There is a considerable literature on the development, evolution and future of professional psychology from the 1940s to its prospects in the emerging health care system. In the years ahead, our profession will be significantly impacted by the Affordable Care Act and the integration of mental health into primary care.
A rosy future was predicted for professional psychology during its halcyon years in the 1970s through the mid-1980s. However, significant changes in health care, following the advent of managed care in the late 1980s, quickly began to negatively affect its fortunes.
These have included a substantial increase in bachelor and masters level clinicians in counseling and social work coupled with the emergence of “split treatment.” Within this intervention model, sub-doctoral clinicians have steadily assumed greater responsibility for the psychosocial aspects of care while physician’s assistants, advanced practice nurses, primary care physicians and psychiatrists serve as medication prescribers. In addition, since the late 1980s managed care has been successful at nearly eviscerating assessment psychology which, historically, had been a protected clinical practice niche.
Efforts to improve career opportunities and position psychologists as influential players in health care practice and reform have stalled, notably movements to obtain hospital admitting privileges and prescriptive authority and to establish board certification as the standard of practice.
The typical licensed psychologist struggles to make a respectable living despite years of post-graduate training and often 60-hourplus workweeks. Early career psychologists confront mounting debt from graduate school and except perhaps for the most ambitious and talented, face an uncertain future
The military is a viable option for some early career psychologists. Recently, prospects in the public sector have improved for psychologists within the Veterans Administration. There has also been a modest uptick in jobs in state hospitals, especially those with specialty training in forensics
Master’s level clinicians have the clear edge on employability in both educational and clinical settings. Good paying jobs, with the possibility of advancement for psychologists, have been few and far between for many years and appear to have more or less “flat-lined.”
There is considerable blame to go around for the situation in which psychologists find themselves. Some of the responsibility is the direct outcome of “overreaching” and other dubious decisions made by our professional organizations, including the overzealous promotion of multiculturalism and social justice, the interminable debates about core curriculum and the expansion of doctoral programs, many with questionable track records in helping to obtain internship/post-doctoral fellowship training for their students.
As well, there has been the seemingly endless proliferation of specialties, sub-specialties and proficiencies – most amount to “distinctions without a clear difference” with respect to clinical practice and contribute to the confusion of third-party payers, prospective employers and consumers as to the competencies and skills of psychologists.
Let’s not forget the petty and puerile conflicts with master’s level groups like school psychologists about their right to practice independently. One of the more disturbing initiatives in recent years has been the push by the APA to have Medicare declare psychologists as physicians despite the fact that most psychologists would flunk a bachelor’s level nursing examination on the fundamentals of clinical medicine.
There have also been the pointless squabbles within some specialties–witness the shameful spectacle, spanning nearly two decades, between the American Board of Professional Psychology and the American Board of Professional Neuropsychology regarding which organization possessed the bona fides to conduct examinations and confer diplomate status/board certification in neuropsychology. The result of this wasted expenditure of time and energy has been an essentially “cold peace” between the two organizations for the past several years. While this senseless turf war waged, the earnings and job prospects for many neuropsychologists remained static and declined for some.
Since its beginnings, professional psychology has been in a perpetual “identity crisis,” related to being “neither fish nor fowl.” We are “mental health doctors” but with scant knowledge of clinical medicine and little clout in medical settings other than procuring funding for publication and research. With the exception of testing skills (possessed by a relatively small number of practitioners), our competencies cannot be reliably differentiated from mental health practitioners with considerably less education/training. Outside of a few states and the territory of Guam where psychologists succeeded in obtaining at least limited prescriptive authority, we are forbidden by law to provide medically based assessments or interventions.
Yet, we expect to be paid at higher rates than masters level practitioners in a reimbursement system which is organized around cost containment, does not consider us preferred providers and often seems to view psychologists as “bête noires” within mental health care.
Professional psychology continues to deny that it is “a canary in the coal mine,” a profession that is arguably more vulnerable to the vicissitudes of a changing health care landscape than other mental health groups. The denial of this reality has contributed to embarking on a multitude of competing political and other agendas that have significantly weakened our profession’s potential influence and power and jeopardized its economic future.
For the foreseeable future the main focus of professional psychology should be securing a viable niche within primary care. In order to accomplish this, much greater emphasis needs to be placed on graduate and post-graduate education/training in medical psychology to allow psychologists to interface in a more knowledgeable and sophisticated manner with primary care clinicians and to further legitimize and support the movement to obtain prescriptive authority. Our profession has to continue to work on adapting psychological assessment/testing to primary care and to persuade third-party payers and medical professionals of its cost effectiveness and clinical utility within this system of service delivery. In general, we must strenuously promote ourselves, as the experts that we are in evidence-based mental health assessment and practice.
Jerrold M. Pollak, Ph.D., ABPP, ABN, is coordinator of the Program in Medical and Forensic Neuropsychology and a staff clinician in emergency services at Seacoast Mental Health Center in Portsmouth, N.H. His e-mail is: firstname.lastname@example.org.