation with others, goals for raising the level of the mental and physical health of Canadians and improving the efficiency of the health care system.

From a slightly different perspective, APA Past President George Albee has been heralding the critical importance of prevention and of educated consumers for nearly a half century, while steadfastly further urging his colleagues to also systematically address the economic and broadly defined environmental aspects of mental health care (Albee, 1986).

Healthy People

Approximately half a decade later, during President Carter’s administration, the surgeon general of the United States issued Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention (U.S. Department of Health, Education, and Welfare [HEW], 1979). To our knowledge, this was the first time within the American health policy debates that the importance of behavioral health had been raised to the level of presidential consideration. In his receiving statement, the president stated, “I have long advocated a greater emphasis on preventing illness and injury by reducing environmental and occupational hazards and by urging people to choose to lead healthier lives. So I welcome this Surgeon General’s Report on Health Promotion and Disease Prevention. It sets out a national program for improving the health of our people—a program that relies on prevention along with cure. This program is ambitious but achievable. It can substantially reduce both the suffering of our people and the burden on our expensive system of medical care” (HEW, 1979, p. v).

Secretary Califano said,

It gives me great pride that virtually my final official act as Secretary of Health, Education, and Welfare is to release this report. . . . Its purpose is to encourage a second public health revolution in the history of the United States. And let us make no mistake about the significance of this document. It represents an emerging consensus among scientists and the health community that the Nation’s health strategy must be dramatically recast to emphasize the prevention of disease. That consensus is as important as the consensus announced in 1964 by the first Surgeon General’s Report on Smoking and Health—a document now remembered as a watershed. This nation’s first public health revolution, of course, was the struggle against infectious diseases which spanned the late nineteenth century and the first half of the twentieth century. (HEW, 1979, p. vii)

Healthy People proclaimed the following:

• Prevention is an idea whose time has come. We have the scientific knowledge to begin to formulate recommendations for improved health.
• Of the 10 leading causes of death in the United States, at least seven could be substantially reduced if persons at risk improved just five habits.
• Because there are limits to what medical care can do for those already sick or injured, people clearly need to make a greater effort to reduce their risk of incurring avoidable diseases and injuries. People must make personal lifestyle choices, too, in the context of a society that glamorizes many hazardous behaviors through advertising and the mass media.

Five data-oriented national goals were proposed, focusing upon the various age groups constituting our nation’s population. Addressing the unique health care needs of healthy adolescents and young adults, the publicationexpresslydiscussed mental health, including the impact of sociocultural factors and society’s expectations. It noted that reaching these goals will require a national effort and the commitment of people extending far beyond what is traditionally considered the health sector.

In addressing healthy adults, the report noted that mental health is a substantial contributor to disability and suffering for American adults. The report’s perspective was that “Beginning in early childhood and throughout life, each of us makes decisions affecting our health. They are made, for the most part, without regard to, or contact with, the health care system. Yet their cumulative impact has a greater effect on the length and quality of life than all the efforts of medical care combined” (HEW, 1979, p. 119). Again, the fundamental policy question for professional psychology is whether the nation’s health care system has yet incorporated psychological and behavioral science expertise within its priorities. Also, will professional psychology accept the challenge of ensuring that this occurs in a timely fashion?

The Institute of Medicine

Over the years the Institute of Medicine (IOM) has served as a health policy think tank for various administrations and Congress. The IOM was chartered in 1970 by the National Academy of Sciences, acting under the academy’s 1863 congressional charter responsibility to be an advisor to the federal government. In 1982, the IOM released its report: Health and Behavior: Frontiers of Research in the Biobehavioral Sciences (Hamburg, Elliott, & Parron, 1982). Once again, the underlying policy theme stressed the importance of integrating the behavioral sciences throughout the nation’s health delivery system both clinically and—in our judgment, equally importantly—when designing research protocols and programmatic strategies. The report noted that

The heaviest burdens of illness in the United States today are related to aspects of individual behavior, especially long-term patterns of behavior often referred to as “lifestyle.” As much as 50 percent of mortality from the 10 leading causes of death in the United States can be traced to lifestyle. . . . One important advance of the twentieth century is recognition that it is possible to employ scientific methods to gain a better understanding of human behavior. The task is difficult and complex, but human behavior can be observed systematically, reliably, and reproducibly. As knowledge progresses, observations can become increasingly quantitative and have considerable predictive power. (Hamburg et al., 1982, pp. 3–4)

The report went on to note that “Diseases for which lifestyle factors are especially significant have a dominant position in causes of mortality and morbidity. . . . The chronic nature of many mental disorders leads to a relatively large demand on the health care system; for instance, patients with schizophrenia occupy about 25 percent of all hospital beds in the United States” (Hamburg et al., 1982, p. 7). It continued, “Much remains to be learned, but the existing research base provides strong evidence that the biobehavioral sciences can make substantial and unique contributions to dealing with much of the disease that now constitutes the main burdens of illness in this country” (Hamburg et al., 1982, p. 16). The IOM noted the following points:

• The primary care sector has a major role in caring for 60% of the adults and a large proportion of the children who have a discernible mental disorder. Thus, there is a clear need for a concerted effort to overcome the serious deficiencies in communications between mental health and general health services.
• Interdisciplinary collaboration is not an end in itself but rather a means to a higher goal—solving a problem.
• Essential to the success of the mission of the report is the attraction of talented and dedicated young people to health and behavior research The first step is wider recognition of the importance of these problems, the burden of illness they impose, their human impact, and the urgency of progress. The second is awareness that scientific opportunities exist for grappling with the problems.
• One of the significant changes of the twentieth century is the growing recognition that the methods of science can be employed in understanding human behavior, even though the task is difficult and complex.

The IOM was careful to provide concrete examples of the very dramatic impact of behavioral interventions on both specific disease entities (e.g., cessation of smoking on blood pressure and on cancer) and also more generic descriptions of systematic implications (e.g., weight reduction on a wide range of clinical complications). It was noted that physical disorders in which stressors have been implicated as risk factors include bronchial asthma, influenza, peptic ulcers, hypertension, hyperthyroidism, and sudden cardiac death. Stressors also seem to be risk factors in the precipitation of such mental disorders as depression, schizophrenia, alcoholism, and drug abuse.

From our public policy perspective, what seems notably absent from the IOM discussion was an appreciation for how difficult it would be over the next two decades for our nation’s health professions’ training programs to be responsive to their vision. Further, the discussion overlooked how slow those who are essentially responsible for paying for our nation’s health services would be in appreciating the longterm cost-effectiveness of the IOM’s underlying message. In our judgment, as one of the learned professions, psychology has a special societal responsibility to address this nexus and to clearly demonstrate to the nation that the ongoing advances in the behavioral sciences can be effectively integrated into the health care delivery in a highly cost-effective manner.

Demonstration of behavioral intervention effectiveness will require both high-quality science and continued education and training in health-related areas, as well as persistent advocacy and lobbying at state and federal levels. Over the twentieth century, the U.S. health care system evolved to treat acute illnesses, and it continues to treat all illnesses from that perspective. The acute illness approach to care is subtly affirmed by the messages in pharmaceuticals advertising, the persistence of outdated educational training, the predomination of federal research funding for basic sciences, and the public’s passion about “finding cures.” New models of care, such as the Cardinal Symptoms Management, have been proposed for the ever-growing segment of the population with chronic illness or disabilities, but few of these models have been tested on a large scale or over a number of years (Frank, Hagglund, & Farmer, in press). Trials of prevention interventions have been more common but remain outside mainstream health care. Large-scale evaluations of care models that integrate psychological, behavioral, and social interventions are rarely designed or implemented without support from major corporate sponsors or the federal government. Gaining support for large-scale demonstrations involving behavioral interventions, let alone payment for behavioral interventions from the public and private sectors, will require persistent, skilled advocacy to counteract the presumption of the need for acute care and cure-oriented science. Similarly, training programs often remain entrenched in traditional values and approaches. Reformations in health care training are occurring (e.g., expansion of problem-based learning), but there is virtually no effort to develop interdisciplinary health training programs or to overlap “medical” and “behavioral” sciences training. Without question, these will be among the most critical challenges facing the profession, and health care, in the twenty-fif rst century.

Healthy People 2010

In many ways, perhaps the most significant change that has evolved within our nation’s health policy leadership since the release of Healthy People has been the growing high-level institutional appreciation for the importance (and “achievability”) of long-range strategic planning, based upon objective goals and standards. In 2000, the surgeon general issued an impressive follow-up policy document: Healthy People 2010: Understanding and Improving Health (U.S. Department of Health and Human Services [HHS], 2000), which was committed to the single, overarching purpose of promoting health and preventing illness, disability, and premature death. Not surprisingly, the underlying policy themes remained highly consistent:

Over the years, it has become clear that individual health is closely linked to community health—the health of the community and environment in which individuals live, work, and play. Likewise, community health is profoundly affected by the collective behaviors, attitudes, and beliefs of everyone who lives in the community. Indeed, the underlying premise of Healthy People 2010 is that the health of the individual is almost inseparable from the health of the larger community and that the health of every community in every State and territory determines the overall health status of the Nation. That is why the vision for Healthy People 2010 is “Healthy People in Healthy Communities.” (HHS, 2000, p. 3)

It is important to appreciate the significance of the fact that although we are specifically addressing “health care” and reflecting upon the policy thinking occurring at the highest levels of the U.S. government, much of the terminology being utilized is essentially that of social and community psychology (or public health nursing), and not the traditional reductionism to biomedical concepts. For example, community partnerships, particularly when they reach out to nontraditional partners, can be among the most effective tools for improving health in communities. Moreover, life expectancy and quality of life can be increased over the next 10 years by helping individuals gain the knowledge, motivation, and opportunities they need to make informed decisions about their health. Also, th eleading causes of death in the United States generally result from a mix of behaviors; injury, violence, and other factors in the environment; and the unavailability or inaccessibility of quality health services. Furthermore, mental health is sometimes thought of as simply the absence of a mental illness but is actually much broader. Mental health is a state of successful mental functioning, resulting in productive activities, fulfilling relationships, and the ability to adapt to change and cope with adversity. Mental health is indispensable to personal well-being, family and interpersonal relationships, and one’s contribution to society.Additionally, although the diversity of the American population may be one of our nation’s greatest assets, diversity also presents a range of health improvement challenges—challenges that must be addressed by individuals, the community and state in which they live, and the nation as a whole. It would be a significant understatement to suggest that what is being discussed today has not been our nation’s traditional concept of health care.

Additional Institute of Medicine Reports

Since the beginning of the twenty-first century, the IOM has released several additional policy documents that continue to emphasize the trends just described in several dimensions. In Promoting Health: Intervention Strategies from Social and Behavioral Research (Smedley & Syme, 2000), the IOM focused in depth upon promising areas of social science and behavioral research that would improve the public’s health:

• The vast majority of the nation’s health research resources have traditionally been directed toward biomedical research endeavors with less than 5% of the approximately $1 trillion spent annually on health care in the nation being devoted to reducing risks posed by preventable conditions. By itself, however, biomedical research cannot address the most significant challenges to improving the public’s health in the new century. Behavioral and social interventions offer great promise to reduce disease morbidity and mortality, but as yet their potential has been relatively poorly tapped.
• Behavior change is a difficult and complex challenge. It is unreasonable to expect that people will change their behavior easily when so many forces in the social, cultural, and physical environment conspire against such change. If successful programs are to be developed to prevent disease and improve health, attention must be given not only to the behavior of individuals but to the environmental context within which people live.
• Children should be a major focus of intervention efforts. Risk factors observed in adults can be detected in childhood. Interventions in early life can change the trajectory of these risk factors.
• Differences across socioeconomic and racial or ethnic groups, or combinations thereof, range up to 10 or more years in life expectancy and 20 or more years in the age at which significant limitations in functional health are first experienced.
• Socioeconomic policy and practice and racial or ethnic policy and practice are the most significant levers for reducing socioeconomic and racial or ethnic disparities and hence improving overall population health in our society, more important even than health policy.

The juxtaposition of the continued prosperity of America and the lack of high-quality health care for a substantial number of Americans also gives us pause. What is the role of psychology in advocacy for those who lack health insurance or are underserved by the health care delivery system? The populations who do not have access to quality health care are vastly overrepresented by people with low incomes, people with disabilities and/or chronic illnesses (including mental illnesses), immigrants, racial and ethnic minorities, those who live in rural areas, and those who are homeless. Obviously, these are diverse groups, but they share two commonalities: They have much poorer access to health care, education, and other resources to maintain health, and they frequently have little voice in public policy. In 2000, approximately 43 million Americans lacked health insurance. It is striking that 69% of these Americans have at least one family member who is working full time (Kaiser Commission on Medicaid and the Uninsured, 2001).

Crossing the Quality Chasm

A New Health System for the 21st Century (IOM, 2001) addresses the extent to which the current American health care system is significantly behind other segments of the economy in utilizing advances in relevant technology and in ensuring that scientific advances are employed in a timely fashion. The American health care delivery system is in need of fundamental change. Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge. Yet there is strong evidence that this frequently is not the case. The lag between the discovery of more efficacious forms of treatment and their incorporation into routine patient care is unnecessarily long, in the range of about 15 to 20 years. Even then, adherence of clinical practice to the evidence is highly uneven.

Technological Advances

Perhaps the single most significant societal change affecting professional psychology is the extraordinary advances that are occurring almost daily within the technology and communications fields, and their direct applicability to health care. The Robert Wood Johnson Foundation (Institute, 2000) recently noted, “The health industry has lagged behind other industries in implementing information technologies that streamline business and clinical processes. We forecast that changes in information technology as applied to health care will be a prime catalyst of change in the future” (p. xviii). Technological change is accelerating in two areas that will affect health care dramatically: medical and information technologies. Medical technology has been one of the major drivers of the health care system since the introduction of effective pharmacological agents in the early part of this century. Its impact will continue in the next decade. However, health care has not made significant use of the advances in information technology that have transformed most other industries. That situation will not continue for much longer as the boundaries between information and medical technologies begin to blur. Telehealth, a combination of computer-supported case management, remote telemetry via sensors, and better-informed consumers, will create new ways of delivering care. Chronically ill patients will be monitored remotely through the use of a variety of sensor devices, such as video cameras, blood pressure monitors, and smart pill boxes. These will be linked to computer systems that will allow the provider to catch potential adverse events before they happen.

The IOM proclaimed that “Health care delivery has been relatively untouched by the revolution in information technology that has been transforming nearly every other aspect of society. The majority of patient and clinician encounters take place for purposes of exchanging clinical information. . . .Yet it is estimated that only a small fraction of physicians offer e-mail interaction, a simple and convenient tool for efficient communication, to their patients” (IOM, 2001, p. 15). The number of Americans who use the Internet to retrieve healthrelated information is estimated to be about 70–100 million. Currently over half of American homes possess computers, and although information presently doubles every 5 years, it will soon double every 17 days, with traffic on the Web already doubling every 100 days (Jerome et al., 2000).

Within organized psychology, we are very pleased to see that there has been a growing awareness of the potential impact of technological advances upon the entire profession, not to mention considerable membership interest. The APA Board of Professional Affairs (BPA) established a special task force on telehealth issues, which has been working collaboratively with a similar task force created by the board of directors. The APA journal Professional Psychology: Research and Practice has featured three special sections composed of articles focusing upon telepsychology initiatives (i.e., October 2000, April 2000, and December 1998), and the APA Monitor, as well as various divisional newsletters, now regularly publishes articles on membership activities in this arena. Public service psychologists, in particular, have been on the cutting edge of demonstrating telepsychology’s clinical applicability. It is expected that the newest revision of the APA ethical standards will specifically address telepsychology concerns. Nevertheless, in many ways, one might also suggest that professional psychology has just begun to explore the extent to which technological advances will radically alter the manner in which psychological services will be offered in the twenty-first century, including making psychological diagnostic interviews and testing readily available to more Americans and in locations (e.g., nursing homes and prisons) where psychologists are virtually absent today.

Public Policy Reflections

As we have suggested, it is our collective judgment that psychology possesses the clinical and scientific expertise necessary, and the societal recognition (e.g., status) and membership numbers, to become a major player in our nation’s public policy arena. What the profession must do first, however, is begin shaping psychology’s own legislative agenda and, in so doing, directly respond to society’s perceived needs. As but one example, professional psychology must take a proactive stance in ensuring that psychological expertise will be reimbursed when its practitioners engage in providing the psychosocial and preventive care that for decades progressive health policy experts have agreed is absolutely critical (Conrad, 1998; VandenBos, DeLeon, & Belar, 1991). To accomplish this objective, psychology’s training programs may well have to emulate the successful efforts of our colleagues in medicine and professional nursing in order to establish treatment “homes of our own” (Rodgers, 1980). During the coming decade we should expect to see behavioral science–based teaching in nursing homes and adolescent runaway shelters, administered by professional psychology training programs. State and federal authorities should be provided with targeted financial resources to support psychology’s graduate students who are actively participating in these programs (e.g., pre- and postdoctoral fellowships).

Professional psychology’s educational institutions should take the lead in establishing collaborative interdisciplinary training programs, for example, with colleagues in business, law, nursing, pharmacy, and public health. Similarly, it should be psychology’s educators, clinicians, and scientists who are on the cutting edge of determining how the ever-escalating advances occurring in information technologies can be effectively utilized to provide enhanced access to quality health care. Reflecting upon medicine’s and nursing’s historical successes, we would predict that it will become psychology’s professional schools that ultimately subsume this charge within their fundamental educational mission. Nonetheless, to date, this element of the profession has been relatively absent from the public policy (and political) process. The time has come for psychology’s educational leaders to be considerably more proactive, rather than reactive. Professional psychology must develop the policy vision required for professional psychology to continue its impressive maturation as we enter the twenty-first century. We would strongly urge that, as psychology moves forward, we never forget that our underlying policy vision must always focus on how society’s interests can best be served.

The Relevance of Clinical Psychology: The Need to Converse with Our Colleagues and Our Culture

How can psychology best serve society’s interests? That single question may best reflect the necessary, evolving, paradigmatic shift in psychology’s perceived mission. The ancient professions of architecture, law, nursing, medicine, and, for that matter, tax accounting all had their historical foundations in the needs established by their social environment. The foundations of the young science of psychology, however, were in the respected but impractical academic realm of philosophy. Indeed, it was not until the early twentieth century that academic courses such as “mental philosophy” began to evolve into what we would now recognize as the first examples of Psychology 101 (C. E. Rice, 2000). Because of these foundations, philosophical considerations in psychology were viewed as vastly more important than the solution of real-world problems. To this day, many research psychologists in academia remain primarily focused on the philosophical underpinnings of therapeutic interventions, whereas most practicing psychologists are posing the more pragmatic question, “What works?”

Moreover, although we now know a good deal about which interventions work (Chambless et al., 1996), we remain poorly equipped to address many of the common clinical problems presented daily in a typical psychology practice. The etiology of this professional weakness is partially attributable to the disconnect that unfortunately developed between psychology’s academic and practice communities. In order for psychology to mature and expand, researchers must conduct relevant as well as scientifically rigorous research, and practitioners must be involved in the critical process of advancing the profession’s knowledge base. One approach to this challenge is exemplified by the concept of the Practice Research Network as organized by the Pennsylvania Psychological Association (Borkovec, Echmendia, Ragusea, & Ruiz, 2001). Such research would serve to unite the elements of the profession while increasing the likelihood of scientific and professional activities that are more likely to directly and immediately serve society.

Psychology’s scores of journals are burgeoning with solid empirical research that has, in only a century, established psychology as the preeminent mental health profession. However, much of this research meets academic, not clinical, needs, and the profession of psychology will surely be replaced by others to the degree that psychology’s research and practice are irrelevant to society’s needs. Toward this end, in addition to basing clinical work more on relevant research, practitioners must move their interventions out of comfortable consultation rooms, into the rapidly changing, technological world of the modern family. Very briefly, here are four examples of social trends that the profession of psychology should be addressing with much greater vigor.

First of all, in a very real way, the American family is in crisis. The divorce rate, which now stands at approximately 50%, has a profound impact on human life. Factors such as personal happiness, vocational stability, income, suicide rates, and longevity have been found to be seriously and negatively affected by divorce (Tucker et al., 1997). What can psychologists do to predict successful marriages through the premarital screening of potential newlyweds? What can psychologists do to improve the success rate of existing marriages? Where is the clarifying body of research to guide family psychologists in their efforts to positively impact the lives of married couples? Given the importance of this social problem, psychology’s response is woefully inadequate.

Second, too few clinical psychologists are preparing for the technological revolution afforded by the internet in general and telehealth in particular, although these technologies dominate our lives more with each passing day. The truth clearly remains that psychologists are ill prepared to defend either diagnosis or treatment of psychopathology facilitated by television or computer. According to an acknowledged leader in this field, Leigh Jerome, as quoted in APA’s Monitor on Psychology, “Unfortunately, there remains a paucity of empirical data that assesses the efficacy and feasibility of telehealth capabilities for clinical applications,” Indeed, most investigators find that there remains a lack of fundamental research in all major areas related to online therapy, including the questions of which technologies are best for delivering which type of services and under what conditions telehealth services lead to improved outcomes (Rabasca, 2000). Unfortunately, recent literature searches have demonstrated that psychology is still well behind the curve in terms of adjusting and incorporating this world-changing technology into psychology’s vast existing base of knowledge (Ragusea, personal communication, 2001).

Third, the Human Genome Project is unlocking the human genetic code. If it is not already in progress, we will certainly soon commence human cloning. As important as that statement is, it addresses a matter that is minor when compared to the greater importance of a change in our genetic reality. We must all fully understand that people will soon be making conscious decisions about how to adjust the human chromosome. As we complete the genetic map and learn how to change design elements, we will begin changing the genes that influence height, weight, intelligence, assertiveness, creativity, memory, athletic skill, and so on. Is there anyone on the planet who seriously thinks that the human race is currently prepared to face the challenges inherent in making these decisions? Psychology has much to contribute in this realm, but, as Shiloh notes,

Despite general agreement about the importance of psychological issues in genetic counseling, the entry of psychologists into this highly professional, competitive, and rapidly developing field will not be easy. The pace will depend in part on their efforts to adapt psychological knowledge to the highly complex subject matter of medical genetics. Nevertheless, considering the rising needs, it is reasonable to assume that more and more psychologists will be engaged in the future in genetic centers and will have to address the implications of genetic counseling in their general practice. (1996)

It can be argued that psychology should be leading the culture’s advances into genetic manipulation by investigating (a) the psychological factors that contribute to the making of suchdecisions,(b)theimpactofsuchdecisionsonindividuals and families, and (c) how psychologists can best work with physicians, ethicists, and social planners to enhance the likelihood that this genetically enhanced chapter of humanity’s book of life will be a rich and joyous tale, not a horror story. However, there is virtually no psychological research published in this critically important, rapidly emerging realm, and therefore psychologists remain ill prepared for challenges of this nature and magnitude.

Fourth, the problem of America’s response to the twin issues of crime and punishment remains. Make no mistake about it: America has won the Worldwide Incarceration Invitational. We in the United States have demonstrated that we have the will and financial resources to put more of our citizens behind bars than any other nation. Indeed, throughout most of the the past decade,America has incarcerated a higher percentage of its population than any other country on Earth (U.S. Department of Justice, 1998). According to a 2001 report by ABC News, 25% of the entire world’s prison population is in U.S. prisons.

Most people tend to forget that prisons, as we know them, are really a very modern invention. For most of human history, with few exceptions, jails were a place to keep prisoners for a short time—until they were punished using techniques such as public humiliation in the stocks, whipping, or hanging. Over the last hundred years, America has embraced a model that involves incarcerating people in prison for very long periods of time. Commonly, people are sentenced to jail terms of 18 months or 5 years or 25 years. Time in prison has itself become the punishment. There are lots of problems with this technique. First, it is expensive. It currently costs approximately $25,000 to keep one prisoner in jail for one year, and that does not include the cost of building the prison itself! Even worse, all that money does not buy much of a solution, given that the recidivism rates for prisoners commonly approach 40–50%.

Most people can agree that some people need to be behind bars. The truth is that there are some people who are so psychosocially disturbed or dangerous that they must to be kept where they cannot hurt other people. That precise number, while unknown, is likely to be relatively small. However, the number of individual human beings we choose to imprison is not small; it is huge.

As of February 2001, the United States of America had more than 2 million of its citizens behind bars. That equals the entire population—every man, woman, and child—in the three states of North Dakota, South Dakota, and Delaware, at an annual cost of approximately $50 billion. Who are those people behind bars? Some of them are violent, dangerous people. Approximately half are in jail for drug- and/or alcohol-related offenses. Additionally, according to a 1998 survey done by the U.S. Department of Justice, 238,000 prisoners are known to be mentally ill, a population approximately equal to that of the city of St. Petersburg, Florida or Akron, Ohio.

How did this happen to our mentally ill? We all know the history of deinstitutionalization. Nationally, state mental hospital populations peaked in 1955 at 559,000 people. By contrast, today’s public mental hospital population is approximately 70,000, and 25,000 of these cases are for forensic evaluation! Thus, although the specific numbers are not available, what we have experienced is nothing short of a mass migration from mental hospitals to prisons (M. E. Rice & Harris, 1997).

Let us not be mistaken for Pollyannas: Some people should be behind bars.Asmall percentage of prisoners will need to be incarcerated for extended periods, and for some that means a lifetime. None of us wants somebody like John Wayne Gacy living next door to our children or grandchildren. However, not every criminal is a monster, and we do not have enough money to put every lawbreaker in jail. We need to start trying a different approach to crime and punishment.

A new movement called Restorative Justice is gathering strength. It is an approach that combines justice with mercy and common sense. Restorative Justice is based upon a redefinition of crime as injury to the victim and the community rather than a challenge to the power of the government. Victims help define the harm of the crime and identify how the harm might be repaired. The essence of the punishment is to fix that which has been damaged. This model of crime resolution has proven very successful and costs much less money as well. What better techniques might be considered? There are, undoubtedly, many alternatives.

It is psychology that should lead the way in prison reform. What other profession has our expertise in human behavior? Using our research methodologies, psychologists could explore a range of new alternatives to our existing criminal justice system. All we lack is the will. The APA’s Task Force on Envisioning, Identifying, and Accessing New Professional Roles (Levant et al., 2001) recently reflected that “Approximately 1% of the population is currently in prison, on probation, or on parole. Many billions of dollars are spent annually to support this massive incarceration effort. Psychologists have not effectively contributed to the resolution of this massive societal problem. Psychologists must become involved at the center of what is fundamentally a psychological problem of learning and behavior.”

Unfortunately, psychologists, like most people, would rather not think of their failures. Prisoners are society’s failures, and many prisoners are psychotherapy failures. We all want to forget about the people who live inside that gray, cold cement-and-steel world of American’s prisons. We are willing to think about the issue of crime and punishment only when it invades our world, our neighborhood, our family. We must do better. Moreover, although prison reform is one of our particular interests, there many cultural challenges for psychologists to tackle.

Psychology must become more actively involved with humanity’s social reality. If psychologists take care of society, society will take care of psychology. If psychology ignores the culture’s needs, however, psychology risks being discarded into the dustbin of history.

Camouflaged Psychologists: The Stealth Leadership Institute of Psychology

Our discussion of the mysterious Stealth Leadership Institute of Psychology (SLIP) will be brief. As business consultants, growing numbers of “professional psychologists by training” are advocating change in public and corporate policy implementation. Often, they do so without much mention of their background in professional psychology or a license to do anything as a scientist or health professional. They are hired as business consultants with contracts for services and the delivery of results, usually with the intent of mutual profit. Many of these “psychologists by training” hire on as apprentice business consultants in lieu of calculating but inexperienced and sometimes interpersonally inadequate MBA graduates. According to Interaction Associates Senior Associate Daniel J. Anderson, “My experience is that business can genuinely appreciate smart, honest, interpersonally facile professionals. Thus, the creation of the Stealth Leadership Institute of Psychology, the extent of [whose] informal membership is, unfortunately, unknown” (personal communication, 2001).

Psychologists are not the only professionals engaged in such activities. In early 2001, McKinsey & Co., Bain, and Deloitte Consulting, to name a few among many multibilliondollar business consulting firms, recruited new PhDs and postdocs in the “hard” sciences (e.g., neurology, economics, physics) from MIT and Harvard for positions starting in the middle six figures with a 30% bonus. These scientists are being hired not to function as professionals in their fields but, rather, as agents of change with or without professional titles or licenses.

In psychology, George Albee has long argued that psychologists would be better off as educators and consultants, not reimbursable health care providers. Even in these capacities, however, they remain psychologists in mind, heart, and soul; no one becomes a licensed psychologist by accident. These stealth psychologists are now business consultants, and most don’t include their professional psychology degrees on their business cards. Advertising one’s profession—even psychology—may actually limit the perceived value of the services in the business reality of an increasingly global capitalist economy. Most often we hear our stealth colleagues dropping phrases such as “I was trained as a psychologist” as a validation for their scientific rigor and discipline. However, their statement is immediately followed by a sharp focus on the particular organization, profession, agency, legislature, and business in need of their specific consulting services.

How much influence for socially responsible consulting— for productive change in policy, corporate or public—do these stealth psychologists have? This is difficult to measure. It is our understanding that one SLIP PhD colleague is responsible for the collaborative design to execute a peace strategy in Belfast.

Some of these psychologists have become scoundrelsfor-hire, and some are great psychologists practicing for the common good—public and private—in all but name.According to Daniel J.Anderson, “There are early indicators that the informal membership in SLIP is growing daily as psychologists seek greater growth opportunities beyond the traditional boundaries of professional identity.”

Policy Opportunities By “Working from the Inside”

State and federal governments are open opportunities for the growth of psychology because of the nature of the health, social, and environmental challenges facing our public leaders. Many psychologists are already in policy positions, some identifying themselves clearly as psychologists and others working in a stealth role. The growing acceptance of psychology as a learned profession and valued contributor to public policy, however, presents an opportunity for expanded policy making by psychologists, rather than those “trained as psychologists.” The APA has a large and well-coordinated government liaison office that is well respected on Capitol Hill. Moreover, most, if not all, states and territories have hired lobbyists to work for their interests at the state level. Psychology interests are sometimes also represented by lobbyists from universities or nonprofit organizations. These groups will occasionally form coalitions, such as those recently formed to support the Mental Health Equitable Treatment Act (S. 543, 107th Congress), which mandates that insurers provide equal coverage of mental health benefits to those of medical and surgical benefits, if mental health benefits are offered. These types of coalitions are found on most major issues and can be highly effective.Advocacy and lobbying are clearly an area in which psychology can benefit from increased participation. During a recent “11th-hour” amendment-drafting session of a major health care bill, a representative of the American Medical Association (AMA) was in one of the democratic “warm rooms” in the Capitol. The bill was already being debated on the Senate floor, but the “manager’s” amendment contained several important changes to the bill, changes that were to be incorporated into the House version (which was debated at a later date). The manager’s amendment was accepted by a voice vote in the final moments of the debate. The final version of the bill that passed the Senate was acceptable to the AMA. Psychology is working toward that level of participation in policy formation.

In addition to the “outside looking in” approach of lobbying and advocacy, psychology has potential to grow within federal and state governments. Inside the halls of Congress, psychology’s legislative initiatives do not often face hostile objection (with some exceptions, such as that regarding prescription privileges), but psychology often suffers from benign neglect. Few federal or state leaders or their staff have a good understanding of the potential contributions of psychologists to health care, criminal justice, education, industry, social system development, and community building. Few federal or state legislators fail to understand or consider the potential contributions of medicine. For example, the initial language for a recent bill to reauthorize large federal programs that provide health care to the underserved diminished the emphasis on mental and behavioral health despite the recent reports by the surgeon general and the IOM. However, in concert with other staff members and with strong, persistent advocacy support by the Education Directorate of the APA, a psychologist congressional fellow was able to expand the role of mental and behavioral health in these high-profile programs. However, this relatively small success came only through several staff-to-staff meetings, phone calls to advocates encouraging them to contact their legislators, and participation in the final drafting of the bill at 10:00 p.m. the night before the committee markup in which the bill was “voted out” and sent to the floor for full debate. Late in that evening drafting session, it was suggested for one particular section of the bill that “we just go back to the old language” in order to reach a compromise on an issue that did not pertain to mental health. The staff member making this suggestion had forgotten, however, that the “old language” of this section did not include mental and behavioral health specialists. It was the psychologist fellow who reminded the staffer that the old language failed to include mental and behavioral health specialists. Psychologists would have been cut out of a major component of the federal program had the old language been used. Working from the inside is an effective method to reduce the benign neglect of psychology on Capitol Hill and in state legislative chambers, and it is best accomplished with psychologists’serving as staffor fellows. Psychologists’(who identify themselves as psychologists) working “on the inside” would go a long way toward increasing inclusion in policy. It would also go a long way toward improving society.

The view from the “inside” is unique, highly energizing, and informative. The two most common ways to become involved are to become a congressional fellow and to be employed as a staffer. Staff members often start as interns or volunteers from campaigns or through personal contacts. Some congressional fellows accept positions on staff after their fellowship year(s). There are many misperceptions about congressional staff, but the truth is that they are bright, articulate, energetic, and hardworking individuals who care about policy as much as or more than they care about politics. A substantial portion of their activity involves reliance on personal relationships, because so much of their job performance relies on negotiation skills. Negotiations occur with staff from the other party, with the administration, and with constituents regarding their desires and needs. Staff members are also ravenous consumers of information, although not typically scientific journal articles. Psychologists have proven to be effective staff members, and some have proven to be effective legislators because of the overlap in skills necessary to succeed in both professions. However, there are too few psychologist congressional or state staff members or legislators. Psychologists have an opportunity to increase their “stock” in the legislative hallways by participating in policy as paid staff or through fellowships. Only four psychologists have been Robert Wood Johnson Fellows health policy fellows, and not many more have applied but not been selected. Increasing the numbers of psychologists who are Robert Wood Johnson Fellows is largely a function of having more psychologists apply to the program.

Prescriptive Authority: Psychology’s Responsibility to Improve Psychopharmacological Service Provision

A central paradox in the provision of modern psychopharmacological agents is that, in spite of their known efficacy, and in spite of tremendous increases in their use over the past decade, they have done little to reduce the societal burden of mental disease—that is, their effectiveness is open to question. This phenomenon has been directly studied in depression (Moncrieff, 2001), but evidence also exists for schizophrenia (Harding, Brooks, Ashikaga, Strauss, & Breir, 1987a, 1987b; Harrison et al., 2001; Hegarty, Baldessarini, Tohen, Waternaux, & Oepen, 1994) and undoubtedly for other mental conditions as well. Numerous explanations for this phenomenon are possible, among the most plausible being (a) that psychotropics are not appreciably more efficacious than placebo; (b) that the effects of psychotropics are insufficiently specific to provide significant amelioration for any one particular disorder; (c) that psychotropics are incorrectly employed—chronically overdosed or, more likely, underdosed—in everyday clinical practice, and (d) that psychotropic medications are, when used as single modalities, insufficient to bring about lasting improvement.

All of these speculations have varying degrees of merit, and all have been the subject of investigation. The placebo issue has come under increasing scrutiny in the past decade (Greenberg & Fisher, 1989; Kirsch, 1997; Kirsch & Sapirstein, 1998; Shapiro & Shapiro, 1998), and it is likely that the placebo response rate to antidepressants approaches 40% (Khan, Warner, & Brown, 2000). Placebo responding is less studied in other conditions, but it is reasonable to assume that a fairly robust placebo response exists even in psychotic conditions and mania. As many as 30% of patients (Emsley, 1999) treated with antipsychotics show essentially no improvement, and the placebo response to antipsychotics, even during an acute psychotic episode, can be relatively robust (Marder & Meibach, 1994). Although antipsychotics are of demonstrable efficacy in controlling, but not ablating, the acute symptoms of psychosis and may be of material assistance in preventing relapse, a “substantial minority” of patients derive little benefit from drug treatment (Wirshing, Marder, van Putten, & Ames, 1995).

On the other hand, it is equally true that most studies of antidepressants and other psychotropics find that active agents not only are more efficacious than placebo in ameliorating acute symptoms but are also effective in preventing relapse to a more significant degree than placebo. Antipsychotics are clearly effective in preventing relapse, but, again, they should not be considered a panacea. Approximately 50% of patients treated with placebo relapse within 4–6 months, as compared with 20% on antipsychotics (Csernansky & Newcomer, 1995).

The placebo response is a function of not only medication but also diagnosis, patient, and even phase of treatment. It is endemic in psychopharmacology, just as it is in all types of allopathic treatment. Discussion of the role of placebo in treatment of mental distress is essential to good clinical use of psychopharmacological agents, because of the repeatedly demonstrated, often substantial, placebo effect associated with them. To acknowledge this response is not to deny the utility of these agents: A substantial number of patients show a robust placebo response to narcotic analgesic, yet we do not question the value of those agents. Nonetheless, this response must be clearly understood by clinicians in order to allow optimum use of antidepressants and other psychotropics.

Also related to the issue of placebo responding is the question of the degree of specificity of response to antidepressants. Kirsch and Sapirstein (1998) argued that much of the response to antidepressants cannot be ascribed to a specific effect on neurotransmitter function or other cause, and that up to 75% of response to an antidepressant is either a placebo or a nonspecific response. This speculation has merit, and is an issue in clear need of further study, but it should not be interpreted to mean that there is not a substantial population that does respond specifically to antidepressants, and that their use has not enhanced both short- and long-term outcome of depression and other mental disorders. Like the placebo response, the degree of nonspecificity of response will vary across patient, diagnosis, and phase of treatment dimensions. A clearer definition of the nonspecific response to psychotropics will aid both researchers who strive to identify biological substrates to mental distress and clinicians who seek guidance as to how to use these agents most effectively. Again, however, we must take great care to avoid the politics surrounding allopathic versus nonallopathic treatments. Hollon (1996) observed that “if psychotherapy works (that is, if it has causal agency), then it really does not matter if it works for specific or nonspecific reasons” (p. 1028)—an observation that remains as trenchant when applied to pharmacotherapy as when applied to psychotherapy.

Of the five points outlined above, we believe the last two— the misuse of psychotropics and the overreliance on psychotropics as a single modality—provide the most compelling explanation as to why psychotropics have not reduced the burden of mental disorders, in spite of their greatly increased use. An understanding of these issues is important in demonstrating how psychologists, using psychotropics in an adjunctive manner and in combination with psychosocial and behavioral treatments of demonstrated effectiveness, can improve the provision of psychotropics and make substantial contributions to the public weal.

Antidepressant medications were the highest-selling category of prescription drugs in 2000 (Pear, 2001), and over $6 billion was spent on antidepressants alone in the 1990s (Croghan, 2001). Surveys of practice patterns in primary care and psychiatry reveal that a significant majority of patients (Pincus et al., 1998)—indeed, as many as 97% (National Depressive and Manic Depressive Association, 2000) of patients—are treated with medication, a trend that has been particularly noticeable in the past decade (Olfson et al., 1998). In psychiatry, the likelihood of a patient’s receiving medication for depression has increased significantly over the past 15 years, to the point that currently approximately 90% of all patients receive medication, most commonly for depression (Pincus et al., 1998). At the same time, other data suggest that many patients in primary care prefer counseling to medication to treat mental distress and that counseling is as effective as medication in managing mild to moderate depression in primary care (Chilvers et al., 2001).

Depression is by all standards undertreated using routine primary care (Lin et al., 1998; Nierenberg & Alpert, 2000). The recent large-scale survey of over 1,000 patients and 800 non–psychiatrically trained primary care physicians (National Depressive and Manic Depressive Association, 2000) underscore this point. Although an extraordinary number of people were treated with medication, most patients were not compliant with a treatment regimen, and over one half experienced side effects that were significant enough to cause them to discontinue or switch antidepressants. Even after taking medication for 3–5 years, most patients had significant residual symptoms of depression. Another finding of importance from this survey was that, although the majority of primary care physicians felt they had adequately informed patients about side effects of medication, only a small number of patients believed they had received sufficient information.

However, poor adherence to drug regimens is only one variable in an equation resulting in suboptimal outcomes. Simon, von Korff, Rutter, and Peterson (2001) compared outcomes for treatment of depression in primary care and psychiatry and concluded that outcomes were poor in either setting. Their data revealed that, regardless of setting, patient visits were few (even among patients of psychiatrists, only 57% made more than three visits in 90 days). These authors commented that systematic issues, such as the fact that Health Plan Employer Data and Information Set (HEDIS) criteria suggest only three visits in 3 months, rather than the care itself, might be responsible for the poor record of treatment of depression. Another large-scale survey of depressed patients revealed that only half of all patients had continuous treatment for more than 6 months (Tierney, Melfi, Signa, & Croghan, 2000). These data indicate that depression, by definition a chronic, relapsing condition, is not only being undertreated in primary and specialty care but, perhaps more importantly, is being treated in a fashion that essentially guarantees that medication will be the most likely treatment—at the expense of either psychotherapy alone, or combinations of medication and psychotherapy, both of which are of apparently greater value in treating depression and other mental conditions.

This situation persists despite data indicating that collaborative (psychologist-physician) care leads to better outcome (Katon et al., 1996). It also appears that minimum improvements in routine care, particularly via the addition of psychotherapy or closer medication management, can improve outcome for depression treated in primary care. Schoenbaum et al. (2001) prospectively studied depressed patients assigned to routine primary care, augmented medication management (monthly contact with nurse specialists to determine medication adherence), and a cognitive behavioral therapy arm. Addition of medication or psychotherapy (sometimes in combination) led to substantially greater improvements in quality of life and productivity. The benefits of added psychotherapy were substantially greater than those of the addition of medication only. The added cost of providing these services was well in keeping with benefits derived.

In summary, all available data suggest that psychotropics, particularly antidepressants, are misused and generally overused. Further, in the vast majority of cases they are used as single therapeutic modalities, and most patients do not receive psychological treatments, either singly or in combination, for mental distress.This had led to a situation wherein the costs of mental health treatment have escalated, but the societal burden of mental distress has not been ameliorated and the vast majority of patients with mental distress do not experience substantive relief. The training of psychologists makes them the most appropriate profession to provide a full spectrum of interventions for mental distress, from appropriate assessment and diagnosis, to empirically validated psychotherapeutic and behavioral intervention, to accurate monitoring of the process of change. Until the recent past, psychologists have not sought to expand their scope of practice to include prescriptive authority. Within the past decade, this has emerged as a priority for the profession, but in the face of considerable opposition. The medical profession views this as a major infringement on their professional territory. In spite of the fact that most psychologists endorse prescriptive authority (Sammons, Gorny, Zinner, & Allen, 2000), some psychologists remain opposed, fearing that the ability to prescribe will be a de facto endorsement of the medical model of treatment for mental disorders (Adams & Bieliauskas, 1994).

Will Prescribing “Medicalize” Psychology?

Some opponents of prescriptive authority for psychologists, both within and outside the profession, believe that those who choose to prescribe will succumb to the medical model of treatment of mental disorders. As cited above, current standards under the medical or psychiatric model for treatment of depression require no more than three visits in 3 months, of which one is recommended to be to a prescriber—a situation essentially guaranteed to produce overreliance on pharmacological interventions.

Medical managed care treatment standards such as HEDIS criteria attract considerable and justifiable criticism from psychologists, few of whom believe that an episode of depression can be appropriately managed in three visits over a 3-month span. It is the fear of these psychologists that much of our practice will be reduced to medication checks and perfunctory management of the symptoms of depression, as is often the case in modern psychiatric treatment of the disorder. On the other hand, psychiatrists and other physicians who oppose psychologists’ prescribing do not do so on the basis of such standards but, rather, argue that psychiatrists are physicians and that a comprehensive medical evaluation is requisite in order for psychologists to learn to prescribe safely and effectively.

Numerous data exist to contradict this. First, we know that psychiatrists rarely practice medicine after completing their residency training. Only about 5% of outpatient psychiatrists ever perform a physical examination on their patients (Kick, Morrison, & Kathol, 1997; Krummel & Kathol, 1987): Physical exams have become so uncommon by psychiatrists that they essentially do not exist. Additionally, most psychiatrists do not take a comprehensive medical history but leave this to other medical professionals to perform. Thus, in terms of performance of one of the basic components of “medical” treatment, the history and physical, psychiatry does not conform to the standards that apply to the rest of the profession. Some attempt has been made to alter this situation in recent years, with the development of residency programs designed to train physicians in primary care or internal medicine and psychiatry. However, these programs are in short supply and typically attract few applicants. In any event, the result is the same. What is produced is a generalist or an internist specializing in psychiatry, not a psychiatrist specializing in internal medicine or primary care.

Many have argued that prescribing psychologists will not become “junior psychiatrists”—that their practice will be fundamentally different from their medical colleagues and will represent a truly psychological model of pharmacologic service provision (Cullen & Newman, 1997).All data accrued to date support this perspective. Prescribing psychologists, just as do their psychiatric counterparts, will probably rely in a collegial manner on the medical skills of colleagues, who are internists, pediatricians, neurologists, other physicians, and midlevel practitioners (e.g., advanced practice nurses and physician’s assistants). The practice of psychiatry is not the practice of medicine; nor will be the practice of psychologists who prescribe.

Nevertheless, the profession must be sensitive not only to our own definition of various forms of mental distress and our notions of the most appropriate treatment but also to changing societal expectations and definitions of mental disorders and their treatment. Depression as currently conceptualized (the “common cold” of mental distress) is far different from the definitions that existed prior to the advent of drugs that could effectively treat the condition in outpatient settings. Indeed, as Healy (1997) commented, prior to the psychopharmacological era, depression was considered to be of sufficient rarity that the existence of an economically viable market for antidepressants was questioned. In other words, depression was defined in the severest terms—as an incapacitating illness with profound effects on every aspect of daily living, most likely requiring long-term institutionalization to manage.

Definitions have changed, and obviously for the better. We now acknowledge less severe forms of depression as true manifestations of mental distress that, while not incapacitating, result in suffering and prevent optimum functioning. However, we must be sensitive to the fact that this redefinition, coupled with the successful marketing of allopathic treatments for depression, has led to significant misperceptions of effective treatment by both the public and the medical profession. The response of many psychologists to this situation has not been adaptive: We characterize the debate in moral terms and argue that nonallopathic treatments represent a morally superior alternative to drugs. Not only is this incorrect, but it also further widens the perceptual divide between allopathic and nonallopathic treatments and perpetuates a situation in which patients and providers are forced to make false choices between drug and nondrug treatments. Evidence suggests that for many forms of mental distress, nonpharmacological treatments are appropriate, but for significant numbers of patients, combined pharmacological and psychological treatments are superior (Sammons & Schmidt, 2001). Psychopharmacological agents can be added to the armamentarium of psychologists without the need to embrace the medical model of mental health service provision. In order to offer the most effective form of treatment to the greatest number of patients, it is incumbent on the profession that we do so (DeLeon, 2001).

Bibliography:

1. Adams, K. M., & Bieliauskas, L. A. (1994). On perhaps becoming what you had previously despised: Psychologists as prescribers of medication. Journal of Clinical Psychology in Medical Settings, 1, 189–197.
2. Albee, G. W. (1986). Toward a just society: Lessons from observations on the primary prevention of psychopathology. American Psychologist, 41, 891–898.
3. Borkovec, T. D., Echemendia, R. J., Ragusea, S. A., & Ruiz, M. (2001). The Pennsylvania practice research network and future possibilities for clinically meaningful and scientifically rigorous psychotherapy effectiveness research. Clinical Psychology: Science and Practice, 8, 155–167.
4. Chambless, D. L., Sanderson, W. C., Shoham, V., Johnson, S. B., Pope, K. S., Crits-Christoph, P., Baker, M., Johnson, B., Woody, S. R., Sue, S., Beutler, L., Williams, D. A., & McCurry, S. (1996). An update on empirically validated therapies. The Clinical Psychologist, 49, 5–18.
5. Chilvers, C., Dewey, M., Fielding, K., Gretton, V., Miller, P., Palmer, B., Weller, D., Churchill, R., Williams, I., Bedi, N., Duggan, C., Lee, A., & Harrison, G. (2001). Antidepressant drugs and generic counseling for treatment of major depression in primary care: Randomised trial with patient preference arms. British Medical Journal, 322, 1–5.
6. Conrad, K. (1998). Making telehealth a viable component of our national health care system. Professional Psychology: Research and Practice, 29, 525–526.
7. Croghan, T. W. (2001). Increased spending for antidepressants. Health Affairs, 20, 129–135.
8. Csernansky, J. G., & Newcomer, J. G. (1995). Maintenance drug treatment for schizophrenia. In F. E. Bloom & D. J. Kupfer (Eds.), Psychopharmacology: The fourth generation of progress (pp. 1267–1275). New York: Raven Press.
9. Cullen, E. A., & Newman, R. (1997). In pursuit of prescription privileges. Professional Psychology: Research and Practice, 28, 101–106.
10. DeLeon, P. H. (2001). 2000APAannual President’s report.American Psychologist, 56, 556–558.
11. DeLeon, P. H., Rossomando, N. P., & Smedley, B. D. (in press). Foreword: The future is primary care. In R. Frank, S. McDaniel, J. Bray, & M. Heldring (Eds.), Psychology in primary care. Washington, DC: American Psychological Association.
12. DeLeon, P. H., VandenBos, G. R., Sammons, M. T., & Frank, R. G. (1998). Changing health care environment in the United States: Steadily evolving into the 21st century. In A. S. Bellack & M. Hersen (Series Eds.) & A. N. Wiens (Vol. Ed.), Comprehensive clinical psychology: Vol. 2. Professional issues (pp. 393–401). UK: Elsevier Science.
13. Emsley, R. A. (1999). Partial response to antipsychotic treatment: The patient with enduring symptoms. Journal of Clinical Psychiatry, 60(Suppl. 23), 10–13.
14. Fowler, R. D. (1996). Foreword: Psychology, public policy, and the congressional fellowship program. In R. P. Lorion, I. Iscoe, P. H. DeLeon, & G. R. VandenBos (Eds.), Psychology and public policy:Balancingpublicserviceandprofessionalneed(pp.ix–xiv). Washington, DC:American PsychologicalAssociation.
15. Frank, R. G., Hagglund, K. J., & Farmer, J. E. (in press). Cardinal symptoms management: An alternative to traditional primary care? In R. G. Frank, S. McDaniel, J. Bray, & M. Heldring (Eds.), Primary care psychology. Washington, DC: American Psychological Association.
16. Greenberg, R. P., & Fisher, S. (1989). Examining antidepressant effectiveness: Findings, ambiguities, and some vexing puzzles. In S. Fisher & R. P. Greenberg (Eds.), The limits of biological treatment for mental distress: Comparisons with psychotherapy and placebo (pp. 1–37). Hillsdale, NJ: Erlbaum.
17. Hamburg, D. A., Elliott, G. R., & Parron, D. L. (1982). Health and behavior: Frontiers of research in the biobehavioral sciences. Washington, DC: National Academy Press.
18. Harding, C. M., Brooks, G. W., Ashikaga, T., Strauss, J. S., & Breier, A. (1987a). The Vermont longitudinal study of persons with severe mental illness, I: Methodology, study sample, and overall status 32 years later. American Journal of Psychiatry, 133, 718–726.
19. Harding, C. M., Brooks, G. W., Ashikaga, T., Strauss, J. S., & Breier, A. (1987b). The Vermont longitudinal study of persons with severe mental illness, II: Long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. American Journal of Psychiatry, 144, 727–735.
20. Harrison,G.,Hooper,K.,Craig,T.,Laska,E.,Siegel,C.,Wanderling, J., Dube, K. C., et al. (2001). Recovery from psychotic illness: A 15 and 25 year international follow up study. British Journal of Psychiatry, 178, 506–517.
21. Healy, D. (1997). The antidepressant era. Cambridge, MA: Harvard University Press.
22. Hegarty, J. D., Baldessarini, R. J., Tohen, M., Waternaux, C., & Oepen, G. (1994). One hundred years of schizophrenia: A metaanalysis of the outcome literature. American Journal of Psychiatry, 151, 1409–1415.
23. Hollon, S. M. (1996). The efficacy and effectiveness of psychotherapy relative to medications. American Psychologist, 51, 1025– 1030.
24. Institute for the Future. (2000). Health and health care 2010: The forecast, the challenge. San Francisco: Jossey-Bass.
25. Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.
26. Jerome, L. W., DeLeon, P. H., James, L. C., Folen, R., Earles, J., & Gedney, J. J. (2000). The coming of age of telecommunications in psychological research and practice. American Psychologist, 55, 407–421.
27. Kaiser Commission on Medicaid and the Uninsured. (2001). The uninsured: A primer. Washington, DC: The Henry J. Kaiser Family Foundation.
28. Katon, W., Robinson, P., von Korff, M., Lin, E., Bush, T., Ludman, E., Simon, G., & Walker, E. (1996). A multifaceted intervention to improve treatment of depression in primary care. Archives of General Psychiatry, 53, 924–932.
29. Khan, A., Warner, H. A., & Brown, W. A. (2000). Symptom reduction and suicide risk in patients treated with placebo in antidepressant clinical trials: An analysis of the Food and Drug Administration database. Archives of General Psychiatry, 57, 311–317.
30. Kick, S. D., Morrison, M., & Kathol, R. G. (1997). Medical training in psychiatry residency: A proposed curriculum. General Hospital Psychiatry, 19, 259–266.
31. Kirsch, I. (1997). Specifying nonspecifics: Psychological mechanisms of placebo effects. In A. Harrington (Ed.), The placebo effect:An interdisciplinaryexploration(pp.166–186).Cambridge, MA: Harvard University Press.
32. Kirsch, I., & Sapirstein, G. (1998, June 26). Listening to Prozac but hearing placebo: A meta-analysis of antidepressant medication. Prevention and Treatment, 1, Article 0002a. Retrieved from http://www.apa.org.
33. Krummel, S., & Kathol, R. G. (1987). What you should know about physical evaluations in psychiatric patients. General Hospital Psychiatry, 9, 275–279.
34. Lalonde, M. (1974). A new perspective on the health care of Canadians: A working document. Ottawa: Government of Canada.
35. Levant, R., Reed, G., Ragusea, S., Stout, C., DiCowden, M., Murphy, M., Sullivan, F., & Craig, P. (2001). Envisioning and accessing new professional roles. Professional Psychology: Research and Practice, 32, 79–87.
36. Lin, E. H. B., Katon, W. J., von Korff, M., Russo, J. E., Simon, E., Bush, T. M., Rutter, C. M., Walker, E. A., & Ludman, E. (1998). Relapse of depression in primary care: Rate and clinical predictors. Archives of Family Medicine, 7, 443–449.
37. Marder, S. R., & Meibach, R. C. (1994). Risperidone in the treatment of schizophrenia. American Journal of Psychiatry, 151, 825–835.
38. Moncrieff, J. (2001). Are antidepressants overrated? A review of methodological problems in antidepressant trials. Journal of Nervous and Mental Disease, 189, 285–295.
39. National Depressive and Manic Depressive Association. (2000). Beyond diagnosis: Depression and treatment: A call to action to the primary care community and people with depression. Retrieved from http://www.ndmda.org.
40. Nierenberg, A. A., & Alpert, J. E. (2000). Depressive breakthrough. Psychiatric Clinics of North America, 23(4).
41. Olfson, M., Marcus, St. C., Pincus, H. A., Zito, J. M., Thompson, J. W., & Zarin, D. A. (1998). Antidepressant prescribing practices of outpatient psychiatrists. Archives of General Psychiatry, 55, 310–316.
42. Pear, R. (2001, May 8). Spending on prescription drugs increases by almost 19 percent. New York Times. Retrieved from http:// www.nytimes.com.
43. Pincus, H. A., Tanielian, T. L., Marcus, S. C., Olfson, M., Zarin, D. A., Thompson, J., & Zito, J. M. (1998). Prescribing trends in psychotropic medications: Primary care, psychiatry, and other medical specialties. Journal of the American Medical Association, 279, 526–531.
44. President’s Commission on Mental Health. (1978). Report to the President from The President’s Commission on Mental Health (Vol. 1). Washington, DC: U.S. Government Printing
45. Rabasca, L. (2000). Taking telehealth to the next step. The Monitor on Psychology, 31(4). Retrieved September 8, 2001, from http://www.apa.org/monitor/apr00/telehealth.html.
46. Rice, C. E. (2000). Uncertain genesis: The academic institution of American psychology in 1900. American Psychologist, 55, 488–491.
47. Rice, M. E., & Harris, G. T. (1997). The treatment of mentally disordered offenders. Psychology, Public Policy, and the Law, 3, 126–183.
48. Rodgers, D. A. (1980). The status of psychologists in hospitals: Technicians or professionals. The Clinical Psychologist, 33(4), 5–7.
49. Sammons, M. T., Gorny, S. W., Zinner, E. S., & Allen, R. P. (2000). Prescriptive authority for psychologists: A consensus of support. Professional Psychology: Research and Practice, 31, 604–609.
50. Sammons, M. T., & Schmidt, N. B. (2001). Combined treatments for mental disorders: A guide to psychological and pharmacological interventions. Washington, DC: American Psychological Association.
51. Schoenbaum, M., Unutzer, J., Sherbourne, C., Duan, H., Rubenstein, L. V., Miranda, J., Meredith, L. S., Carney, M. F., & Wells, K. (2001). Cost-effectiveness of practice initiated quality improvement for depression: Results of a randomized controlled trial. Journal of the American Medical Association, 288, 1325–1330.
52. Shapiro, A. K., & Shapiro, E. (1997). The placebo: Is it much ado about nothing? In A. Harrington (Ed.), The placebo effect: An interdisciplinary exploration (pp. 12–36). Cambridge, MA: Harvard University Press.
53. Shiloh, S. (1996). Genetic counseling: A developing area of interest for psychologists. Professional Psychology: Research and Practice, 27, 475–486.
54. Simon, G. E., von Korff, M., Rutter, C. M., & Peterson, D.A. (2001). Treatment process and outcomes for managed care patients receiving new antidepressant prescriptions from psychiatrists and primary care physicians. Archives of General Psychiatry, 58, 393–401.
55. Smedley, B. D., & Syme, S. L. (Eds.). (2000). Promoting health: Intervention strategies from social and behavioral research. Washington, DC: National Academy Press.
56. Street, W. R. (1994). A chronology of noteworthy events in American psychology. Washington, DC: American Psychological Association.
57. Tierney, R., Melfi, C. A., Wigna, W., & Croghan, T. W. (2000). Antidepressant use and use patterns in naturalistic settings. Drug Benefit Trends, 12(6), 7–12.
58. Tucker, J. S., Friedman, H. S., Schwartz, J. E., Criqui, M. H., Tomlinson-Keasey, C., Wingard, D. L., & Martin, L. R. (1997). Parental divorce: Effects on individual behavior and longevity. Journal of Personality and Social Psychology, 73, 381–391.
59. S. Department of Health, Education, and Welfare (HEW). (1979). Healthy people: The surgeon general’s report on health promotion and disease prevention [DHEW Pub. No (PHS) 79-55071]. Washington, DC: U.S. Government Printing Office.
60. S. Department of Health and Human Services (HHS). (2000). Healthy people 2010: Understanding and improving health. Washington, DC: U.S. Government Printing Office.
61. S. Department of Justice. (1998). Sourcebook of criminal justice statistics, 1997 (K. Maguire & A. Pastore, Eds.). Washington, DC: U.S. Government Printing Office.
62. VandenBos, G. R., DeLeon, P. H., & Belar, C. D. (1991). How many psychologists are needed? It’s too early to know! Professional Psychology: Research and Practice, 22, 441–448.
63. Wirshing, W. C., Marder, S. R., van Putten, T., & Ames, D. (1995). Acute treatment of schizophrenia. In F. E. Bloom & D. J. Kupfer (Eds.), Psychopharmacology: The fourth generation of progress (pp. 1259–1266). New York: Raven Press.