Psychotherapy Bulletin

Psychotherapy Bulletin

“An Old Cowboy Went Riding Out One Dark and Windy Day”

Spring brought to our nation’s Capital the 37th annual APA Practice Leadership Conference (PLC), which is always the highlight of my professional year. I especially appreciate the enthusiastic support of Susan Lazaroff and Dan Abrahamson for sharing this exciting experience with our next generation of military psychology and nursing leaders during their graduate student days at the Uniformed Services University (USU). This year, they joined with 350 engaged colleagues from around the nation. As Jared Skilling, APA Chief of Professional Practice, noted during the Opening Reception: “PLC is a perfect place to hone your professional skills, leadership skills, and advocacy skills and start putting them to work.”

Susan Farber of Idaho and Beth Rom-Rymer of Illinois participated on a panel entitled So You Passed RxP in your State – What’s Next?  Sue: “PLC offered a timely presentation of issues that arise after RxP bills are adopted. Most RxP advocates are clinicians who lack experience in setting up bureaucracies. This can lead to unanticipated problems. A few occurred in Illinois and Idaho following RxP enactment. One Idaho issue was a conflict between our open meeting law – a good law that values transparency in government – versus finding a way to allow an advisory committee to discuss various issues on behalf of the board of psychology. It turned out that meetings could only occur when the Bureau of Occupational Licenses could schedule and pay for all the personnel that needed to be present. Two good laws collided, and we are still working it out.

“A second problem was designating channels of communication that worked efficiently when applicants for licensing had questions. For the moment, we are advising applicants for licensure who have fulfilled all of the requirements for endorsement or licensure in Idaho to apply directly to the Idaho Board of Psychologist Examiners. All other questions should go to our newly opened psychopharmacology program – Eric Silk ([email protected]), Page Haviland ([email protected]), or myself ([email protected]). This program is in the College of Pharmacy and currently is an in-person, full-time two-year program that is ‘state of the art.’ Students go to class on Thursdays and Fridays and cover their practicum work during the summer. For about the price of a mid-level car, students can graduate in two years while working, and have a master’s degree, be prepared for the PEP exam, and have covered all supervised experience.

“Finally, in an exceptional measure, APA President Sandra Shullman is gathering together a group of applied psychology advisors to help states with issues that arise after RxP is adopted. It is impressive how our national organization is assisting our profession to mature into this new endeavor” (Sue Farber). For those dedicated to the RxP quest, Beth Rom-Rymer let those attending know that she has decided to run for APA President in the next election cycle.

Jared further opined: “What’s ahead for our profession and how we could come together to broaden psychology’s impact. PSYPACT is the psychology inter-jurisdictional compact that allows psychologists to practice telehealth between states that passed the PSYPACT law without needing additional licensure. It’s possible that in the near future, more than half of the states might have this law in place. PSYPACT will help improve the accessibility of our services to the public, and especially to rural and underserved communities – communities that really need our care.”

Alex Siegel: “Prior to the COVID-19 crisis, few psychologists were aware of what constituted telepsych services. Since February 2020, most psychologists are now aware of telepsych services but now have questions about how to use it or where they could use it to provide electronic services to patients, in particular with regard to inter-jurisdictional practice.  This is defined where the psychologist and patient are not in the same jurisdiction. Historically (prior to the pandemic), the psychologist and patient had to be in the same jurisdiction to be able to use telepsych. If they were located in different states, the psychologist typically had to be licensed in both states in order to provide electronic psychological services.

“When the pandemic hit the US, several state governors issued emergency Executive Orders which suspended or relaxed licensure regulations with regard to interjurisdictional telepsych practice. Most of these orders allow licensed psychologists to provide electronic services from where they are located to where the patient is located without having to be licensed in the state where the patient is located. However, not all of these Executive Orders are the same.  Some require out-of-state psychologists to register with the distant licensing board before practicing into that state, while others do not require notification. Some orders only allow psychologists to treat existing patients who have moved into their states, while others allow psychologists to see anyone. The Association of State and Provincial Psychology Boards (ASPPB) web site has information pertaining to what states allow/require during the COVID-19 crisis to provide telepsych services into their states.  The link can be accessed at: https://www.asppb.net/page/covid19.

“These Executive Orders are an efficient and effective way to allow for psychologists to provide psychological services across state borders. These orders, however, are only temporary and will expire after a certain number of days or when the COVID-19 crisis is over. At that point, those individual state laws and/or regulations pertaining to inter-jurisdictional practice will be once again be enforced and controlling. That is, psychologists will have to go back to following their pre-COVID-19 state laws and/or regulations.

“Fortunately, there is a long-term solution to providing inter-jurisdictional practice without having to be licensed in both states. This is where PSYPACT comes into play, as Jared stated at PLC. PSYPACT allows psychologists to provide electronic telepsych services from one compact state into the receiving compact state where the patient is located. It also allows for temporary in-person, face-to-face practice of psychology from one compact state into the distant compact state where the patient is located. Currently, there are 12 states which have adopted PSYPACT. There is active legislation in 15 additional states. It is hoped that once the crisis is over (and it will be over), that these states and others will realize how practical and useful interjurisdictional practice was to provide psychological services to their citizens to ensure increased access to care and continuity to care. Having the experience of working with telepsych during the COVID-19 crisis, psychologists are encouraged to work with their state psychological associations to let legislators know how important and beneficial it was for their patients to receive psychological services during the COVID-19 crisis and to advocate for the adoption of PSYPACT in their jurisdiction so interjurisdictional telepsych practice can continue” (Alex Siegel [[email protected]]).

Warnings from the Past

The recent coronavirus (COVID-19) pandemic prompted me to review the Institute of Medicine (IOM) 1996 report Healthy Communities: New Partnerships for the Future of Public Health. More than two decades ago these distinguished experts cautioned: “In recent years, we have witnessed the emergence or re-emergence of infectious diseases such as hantavirus, cryptosporidiosis, Escherichia. coli 0157, and Ebola virus.”  The IOM Committee strongly reaffirmed the importance of an even earlier similar prophetic report.  “The public’s health depends on the interaction of many factors; thus, the health of a community is a shared responsibility of many entities, organizations, and interests in the community, including health service delivery organizations, public health agencies, other public and private entities, and the people of a community. Within this shared responsibility, specific entities should identify, and be held accountable for, the actions they can take to contribute toward the community’s health.” “The function of local public health agencies should include an assurance that high-quality services, including personal health services, needed for the protection of public health in the community are available and accessible to all people.” “Governmental public health agencies have a unique function in the community: to see to it that vital elements are in place and that the [public health] mission is adequately addressed. These elements include assessment, policy development, and assurance.”

The Committee’s vision was expressed in the era of increasing managed care and increasing distrust of government. Proponents of managed care argued that its goals and tools were consistent with public health. Many public health professionals indicated concern about managed care organizations’ motives and ability to deliver on these promises. Critical to the IOM Committee was the development of the proper kinds of partnerships between managed care organizations and governmental public health departments to make this possible. The Committee further called for training within Schools of Public Health for professionals to work with health service organizations to ensure quality-related personal health services within communities as an essential element in providing for the health of the public.

In retrospect, one could seriously question whether our nation’s health policy leadership took seriously the importance of the underlying IOM recommendation that the government must fulfill its responsibility for “society’s interest in assuring conditions in which people can be healthy.” Nevertheless, giving credit where clearly due, in response to the pandemic, the Drumpf Administration made sweeping regulatory changes, which allowed healthcare practitioners to function to the fullest extent of the education and training, including ordering tests and medications that may have previously required a physician’s order. The Centers for Medicare and Medicaid Services (CMS) allowed for more than 80 additional services to be furnished via telehealth with providers being able to bill for telehealth visits at the same rate as in-person visits. Psychological and Neuropsychological Testing and clinical psychological services were specifically authorized, including the provision of e-visits by licensed clinical social workers and clinical psychologists, as Alex discussed above.

Reflections from the Past

“The most rewarding feature of my Presidency was perhaps seeing and working with the massive numbers of volunteers, our colleagues, who are deeply committed to the many causes APA reflects. It was a genuine and humbling privilege to be part of that. Add to that the APA staff, senior but at all levels, who put in very long hours routinely to make APA work so well. For example, the staff routinely give up weekends for Board meetings and prepare detailed reports occupying reams of paper (paper was used in those pre-pdf days, it may have been papyrus, I forget).

“The organization generates many Task Force reports on topics that reflect the diversity of divisions, interests, and priorities. Presidents typically generate a few during their term on issues of concern to them. I tried to read as many of those as I could. I was dazzled with the superb recommendations and thoughtful comments but also lamented that there appeared to me that there were too few efforts to implement the recommendations. Perhaps this was a structural and organizational issue. To my very limited history outside of APA, I would designate strategic planning committees on some issues then ‘sunset’ the committee once their work was completed.  I would follow this up with an implementation committee with budgets, when needed and where possible, to move to palpable change. This response is easy to do in a small organization (e.g., university departments) where there is not the scope of interests and priorities as evident in an organization as APA. That said, a super challenge of APA is managing the diversity of interests, priorities, and actually ‘professions,’ and one can only marvel at how the organization has so many successes.

“As for my term as President, perhaps only a couple of things endured. I started a new APA journal (Violence) that is doing well and an international collaboration for an organization devoted to prevention of violence (with Bob Geffner and Jackie White) – National Partnership to End Interpersonal Violence Across the Lifespan: Global Partners for Peace https://www.npeiv.org/.  These have endured and expanded without any influence on my part.

“I see the goals of APA to have palpable impact on improving public life. Since psychology is a science, I would lobby strongly for markers, measures, and indices that convey changes or improvements. For example, we love our evidence-based treatment and evidence-based practice, not at all the same, of course. Yet, the vast majority of people in need of mental health services receive absolutely nothing. And, it would be easy to identify a plethora of other critical issues in which more needs to be done (e.g., ensuring equity of pay among women and men, end to domestic violence, reduction of stigma, reduction or elimination of corporal punishment in the schools). For me, we ought to do more to make changes the members identify as needed and be sure that any reports, position statements, or messages to our legislators are followed up with stronger strategies to effect genuine change. We have some of the best researchers and data people in science, so evaluation issues are not at all insurmountable.  Perhaps to prioritize, we can identify the ‘grand challenges’ to which we can commit and include in that challenge ways of demonstrating a difference. We are all aware of the maxim, ‘First, do no harm.’ There is one that guides me and in the spirit of ‘improv’ in theater, I would add, ‘Yes and be sure not to give the illusion of helping,’ We collect data and evaluate not so much because that research is important but that people (animals and nature) are too, and we need some assurances that what we do is making a difference” (Alan Kazdin). “Ghost Riders in the Sky” (Johnny Cash).

Aloha,

Pat DeLeon

Former APA President – Division 29

Be the 1st to vote.
Cite This Article

DeLeon, P. (2020). “An old cowboy went riding out one dark and windy day.” Psychotherapy Bulletin, 55(2), 23-27.

References

0 Comments

Submit a Comment

Your email address will not be published. Required fields are marked *