1) Please describe your contributions to the independent practice of psychology, including any positions held and committee work past and/or currently you have made to Division 42.
My primary contribution to independent practice has been to chair the steering committee advising the APA in the generation of clinical practice guidelines. The empirical science is clear; there is no non-psychotic disorder (the vast majority of the people who seek mental health services) for which psychosocial interventions are not at least as efficacious as medications and often longer-lasting. Nonetheless, psychotherapy has been losing market share to medications. A quarter-century ago two-thirds of the people treated for depression were treated with psychosocial interventions alone; with the advent of the SSRIs that ratio has been reversed. The United Kingdom, which relies on NICE guidelines to determine what works best, has invested £700 million pounds to train more psychotherapists so as to not have to rely so much on medications. Reimbursement is about to undergo a fundamental change in this country and we need clinical practice guidelines to make our case.
2) If APAPO no longer exists in its current form, how do you envision the role of legislative advocacy for psychologists in the future? What measures will you prioritize in order to advance, defend and protect the practice of psychology?
The best defense is a strong offense. Psychotherapy is simply more cost-effective than medication treatment for the vast majority of patients (it has enduring effects that medications lack) and we need to make that clear to third-party payers. I am not a fan of prescription authority; psychiatry has virtually abandoned the provision of psychotherapy and it is not clear why we press to do something poorly that psychiatry does well when we are so much better at doing that which is more cost-efficient. If we can get psychiatry to join us in generating clinical practice guidelines (they currently do their own and will not work with us so long as we pursue prescription authority) we can force them to stick to the empirical data and join in recommending psychotherapy over medications for the vast majority of patients. If we do third-party payers will notice and adjust reimbursement accordingly.
3) Please provide your position and how you intend to address each of these important APA governance concerns: a) the Good Governance Project, particularly the delegation of fiscal and operational responsibilities exclusively to the APA BOD; b) Accreditation of Masters programs in psychology c) Development of treatment guidelines.
- I am strongly supportive of the goals of the Good Governance Project, particularly the delegation of fiscal and operational responsibilities exclusively to the APA BOD. Unlike Council, APA members directly elect BOD members. It is small in number, forward thinking with respect to major issues, and nimble in its approach. Members of Council are no doubt well-intentioned and highly competent but as an institution, it represents encrusted interests and is unduly conservative when it comes to issues of governance. To paraphrase Reagan “Council is not the solution, it is the problem.” APA has lost over 15,000 members over the last decade and is having trouble getting early career professionals to join (that could be resolved by giving them the vote). If we are to adapt to 21st-century demands we must move beyond 20th-century institutions and Council by its very constitution will opt for the old over the new.
- I am a big fan of accreditation of Masters programs in psychology and strongly support whatever increases the pool of well-trained practitioners in psychology including independent practice at the Masters level. We have treatments that work but too few people have access to them. Guild issues suggest keeping the pool of practitioners small; the public interest argues for its expansion. I have trained lay counselors to do behavior therapy for depression in rural India; it worked and the benefits held up over time. What works in rural India can work in the US. The UK has expanded access to psychotherapy in a stepped care model; less highly trained therapists to provide less intensive therapies and patients who do not respond move on to doctoral level therapists for more intensive care. The system pays for itself in terms of reduced costs and increased patient productivity. We could do the same.
- I am a huge fan of treatment guidelines. We are twice as likely to medicate non-psychotic patients in the US than they are in the UK or Western Europe and the reason is that they have clinical practice guidelines and we do not. The empirical literature strongly supports psychotherapy over medications for the nonpsychotic disorders; it is at least as efficacious and often longer lasting. What we need to do is make common cause with psychiatry to produce clinical practice guidelines jointly; if we do we can force them to adhere to the empirical literature and endorse the superiority of psychotherapy for nonpsychotic patients. So long as each discipline generates its own guidelines psychiatry will be able to maintain the fiction that medications trump therapy. The public trusts physicians; if both disciplines generate guidelines then the public and third-party payers will give more credence to those generated by psychiatry.
4) What do you see as an additional vital area facing the independent practice of psychology? How do you plan to confront these areas during your presidency?
We need to make the case that psychotherapy is at least as efficacious as medications for the non-psychotic disorders (the vast majority of people seeking treatment) and often longer lasting. As good as medications are they are purely palliative (they only work for so long as you take them) whereas psychosocial interventions are often curative. The empirical data are clear and in the other western democracies, they guide the reimbursement process (see the marvelous treatise Thrive by Richard Layard and David Clark that changed funding patterns in the United Kingdom). We are one of only two countries that allow direct-to-consumer advertising for medications (something that the AMA opposes) and no other country in the world depends so much on medications. We need to press for multidisciplinary guidelines based on the best scientific evidence (as the IOM recommends) and if we do the psychosocial interventions will thrive as in the UK.