INVITED EDITORIAL THE CHANGING FACE OF CLINICAL PSYCHOLOGY:

IMPACT OF SERVICE DELIVERY CHANGES

The history of clinical psychology, including its emergence during and immediately after World War 11, is a familiar story,that is well documented elsewhere. The purpose of this paper is neither to recount nor augment this history, and 1 shall refrain from alluding to anything beyond the high points of this story. Suffice it to say, however, that if we proceed with some appreciation for Zeitgeist effects on the evolution of clinical psychology, then the historical context in which we now find ourselves, as well as some of the conclusions of this article, may be more understandable.

A major point to be kept in mind is that, from the beginning, the field of psychology has been highly responsive to the major historical events of the time. Even Wundt’s lab was a culmination of scientific evolution, particularly in the area of psychophysics, which resulted in the initial emergence of psychology as a separate discipline. World War I1 created a greatly increased need for clinical psychological services, both during the war and for veterans immediately after that global conflict. And now, when one looks at the current point in history, there is little doubt that major changes are under- way. The delivery of health (including psychological) services is the issue around which most of the turmoil and change revolve.

DIPLOMA MILLS AND THE WEAKER PROFESSIONAL SCHOOLS Diploma mills are not a new problem for psychology, but the number of such in-

stitutions continues to increase. The problem is aggravated by the professional school movement, a phenomenon of the last decade. These institutions, which were conceived to provide better service delivery skills for clinical psychologists, have produced more than their share of poorly trained practitioners and more than their share of other problems.

This segment, however, is not intended as an indictment of professional schools of psychology. Clearly, the better professional schools (e.g., the Ohio Professional School, Rutgers, etc.) are probably among the best clinical psychology training pro- grams in this country. However, too many professional schools are distinguished only by the absence of adequate facilities, poor libraries, poor financial support, low quality of faculty members, etc. Their major weakness, though, is best portrayed by the large number of graduates, who greatly outnumber full-time faculty. In the last decade, an increasingly large ratio of all Ph.D. graduates in psychology have come from profes- sional schools. We now can extrapolate to a point in the near future where the great majority of doctoral graduates will be from professional schools. The large numbers of poorly trained and marginally ethical practitioners who are graduating from these institutions will continue to glut the market place; they will create a risk for consumers and work a hardship for responsible service providers. The risk is that clinical psychology will become a low-prestige, quack-infested field that will take its place among the weaker professions currently in the service arena (e.g., chiropractic, “counselors” of all varieties, faith healers, etc.).

THE OVERSUPPLY OF PHYSICIANS AND THE AGGRESSIVE POSTURE OF ORGANIZED MEDICINE The current Zeitgeist with regard to an oversupply of M.D.s has produced several

changes, including the loss of hospital privileges by clinical psychologists. Within the last decade, the medically dominated Joint Commission on Accreditation of Hospitals (JCAH), with one stroke of the pen, made it impossible for any hospital to be accredited

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that provided active staff status (with accompanying privileges to discharge, to write behavioral orders, to vote in committees, etc.) for psychologists. Organized medicine is impacting further on psychology through state legislative efforts that prohibit psychologists from providing diagnosis for mental and emotional disorders. They also are attempting to redefine psychotherapy as a medical process. Without an effective response to these challenges, psychologists will be systematically deprived of their hard- fought rights in the areas of freedom of choice, third-party reimbursement, etc. The field of psychology is confronted with the challenge of producing a well-orchestrated network and advocacy program to lobby at both the state and national levels. The emergence of PsychNet (psychology’s state association/chapter organization network) and the APA’s new, differential dues-financed professional advocacy program produced a few rays of hope in this area.

THE ECONOMY, RISING HEALTH COSTS, AND INSURANCE COMPANIES The condition of the economy in the first half of the 1980s, combined with the es-

calating cost of health care, engendered a financial crisis for insurance companies. They were forced to undergo dramatic changes in order to avoid bankruptcy. Unfortunately for psychologists, most of these changes involved the concept of capitation. With capita- tion, something is capped or limited. For example, the cost per hour for psychotherapy is fixed at $50.00 or less. The number of visits that any one client can make is, in some cases, held to 30 or fewer. The total recoverable costs for mental health services per claimant are limited, say, to $1,000 or less. The most effective way to capitate, however, may be by limiting the number of providers. Every health economist knows that the fewer the number of providers, the less the service that is consumed. The amount of mental health service in a given community seems to expand almost infinitely to ac- comodate the practice of available providers. Thus, a most effective way in which in- surance companies can limit costs is to exclude large numbers of providers. The best means for excluding providers is to exclude entire classes of providers, such as all psychologists.

There are several means to exclude psychologists. One is an exploitation of the Erisa amendment, which is an inadvertent (but as yet unretracted) federal appropriations act that is sufficiently ambiguous to allow many insurance companies to ignore freedom of choice statutes in many states. Another method of excluding psychologists involves the emerging HMO and PPO organizations in the health delivery system. An increasing percentage of consumers are receiving their services through HMOs and PPOs. Thus, if psychologists are excluded from HMOs and PPOs, the number of providers again has been reduced significantly.

THE APA’s “FUTURES” (FLEXNER) TASK FORCE Each of the major health professions in this country has undergone one major

evaluation and upgrading during its lifetime. In medicine, this occurred between 1910 and 1920. The same process was replicated in dentistry by the Geis Report of the early 1930s. In 1983, the APA appointed a Task Force on the Future of Professional Psychology, which is sometimes referred to as psychology’s “Flexner” group. As had been the case with medicine and dentistry, it was anticipated that this body would recom- mend that psychologists be required to graduate from a nationally accredited training program before they were allowed to sit for a license exam. The Task Force has come forth with such a recommendation, and APA’s Council of Representatives will vote on this issue in 1987. In the meantime, large numbers of psychologists from weak training programs continue to graduate and to be licensed. Approximately 50% of all

Invited Editorial. The Changing Face of Clinical Psychology 843

psychologists licensed in the United States over the last 10 years have been from non- APA-accredited programs.

Many psychologists fail to appreciate the negative repercussions of being the only profession in the health service arena that does not require graduation from an accredited training program for entry into practice. The fall-out from this problem is not only with consumers, but with legislators and insurance carriers as well. These problems were brought home to me a few years ago when I was asked to lobby a gentleman named Stan Jones, who was authoring a national health insurance bill for Edward Kennedy’s Subcommittee in the U.S. Senate. In its initial draft, the bill did not provide for the reimbursement of psychologists. When I began my pitch to get psychology included, I was cut short by his statement, “If you can tell me what a psychologist is, I will tell you whether or not we can include you in national health insurance.” He went on to say that he did not know if psychologists were persons with a doctoral degree or a Master’s. Or, whether they rendered human services or did animal research. If they did possess doctoral degrees and rendered human services, were they from APA-accredited training programs? Have they had an APA-accredited internship?

Because of the above and similar experiences, I have been convinced that much of our energy should be directed toward the improvement of our product (psychologists) rather than simply selling the product.

Just recently, I accompanied four other colleagues on a special mission to Detroit to meet with the individuals in charge of the United Auto Workers’ (UAW) health plan. Our mission was to influence them to reverse their recent decision to exclude psychologists from direct independent reimbursement. After making our pitch, we were told: “When we reimburse psychologists, we get too much chaff with the wheat.” The point was that psychologists as a group are so heterogeneous in ability, training, and professionalism that we constitute a risk to their plan. To drive home the point even more forcefully, we were asked, “By the way, can you still get a psychologist’s license for your alligator in Florida?” This, of course, referred to the psychology licensure law in Florida, which for a time required only a mailed application. One psychologist requested such a license for his pet and it was granted.

Being out of step with other professions on the requirement for accredited training has greatly lowered our image among legislators and third-party reimbursers, to the point that anyone who wishes to deliver clinical psychology services works under a handicap.

THE REORGANIZATION OF THE APA In recent years, there has been a systematic rise in the proportion of APA members

who are identified with the practice of psychology and a corresponding shrinkage in numbers and influence of traditional research/academic psychologists. The best estimates are that only about one-quarter of all new graduates in generaVexperimenta1 areas of psychology bother to join the APA. There is an imminent danger that experimentalists will secede from the APA. Even if this does not occur, the erosion eventually will result in the APA’s becoming another professional organization essentially without scientists. This would rob psychology of its most distinctive ingredient (i.e., practitioners who possess a scientific orientation, who make judgments on the basis of the best data available, and who feel a sense of responsibility to generate and communicate new knowledge in their field. Without science, clinical psychology would become simply another form of psychiatry or social work. It no longer would remain distinctive within the health service field. At present, there is a reorganization plan on the drawing board that would grant autonomy in areas of practice to one APA society or assembly and autonomy in research and academic matters to another group within APA. This would allow psychologists with diverse interests to remain together within the same association.

844 Journal of Clinical Psychology, September 1986, Vol. 42, No. 5

THE FUTURE: CORPORATE HEALTH Dramatic changes in the health service field over the past 5 years provide a glimpse

of what may occur in the near future. The most startling prospect is the “corporatizing” of health (including mental health). In such a system, almost all services will be delivered by large corporations. Practitioners will purchase franchises from corporations, which will provide them with clients, tips on marketing, etc. The increasing demand for employee assistance programs (EAPs) will be met by large corporations. It has been predicted that as much psychological service will be delivered through EAPs during the next decade as currently is provided by independent practicing psychologists. And, there is the whole matter of health (not just mental health) services. Physical health has become a matter of lifestyle and, therefore, of personality and character. As such, physical health has become primarily a psychological matter. In addition to clinical psychology, there are components of educational psychology, motivation, and other psychological subspecialties that could be brought to bear upon this topic. The point is that psychologists will participate in both the mental health and physical health plans. We need to move to the forefront of this emerging trend in order to shape it in the best interest of psychology, as well as the public interest.

To summarize, “the times they are a changing.” Most of the changes now under- way involve the delivery of psychological services and, thus, clinical psychology. Clinical psychology’s survival depends upon practitioners responding to these changes. If the practice of psychology suffers, then support for clinical research and clinical training will shrink. By the same token, high demand for clinical services means more support for training and research.

Logan Wright University of Oklahoma

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