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Reflections on the Future: Psychology as a Health Profession
Cynthia D. Belar American Psychological Association
The author describes a vision of psychology’s future as a health profession. In broadening its focus from mental health to a range of health issues, the profession is faced with a number of challenges related to establishing its identity, ensuring public confidence, and participating in the health care system. Specific imperatives include the need to articulate the core competencies of health service psychologists, assure quality in preparation and practice, and work collaboratively with other professions while participating actively in the redesign of the health care system.
Keywords: health service psychology, competencies, quality assurance, interprofessional
My vision for professional psychology is extraordinarily broad. Although psychology can and does contribute to many domains of professional practice, my own career has been within the area of health; thus it is in this area that my vision is clearest.1 Psychology has a number of important roles to play in health and the future health care system, including teaching, research, practice, and policy (see Figure 1). We do this work at multiple levels—at the level of the individual, family, health care provider/system, and sociocultural context.
As practitioners, our work is relevant to each and every one of the health problems identified by the International Classification of Diseases (ICD-10; World Health Organization [WHO], 1992). Models for assessment, treatment, and consultation are described in more detail in earlier work by myself and others (Belar & Deardorff, 2009; Belar, Deardorff, & Kelly, 1987; Belar, Paoletti, & Jordan, 2001; Boll, 2002–2004). Although there are knowledge and skills specific to each component of this model, there are also a number of cross-cutting issues requiring expertise, for example, dealing with issues of treatment adherence and understanding implications of health belief models. Moreover, there is an impor- tant fourth dimension that makes for an even more complex model—a dimension that includes health promotion, primary pre- vention, and secondary prevention.
Historically, practitioners in psychology have focused primarily on only one slice of the psychology and health model—that related to the ICD-10 category of Mental Disorders (the 5th of 16 cate- gories). Yet as psychological science and practice have evolved over the past 40 years, organized psychology now recognizes and advocates for the profession’s broader role in health. (A history of the development of health psychology per se can be found in the work of Belar, McIntyre, & Matarazzo, 2012.) Because I believe these trends will continue into the future, I envision psychology as a widely recognized health profession with practitioners who are competent to provide a range of health care services consistent with the American Psychological Association’s (APA’s) definition of health service psychologists:
Psychologists are recognized as health service providers if they are duly trained and experienced in the delivery of preventive, assess- ment, diagnostic, and therapeutic intervention services in relation to the psychological and physical health of consumers based on (1) having completed scientific and professional training resulting in a doctoral degree in psychology; (2) having completed an internship and supervised experience in health care settings; and (3) having been licensed as psychologists at the independent practice level (American Psychological Association [APA], 1996; reaffirmed in American Psy- chological Association [APA], 2011).
Per Figure 2, health service psychology (HSP) is conceptualized as including most of the doctoral education and training currently being conducted in accredited professional psychology programs. Conceivably, there are some communities within clinical, coun- seling, and school psychology that do not focus on the provision of
1 This article represents my own opinions and not necessarily those of the American Psychological Association. Although my focus here is on health, I view professional psychology broadly as the application of psychological science to real-world issues. There are many areas of practice that need vision and nourishing, especially those in the sector of education, an area of signif- icant national need. Given my own experience of having argued for over 35 years for a broader role of psychology in health, I often wonder about those psychologists who are now expanding the boundaries of scientifically based practice in areas that we in organized psychology have yet to appreciate and incorporate into our vision for professional psychology. Will it take another 30 years for organized psychology to capitalize on their work? What are we missing in the meantime, and if their work does continue to flourish, what will the world of psychology be like then?
Editor’s Note. This article is one of 11 in this special section on Visions for the Future of Professional Psychology.—MCR
This article was published Online First September 17, 2012. CYNTHIA D. BELAR received her PhD in clinical psychology from Ohio University after an internship at Duke University Medical Center. She is executive director of the American Psychological Association Education Directorate and professor emerita in the Department of Clinical and Health Psychology at the University of Florida Health Science Center. Her areas of research, practice, and teaching have included clinical health psychology and health policy. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Cyn- thia D. Belar, Executive Director, Education Directorate, American Psy- chological Association, 750 First St. NE, Washington, DC 20002. E-mail: [email protected]
Professional Psychology: Research and Practice © 2012 American Psychological Association 2012, Vol. 43, No. 6, 545–550 0735-7028/12/$12.00 DOI: 10.1037/a0029633
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health care (e.g., executive coaching, educational assessment, and vocational and academic counseling), but it is estimated that the bulk of practitioners in these areas do provide health care services, many of which are broader than traditional mental health services.
Significant influences on our transition to a health profession are societal needs and demands, a changing health care system with its related economic forces, and the growth of psychological science related to health and behavior. To successfully make this transi- tion, we will need more progress in establishing our identity, ensuring public confidence, and participating in the health care system. More specifically, I offer the following imperatives.
Health Service Psychologists Must Develop a Clear Identity in Terms of Their Core Competencies
Given psychology’s breadth and diversity as a profession, as well as our value of inclusiveness, we have not yet sharpened our identity (or quality assurance mechanisms) related to the provision of health services. Yet we must be able to clearly define the health service subset of professional psychology if we are to communicate effec- tively with students, the public, health policymakers, and other pro- fessions. The provision of mental health services is an extremely
Figure 1. Psychology and health (adapted from C. D. Belar, 2003). ICD-10 � International Classification of Diseases.
Figure 2. A conceptual model of health service psychology (from Health Service Psychology Education Collaborative, in press).
546 BELAR
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important part of psychological practice, but only one subset. We need a broader definition that can be directly linked to the education and training received and the competencies of our graduates if we are to maximize our potential in the health care system.
I have been strongly committed to advancing a culture of competence in professional psychology. The competency move- ment in education and training is consistent with psychology’s focus on student learning outcomes and parallel work in other health professions. Its history has been described elsewhere (Rubin et al., 2007). It is based upon the integration of scientific knowl- edge and methods with practice, and should not be characterized as a simple checklist of techniques or skills to be mastered.
The articulation of professional competencies demonstrates the discipline’s commitment to accountability in the higher education system and to the various publics served. Specifically, it informs the public and policymakers and promotes an understanding of the distinctive features of psychologists’ knowledge and skills that prepare them for participation in the health care system. It also informs prospective students in their review of program offerings in the context of anticipated career paths. Recognizing the need for a clear set of learning outcomes expected of all graduate programs that have as a goal the preparation of health service psychologists, such a statement was developed in 2012 by the interorganizational Health Service Psychology Education Collaborative after a period of public comment and review by numerous organizations in psychology (Health Service Psychology Education Collaborative, 2012).2
The HSP competencies are organized around the cluster system adopted in the competency benchmarks model (Fouad et al., 2009). They were not intended to be specific to areas of practice such as primary care or specialties such as Clinical Health Psychology but represent the broad and general training expected of all health service psychologists. These competencies have clear emphases on integrating knowledge from biological and social sciences with that of core psychology (regardless of area of practice), under- standing the context of health care delivery along with competence in interprofessional collaboration, and conducting practice-based research, regardless of training model.
Knowledge From Other Disciplines
Health professions such as medicine have always relied on other disciplines—such as biology, chemistry, and behavioral science— for foundational knowledge. Most recently, in keeping with the growth of knowledge regarding health and behavior, medicine has markedly increased its focus on the social and behavioral sciences for entry to medical school, within the curriculum itself, and in practice. Professional psychology’s history differs from other health professions in that it originated as its own academic disci- pline. Although always very reliant on statistics, the core curric- ulum in professional psychology has had little emphasis on other disciplines. Yet as our understanding of health has become increas- ingly biopsychosocial, it is important that the preparation of psy- chologists include more working knowledge in areas such as core biology, pathophysiology, genetics, pharmacology, and anthropol- ogy as well as an understanding of health policy. “Even programs that profess to follow the biopsychosocial model for the assess- ment and treatment of patients often fail to consider the impact of financial payment systems and service delivery design on concep- tual models, clinical decision making, and kinds of services of-
fered” (Belar, 1989, p. 392). Some of this knowledge could be required as prerequisites for graduate education in health service psychology, and I do expect a “preclinical” curriculum to evolve. Certainly a more streamlined training model of graduate education would be possible if there were more integration with the under- graduate curriculum.
Interprofessional Practice
Although calls for interdisciplinarity go back decades (Institute of Medicine [IOM], 1972) and team-based approaches in some practice areas have been commonplace for many years, there has been renewed energy related to this topic over the past decade. The seminal report To Err Is Human (IOM, 2000) alarmed both poli- cymakers and the public about significant problems of safety in the health care system. Problems in communication and coordination among health professionals were cited as basic causes. To improve safety and address preventable mortality and morbidity, findings from other high-risk industries that relied on the scientific litera- ture in human factors, cognitive psychology, group dynamics, and organizational change (much of which was created by psycholo- gists) were employed in health care. A subsequent report, Crossing the Quality Chasm, documented escalating costs without concom- itant demonstration of quality, thus increasing the demands for health care reform (IOM, 2001). That report concluded that patient-centered, safe, effective, efficient, and equitable health care would require development of effective teamwork and the redesign of the health care delivery system itself. Soon after, the 2003 IOM report, Health Professions Education: A Bridge to Quality, con- cluded that work in interdisciplinary teams was one of the five core competencies for all health professionals (IOM, 2003).
In May 2011 the Interprofessional Education Collaborative re- leased the report Core Competencies for Interprofessional Collab- orative Practice (Interprofessional Education Collaborative [IPEC], 2011). The core competencies noted are in the domains of values/ethics for interprofessional practice, roles/responsibilities, interprofessional communication, and teams and teamwork. These competencies are being promulgated by a number of health pro- fessions—many of which have or are moving to include them into their criteria for accreditation of education and training programs. The Agency for Health care Research and Quality also has a sustained focus on teamwork, and there is growing evidence to support its importance in quality care (Baker, Gustafson, Beaubien, Salas, & Barach, 2005).
Fundamental to competence in interprofessional functioning is interprofessional education (IPE): “When students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes” (WHO, 2010). Although there have not yet been widespread changes in the education of the health professions, I expect interprofessional
2 This group comprised representatives appointed by the APA Board of Educational Affairs, the Council of Chairs of Departments of Psychology, and the Council of Chairs of Training Councils; it was supported by APA. Authors of the document included Cynthia Belar, Cathy Grus, Frank Andrasik, Sharon Berry, Clark Campbell, Margaret Gatz, Carol Goodheart, Cindy Juntunen, Elizabeth Klonoff, Theresa Lee, Janet Matthews, M. Ellen Mitchell, Celiane Rey Casserly, and Michael Roberts. HSPEC has also created A Blueprint for HSP Education and Training, which is forthcom- ing.
547FUTURE AS A HEALTH PROFESSION
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education to become increasingly prominent.3 How is this relevant to the future of practice? As interprofessional education becomes prevalent in the preparation of other health professions, psychol- ogy cannot expect to be added to the health care team when team members did not train with our students and faculty. As a hub science, psychology interacts with numerous disciplines. Those training to become health service providers must have continuing contact with the other health professions, and our graduate pro- grams need to reach out to health care settings for more advanced training, and not rely totally on single discipline clinics.
Practice-Based Research
Creating the vision of a patient-centered health system that is responsive to community needs will require local research efforts and population-based data. Skills in program development and evaluation are essential in an integrated care system, and psychol- ogists are especially well suited to these roles (Belar, 1989). Yet the role of training to conduct research has been associated with considerable tension in our field. In breaking away from the scientist–practitioner model, many at the Vail Conference argued that psychologists need only be trained as consumers of research (Korman, 1974). Others have argued for rigorous training as a “local clinical scientist” (Trierweiler & Stricker, 1998). There are now well-accepted pathways to practice that include different emphases on research, from training to become an independent investigator to training to become an educated consumer of ad- vances in research. For our future health workforce, I believe that all practitioners will need skills in conducting practice-based re- search, particularly for assessing patient outcomes and for quality improvement efforts. Quality improvement methodologies will be essential in the repertoire of future practitioners.
Professional Psychology Must Recognize the Participation of Other Behavioral Health Providers and Articulate Its Distinctive Contributions to the
Health Care System
Related to a clear articulation of our professional competencies for health service providers, psychology needs to recognize the competencies of other professions—a core component of interpro- fessional competence. Psychologists actually participate in the training of multiple health professionals to foster the application of psychological science to the health care system and patient prob- lems. They are active participants in curricula for physicians, dentists, nurses, and counselors, among others. For example, our science has become an increasingly important requirement in physician training, including entry to medical school (Association of American Medical Colleges [AAMC], 2012; IOM, 2004). His- torically, we have valued “giving psychology away,” and we have worked hard to do so for the public welfare. That does not mean psychology does not need a strong guild to protect professional interests, but it does mean that our guild needs to work collabora- tively with other health professions.
Although trained by psychologists, other professions have now matured and often provide services such as psychotherapy at a lower cost. During my years as chief psychologist at the Los Angeles Kaiser Permanente Medical Center, I was successful in hiring new psychologists because of specialty services (e.g., neu-
ropsychological assessment, clinical child, clinical health) and program development skills. Challenges only existed when psy- chologists were seen as doing the same thing as social workers (Belar, 1995). While others have argued that irrefutable data on cost effectiveness of psychological services will secure our future as practitioners, I still recall our history of “giving psychology away.” My vision continues to emphasize that
[i]t is the research skills used in the development of the new treat- ments or methods of service delivery and the empirical approach to these same activities that will ensure the survival of psychology. There are increasing demands in . . . health care for measurement of quality of care, assessment of cost effectiveness, documentation of service needs, program development and evaluation, and systematic clinical management. These areas require the measurement and data- analysis skills obtained during research training. Merely being a consumer of research will not suffice; other disciplines already train their practitioners as consumers of research. (Belar, 1989, p. 393)
We must recognize the context within which we work, recog- nize, and respect the contributions of others, yet assert the distinc- tive contributions that psychologists are prepared to make. As all professions are expected to work to the highest level of their education and training, our roles in supervision, program develop- ment, management, and team leadership will be increasingly prominent.
Psychology Must Be Seen as a Mature, Autonomous, Self-Regulating Profession
Although organized psychology has endorsed the importance of APA accreditation for doctoral programs, its attention to the need and advocacy for accreditation in internship training has been lacking (despite such a requirement by many employers). Recent events suggest that this is changing;4 I believe it must change for the profession to be seen as mature. The internship is the most intensive training experience in preparation for practice.
The social contract between a profession and the public is that in return for its autonomy, the profession is self-regulating to serve the public interest. While the state may credential individual psycholo- gists to protect the public, the standards for education, training and practice are set by the profession. With respect to standards for education and training, program accreditation by national psychology serves as the self-regulating quality assurance mechanism. APA’s Commission on Accreditation is recognized by the U.S. Secretary of Education and the Council for Higher Education Accreditation as the specialized accreditor for professional psychology.
There is already a norm among other health professions: graduation from a program accredited by the profession is a requirement for sitting for the licensure exam or licensure. Psychology is seen as quite unusual by our colleagues in medicine, dentistry and pharmacy, among others. They are surprised to learn that training accredited by the profession is not required by many states for licensure. They are even more alarmed to hear that state regulations often define which
3 A Cochrane Review found that four of six studies demonstrated a positive impact of IPE on working culture, patient satisfaction, and care provided, including decreased errors (Reeves et al., 2008).
4 The Council of Chairs of Training Councils, the APA Board of Educational Affairs, and the Association of State and Provincial Psychol- ogy Boards have all made moves in this direction within the past 2 years.
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courses or experiences should be in a doctoral or internship curricu- lum — such definitions are seen as the province of a mature self- regulating profession, not the state.
The state steps in when there is a lack of confidence in the self- regulation of the profession. Psychology cannot afford to devolve in this manner. Many excellent, well-intentioned psychologists partici- pate in state licensing boards and while other ways of identifying appropriate education and training may have been necessary in the past, the time has come for psychologists (from academic trainers and field supervisors to state regulators and employers) to accept and rally around the single standard of APA accreditation. If the goal of an APA-accredited program is to prepare psychologists for entry to practice, we need to ensure that the public and the state are confident that our goals are being achieved. That is where we must put our effort. If we fail, we will not only do a disservice to the public, but we will never have parity with other health professions. (Belar, 2011, p. 49)
I believe that to obtain credibility with other professions and the public, psychology needs to have a workforce that has been trained in programs that have been deemed to meet the standards of the profession through a recognized quality assurance mechanism. The public also needs assurance that psychologists maintain and update their skills in practice.
Professional Psychology Must Develop a Credible System for Maintenance of Competence
The public and its regulatory groups have demonstrated in- creased concerns about the maintenance of competence for pro- fessional practice throughout the professional life span. This is in part driven by the recognition of the decreased half-life of knowl- edge, but perhaps more so by the consumerism movement that impacts both individual and organizational behavior. Historically, psychology has relied on a commitment to our ethics code to promote continued professional development. In addition, many states require the documentation of formal continuing education (CE) for credentialing processes. However, as public pressures for accountability increase, measures of “seat time” will not suffice any more than they do now for the demonstration of adequate preparation for professional practice. Rather than relying on par- ticipant satisfaction, we should anticipate more focus on the direct assessment of learning outcomes as formal CE becomes a signif- icant load-bearing mechanism for documenting the continued pro- fessional development demanded by the evolving health care sys- tem. We should also expect movement toward more direct assessment of competencies for continued practice, because the link between formal CE and its translation to practice is not well established. The use of standardized patients and computer simu- lations currently prevalent in medicine (and often developed by psychologists) is likely to enhance this movement.
Professional Psychology Must Be Ready to Participate Fully in a Redesigned Health Care System: Psychology
Is Both a Primary Care Profession and a Specialty Care Profession
The expansion of primary care is seen as fundamental to a reformed health care system. Legislation such as the Recovery and Reinvestment Act of (2009) and the Patient Protection and Afford-
able Care Act of 2010 have promoted the expansion of primary care. Organizations representing employers, payers, providers, and consumers advocate for models such as the “patient-centered health home” that rely on interprofessional teamwork and team- based care for implementation. Indeed, there are already 3300 practices recognized as patient-centered medical homes by the National Commission on Quality Assurance (NCQA, 2011).
The federal government has looked to its community health center program established under former President Lyndon B. Johnson to provide the “safety net” system of health care for underserved populations. This program has strong bipartisan sup- port and has received considerable increases in funding over the years despite cuts in other areas. Many believe that it is destined to be a centerpiece of efforts to improve access to primary care. At present there are nearly 8000 service centers throughout the coun- try, but fewer than 400 psychologists employed therein (Wake- field, 2012). Barriers exist, especially those related to same-day billing and reimbursement by Medicaid. If these problems are not solved, psychology’s future will not be as bright.5
Although specialty mental health practices will remain impor- tant components of the health care system through the “neighbor- hoods” developed by accountable care organizations, professional psychology must have a strong presence in the primary care system itself if it is to maximize its contributions. In addition to building bridges to specialty mental health care, it is important to note that it is in primary care where most patients, even those with mental health problems, are actually seen. Primary care has long been recognized as the de facto mental health system (Regier, Goldberg, & Taube, 1978). Moreover, behavior and health are inextricably intertwined; 100% of medical visits have psycholog- ical/behavioral components (Belar, 1996). It is in primary care where many patients with chronic diseases are managed, and to which psychological services can make significant contributions. In terms of the health reform framework, psychology is both a primary care health profession and a specialty care profession, similar to medicine.
In conclusion, psychology as a discipline is making, and will continue to make, significant contributions to health through edu- cation, research, and service. But if we are to maximize our potential as practitioners to contribute to our nation’s health care system, psychology needs to meet the five imperatives noted above. How might we do that? Each requires sustained effort and collective action, which in turn depends upon the individual mem- bers of the profession as the real agents of change. We will need to capture the energy of the diverse groups in our profession to proactively seek similar goals, including continuous quality im- provement. We must agree on setting standards and maintaining quality assurance mechanisms that are trusted by the public. We will also need a united voice in advocacy efforts at the local, state, and federal levels.
5 In this issue, Dr. Nordal emphasizes the importance of advocacy for the future of professional psychology. I am in complete agreement. I also want to note that education advocacy supports advocacy for practice. For ex- ample, federal funding for education and training has established psychol- ogy as a health profession in the HRSA Bureau of Health Professions. It is also well accepted that federal support for training facilitates federal support for reimbursement of services.
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Received December 27, 2011 Revision received July 7, 2012
Accepted July 10, 2012 �
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