A profession in search of legitimacy

By Thomas A. Habib, Ph.D.
September 1, 2006



Well, it’s happened. Managed Health Network (MHN) will provide “priority consideration” to those elite clinicians who practice “Empirically Supported Treatment.” What’s wrong with our professional associations promoting empirical verification regarding what works and doesn’t work in psychotherapy you might ask? Well … nothing, providing you also have your eye upon the hostile business climate in which the vast majority of APA members practice.

It sure would be nice if our national association tried harder to avoid making our lives more difficult by giving health insurance executives a means to disqualify the majority of providers and to unduly influence the practice of psychology. In a recent letter to its network providers MHN listed the requirements to be designated an elite clinician:

Supervised experience, from taped sessions, of an empirically supported psychotherapy protocol with two patients (i.e., cognitive behavior therapy).

Homework assignments … of course from an empirically supported therapy. (e.g. Thought stopping and rubber bands on the wrist.)

The use of outcome measures … of course from an empirically supported therapy. (e.g. The Beck Depression Inventory-II.)

Although evidenced based practices may prove both good and bad for our brethren in medicine, it will prove troublesome for the development and practice of professional psychology. The problem for our physician friends will include a struggle between cookbook curtailments and necessary off-label prescribing. But this pales in comparison to how it will hurt the development of psychotherapy.

Psychology isn’t ready for the strait jacket imposed by evidenced based treatments. We are a young profession that is still very much evolving. Our scope of treatment, the human condition, is much broader and more dynamic. This has been indicated in research showing it isn’t so much what we do that affects treatment outcome but qualities within the patient therapist relationship.

Obsessive search for legitimacy

Of course the APA Council of Representatives and the most vocal proponents of evidence based practice such as David Barlow, Ph.D., never intended to provide the money changers in mangled care a means to further narrow the scope and practice of psychotherapy. Yet this is what they are complicit in promoting, despite repeated warnings from those of us in the trenches.

The culprit is the high visibility that APA accorded its task force of academicians. It is an expression of the profession’s shadow work and its obsessive search for legitimacy through scientific illumination. Thus it follows that we have bequeathed excessive influence within a professional association to our academic colleagues.

This pursuit of evidenced-based practice didn’t require the urgency or visibility of a presidential task force nor a lead article in The American Psychologist. The failure to evaluate its detrimental effects upon the practice of psychotherapy is egregious and negligent. Never mind that clinicians foot the bill for APA and have maintained unwavering support of our disgruntled academic colleagues.

The Council of Representatives failed to adequately evaluate the real world conditions of the market place. And what should one expect? The task force was stacked with people who do not work outside their ivy encrusted towers and have step-by-step guide manuals to promote. The sad thing is our academic colleagues have likely concluded that they have accomplished something worthwhile by elevating the importance of evidenced based practices.

Just think of the glee in the hearts of the marketing departments like MHN. Mangled care can present this seemingly rigorous cookbook psychotherapy to the public and the payers of these services and look “cutting edge!” Of course their real motive is eventually to dwindle the pool of providers to a few elite clinicians.

Psychology’s shadow work

How have the academicians hijacked APA? By tapping into psychology’s obsessive search for legitimacy and our collective professional doubt. And why shouldn’t the segment made up of clinicians also suffer from this collective professional doubt? We are not “real doctors.” Real doctors dispense the most ingrained symbol of western health care … the pill. We compound this alienation in breeding grounds far from the feeding trough of real doctors … the hospital.

Our empirical methods further codify this doubt with the front and center position we afford the null hypothesis, confidence intervals and the ubiquitous alpha level. We frequently meet patients who are initially skeptical and mistrustful of what we do.

Meanwhile, we practice in a competitive world where we valiantly fight our way through the hospital doors and defend the professional identity that comes with licensing. We cope daily with the reluctant approval of third-party payers while exerting efforts to become players with our legislators. All the while we hear the sneers of our academic colleagues emanating from those hallowed halls untouched by the messy business of applied psychology. Yes, we have reason for our collective doubt.

Collective repression

Last fall, at a wonderful conference titled The Evolution of Psychotherapy, I asked Nicolas Cummings, Ph.D., why business training wasn’t included in the early days of the professional school movement? He said he wanted to but that they pushed him out of the school prior to establishing this obvious need. Too much change too quickly for the academicians. The professional school movement succeeded in redefining applied psychology and training enough practitioners to meet the challenges they would actually face.

I wonder how many patients would have had to turn to the bottle of pills or fundamentalist interpretations of the world if the growth of psychology was not spearheaded by the Dr. Cummingses of our profession. Nevertheless, to this day we are prohibited from collecting continuing education credits for practice development and marketing courses.

More than ourselves

We are a profession that lives its core values. This includes an ongoing search for truth, pluralism, and an unparalleled respect for the doctor/patient relationship. We are an empathic profession that strenuously attempts to place our patient’s needs above our own. In a culture of capitalistic self-interest, this is remarkable. The services we provide are deeply valued by our patients and their families despite their initial anxiety.

Our domain is nothing short of the senior engineers for the software on living. Similar to the software supremacy in computers, our software on living will prove far more important than the “boxes” that hold it. Despite our historical professional ambivalence (e.g. Medicare inclusion sat on the APA President Brunner’s desk, 1965) the importance of what we do is so valued and ultimately respected that it’s been our saving grace.

The tail shouldn’t wag the dog

Our scientific roots and our empirical quest to advance psychology is an obviously valuable and needed endeavor. No one is against evidenced based practices. As mentioned above, how this goal was pursued and the disregard of how this might strait jacket psychology and be misused by mangled care is the problem. Each one of us is responsible for this state of affairs. Clinician’s respect for the work of our academic colleagues has not been reciprocated. It is unfortunate, that our academic colleagues haven’t found a way to work with the majority of APA (who are clinicians) that is mutually supportive and relatively free from professional competition.

We cannot wait any longer for this wound to heal. The time has come for the practicing community to insist upon an APA Council of Representatives that more fully reflects the needs of the clinicians. Meanwhile, we will watch closely the development of the National Alliance of Professional Psychology Providers. The stakes are too high and the struggle for a viable role in health care is too difficult for our national professional association to allow the undue influence of the academic community.

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Thomas A. Habib, Ph.D., is chairman of the Physician Well Being Committee at Children’s Hospital of Orange County. He is also the founder and managing partner of Mission Psychological Consultants Inc. in San Juan Capistrano, Calif. (www.MPCCares.com) His e-mail address is: MPCCares@aol.com.

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