The more than 12,300 colleagues who attended the 126th annual APA convention in San Francisco were especially fortunate to be gently reminded, especially during the remarkable Opening Session, why we had chosen psychology many years ago. The Keynote address by Attorney Bryan Stevenson provided an emotionally moving glimpse into the lives of those caught up within the criminal justice system—especially children—who have historically been “powerless.” Advancing social justice clearly remains a high priority for many of those in attendance. Throughout the convention, the personal stories of President Jessica Henderson Daniel’s Citizen Psychologists provided an awesome appreciation for how individuals can make a real difference in the lives of our nation’s citizens at the grassroots level. The unique and pressing needs of rural America, Veterans and military family members, and Rod Baker’s “Meaningful Retirement” symposium presentation highlighted areas in which psychology possesses truly unique expertise. On a personal level, I especially appreciated hearing the stories of the profession’s leaders—past, present, and future—during which APA President-Elect Rosie Phillips Davis spontaneously joined Recording Secretary Jennifer Kelly and Uniformed Services University (USU) graduate student Fernanda De Oliveira for “Getting Involved in the Policy Process—Challenges, Successes, and Strategies.”

Dr. Kelly’s presentation, “Strategies for Effective Advocacy in the Passage of Mental Health Legislation,” focused on the importance of effective advocacy in raising awareness on mental health issues and ensuring that mental health is on the national agenda of governments. She noted that advocacy on the Federal level is important as the federal government impacts psychology in numerous ways, including the funding of basic, applied, and clinical research; creating and administering social programs critical to the livelihood and health of the people psychologists serve; providing reimbursement for service delivery; and expanding opportunities in psychology education and training. She discussed ways to effectively advocate, such as making phone calls, writing letters and emails, and, most importantly, in-person visits with the lawmakers and their staffs. Dr. Phillips Davis presented her forthcoming Presidential initiative on “Deep Poverty.” She is forming a work group to explore the communication patterns that have led to poverty being considered an individual shame rather than a national problem. Her work group will explore how psychologists can use psychological science to partner with cities as mayors explore ways to improve the economic outlook for their citizens. They will also explore advocacy options with policy makers, service providers, individuals living in Deep Poverty, and psychologists who want to impact the number of people living in poverty.

As discussant, Fernanda De Oliveira  reflected on the recommendations provided by Jennifer and Rosie as they apply to students eager to advocate for their ideas at the institutional level, and commonly expressed barriers to seeing oneself in the role of an advocate within our field. More specifically, she noted how the same self-reflective nature that draws many of us to psychology can also keep us from believing in our capacity to advocate for our ideas and to promote change on behalf of those we serve. She concluded her comments by urging audience members to mentor their juniors on how to develop their identity as advocates of their ideas, knowledge, and profession.

The unprecedented advances occurring within the communications and technology fields, as well as the ever-shifting landscape of our nation’s healthcare environment, continue to have a major impact upon society and therefore the profession of psychology. Accordingly, the implications of these developments were present throughout the convention. Presentations on telehealth, including its complex ethical considerations, were especially timely. Fred Millan, Past President of the Association of State and Provincial Psychology Boards (ASPPB); Dr. Linda Campbell, and Jana Martin, CEO of The Trust, have been providing presentations on telehealth since the APA guidelines were adopted (they were co-chairs of the Task Force creating the guidelines) in 2013. They have an impressive case-oriented style which generates active audience participation. This year they shared scenarios on Confidentiality and Informed Consent. APA’s Deborah Baker also participated by discussing legal issues and state telehealth coverage mandates. Not surprisingly, the federal government has long been on the cutting-edge of effectively utilizing telehealth and fostering integrated care, as reflected in symposiums chaired by Chris Kasper, formally at USU and now Dean of the School of Nursing at the University of New Mexico, and Lisa Kearny, Chair of the Board of Professional Affairs (BPA). Both of these evolving initiatives, with their inherent implications for licensure mobility, present intriguing challenges and opportunities for all of the health professions.

Transformative Challenges

Psychology and each of the mental health/behavioral health professions must come to appreciate the transformational nature of telehealth. A recent communication from a longtime Hawaii colleague, who once again is serving as Director of our Department of Health:

Telehealth could be a valuable tool in evaluating individuals with behavioral issues who are brought to emergency rooms by police officers (i.e., ‘MH-1s’). Basically, MH-1s are brought to emergency rooms because they were disruptive and pose a threat to themselves or others. I believe one of the significant barriers to hospitals accepting these individuals is the lack of psychiatrists, psychologists, and other health professionals to evaluate MH-1s quickly and accurately when they are brought in, particularly in rural areas. As a result, only the large hospitals that have psychiatrists and other mental health professionals on staff 24/7 are comfortable taking most of them (i.e., Queen’s and Castle). Fortunately, some Neighbor Islands hospitals (e.g., Hilo, Kona, Maui Memorial, KVMH and Kauai Veterans) have found ways, but MH-1s are still considered a strain on limited resources. I believe telehealth would be a great way to assure a timely evaluation, so that the police officer doesn’t spend hours attending the person he or she brings into the ER waiting for an evaluation and, of course, it is good for the patient to be evaluated quickly, too. It seems to me that telemedicine, and particularly telepsychiatry, is a potentially terrific tool to expand the availability of mental health services in Hawaii. (Bruce Anderson)

A related, although slightly different perspective, regarding the long term implications of telehealth from a former BPA staff director:

As it continues to unfold, it will challenge the very basis of independent practice as we have known it since the late 1940’s. Licenses will cease to limit access to markets and the rationale for state regulation of practice will be called into question. APA’s policy infrastructure is not up to this, nor is its politics. As a strong, vocal, and visible advocate for these changes, I would encourage you to remember what happened to your CHAMPUS peer review project. The independent practice folks killed it and ushered in managed care. One would hypothesize the same will happen here. Systems of care will adapt. Private practice will soon see the threat of nationalized companies offering 24/7, 365 days service on demand. Batten down the hatches as we move forward because it’s unlikely to be as pretty as your columns suggest. (Dick Kilburg)

The Global Context

One of the most satisfying aspects of working within an academic environment, such as USU, is the daily exposure to intellectual colleagues who appreciate the “bigger picture” and who constantly remind one of the importance of being aware of the values and experiences of those from different professional and cultural backgrounds—that is, looking beyond perhaps comfortable, but intellectually isolating, “silos.” Dale Smith, USU Professor of Military Medicine and History, recently provided “A History of PhD Education” for the newly enrolled PhD students (“2018 Warrior Scholars”) at the Daniel K. Inouye Graduate School of Nursing.  Emphasizing the revolutionary impact of education upon practice, and vice versa, he quoted Daniel Coit Gilman: “The best teachers are usually those who are free, competent and willing to make original researches in the library and the laboratory.”

In 1900, 14 educational institutions joined together to create the Association of American Universities with the laudable goal of ensuring the overall quality of higher education. Psychology’s visionary Boulder Conference was held in 1949. In the mid-1960s, the Professional School PsyD concept arrived, shepherd by visionaries Drs. Nick Cummings at CSPP, Ron Fox at Wright State University, and Don Peterson at Rutgers University. In the 1950s, nursing moved from its historical, often hospital-based, diploma degree to the BSN standard. By 1970, there were 20 nursing educational institutions granting advanced practice master’s degrees; this number increased to 78 institutions by the year 2000. In 2001, the University of Kentucky had established the Doctor of Nursing Practice (DNP) degree. Today, there are 278 DNP programs and approximately 132 nursing programs granting the PhD.

As Dale described how nursing’s educational standards had evolved over time—especially within the larger societal context—those with a psychology or clinical pharmacy background could quickly appreciate the similarities with their own profession’s maturation. From this perspective, the landmark 2010 Institute of Medicine report The Future of Nursing, which calls for allowing nursing graduates to practice to the full extent of their education and training and to be full partners with physicians and other health care professionals, in fact, reflects both the changing dynamics of education and how educational advances have significantly modified what each health profession’s clinical practice is and will be expected to become. Society’s very definition of “quality care” has been constantly undergoing significant change. “We all live in a yellow submarine” (The Beatles, 1966).

The Advanced Practice Registered Nurse (APRN) Legislative Experience

When one appreciates that each of the health professions functions within a changing American healthcare environment, the importance of building interprofessional relationships and collaborative legislative coalitions becomes increasingly evident. Carole Myers and Jill Alliman recently published in an American Association of Nurse Practitioners (AANP) journal Updates on the Quest for Full Practice Authority in Tennessee, which is considered one of the most restrictive states in the nation. In 2016, the Tennessee General Assembly established a Scope of Practice Task Force to “make recommendations on the implementation of a plan to allow health care providers to work to the full extent of their education, experience, and training and identify… unnecessary regulations.” The authors noted that the resistance to progressive change that they are experiencing in Tennessee is similar to experiences in other restrictive states, many of which are located in the Southeastern United States. Advancing full practice authority will require new strategies.

Their Task Force met four times and polarization between the physician and nurse members was apparent from the first meeting. The physicians attempted to draw attention away from the assigned objectives by utilizing distractions and distortions. They assaulted the adequacy of APRN education; dismissed evidence of cost, quality, effectiveness, and acceptability of APRN-provided care; denied health care access problems existed; and blamed APRN prescribers for the state’s prescription drug abuse epidemic. Attempts by the nursing members to respond to these tactics with evidence and logic proved ineffective at dispelling misconceptions and false statements. If evidence-based medicine was to be the acceptable standard of care, then actual care should be evaluated using clinical and patient-satisfaction outcomes, not the number of years of education. Perhaps physicians are, in fact, over-prepared to deliver the majority of direct primary care services and are better suited to roles related to population health management and caring for populations with complex needs. Simply stated, the physicians refused to recognize the evidence presented by nursing during the Task Force proceedings.

The key lessons learned: *It is imperative to engage nurses and stakeholders from non-nursing sectors, including business and industry. *Evidence is a beginning and a means, but not an end. It is important that evidence be translated into an easy-to-understand, effective message that resonates with stakeholders and motivates them to act. *Unity is powerful. In the past, there have been numerous efforts by a variety of organizations to divide nurses. And, *Full practice authority is primarily about access to high-quality, cost-effective care that honors patients’ choice of providers. The motivation and discussion on full practice authority must remain patient-centered. Those dedicated to psychology’s prescriptive authority (RxP) agenda should not be surprised to learn that Bethe Lonning reports that at their Administrative Rules Review Committee meeting for the Iowa legislature, the lobbyist for the Iowa Psychiatric Society spoke in the public comment section to indicate that her members had concerns about the education and training of potential RxP psychologists, as written in the proposed rules.

Aloha.

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Pat DeLeon, Ph.D.