Observer

January 2002
Volume 15, Number 1

Looming Ahead

Incoming Academy President Don C. Fowles of the University of Iowa, an APS Fellow, says three "overlapping issues" loom large in the coming years.

1. Managed Care. The emphasis on cutting health care costs "has reduced the demand for PhD level providers of clinical services in psychology, both in terms of trying to limit psychological services to contain costs and in terms of substituting MA level psychologists and social workers. In some ways that affects our programs less than more practitioner-oriented programs, but it still is a changing environment for our graduates."

"Our programs were already in a better position to provide better ways of evaluating efforts and program development," adds current APCS President Richard Bootzin of the University of Arizona, an APS Fellow and Charter Member. "Changes in the health care environment have been challenges for everyone, but they also are an opportunity for many of our programs to strengthen some of the things that were already moving in that direction.

"Managed care narrowed the focus and made it much more evidence-based. That required having an evidence base. If you're going to provide only those interventions demonstrated to be effective in the literature, you need that literature. Our membership helps provide the evidence for more effective applications and better understanding of the problems. In that sense, although it's a frustration to deal with managed care in many ways, the focus on evidence-based interventions actually supports a major aspect of our program." It also means the role of psychologists in applied settings should broaden, involving the evaluation of services and possibly even administering programs.

2. Developing guidelines for empirically supported treatments (EST). "On the one hand," says Fowles, the need for such guidelines "is strongly consistent with clinical science and is easily defended in the context of managed care. On the other hand, such research tends to reify the DSM-IV (fourth edition of the Diagnostic and Statistical Manual), because much of the research validates specific treatments as applied to DSM-diagnosed disorders.

"To show that a given treatment does work with a group of individuals meeting criteria for a specific diagnosis is not to say that the treatment does not work with other individuals, or that other treatments would not work with the same individuals. Also, common factors account for a portion of the effectiveness of treatments and it is not always clear that a given EST is actually effective because of specific features in that approach."

The unanswered questions need further research, Fowles says, but sometimes "the scientific debate takes place in a heated political atmosphere. Some practitioners feel threatened by the EST movement, because it restricts the types of treatment-patient combinations likely to be reimbursed, and they may want to oppose all attempts to develop standards for ESTs. Some advocates of EST may have a political agenda of achieving recognition for psychological treatments and parity with pharmacological treatments. In some ways, then, support from managed care organizations for ESTs may support a clinical science approach, but it is important to understand that their primary agenda is cost containment, not science."

3. Prescription Privileges. "As everyone knows, there is a politically strong movement for prescription privileges for psychologists, and a fairly intense national debate about the merits of such a development. At least in part, this is a response to the reduced demand for services as a result of managed care. The vast majority of faculty I've heard comment are strongly opposed to it, but obviously a great many clinical psychologists support it. If the movement for prescription privileges is successful, it would have a major impact on graduate training, as well as the field in general." The Academy has taken no position on prescription privileges for psychologists.