CURRENT ISSUES IN CLINICAL PSYCHOLOGY
As clinical psychology grew and the number of practitioners multiplied, issues of professional competence began to arise. How is the public to know who is well trained and who is not? Many people have neither the time, inclination, nor sophistication to distinguish the professional from the charlatan. Professional regulation, therefore, has attempted to protect the public interest by developing explicit standards of competence for clinical psychologists.
Certification is a relatively weak form of regulation in most cases. It guarantees that people cannot call themselves “psychologists” while offering services to the public for a fee unless a state board of examiners has certified them. Such certification often involves an examination, but sometimes it consists only of a review of the applicant’s training and professional experience.
Certification is an attempt to protect the public by restricting the use of the title “psychologist.” Its weakness is that it does not prevent anyone (from the poorly trained to outright impostors) from offering psychological services to the public.
Certification laws were often the result of effective psychiatric lobbying of state legislatures. Because many psychiatrists wanted to reserve psychotherapy as the special province of medicine, they resisted any law that would recognize the practice of psychotherapy by any non-medical specialty. As a result, certification laws were the best regulation that psychologists could obtain.
Licensing is a stronger form of legislation than certification. It not only specifies the nature of the title (“psychologist”) and training required for licensure, it also usually defines what specific professional activities may be offered to the public for a fee. With certification, for example, individuals might call themselves “therapists” and then proceed to provide ‘psychotherapeutic” services with impunity.
Many state licensing laws are designed to prevent such evasions by defining psychotherapy and specifically making it the province of psychiatry, clinical psychology, or other designated professions. However, determined impostors are difficult to control, and such persons may be very clever in disguising the true nature of their activities.
To help strengthen this system of oversight and consumer protection, the American psychological Association developed a model act for the licensure of psychologists in 1987. The American Association of State Psychology Boards (AASPB) published a more recent revision in 1992. States and provinces have used these guidelines to develop their own specific requirements for licensure in their jurisdictions. Although licensing laws vary from state to state (and province to province), there are several common requirements. These are summarized here.
SUMMARY OF TYPICAL REQUIREMENTS FOR LICENSURE
A doctoral degree from an APA-accredited program in professional psychology (such as clinical) is required.
One to two years of supervised postdoctoral clinical experience is required.
A candidate for licensure must pass (that is, score at or above a certain threshold score) the Examination for Professional Practice in Psychology (EPPP). In addition, some states and provinces require an oral or essay examination.
Additional requirements include citizenship or residency, age, evidence of good moral character, and so on.
Licensure to practice psychology is generic. However, psychologists must practice within the scope of their demonstrated competence, as indicated by their educational background and training.
Most states and provinces require applicants for licensure to sit for an examination. In addition, the licensing board usually examines the applicant’s educational background and sometimes requires several years of supervised experience beyond the doctorate. Many states also have subsequent continuing education requirements. It appears that licensing boards are becoming increasingly restrictive, sometimes requiring specific courses, excluding master’s candidates, and demanding degrees from APA approved programs. They are also occasionally beginning to intrude into the activities of academic and research psychologists.
ISSUES REGARDING LICENSING
Licensing and certification remain topics of intense professional interest. Some insist that licensing standards should not be enforced until research demonstrates their utility and positive client outcomes can be shown to relate to the licensee’s competence (Bernstein & Lecomte, 1981). Others have pointed out that certification and licensing are in no way valid measures of professional competence (Koocher, 1979). However, others suggest that licensing should be designed to ensure that the public will not be harmed, rather than to regulate levels of competence (Danish & Smyer, 1981). Kane (1982) reinforces this view, arguing that at the present time licensing examinations help provide safeguards against poor practice.
Finally some academic clinical psychologists are concerned that licensing requirements violate academic freedom because these requirements essentially dictate the coursework that is offered by clinical psychology programs. They argue that the faculty members involved in a clinical psychology-training program have a better idea of what coursework is needed to produce well-trained clinical psychologists.
Despite these questions and problems, the regulation of professional practice seems here to stay. To date, it is the only method we have, imperfect though it is, to protect the public from the poorly trained.
AMERICAN BOARD OF PROFESSIONAL PSYCHOLOGY (ABPP)
Because of the failure of the individual states to take the lead, the American Board of Examiners in Professional Psychology was established as a separate corporation in 1947. In 1968, its name was shortened to American Board of Professional Psychology (ABPP).
ABPP offers certification of professional competence in the fields of behavioral psychology, clinical psychology, counseling psychology, family psychology, forensic psychology, health psychology, industrial and organizational psychology, school psychology, and clinical neuro-psychology. An oral examination is administered, the candidate’s handling of a case is observed, and the clinician is asked to submit records of his or her previous handling of cases.
Candidates for the ABPP examinations must have also had five years’ postdoctoral experience. Overall, requirements are more rigorous than those involved in state certification or licensing. In essence, the public can be assured that such a clinician is someone who has submitted to the scrutiny of a panel of peers.
In recent years, insurance companies have increasingly extended their coverage to include mental health services. At the same time, clinical psychologists have gained recognition as competent providers of those services involving prevention, assessment, and therapy. In 1975, the first National Register of Health Service Providers in Psychology was published.
The Register is a kind of self-certification, listing only those practitioners who are licensed or certified in their own states and who submit their names for inclusion and pay to be listed. Along with the increasing numbers of clinicians in private practice and their recognition as health care providers by insurance companies such as Blue Cross and Blue Shield, the Register is one more indication of the growing professionalism of clinical psychology.
ISSUES OF MANAGED HEALTH CARE
The character of health care in America changed dramatically during the 1980s and 1990s, with managed health care playing an increasingly greater role in the provision of health care to individuals and families. Under managed health care systems, decisions about an individual’s health care are regulated either by companies that provide health care services or by insurance companies that underwrite the cost of services.
Traditionally, physicians treated patients simply as they saw fit, and medical insurance paid for whatever procedures the doctors ordered. The physician decided what diagnostic and treatment approaches were in the best interest of the patient, and insurance companies supported and funded the physician’s discretion in making professional judgments. Lacking medical degrees, clinical psychologists could not be reimbursed by medical insurance companies.
In the 1970s, however, psychologists lobbied state legislatures to pass “freedom-of-choice” laws that would allow anyone who held a license to practice in the mental health field (e.g., psychologists, social workers) to be eligible for medical insurance reimbursement.
While physicians vigorously argued that only physicians (such as psychiatrists) should be allowed to treat patients in psychotherapy (and therefore be reimbursed by medical insurance), psychologists successfully argued that a mental health professional did not need to be a physician in order to conduct psychotherapy and other psychological services (e.g., psychological testing, consultation).
By 1983, 40 of the 50 states had passed legislation. Allowing people to obtain psychological services from any licensed mental health profession and be eligible to receive some insurance reimbursement (Nietzel, Bernstein, & Milich, 1991). Psychology enjoyed the advantages of freedom of choice legislation for about 10 to 20 years (although this time frame varies significantly from state to state).
Psychologists, like physicians, quickly became accustomed to treating patients as they saw fit and having insurance companies reimburse them and their patients for their professional services. Thus, psychologists could offer various types of psychotherapy (e.g., psychodynamic, cognitive-behavioral, humanistic, family systems, eclectic) and various types of modalities (e.g., individual, couple, family, group) for any diagnosable problem.
Typically, insurance would reimburse 50 percent to 80 percent of the fees charged by the psychologist, and patients paid the remaining portion. With these arrangements, psychologists and patients decided on a treatment plan without input from or parameters from other parties such as insurance companies.
These private, fee-for-service insurance arrangements began to change radically during the latter part of the 1980s. Health care costs rose steadily and dramatically during the 1970s and 1980s. Significant improvements in medical technology, newer and more expensive diagnostic tools such as CAT, PET, and MRI scans, as well as newer and more expensive treatments resulted in enormous amounts of costly medical insurance claims.
Furthermore, very ill patients could live longer using these newer technologies, so costs continued to escalate for the treatment of chronic and terminal conditions. Medical education and physician salaries continued to rise as well. In fact, health care costs have increased about 2.7 times the rate of inflation in recent years (Cummings, 1995; Resnick & DeLeon, 1995).
By 1995, health care costs have increased to over one thousand billion dollars per year, accounting for about 15 percent of the gross national product (GNP) (Cummings, 1995). By 2000 health care costs will account for over 20 percent of the GNP (Resnick & DeLeon, 1995).
These escalating costs have clearly become unacceptable to insurance companies and other organizations (such as government agencies) that pay for medical services. Furthermore, it has been estimated that about 30 percent of all health care costs are for procedures that are unnecessary, ineffective, inappropriate, or fraudulent (Resnick & DeLeon, 1995).
DIAGNOSIS-RELATED GROUPS (DRGs)
In 1983 Congress passed legislation that initiated a new method of paying hospitals with a fixed and predetermined fee for treating Medicare patients. Under this plan, payment was determined by the patient diagnosis rather than by the actual total cost of treatment. Patients were categorized into diagnosis-related groups (DRGs), and the costs were calculated based on the average cost per patient for a given diagnosis.
Thus, a hospital would receive a fixed fee for treating a patient with a particular diagnosis. If the hospital needed more time or money to treat the patient, monies would not be available for the additional services; or if the patient could be treated using less than the designated amount, hospitals would keep the difference to pay for other costs.
Following the advent of DRGs in the early and mid 1980s, managed health care plans such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs) exploded onto the health care scene during the late 1980s and the 1990s. The aim of these programs was to provide a more cost-effective way to pay for health services including those services offered by mental health professionals such as clinical psychologists.
While 96 percent of people who had health care insurance still had fee-for-service plans in 1984, only 37 percent still had these plans by 1990 (Weiner & de Lissovoy, 1993). The number of Americans with fee-for-service plans continues to diminish rapidly (Cummings, 1995; B roskowski, 1995). In fact, over 35 million Americans now belong to a health maintenance organization, and about 130 million Americans are covered by some form of managed health care (Cummings, 1995).
HEALTH MAINTENANCE ORGANIZATIONS (HMOS)
Contrary to the traditional fee-for-service plan outlined above, an HMO provides comprehensive health (and usually mental health services) within one organization. An employer (or employee) pays a monthly fee to belong to the HMO. Whenever health care is needed, members obtain all their care from the HMO for no additional cost above the monthly membership fee or a small co-payment fee (e.g., $5 per office visit).
Patients have little or no choice regarding which doctor or other health care provider can treat them. Furthermore, they must obtain all their services (from flu shots to brain surgery) from health care professionals working at the HMO. Unlike private practitioners, these providers are paid a yearly salary rather than a certain fee for each patient they treat.
In order to be profitable, the HMO must control costs and minimize any unnecessary and expensive services. For example, Cummings (1995) reported that only 38 large HMOs “the size and efficiency of Kaiser-Permanente can treat 250 million Americans with only 290,000 physicians, half the present number, and with only 5% of the gross national product”.
Thus, it is theoretically possible for physicians and organizations to provide medical services at a fraction of the cost associated with traditional fee-for-service arrangements. The important concern is whether these more efficient services are of high quality and in the best interest of patient care.
PREFERRED PROVIDER ORGANIZATIONS (PPOs)
A Preferred Provider Organization (PPO) is a compromise between the traditional fee-for-service and the HMO style of health care. A PPO is a network of providers who agree to treat patients affiliated with the PPO network for discounted rates. Therefore, traditional private practice professionals in all medical specialties as well as clinical psychologists and other mental health professionals can choose to apply to be on the PPO network.
Professionals in the community who have agreed to serve on the PPO panel of providers must treat a patient who is on a PPO plan. Furthermore, large health organizations such as clinics and hospitals also may apply to be on the PPO network panel. The PPO network and the providers of professional services (including hospitals) agree to set fees for various types of professional services such as surgery, office visits, and psychotherapy.
A patient who needs services may contact one of a number of hospitals, clinics, or private practice providers. Some of the services, however, still need to be authorized by the PPO network organization before they can be guaranteed payment. Thus permission is needed by the insurance company before many major diagnostic or treatment services can be offered by any provider on the panel.
With the advent of HMOs and PPOs, spiraling health care costs and some unnecessary procedures have been better contained. The HMO and PPO companies determine, along with the professional treating a patient, the most cost-effective and reasonable diagnostic or treatment plan to follow. Therefore the insurance companies paying for physical and mental health care services now have an important vote in the types of services that can be rendered.
EVALUATION OF HMOs & PPOs: IMPACTS OF MANAGED HEALTH CARE ON CLINICAL PRACTICE
Some arguments have been made that ultimately these changes in managed health care do not save money (Fraser, 1996). In fact, some argue that the monies going to health care have shifted from hospitals and providers to the managed care insurance industry (Matthews, 1995). Evidence that the managed-care insurance industry is one of the most profitable industries in the United States, with CEOs and other top executives enjoying salaries of over 6 million dollars per year, supports this claim (Matthews, 1995).
Generally, providers and patients are not as satisfied with these managed care programs as are those who still use the traditional fee-for-service professionals. While costs are theoretically contained in managed-care models, freedom of choice for both patient and provider is strictly controlled.
A recent survey of over 17,000 HMO patients revealed general dissatisfaction with their health plans, while patients still on the fee-for service plans expressed the most satisfaction (Rubin et al., 1993). These survey results have raised concerns about the quality of service provided by managed health care.
Managed care companies now routinely survey their members concerning client satisfaction (Broskowski, 1995). Psychologists and other mental health professionals tend to be unhappy with managed health care and have even formed special interest groups to curtail its impact and abuses (e.g., the National Coalition of Mental Health Professionals and Consumers).
A recent survey of over 14,000 members of the American Psychological Association revealed that 78 percent of the group felt that managed care had a negative impact on their professional work, with only 10.4 percent reporting a positive impact (Phelps, 1996). A survey of over 200 diplomates in clinical psychology from the American Board of Professional Psychology revealed that over 90 percent felt that managed health care was a negative and problematic trend (Plante, Boccaccini, & Andersen, in press).
In another national survey, 49 percent of 718 psychologists surveyed reported that their patients were negatively impacted by managed care that delayed or denied services while 90 percent reported that managed care reviewers interfered with appropriate treatment (Tucker & Lubin, 1994). Other surveys have demonstrated that psychologists generally feel that managed health care has requested that practitioners compromise professional ethics to contain costs (Murphy et al., 1998).
The president of the American Psychiatric Association, Harold Eist, has stated, “We are under attack by a rapacious, dishonest, disruptive, greed-driven insurance-managed care business that is in the process of decimating all health care in America, but most egregiously, the care of the mentally ill” (Saeman, 1996).
The mental health professional’s deep discontent with managed-care stems from several concerns.
First, all professional decisions (such as type and frequency of therapy services) must be authorized by the managed care insurance company. The cases must go through utilization review, which means that a representative of the insurance company reviews the services and plans of the professional before authorization for services can occur.
Often the insurance agent with whom the psychologist works in this regard is not a licensed mental health professional. Therefore, many psychologists resent that they must “sell” their treatment plans to someone who is not as well trained in providing professional services.
Furthermore, many feel that these reviewers are primarily interested in minimizing costs for the insurance company rather than being concerned about what is in the best interest of the patient (Anders, 1996).
Second, concerns about patient confidentiality have arisen. Details about the patient must be disclosed in order to obtain authorization for services. Many mental health professionals (as well as patients) feel that informing the insurance company about intimate details of the patient’s life and problems compromises their confidentiality. Many patients fear that this information might be misused or provided to their employer.
Third, many psychologists feel overwhelmed by the paper work that is required of managed-care providers. In addition to lengthy application forms for each separate panel to which the professional belongs (copies of malpractice insurance, license, transcripts from all professional training, updated curriculum vitae, documentation of medical staff affiliations), other lengthy forms often need to be completed after each session with a patient.
Fourth, many psychologists resent having to accept significant reductions in their typical fees for managed care patients. For example, a psychologist might charge $100 per hour for services, but in order to be admitted to a PPO panel, he or she might have to accept a $65 per hour rate.
Furthermore, the additional paper work and time on the telephone for authorization and utilization review is not reimbursed.
Fifth, psychologists (and patients) often feel that too few sessions are authorized by the managed-care company (Murphy et al., 1998). For example, only 3 or 5 sessions might be authorized for services. Many psychologists feel that patients that truly need more services are being denied access to treatment (Phelps et al., 1998).
And finally, many psychologists resent having someone tell them how they should treat their patients. For example, a managed-care company might urge the psychologist to have the patient enter group rather than individual therapy in order to save costs, given the typically lower fee for group as opposed to individual treatment. Furthermore, many psychologists are concerned about the growing use of capitation methods by managed care companies.
In a capitation program, the insurance company will pay a set fee for the treatment of a given patient no matter what treatment or how many sessions are required. For example, when a managed care insurance company refers a patient to a practitioner, the company may pay $250 for whatever services are needed. If services can be provided within 1 to 3 sessions, the practitioner covers his or her costs. If many more services are needed (e.g., 20 sessions), the professional loses a good deal of time and income.
Many managed-care companies have thus transferred the risks of expensive services from the insurance company to the practitioner. In the words of Bertram Karon, “What started reasonably is becoming a national nightmare” (Karon, 1995, p.S).
Some psychologists, however, have noted that managed care offers a variety of hidden benefits (Anonymous, 1995; Clement, 1996, Hayes, 1996). For example, justifying treatment plans to managed care companies encourages professionals to think clearly about how best to treat their patients in a cost-effective manner, to make their clinical skills sharp and motivation for success high.
Furthermore, managed care promotes interdisciplinary collaboration by forcing professionals to work with other professionals (such as physicians) also treating a given patient as well as with professionals representing the managed-care company. Finally, managed health care demands that professionals be held more accountable for everything they do and for the price of their services. These changes have encouraged psychologists and other professionals to use empirically validated treatment approaches as well as brief, problem-focused treatments.
PRESCRIPTION PRIVILEGES FOR CLINICAL PSYCHOLOGISTS
A highly controversial issue facing clinical psychology is the possibility of obtaining the legal and professional ability to prescribe psychotropic medications. Historically, psychiatrists have been the only mental health professionals legally allowed to prescribe medication for their patients. Curiously, however, any physician from any specialty area (e.g., cardiology, urology, internal medicine) may legally prescribe psychotropic medications even if the physician lacks mental health training or experience.
In fact, the majority (approximately 80%) of psychotropic medications prescribed to alleviate anxiety and depression are prescribed by general family practice or internal medicine physicians and not by psychiatrists (DeLeon & Wiggins, 1996). Although a number of psychologists actively conduct research on the neurobiology and psychopharmacology of behavior, and approximately two-thirds of graduate training programs in psychology offer psychopharmacology courses to their students (Popanz, 1991), psychologists have not obtained legal permission to prescribe medications to the public.
The American Psychological Association, after careful study, has supported efforts to develop a curriculum to adequately train psychologists in psychopharmacology and to lobby state legislative groups to pass laws allowing psychologists to prescribe medications (American Psychological Association, 1992b; Cullen, 1998; Martin, 1995; Smyer et al., 1993). During the past several decades, there has been an explosion of research on the effects of various medications on psychiatric problems such as anxiety, depression, impulsivity, and thought disturbance.
New and effective medications have become available to assist those experiencing a wide range of emotional and behavioral problems. For example, the development and popularity of Prozac has led numerous people to become interested in using the drug to combat depression and other problematic symptoms such as bulimia. Additionally, the influence of alcohol, cocaine, nicotine, and other substances on behavior (such as substance abuse, domestic violence, and crime) continues to be a major issue for all health care and mental health professionals.
These substance abuse problems are often treated with medications such as ant-abuse for alcohol addiction and methadone for heroine addiction. Advances in the development and availability of psychotropic medication as well as the influence of substance use and abuse on behavior have set the stage for the controversial issue of the development of prescription privileges for psychologists.
Furthermore, as more integrative and bio-psychosocial perspectives replace traditional one-dimensional theoretical models (e.g., psychodynamic, behavioral) of diagnosis and treatment, biological and medication issues become increasingly relevant for practicing psychologists.
OPPOSITION FROM OTHER PROFESSIONS
A prescription privilege for psychologists is a hotly debated topic both within and outside the profession. For example, both the American Medical Association and the American Psychiatric Association are adamantly opposed to allowing psychologists the privilege of prescribing medication (American Medical Association, 1984). A recent survey of approximately 400 family practice physicians revealed strong opposition to psychologists obtaining prescription privileges (Bell, Digman, & McKenna, 1995). They claim that a medical degree is necessary to competently administer medications that deal with the complexities of mind-body interactions.
OPPOSITION FROM WITHIN PSYCHOLOGY
Even within psychology, many are opposed to having psychologists prescribe medication for their patients (DeNelsky, 1991, 1996; Hayes & Heiby, 1996). Some psychologists are adamantly opposed to prescription privileges (DeNelsky, 1996). Some are concerned that allowing psychologists to prescribe medication would distract them from their traditional focus on non-biological emotional and behavioral interventions (e.g., psychotherapy, education etc.).
Some have argued that by obtaining prescription privileges psychology would lose its unique identity and psychologists would become “junior psychiatrists” (DeNelsky, 1996; Lorion, 1996). Finally, many are concerned about the practical problems associated with prescription privileges such as sizable increases in the costs of malpractice insurance or the increased influence of pharmaceutical companies on the field of psychology (Hayes & Hieby, 1996).
On the other hand, many have argued for the development of prescription privileges for psychologists. A number of clinical psychologists support prescription privileges. Furthermore, about half of all graduate students in clinical psychology wish to be able to prescribe medication with the majority wanting the option available for the profession (Smith, 1992).
Proponents argue that with appropriate and intensive training for those who wish to prescribe medications, psychologists would be excellent candidates to provide psychotropic medications for patients, including the underserved populations (e.g., the elderly, the military, people with low socioeconomic status, and people who live in rural areas) who have little opportunity to be treated by a psychiatrist (Brentar & McNamara, 1991; DeLeon & Wiggins, 1996; Smith, 1992).
Many point out that other non-physicians (e.g., nurse practitioners, optometrists, podiatrists, dentists) already have the appropriate training and legal authority to prescribe a limited array of medications. In fact, nurse practitioners have prescription privileges in 49 states, physician assistants can legally prescribe medication in 40 states, and optometrists can prescribe medication in all 50 states (DeLeon & Wiggins, 1996).
Because medical schools in the United States typically spend only an average of 104 hours of classroom instruction on pharmacology (Association for Medical School Pharmacology, 1990), psychologists have argued that obtaining a medical degree is not necessarily needed to prescribe medications if sufficient and specific training is available.
Despite the advantage of no longer having to send patients to other professionals for medication, psychologists generally tend to have mixed feelings about obtaining prescription privileges and thus are not uniformly in favor of it (e.g., Boswell & Litwin, 1992; DeNelsky, 1996; Evans & Murphy, 1997; Hayes & Heiby, 1996; Plante et al., 1997).
As noted by Brentar and McNamara (1991), clinical psychologists in recent years have expanded their area of interest from mental health to health issues in general. This redefinition of clinical psychology’ as a field concerned with general health (including mental health) raises a number of interesting issues regarding how best to ensure that clinical psychologists can function autonomously and not be controlled or regulated by medical or other professions (Fox, 1982).
Several advocates have argued that obtaining prescription privileges will ensure the autonomy of clinical psychologists as health service providers and will enable a continuity of care that is missing when a psychiatrist prescribes the patient’s medications and a psychologist provides the same patient’s psychotherapy.
Further, DeLeon (1988) has argued that it is our professional and ethical duty to improve and broaden the services we offer so that society’s needs can be met. Clinical psychologists with prescription privileges would be available to meet the needs of underserved populations (for example, rural residents, geriatric patients).
However, the pursuit of prescription privileges has been questioned on philosophical grounds. HandIer (1988) has argued that the need for professional boundaries between clinical psychology and psychiatry dictates that we should not incorporate medical interventions (medications) into our treatment repertoire. Handler further asserts that it is clinical psychology’s non-medication orientation that identifies it as a unique health profession and that is responsible for the field’s appeal. DeNeisky (1991, 1996) notes that, even without prescription privileges, more and more psychologists have become providers of outpatient services, whereas the opposite trend is true for psychiatry.
PROS AND CONS OF PRESCRIPTION PRIVILEGES
Following are some of the major arguments for and against prescription privileges.
A number of arguments have been made In favor of seeking prescription privileges; we will briefly present several of the most commonly cited reasons. These arguments were discussed in a 1995 interview with the executive director of the Practice Directorate of the American Psychological Association (Nickelson, 1995) and have been emphasized by others advocating prescription privileges (for example, DeLeon & Wiggins, 1996).
First, having prescription privileges would enable clinical psychologists to provide a wider variety of treatments and to treat a wider range of clients or patients. Treatment involving medications would now be an option, and this would lead to more involvement by clinical psychologists in the treatment of conditions in which medications are the primary form of intervention (for example, schizophrenia).
A second advantage of having prescription privileges is the potential increase in efficiency and cost-effectiveness of care for those patients who need both psychological treatment and medication. These individuals often enlist more than one mental health professional (a psychiatrist for medications, a clinical psychologist for cognitive-behavioral treatment). A single mental health professional who could provide all forms of treatment might be desirable from both a practical and an economic standpoint.
There is also the belief that prescription privileges will give clinical psychologists a competitive advantage in the health care marketplace. The health care field is becoming increasingly competitive, and prescription privileges would provide an advantage to clinical psychologists over other health care professionals (such as social workers).
Finally, some view obtaining prescription privileges as a natural progression in clinical psychology’s quest to become a “full-fledged” health care profession, rather than just a mental health care profession.
Other clinical psychologists have voiced concerns about the possibility of obtaining prescription privileges (including Brentar & McNamara, 1991; DeNeisky, 1991, 1996; Handler, 1988; Hayes & Heiby, 1996).
These critics point out that prescription privileges may lead to a de-emphasis of “psychological” forms of treatment because medications are often faster-acting and potentially more unsafe. Many fear that a conceptual shift may occur, with biological explanations of emotional conditions taking precedence over psychological ones.
The pursuit of prescription privileges may also damage clinical psychology’s relationship with psychiatry and general medicine. Such conflict may result in financially expensive lawsuits. This new financial burden, as well as the legal fees necessary to modify current licensing laws, would come at the expense of existing programs. In addition, the granting of prescription privileges would likely lead to increases in malpractice liability costs. In short, it may not be worth it.
MEDICAL STAFF PRIVILEGES
Historically, only physicians were allowed to treat patients independently in a hospital setting and serve on the medical staff of a hospital. Medical staff privileges allowed a physician to admit and discharge patients as needed as well as organize or manage the treatment plan of patients while hospitalized.
Therefore, if a psychologist was treating a patient in an outpatient environment (such as a community mental health clinic or in private practice) who then later required hospitalization, the psychologist would have to turn the hospital portion of the care over to a physician (such as a psychiatrist), who would admit, discharge, and direct treatment.
The psychologist would be allowed to see the hospitalized patient only as a visitor, just like family members) and not as a professional. The psychologist also could not offer treatment services (such as psychotherapy) while the patient was in the hospital setting.
Psychologists have been interested in obtaining medical staff privileges to provide independent inpatient care for their patients. Many psychologists feel that physicians (such as psychiatrists) do not need to supervise their work in hospital settings. Physicians, however, have generally opposed medical staff privileges for psychologists (American Medical Association, 1984).
After about 10 years of legislative advocacy and activity, approximately 16 percent of clinical psychologists have obtained full medical staff privileges in the United States. Yet, many hospital-affiliated psychologists continue to struggle to maintain autonomous status within hospital settings.
In 1978, legislation was passed allowing psychologists to be able to obtain medical staff privileges independently in California. However, many hospitals and physician groups fought the legislation. A past president of the American Psychiatric Association stated that it was a “dangerous trend” for psychologists to obtain hospital staff privileges (Fink, 1986, p.816).
ISSUES IN PRIVATE PRACTICE
The number of clinical psychologists choosing to work in full-time or part-time private practice has grown steadily in the past several decades. Currently, about 35 percent to 40 percent of clinical psychologists primarily work in solo or group private practices. Over two-thirds of clinical psychologists maintain at least some part-time private practice activities. This proportion represents a 47 percent increase since 1973 (Garfield & Kurtz 1974 Norcross et al., 1989, 1997).
While survey results have revealed a larger and larger percentage of clinical psychologists conducting at least part-time private practice activities, experts generally now predict that this trend will quickly reverse itself owing to the rapid changes in the health care delivery and insurance reimbursement systems.
For example, a recent survey of over 15,000 members of the American Psychological Association revealed that over 40 percent of practitioners who obtained their license prior to 1980 were working in solo independent practice, compared with only about 30 percent of those who obtained their license after 1990. Managed health care has made it increasingly difficult to develop and maintain an independent practice in clinical psychology.
In the words of Russ Newman, director of the Practice Directorate of the American Psychological Association, “It is going to be very difficult to continue as a solo practitioner in the integrated marketplace of the future”. Managed-care companies, in their efforts to provide cost-effective services, have looked to master’s-degree trained counselors as a lower cost alternative to clinical psychologists. Furthermore, the companies are less likely to pay for services that have been traditionally an integral part of a psychologist’s independent practice (e.g., long-term insight-oriented psychotherapy).
RECENT TRENDS IN PRIVATE PRACTICE
Traditional, fee-for-service private practice is a thing of the past (R. J. Resnick, 1997; Schneider, 1990); managed health care now dominates the scene. Private practice psychologists have felt the brunt of this change. However, training programs must ensure that future clinical psychologists are not sent out into the real world lacking the requisite skills and knowledge demanded by managed health care systems.
CURRENT ISSUES IN CLINICAL PSYCHOLOGY
Clinical psychology is changing and growing at a rapid pace. Some of these changes are very positive; some clearly negative. On the positive side, psychology has greatly contributed to a better understanding of human behavior and ways to improve the quality of life for many. Assessment, treatment, research, teaching, and consultation are all much more effective today than in the past.
Psychology has also attained increasing independence as a discipline. Licensing laws, medical staff privileges, prescription privileges, and freedom of choice legislation have all contributed to the development of psychology as a respected independent profession. As the profession and field has matured, a more in-depth and sophisticated understanding of human behavior has unfolded. Unfortunately, however, the trend toward managed health care and further constraints in funding for research and practice potentially threaten the growth and types of services psychology can provide. In addition, sizable increases in the number of students being trained as psychologists, especially at large free standing professional schools of psychology, may intensify competition for available job positions.
Despite the challenges confronting this as well as all related fields, clinical psychology as a profession remains a fascinating and exciting endeavor with a tremendous potential to help individuals, groups, and society in the course of a truly fulfilling professional career. Although the future of clinical psychology is uncertain, it is likely to continue to be a rewarding career for many. Future clinical psychologists must be flexible to adapt to changing needs and requirements as society and the discipline evolves and changes.