RE: Discussion Questions_wk5

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Question A:  Explore contemporary issues in clinical psychology. (200 word minimum with 1 peer reviewed reference. Make sure to include your opinion, observation, etc)

Question : Discuss the future of clinical psychology as a profession. (200 word minimum with 1 peer reviewed reference. Make sure to include your opinion, observation, etc)

Question C: Conflict between researchers and clinicians (200 word minimum with 1 peer reviewed reference. Make sure to include your opinion, observation, etc)

In the last several years it has become more apparent that there is a growing conflict between those who research the information and those who directly work with patients. But why? Should every aspect of clinical practice be based on empirically-based research?

The issues between researchers and clinicians interesting depending on the decisions based on the resolution of the conflict, it could have both a negative and positive influence on clinical practice. What are the issues? And if there is empirically based research to change society's ways of treating mentally ill individuals who need help, why is it not being done?

Question D: Code of ethics – one more time (200 word minimum with 1 peer reviewed reference. Make sure to include your opinion, observation, etc)

Ethics remains one of the most important issues in mental health. The relationship between therapist and client is one of vulnerability and it is the professional who bares all the responsibility to keep the client safe.

Ethical violations - a review

We are revisiting this issue because there are many clinicians who make poor choices and find themselves in front of the state Board of Psychology trying to defend their actions. We have looked at the issues related to sexual misconduct but the Code covers many issues.

 For our last week, advance for discussion at least one ethical breach (not sexual misconduct) and discuss why the issue is an ethical concern for the individual patient or the community. Do you have any ideas what penalties might be imposed? You can develop your own.

Question E: ERR: The Future of Psychology Practice and Science (200 word minimum with 1 peer reviewed reference. Make sure to include your opinion, observation, etc)

Question F: ERR: The Present and Future of Clinical Psychology in Private Practice (200 word minimum with 1 peer reviewed reference. Make sure to include your opinion, observation, etc)

Question G: ERR: The Future of Clinical Psychology: Board Certification (200 word minimum with 1 peer reviewed reference. Make sure to include your opinion, observation, etc)

Question H: ERR: The Role of Clinical Psychology in Rural Mental Health Services: Defining Problems and Developing Solutions (200 word minimum with 1 peer reviewed reference. Make sure to include your opinion, observation, etc)


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The Role of Clinical Psychology in Rural Mental Health Services: Defining Problems and Developing Solutions CLINICAL PSYCHOLOGY PSYCHOLOGY: AND SCIENCE MENTAL Published HEALTH AND PRACTICE JAMESON • V14 N3, & BLANK SEPTEMBER 2007 Original XXX Blackwell Malden, Clinical CPSP © 0969-5893 2007 American Psychology: USA Articles Publishing Psychological Science IncRURAL andAssociation. Practice by •Blackwell Publishing on behalf of the American Psychological Association. John Paul Jameson, Department of Psychology, University of Pennsylvania Michael B. Blank, Center for Mental Health Policy and Services Research, Department of Psychiatry, University of Pennsylvania Rural areas of the United States continue to struggle to provide residents with adequate access to quality mental health care. Problems with adequately defining rurality for research and policy purposes, a shortage of qualified personnel, a lack of integration between primary-care and specialty mental health services, and stigma associated with mental illness have contributed to the mental health service crisis in rural areas. The assertion is made that psychologists can help to alleviate these problems through specialized training for rural service, the utilization of technology for service delivery, the dissemination of empirically supported treatments, and grassroots advocacy. Furthermore, the advantages and disadvantages of prescription privileges for psychologists and the unclear status of subdoctoral providers are discussed in terms of potential impact on rural areas. Finally, psychologists are encouraged to direct research efforts toward the development and implementation of novel solutions to the service problems in rural areas. Key words: mental health services, psychologists, rural environments. [Clin Psychol Sci Prac 14: 283–298, 2007] INTRODUCTION Throughout our history, the United States has enjoyed portraying itself as a rural nation. Our songs speak of Address correspondence to John Paul Jameson, Department of Psychology, University of Pennsylvania, 3720 Walnut Street, Philadelphia, PA 19104-6241. E-mail: jjameson@psych.upenn.edu. the majesty of our mountains and the fruitfulness of our planted plains, our literature relates stories of hardships of farming and the loneliness of the frontier, and our artists give renditions of wide open spaces and the simplicity of country living. Even today, we pride ourselves on our independence and frontier spirit, although only approximately 20% of Americans live in rural areas (United States Bureau of the Census, 2001). Despite our heritage as a rural society, individuals in rural areas today can be characterized as a vulnerable population. Rural residents are more likely to live in poverty, lack health insurance, report poor health, have a chronic health condition, and be unemployed (see Wagenfeld, 2003, for a review). As a population, rural inhabitants earn less income and include a higher proportion of the elderly. Additionally, rural areas lack the social and health services necessary to accommodate its inhabitants. Services that do exist have been described as fragmented and inconsistent (Fox, Blank, Kane, & Hargrove, 1994). This is especially true of mental health care in rural areas. Empirical research on mental health care in rural areas is scarce, and the research that does exist paints a bleak picture of the available services. Furthermore, research conducted on rural areas, including many of the studies cited in this article, has often been limited to sampling rural areas in one particular geographic region of the country. The generalizability of many studies can be questioned for this reason. That said, the prevalence of mental illness in rural areas does not appear to differ from rates seen in nonrural areas, based on results from the National Comorbidity Study and the Epidemiologic Catchment Area Study (Kessler et al., 1994; Robins © 2007 American Psychological Association. Published by Blackwell Publishing on behalf of the American Psychological Association. All rights reserved. For permissions, please email: journalsrights@oxon.blackwellpublishing.com 283 & Reiger, 1991). The purpose of the present article is to provide an overview of the mental health care problems in rural areas, offer suggestions for the amelioration of the problems faced, and help direct future research efforts. Issues of Definition: What Is Rural? Defining rurality is an issue that invariably arises in any discussion of rural problems. Wagenfeld (2003, p. 33) described the consideration of definitions of rural as “a surprisingly difficult task.” This task should not be taken lightly: The method by which rural is defined can have far-reaching impact on the application of policy. The definitions of rural most commonly used in research are those supplied by the U.S. Census Bureau, the Office of Management and Budget (OMB), and the United States Department of Agriculture (USDA). All of these methods rely on population as the central metric of determining what is rural and what is not. Each of the definitions has advantages and disadvantages, and none are completely adequate to delineate all areas that most would consider to be rural. Furthermore, there is not complete overlap of areas using these definitions. For example, Ricketts, Johnson-Webb, and Taylor (1998) reported that in 1990, 37.3% of individuals living in OMB-defined nonmetropolitan areas were categorized as urban dwellers by the U.S. Census Bureau and 13.8% of individuals in OMB-defined metropolitan areas were defined as rural dwellers by the census. The USDA (United States Department of Agriculture Economic Research Service, 2003) provides what is probably the most popular method for defining rural among researchers (Blank, Fox, Hargrove, & Turner, 1995; Wagenfeld, Goldsmith, Stiles, & Manderscheid, 1993). The USDA uses urban–rural continuum codes to indicate a county’s degree of rurality. The coding scale assigns a designation on a scale of 1 (most urban) to 9 (most rural). Counties coded 1–3 are considered metropolitan, whereas counties coded 4–9 are considered nonmetropolitan. Metro counties are designated based on population; nonmetro counties are designated based on population and proximity to urban areas. There is good reason for its popularity; to an extent, one can infer the influence of urban areas on rural areas using this system, an important consideration when evaluating the availability of mental health services. However, this definition has serious shortcomings as well. Perhaps the most damning CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • flaw is that codes are assigned at the county level, limiting the ability to precisely demarcate rural areas. This is particularly problematic for large western counties, in which inhabitants can live minutes or hours from a large city and inhabit the same county. An illustrative example of this problem is Coconino County in Arizona. Coconino County contains the city of Flagstaff, and is coded as a 3 (metropolitan county with a population fewer than 250,000). However, residents of the sparsely populated northern reaches of this county must travel 150 miles to Flagstaff! Established methods of defining rural are plagued by a number of difficulties. Rurality is certainly a continuous variable, and attempts to label it as categorical will probably always be problematic. None of the methods take into consideration the economic base, values, or perceptions of inhabitants as to the rurality of their area. Alternative methods have been derived to take into consideration some of these factors. For example, Hewitt (1989) recommended a categorization system for rural counties that considers counties’ economic bases for the study of health care availability, but this method has not gained widespread acceptance by researchers at this point. It is doubtful that a consensus will ever be reached on a definition that fully captures the demographic, cultural, and economic aspects of rurality, but efforts to incorporate these features should be undertaken if research on rural areas is to accurately reflect its subject. The Services Crisis in Rural Mental Health One of the most serious issues facing mental health care in rural areas today is the difficulty in recruiting and retaining qualified personnel to provide services to individuals in need. There is a well-established shortage of qualified mental health professionals in rural areas (Goldsmith, Wagenfeld, Manderscheid, & Stiles, 1997). Additionally, the increase of mental health professionals in rural areas was minimal during the 1990s, despite a substantial increase in population. According to a report published by the United States Department of Health and Human Services, nearly three-fourths of counties with populations between 2,500 and 20,000 lack a psychiatrist and approximately half are without a master’slevel or doctoral-level social worker or psychologist working in health care and residing within the county (Holzer, Goldsmith, & Ciarlo, 1998). Furthermore, V14 N3, SEPTEMBER 2007 284 inpatient facilities are virtually nonexistent in rural communities: Wagenfeld et al. (1993) found that only 13% of nonmetropolitan counties had inpatient facilities, and none of the most rural counties had such services. Although the situation is not quite as bleak with regard to primary-care providers, approximately one-third of counties with a population of less than 2,500 do not have a physician practicing general medicine within their boundaries. Based on this finding, it has been surmised that one-third of the most rural counties lack any health professionals available to address mental health problems, and a much greater percentage of these counties lack any kind of specialty mental health services (Gamm, Stone, & Pittman, 2003). One implication of such shortages is that individuals in need of treatment for mental health problems must travel great distances in order to obtain services. Greater travel distances for mental health and substance abuse treatment have been associated with reduced outpatient visits and increased likelihood of expensive hospitalization (Fortney, Booth, Blow, Bunn, & Cook, 1995; Fortney, Owen, & Clothier, 1999). Hargrove (1991) has proposed several reasons why clinical psychologists may favor more urban environments for employment and practice. He argues that because of increased specialization in doctoral programs, clinical psychologists are not well prepared to handle the wide scope of clients with a wide range of problems that are encountered in rural areas. Additionally, psychologists in rural areas are often quickly moved to administrative or supervisory roles. This may reduce the attractiveness of rural employment, as individuals in these positions often cease to directly provide services to patients. The reduced patient contact hours may be evaluated as a negative, in that many doctoral-level psychologists may see providing direct care as their primary role. Moreover, mental health care in rural areas is dominated by the public sector, which may have difficulty compensating psychologists at a rate competitive with private urban service providers. As such, social workers increasingly provide services in community service organizations that have been traditionally associated with psychologists. Finally, the argument has been made that the cultural richness that students become accustomed to during their graduate training (especially in larger programs in urban areas) cannot be matched by rural areas. Additionally, DeLeon, Wakefield, and Hagglund (2003) suggest that PSYCHOLOGY AND RURAL MENTAL HEALTH • job satisfaction may be lower for psychologists in rural areas because of cultural barriers and a lack of respect for their professional judgment, thereby making it difficult to retain their services. All of these reasons may contribute to the general absence of psychologists in rural areas, although we could locate no attempts to systematically study the reasons psychologists tend to be attracted to urban areas. Individuals residing in rural areas in need of mental health treatment often turn to informal sources of care.These sources include self-help, family, spouses, neighbors, friends, and religious organizations (Blank, Mahmood, Fox, & Guterbock, 2002; Fox, Merwin, & Blank, 1995). However, we have not examined the effectiveness of such interventions (Fox et al., 1995). More research must be conducted to determine whether these informal sources represent an effective alternative to specialty mental health care. In addition to the shortage of specialty mental health professionals in rural areas, there is evidence that the providers who do practice in rural areas experience very high rates of burnout. In a study conducted by Kee, Johnson, and Hunt (2002), 192 full-time, master’s-level licensed professional counselors and licensed master’slevel psychologists practicing in nonmetropolitan areas of Kansas completed the Maslach Burnout Inventory (Maslach & Jackson, 1981). Results indicate that 65% of the counselors surveyed experienced at least moderate levels of burnout, indicating a greater degree of burnout than in a normative sample. Emotional exhaustion was the most prevalent form of burnout, with 69.3% of respondents experiencing at least moderate levels. Burnout was predicted by a lack of social integration with other professionals, a lack of guidance and advice from authoritative sources, and the absence of reliable support from others for assistance. These findings suggest a lack of collaborative efforts between mental health professionals in rural areas. This comes as no surprise, given the overall scarcity of professionals in these areas.The opportunities for support among co-workers in rural areas seem to be as rare as the providers themselves. The authors recommend incorporating these issues into training programs. Additionally, the authors advocate creating opportunities for greater peer collaboration and support through retreats and professionally led support groups, but caution that funding is in short supply. As such, programs like these may not be economically feasible. JAMESON & BLANK 285 Lack of Integration With Primary-Care Providers The integration between primary-care professionals (such as general practice physicians and nurses) and specialty mental healthcare providers is often seen as low in rural areas, and a great deal of research has lent credence to this assertion. Based on findings from Geller (1999), primary-care physicians in rural areas see themselves as playing a larger role in the provision of mental health care than do primary-care physicians in urban areas. However, these findings resulted from a focus group conducted with physicians in the rural Midwest, so their generalizability to other rural primary-care providers is questionable. Research also suggests that rural primarycare practitioners treat more cases of depression without consultation with or referral to a specialty provider than do their urban counterparts (Hartley, Korsen, Bird, & Agger, 1998; Lambert & Agger, 1995). However, these providers acknowledge a number of constraints on their ability to provide mental health services (Hartley et al., 1998). A study of largely rural primary-care practitioners revealed that a majority thought that a lack of knowledge about treatment, a lack of time, patients’ refusal of treatment, and the unavailability of a specialist consultant hindered their ability to treat depressed patients at least somewhat. Despite the acknowledgment of these barriers to primary-care treatment, the practitioners also cited several impediments to providing depressed patients with referrals to specialty mental health care providers. A majority of practitioners perceived a lack of available services, the physical distance of specialty services, issues with reimbursement for specialty services, patient unwillingness to use specialty services, and long waits for appointments as moderate or major hindrances to providing services. The willingness of primary-care physicians to treat depressed patients or provide them with referrals was not directly associated with the local supply of specialty mental health providers, but practitioners who were confident in their ability to treat depression were more likely to treat patients. The authors suggest increasing the availability of continuing education programs to improve practitioners’ knowledge and competence in the treatment of depression, especially in isolated areas where specialty care may be unavailable. Such programs could be integrated into existing continuing education programs such as Area Health Education Centers. CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • Additionally, primary-care physicians often seem reluctant to diagnose mental disorders. In a nationwide survey, Rost, Smith, Matthews, and Guise (1994) found that approximately half of physicians in primary-care settings deliberately misdiagnose depression. These physicians cited uncertainty about the diagnosis, problems with reimbursement for services if a diagnosis of depression is given, and fear that the patient may not be able to obtain health insurance in the future as the most common reasons for purposefully misdiagnosing depression. Instead, they often give diagnoses of fatigue/malaise, insomnia, or headache to depressed patients. The authors suggest that the rates of deliberate misdiagnosis found in the study are likely an underestimate of the actual prevalence of this practice because of the survey methods used. In addition to the moral and ethical questions that this common practice raises, there may be implications for treatment as well. Patients receiving an alternative diagnosis may be much less likely to be referred to a mental health services provider or to seek out specialty treatment, representing a further disconnection between primarycare and specialty mental health services. Furthermore, they may be less likely to receive appropriate prescriptions from their primary-care provider. However, the extent to which misdiagnosis affects treatment seeking and treatment outcome is not known. Anecdotal evidence also supports the notion that primary-care physicians see the treatment of mental illness as a difficult issue in terms of practicality and maintaining relationships with patients. For example, interviews with six rural physicians in Nebraska yielded several common themes: Depression is common in their practices; depression is often easily recognized, but difficult to diagnose with precision; depression can be treated effectively, but requires the cooperation of the patient to mange; and depression is important to treat, but difficult to manage because of constraints on time and resources (Susman, Crabtree, & Essink, 1995). The apparent recognition of these issues by physicians is important; they may also see a need for increased integration with specialty mental health care. As noted by Lambert and Hartley (1998, p. 966), “Organizations cooperate with each other when it is in their interests to do so.” It is certainly in the interests of the populations served by rural physicians and specialty mental health services to have these institutions collaborate to increase the quality of care they receive. V14 N3, SEPTEMBER 2007 286 Individual and Social Factors as Barriers to Treatment Rural dwellers have long been characterized as having a strong sense of community and extended social networks, and rural communities are often seen as places where word travels fast and everybody knows everybody. Although the empirical basis of these beliefs is open to debate, individuals in rural areas often do cite social stigma and lack of privacy as reasons not to seek help for mental distress. Social stigma has been associated with several factors detrimental to the treatment and rehabilitation of the mentally ill. High perceptions of stigma have been associated with low self-esteem and low quality-of-life ratings in seriously mentally ill patients, as well as greater withdrawal from social interactions after treatment (Link, Struening, Neese-Todd, Asmussen, & Phelan, 2001; Perlick et al., 2001; Rosenfield, 1997). Additionally, stigma has been associated with reduced life satisfaction (Rosenfield, 1997). Clearly, stigma associated with mental illness plays a significant role in the lives of the mentally ill. Many studies (but not all) have found social stigma associated with mental illness to be higher in rural areas than in nonrural areas. A survey of adults by Hoyt, Conger, Valde, and Weihs (1997) found higher perceived stigma associated with mental health care in rural areas than in nonrural areas. Furthermore, the degree to which stigma was perceived predicted willingness to seek treatment for mental health problems. Individuals in rural areas also perceive a lack of privacy for primary-care treatment of mental illness (Fortney et al., 2004). Stigmas associated with mental illness in rural areas have legal consequences as well: A study conducted by Sullivan and Spritzer (1997) indicates that seriously mentally ill individuals residing in rural areas have a greatly inflated chance of being detained without criminal charges while awaiting inpatient treatment. However, not all research suggests that stigma and resulting utilization are worse in rural areas than in nonrural areas. A study of seriously mentally ill patients found that rural patients were more likely to receive treatment and less likely to list stigma as a barrier to treatment than their nonrural counterparts (Kessler et al., 2001). Deductively, these findings run counter to those of Dottl and Greenley (1997), who found that seriously mentally ill patients in rural areas had greater levels of general pathology and lower involvement in vocational activities. The contrary findings may be due to differences in geographical locations of the sampled PSYCHOLOGY AND RURAL MENTAL HEALTH • population, as well as small sample sizes of seriously mentally ill patients in rural areas. Furthermore, access to care does not necessarily equate to effective care in rural areas, especially considering the lack of well-trained service providers and adequate healthcare facilities (Wagenfeld, 2003). Additionally, findings indicate that seriously mentally ill patients tend to migrate from rural areas to medium-size, low-income urban areas (Dembling, Rovnyak, Mackey, & Blank, 2002). The shifted burden on these urban treatment centers may also account for the low treatment rates in rural areas. In addition to the social stigma associated with mental illness, rural dwellers often do not recognize the need for treatment. In a large study of rural Southerners, 90% of individuals who screened positive for a mental disorder had not sought treatment one month after receiving the diagnosis and an educational intervention (Fox, Blank, Berman, & Rovnyak, 1999). This is not due to ignorance of treatment availability: All participants in the study were provided with referrals to nearby services. Of the individuals who screened positive for a disorder and did not seek treatment, approximately 81% reported that they did not feel the need for treatment. Furthermore, of the individuals who screened positive and discussed the screening with a friend or family member, only 13% reported receiving encouragement to seek treatment from the significant other. In fact, the data from this study suggest that individuals who were accompanied by a significant other when they received information about the disorder for which they screened positive were less likely to seek help than those who received this information alone (however, this difference did not reach statistical significance). The finding suggests that the denial of need for treatment may even be reinforced by social contacts in rural areas. ADDRESSING THE MENTAL HEALTHCARE PROBLEMS OF RURAL AMERICA Clearly, there is not one answer to the problems of mentally ill individuals living in rural areas. The factors contributing to the plight of these individuals are numerous: The attitudes of rural people, the lack of integration among social institutions, lack of well-trained personnel, and the physical geography of rural areas all play roles as barriers to adequate mental health services. However, the situation is not hopeless. Psychologists are well JAMESON & BLANK 287 positioned to make a significant impact on the problems faced by rural America through clinical work, research, and training. The following section details contributions that can be made by psychologists to help alleviate the mental healthcare difficulties in rural areas. Training for Rural Service If the manpower shortage in rural areas is to be successfully addressed, training in graduate school and beyond must be tailored to fit the needs of rural practitioners. Hargrove and Breazeale (1993) have outlined a training model for psychologists who consider these distinct needs. They caution that specialization is not suitable for rural practitioners, as specialized services are rarely sought and practitioners often must treat a wide variety of clients. Therefore, the skills required for general practice should be stressed above specialization in a few disorders or methods of treatment. A second recommendation given by this model is the need for increased administrative training. Administrative training is not provided in many PhD programs despite the high likelihood of doctoral-level psychologists assuming such duties. A third change recommended by this model is the need for increased integration with other healthcare professionals, such as social workers, primary-care physicians, and administrators. The authors recommend teaching trainees to work with and establish relationships with these healthcare professionals to provide more comprehensive care to patients. The issue of recruiting and retaining psychologists for work in rural areas is also worth examining. Incorporating specialized training for rural work is important, but has little value if trainees cannot be convinced to ply their trade in these needy areas. Paramount to this effort is the need to make positions in rural areas as attractive as possible. Hargrove and Breazeale (1993) have made several recommendations for improving new graduates’ perceptions of rural work. First, there is a need to increase practica and internship opportunities in rural areas (Hargrove & Breazeale, 1993; Murray & Keller, 1991). It is believed that internship sites in particular have a great deal of influence on the location of new psychologists’ first jobs, and placing individuals in rural internships would increase the likelihood of their working in a rural setting after internship. However, the current shortage of doctoral psychologists in rural areas may greatly hinder CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • the establishment of new internships and practica. Additionally, Hargrove and Breazeale have recommended the creation of a program similar to the National Health Service Corps to place psychologists in high-need areas. This program uses the incentive of loan repayment to encourage physicians, nurse practitioners, dentists, and physician’s assistants to work in areas with inadequate health services. However, there are no demonstrations of the effectiveness of such a program for psychologists. Hargrove (1991) describes the University of Nebraska– Lincoln Clinical Psychology Training Program as a moderately successful model for training doctoral-level psychologists for rural service in terms of training and job placement. The program offered a rural specialty track, in which coursework, research training, and clinical experience were tailored for individuals interested in rural work. The curriculum included seminars in community psychology and rural communities, the clinical component required that trainees be placed in rural settings and complete a three-month placement in a rural facility, and the research component required that the dissertation topic was relevant to rural issues. Otherwise, the rural track did not differ from the general clinical psychology track. Of the 24 students examined, 33% remained in rural areas after completing the program. Unfortunately, this particular rural training program no longer exists. However, other psychology training programs also have developed a rural specialty, including the University of Mississippi, the University of Wyoming, the University of South Dakota, the University of Iowa, the California School of Professional Psychology at Fresno, and Washington State University (Hargrove & Breazeale, 1993). Still, the schools that provide such a specialty represent a very small proportion of the doctoral training programs in the United States. Telehealth The use of new technologies such as broadband Internet and videoconferencing can potentially have a large impact on the delivery of services to rural areas. The term telehealth is used to describe the use of communications technology in the educational, clinical, training, administrative, and technological aspects of health care; telemedicine is used to describe the aspects of telehealth involved in patient care (Stamm & Peredina, 2000). The methods of telehealth delivery vary widely: Telephone consultations, Web site V14 N3, SEPTEMBER 2007 288 access, email, store-and-forward technology, videoconferencing, and virtual reality programs all represent approaches that have been used to varying extents (Stamm, 2003). Interest in the use of telehealth systems in behavioral health care is growing rapidly; at one point, it was estimated that the literature on telehealth was doubling approximately every six months (Stamm, 1998). In fact, telemedicine now has a journal dedicated to the topic ( Journal of Telemedicine and Telecare, founded in 1995). Telehealth has the potential to address a number of problems faced by rural caregivers. First, the use of telehealth gives patients in remote areas increased access to services. Assessment, psychotherapy, crisis, intervention, psychoeducation, medication consultations, and case management can be conducted from great distances, often through videoconferencing when economically feasible. Research suggests that patients are generally happy using telehealth services. One study of adults and children in Kentucky reported that 98% of recipients of consultations were at least as satisfied with the remote consultation as with an in-person consultation (Blackmon, Kaak, & Ranseen, 1997). Furthermore, participants reported little discomfort associated with using the videoconferencing equipment. Researchers also have investigated the attitudes of rural dwellers toward the use of telemedicine. A telephone survey conducted by Rohland, Saleh, Rohrer, and Romitti (2000) found that two-thirds of individuals in rural midwestern communities were willing to receive mental health services through live two-way audio and video transmission. Individuals who were not willing to use the telemedicine approach to treatment most often cited concerns about confidentiality and the impersonal nature of the telemedicine approach. However, the authors caution that the rates of acceptance in this study may overestimate the willingness of rural individuals to use telemedicine for mental health services, because those interviewed were not necessarily in need of services and therefore might be less reluctant to report discomfort utilizing them. There is a great need for the assessment of telemedicine effectiveness to determine whether it represents a viable alternative to traditional treatment. Many studies are currently underway to help answer this question (Stamm, 2003). One recent randomized control trial compared the effectiveness of medication consultations for depressed patients done in person or through videoconferencing PSYCHOLOGY AND RURAL MENTAL HEALTH • (Ruskin et al., 2004). Results indicate that both groups improved on measures of depression, and improvement did not differ between groups. Furthermore, dropout rates, medication adherence, and measures of patient satisfaction did not differ between groups. Treatment in the telemedicine condition was found to be more expensive than the in-person condition, but this difference disappeared when costs associated with psychiatrists’ travel were considered. However, the patients in this study were located in nonrural areas. The results may not generalize to a rural population. Furthermore, it is not known if similar results would be achieved with psychotherapy. A particularly interesting telemedicine system in development is the use of computerized therapy programs. Generally, these refer to therapy interventions presented on a computer rather than through face-to-face contact with a therapist. One such program, Beating the Blues, has shown substantial promise. The program creates a personalized therapy regimen based on patients’ input. Anxious and/or depressed patients in primary care have shown greater improvement than treatment-as-usual in a large randomized control trial (Proudfoot et al., 2002). Furthermore, completion rates were similar to those found in studies of face-to-face therapy. Use of the Beating the Blues program has also been well received by professionals in community mental health environments (Van Den Berg, Shapiro, Bickerstaffe, & Cavanagh, 2004). However, this program is not without limitations. First, a physician or mental health professional must be available to give the initial diagnosis and to review the outputs produced by the program after each session (e.g., ratings of suicidal ideation). Second, a dedicated private room is highly preferred for the system, which is problematic for clinics short of space. Third, studies of the program have been conducted primarily with patients residing in urban areas of the United Kingdom; generalization to rural areas of the United States is not assured. Despite these limitations, the development and implementation of programs such as Beating the Blues could prove an advantageous extension of telehealth in rural areas. Additionally, the use of technologies as a supplement to therapy has shown great promise. A study conducted by Newman, Kenardy, Herman, and Barr-Taylor (1997) compared the effectiveness of a four-session computerassisted cognitive–behavioral therapy (CBT) regimen with JAMESON & BLANK 289 a more traditional 12-session CBT regimen for panic disorder. Individuals assigned to the computer-assisted CBT condition used a palmtop computer loaded with CBT software for 12 weeks and received weekly faceto-face therapy for only the first four weeks. Although patients in the traditional CBT condition were slightly more likely to demonstrate clinically significant change at posttest, these differences disappeared at six-month follow-up. Furthermore, there was no difference between conditions in patient satisfaction. These results have since been replicated in a similar multisite study (Kenardy et al., 2003). While studies of computer-assisted interventions have been limited mainly to the treatment of anxiety disorders, their use for the treatment of other disorders warrants the attention of researchers. There are numerous advantages to using computer-assisted interventions, and these advantages are likely to be especially appreciated in rural areas. First, they appear to be significantly more cost-effective than traditional face-to-face therapy. While clinics wishing to adopt these technologies would certainly incur initial costs of the hardware and software, computer-assisted therapy has been estimated as costing approximately one-third less than 12-session CBT for panic disorder (Kenardy et al., 2003; Newman et al., 1997). Second, the reduced patient contact time may make it possible for clinicians to increase their caseloads without sacrificing quality of care. An additional advantage of using telehealth systems is the potential increase in professional collaboration among rural mental health professionals. Telehealth systems enable caregivers in isolated areas to interact with other professionals. Interactions include consultations, grand rounds, and supervision. These contacts could be important in keeping rural mental health professionals abreast of developments and issues in the field, increasing the quality of care they are able to offer to their patients through consultations with specialists, and aiding the obtainment of continuing education credits required by most state licensing boards. In addition to these obvious benefits of greater contact with other professionals, the increased integration can potentially help shield caregivers from the high rate of burnout found among mental health professionals in rural areas (Kee et al., 2002). There are several challenges to the implementation of telehealth in rural areas (Stamm, 2003). The economic feasibility of telemedicine for mental health has been CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • brought into question (Werner & Anderson, 1998). For example, Stamm (1998) estimates that a videoconferencing unit can range in cost from $1,000 to $50,000 with additional costs for technical support and access to communications networks (e.g., Internet service). Considering the proliferation of technology since that writing, it is likely that costs now are much lower. Other researchers have argued that limits in economic resources should not alone determine whether a service that increases access to care should exist (e.g., Chen, Blank, & Worrall, 1999). Furthermore, reimbursement for services provided through telemedicine has not gained total acceptance yet, although that acceptance is growing (Stamm, 2003). The remote care provided by telemedicine systems also raises problems with licensure. Stamm (2003, p. 149) points out the following licensure dilemma: “. . . should the provider of care be licensed in the state from which he or she originates or in the state to which the care goes?” These issues have not yet been adequately addressed by the legal system. A final barrier to the implementation of telehealth systems is the comparatively weak technological infrastructure of rural areas. Many rural areas may not yet be equipped with technologies capable of transmitting the large quantities of data required for use of devices such as videoconferencing units. Although the magnitude of this problem almost certainly decreases as time passes, this may be an issue for years to come, especially in the most sparsely populated areas of the country. Despite these criticisms, telehealth systems seem to hold great promise for increased accessibility and quality of care in rural areas. The Dissemination of Empirically Supported Treatments to Rural Clinics The previous sections detail some possible solutions to the mental health service problems of individuals in rural areas. However, they are at best long-term solutions. Changes to training programs or the implementation of telehealth systems are not likely to happen overnight, and the effect of these changes may take years or decades to feel. However, the dissemination of empirically supported treatments (ESTs) to rural clinics may be the most helpful in the short term. A particularly promising application of ESTs to rural clinical practice exists in their utilization in community mental health centers (CMHCs), which have served as the cornerstone of specialty mental health care in rural areas since their V14 N3, SEPTEMBER 2007 290 inception. As with telephone lines, cable television, and more recently broadband Internet connections, rural areas are generally among the last to benefit from advances in technology. The lack of published research on the effectiveness of ESTs in rural areas suggests (but does not demonstrate) that the dissemination of ESTs has followed this familiar trend, especially in locally funded organizations. Arguments can be made that the utilization of ESTs in rural CMHCs may have a positive impact on the issues previously described, namely, personnel shortages, lack of integration with primary care, and stigma associated with mental illness. Although treatment outcome research has yielded therapies that have been shown to be efficacious across multiple studies, researchers have cautioned that the promising results may not readily generalize to clinical settings such as rural CMHCs (Borkovec & Castonguay, 1998; Chambless & Hollon, 1998; Goldfried & Wolfe, 1998; Westen, Novotney, & Thompson-Brenner, 2004). In recent years, however, investigators have made attempts to demonstrate the effectiveness of empirically supported treatments in clinical settings, with some success (e.g., Addis et al., 2004; Wade, Treat, & Stuart, 1998; see Chambless & Ollendick, 2001, for a review). There is good reason for feelings of guarded optimism in response to these studies, as generalization from laboratory findings to clinical practice is a crucial first step in gaining widespread acceptance of these treatments in areas that may need them the most. As discussed previously, rural areas suffer from a severe shortage of mental healthcare professionals. Therefore, service providers in these areas must adopt strategies to administer effective treatments in a time-efficient manner if they hope to compensate for understaffing and insufficient funding. The characteristics of empirically supported treatments lend themselves to be included in such strategies; they are typically short in course in comparison to more traditional treatment options. Additionally, patients who successfully complete these treatments tend to maintain improvements for substantial periods of time (e.g., Stuart, Treat, & Wade, 2000). If this holds true in rural treatment centers, the so-called revolving door phenomenon may be diminished. Furthermore, empirically based treatments are often manualized in great detail. This feature may lead to effective training in a relatively short period of time with manageable costs. PSYCHOLOGY AND RURAL MENTAL HEALTH • A second problem that has been identified in rural mental health services is lack of integration with primary care. The successful implementation of ESTs in rural mental health facilities may help to diminish some of the concerns expressed by primary-care providers, thereby increasing integration between primary care and specialty mental health care. Primary-care physicians in rural areas may be more willing to collaborate with specialty mental health service providers if there is an understanding that state-of-the-science treatments are to be employed. Mental health providers who are able to discuss treatment with physicians in terms of expected outcomes and treatment success may overcome some of the cultural differences that have been identified between physicians and therapists (see Bray, Enright, & Rogers, 1997, for a review). Furthermore, primary-care workers may have better success convincing needy patients to seek out these services if they are able to make a compelling argument based on empirical findings. The social stigma associated with mental disorders is a third obstacle to treatment in rural areas. The perceived stigma, coupled with the lack of encouragement from loved ones to seek out treatment, paints a very bleak picture for individuals in need of help in these areas. However, evidence suggests that clients consider decisions informed by clinical research as a very favorable method for deciding on a treatment strategy (O’Donohue, Fisher, Plaud, & Link, 1989). Despite this evidence, practitioners rarely give a rationale of any kind for the treatment strategies they develop; in cases where a rationale is provided, clinical research is rarely cited (O’Donohue, Curtis, & Fisher, 1985). The ability of practitioners to tell prospective clients that a particular treatment works based on empirical evidence may alleviate some of their concerns.The medical model that serves as the philosophical basis for efficacy trials may also help clients view their problems as being common and treatable rather than a sign of weakness or a personality flaw, therefore reducing the perceived stigma associated with mental disorders. One of the greatest challenges to the dissemination of ESTs is mental healthcare providers’ perception of manualized treatments (Kendall, 2002). Because most ESTs have been manualized, it is important to understand how practitioners feel about using manuals in practice and training. Manuals likely represent the stepping-stone from the development of ESTs to their utilization in JAMESON & BLANK 291 clinical settings, and their use has been recommended to facilitate learning the principles of the treatments (Moras, 1993). While the use of manuals to improve training has not been well researched, a study by Addis and Krasnow (2000) suggests that attitudes toward the use of treatment manuals in practice among doctoral psychologists are mixed. In their survey, approximately one-third of respondents reported they were not clear or only somewhat clear on what a treatment manual was. Only 6% reported using manuals often or exclusively in their practices, and 47% reported never using manuals at all. Additionally, one-fifth of respondents had negative experiences with manuals; slightly less than half reported neutral experiences, and slightly more than one-third had positive experiences. Interpreting these results in terms of rural practitioners is difficult, as geographic location of the practice was not a variable used in the analysis. A similar study of rural providers would be helpful in designing strategies to make the use of manualized ESTs more palatable in their practices. The impact of implementing empirically supported treatments in rural CMHCs is potentially profound. ESTs seem particularly well suited for use in areas facing personnel shortages, a lack of integration with other community services, and a hesitant client base. However, initial groundwork must be laid before any significant course of action can be designed, tested, or applied. Furthermore, the input of rural mental health service providers on the front line is essential if any initiative is to succeed in practice. They are uniquely able to provide insight to immediate needs based on the types of patients they see, potential barriers, and financial and structural feasibility of EST implementation. Additionally, providers logically should play the major role in directing future research efforts regarding the dissemination of ESTs to rural settings, because they are the ones who would potentially provide the services. If ESTs are to play a significant role in helping to solve the mental healthcare problems faced by rural communities, collaboration between researchers and clinicians is imperative. The Rural Psychologist as a Grassroots Advocate The role of the psychologist in the rural community should not be limited to providing patients with treatment and services. Perhaps even more so than their urban counterparts, the rural psychologist should have an active voice CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • in the community. Psychologists in rural communities have the deck stacked against them: Barriers to quality care are numerous, and suspicion of “shrinks” is high. Psychologists may be seen as stuffy, overly intellectual elitists as well. This perception (right or wrong!) does little to instill a sense of partnership and trust with the community. To be more effective in treating individuals in rural communities, psychologists must effectively combine their role as a mental healthcare provider with their role as concerned community member. This can include reaching out to community leaders such as ministers, school administrators, business owners, and local government officials, as well as community organizations (Rotary Club chapters, chambers of commerce, Kiwanis Club chapters, women’s organizations, state cooperative extension service offices, etc.). Furthermore, education and awareness programs may be designed for the community as a whole. Talks at local schools or community centers may provide community members with access to information that they would not normally receive. Crucial to these efforts is balancing an air of professionalism with the ability to recognize and relate to the needs of the community and the audience (see Fox et al., 1994, for a thorough discussion). The subject matter of community education and awareness initiatives should be carefully tailored to the segment of the community that they are intended to reach (e.g., a presentation on the impact of the farm crisis on the mental health of farming communities to a cooperative extension service group, or a discussion of the economic impact of depression for a talk at the chamber of commerce; Kendall, 2002). Additionally, the presentation of scientific data to community groups should be informative and insightful, but care should be taken not to dilute the messages one hopes to convey with unnecessary detail about methodology or statistical analysis. Even manner of dress may impact the effectiveness of such advocacy efforts. Although these considerations seem arbitrary, they may seriously impact the perceptions that rural community members develop of mental health care and its representatives. Cues from the culture of the community should be taken seriously if advocacy efforts are to influence community acceptance. Cultural competence and sensitivity are important considerations if linking the community members to the mental health service system is to be an achievable goal; this includes developing local knowledge, an understanding V14 N3, SEPTEMBER 2007 292 of belief systems and values unique to each community (Hill & Fraser, 1995). Furthermore, behavior outside of practice does not go unnoticed in a rural community. Rural individuals may not as readily separate professional behavior from private behavior, and there is often little anonymity. Rural psychologists must also be prepared to offer services to their patients above and beyond what might be expected of clinicians operating in more populated areas. This may be especially important for seriously mentally ill (SMI) patients. SMI patients in rural areas are less likely to receive case management, day treatment, and home visits from care providers (Sullivan, Jackson, & Spritzer, 1996). Furthermore, rural SMI patients are more likely than urban patients to be jailed without criminal charges while waiting for a bed at an inpatient facility (Sullivan & Spritzer, 1997). Psychologists may wish to enlist family members or spouses to actively participate in treatment in order to help compensate for the lack of services. This may include psychoeducational interventions for family members. While these interventions vary widely in content, they often share similar goals: helping families cope with the illness, improving medication adherence, improving communication between the patient and family, and improving problem solving. Such interventions have been shown to reduce relapse and hospitalization of patients with bipolar disorder, schizophrenia, major depression, and other disorders (see McFarlane, Dixon, Lukens, & Lucksted, 2003, for a review). While most research has examined the effectiveness of family psychoeducation with individual families, success has been seen with multifamily group formats as well (e.g., Dyck, Hendryx, Short, Voss, & McFarlane, 2002), thereby reducing the time commitment necessary to implement such services. Such interventions are necessary to help compensate for the shortage of specialty services (e.g., inpatient facilities) in rural areas. Ethical concerns often arise in rural practice and advocacy, most notably the existence of dual relationships. Dual relationships seem to be inevitable in small communities where services are limited (Schank & Skovholt, 1997). Overlaps often arise in social relationships, business and professional relationships, relationships among clients (e.g., having more than one member of a family as a client), and psychologists’ families (spouse, children, or relatives have social or business relationships with clients). Rural psychologists must use more flexibility in PSYCHOLOGY AND RURAL MENTAL HEALTH • dealing with these relationships than their urban counterparts if life is to be tolerable. However, it is not uncommon for rural professionals to experience discomfort in maintaining a professional relationship while managing a secondary one. Campbell and Gordon (2003) outline several guidelines for avoiding negative outcomes resulting from dual relationships: Imagine the worst-case scenario when deciding if a dual relationship is potentially harmful; set clear expectations and boundaries with clients in as many areas as possible; consult often with other professionals to avoid subjective oversight; maintain clients’ confidentiality at all costs; and terminate multiple relationships as soon as possible. Additionally, Schank and Skovholt (1997) suggest developing a very clear understanding of state laws and codes governing ethical behavior before starting practice and maintaining a fulfilling life outside of practice to prevent exploitation of clients as strategies that can prevent the negative outcomes that dual relationships can foster. The Prescription Privileges Controversy: Increasing Access or Decreasing Comprehensive Care? The notion of giving prescription privileges to psychologists has been the subject of heated debate in the field (see Heiby, 2002, for a review). Although the following section is not an attempt to thoroughly rehash the advantages and disadvantages of the existence of prescribing psychologists, this highly controversial issue is worth considering in the context of rural mental health care. Arguments can be made that giving psychologists prescription privileges could either help or hinder rural dwellers in need of treatment. The issue is certainly complex, and there is no clear evidence that provides a strong empirical basis for either position. Three questions should be kept in mind when considering the impact on rural areas: (a) Would giving psychologists license to write prescriptions improve access to mental health services, (b) Would giving psychologists license to write prescriptions improve the quality of care available, and (c) Would the impact of prescription privileges on access and quality differ between a short-term perspective and a long-term perspective? Proponents of prescription privileges for psychologists often argue that this change reflects the changing role of psychology as a healthcare field (Norfleet, 2002). Psychologists have recently assumed an increasingly central JAMESON & BLANK 293 role in hospital settings, and often consult with psychiatrists and other physicians regarding medications. This requires at least a working knowledge of medications. Furthermore, there is a belief that prescription privileges are necessary for the survival of clinical psychology in the managed care era. Proponents suggest that third-party reimbursement for the treatment for mental disorders is increasingly limited to drug therapy. A major fear among opponents to prescription privileges for psychologists seems to be that the psychologists will turn into a group of low-rent psychiatrists. That is, psychology practice will trade in the behavioral interventions, psychosocial treatments, and talking cures that have become trademarks of the profession for 15 minute medication consultations and a strict biological perspective of mental disorders (Albee, 2002). In recognition of the declining incomes of many psychologists, they suggest that practicing psychotherapists move away from private practice and into other areas such as the public sector. Furthermore, critics wonder what current coursework and practica requirements will be displaced by psychopharmacology training in graduate programs. Although no data are currently available on the long-term impact of prescription privileges on the rural population, a discussion of the possible outcomes based on past professional trends might prove useful. First, it is questionable that rural areas would attract prescribing psychologists for the same reasons that they do not currently attract doctoral-level psychologists and psychiatrists. Furthermore, considering that many doctoral-level psychologists in rural areas work in administrative roles, it is not certain that they would play a more significant role in treatment if they prescribed. Second, individuals with mental disorders generally seek help from their primary-care providers at least initially. Therefore, they initially access a professional with the ability to prescribe medications. From a patient’s perspective, it might be difficult to justify seeking treatment from a second professional who would provide the same services as the family doctor. Psychologists currently offer a unique product in mental health care; it is difficult to anticipate the reaction of the consumer if this product were replaced with one that could be obtained from other sources. Third, prescription privileges may create a rift between psychologists and primary-care providers rather than increase integration and collaborative care. Primary-care CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • providers may equate referring patients to prescribing psychologists with a sign of their own professional limitations regarding the treatment of mental illness. They may also be uncomfortable referring patients to a professional who has less training and background in pharmacology. Alternatively, prescription privileges may prove to be a boon to rural mental health care in the long term. First, the addition of prescription privileges to psychology’s treatment repertoire may make the field much more attractive to bright young minds who might otherwise be considering an MD career track. The increased output of trained psychologists may weaken the job market in urban areas, forcing graduates to consider positions in rural areas, thereby increasing the mental health services manpower in these areas. Second, the ability to prescribe may improve the image of psychology as a health profession in the eyes of individuals who would potentially utilize mental health services. The stigma associated with mental illness in rural areas might be attenuated if disorders were approached from a biological perspective. Rural individuals might be more inclined to seek help if they thought that their problems were physiologically based rather than rooted in some character flaw or maladaptive coping strategy. Some support for this argument can be found anecdotally; it is often said that rural patients tend to somatize their symptoms (e.g., anxiety may be described as “a feeling in my gut”). Third, it does not have to follow that giving psychologists the right to prescribe will restrict the role of psychologists to inexpensive medication consultants (Sammons, 2003). If the standards of therapy coursework and instruction are upheld in psychology training programs, then traditional approaches do not have to take a backseat to medication. The use of medication as a conjunctive treatment could represent an increase in service quality for patients. Fourth, although resistance from the medical community seems to be strong, primary-care providers may come to appreciate psychologists’ prescription privileges because of the reduced burden of patients with mental illness on their practices. The outcome of this controversy for rural individuals is unknown. Prescription privileges could be harmful or helpful; convincing arguments can be made either way. In the short term, it is doubtful that granting prescription privileges would have any tangible impact. It may be V14 N3, SEPTEMBER 2007 294 years before enough data on licensed prescribers are collected to determine whether they improve access and quality of treatment in rural areas. It is recommended that the activities of psychologists in the states that have granted prescription privileges be studied with great care: Comparisons of treatment outcomes and patient satisfaction between prescribing and nonprescribing psychologists in rural areas of these states could lend an empirical basis to either side of this debate. These comparisons are possible, as the states that have allowed psychologists to prescribe (New Mexico and Louisiana) contain large rural populations, perhaps not coincidentally. The Role of Subdoctoral Practitioners in Rural Areas As a profession, psychologists are generally thought of as possessing some form of doctoral degree, usually a PhD or PsyD. This belief is evidenced by the membership requirements of the American Psychological Association (2005). However, master’s- and baccalaureate-level practitioners are thought to supply most of the mental health services in many rural clinics (Hargrove & Breazeale, 1993). Despite their regular presence as mental health service providers, state licensure agencies often reserve the title of psychologist to those with doctoral degrees and label subdoctoral professionals as “professional counselors.” The disenfranchisement of subdoctoral practitioners in rural areas is potentially very dangerous. If indeed they provide a substantial amount of services (which seems to be the case), exclusion from eligibility for state licensure could set a perilous precedent. In an age when private insurance companies play a major role in access to care, treatment provided by subdoctoral professionals could fall victim to cost-reducing efforts. One study of professionals in Ohio found no difference in reimbursement rates between doctorallevel and master’s-level providers (Zimpfer, 1995). However, this study was conducted over a decade ago and holds little meaning considering the rapid changes in health services. The concern that private insurers and public healthcare assistance programs may exclude subdoctoral practitioners is especially relevant to rural areas, because access to doctoral-level providers is severely limited. Clearly, there will never be enough doctoral-level psychologists to fulfill the needs of rural America (Hargrove, 1991). A significant degree of the burden of PSYCHOLOGY AND RURAL MENTAL HEALTH • caring for rural individuals has fallen on and will continue to fall on subdoctoral professionals. Hargrove and Breazeale (1993) recommend that research be undertaken to delineate the clinical skills possessed by master’s-level professionals from those unique to doctoral service providers in order to better develop positions in mental healthcare systems that fit each group’s strengths. In addition to the recommendation of Hargrove and Breazeale, professional organizations are urged to advocate for these professionals to help ensure their continued service in mental health care. Furthermore, states with substantial rural populations should be urged to reconsider what level of training constitutes a psychologist in order to ensure equitable access to care for rural dwellers. For some states, this may require revisiting past legislation (e.g., Minnesota, which licensed master’s-level psychologists until 1991). CONCLUSIONS The plight of providing adequate mental health care for individuals in rural areas is a complex issue, and the solutions to the problems faced are not easily definable. However, psychologists can make significant contributions toward the alleviation of problems through research, practice, training, and advocacy. The literature suggests that research efforts have done a better job describing problems than creating novel solutions. Solutions that have been tested and shown promise seem to terminate with the publication of an article in a scholarly journal. Efforts have not been focused on disseminating and funding potentially powerful interventions. This is not to say that studying the problems with mental healthcare services in rural areas is an unimportant endeavor; identifying these problems is crucial to developing solutions. However, research on barriers to services alone does not, in the end, impact the people in need of services. 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Finch, Jr., The Citadel Norma P. Simon, New York Christine Maguth Nezu, Drexel University The present article presents the future of clinical psychology board certification. With the increasing specialization in the field of professional psychology and the generic nature of state licensure, clinical psychology as a specialty will develop into a specialty area in a similar fashion as have specialties in medicine. A brief history of board certification in professional psychology by the American Board of Professional Psychology is reviewed and the process of becoming board certified in either clinical psychology or clinical child and adolescent psychology is discussed. Key words: board certification, clinical, professional, specialty. [Clin Psychol Sci Prac 13: 254–257, 2006] THE INCREASING TRAINING DEMANDS FOR PROFESSIONAL PSYCHOLOGY PRACTICE Training in clinical psychology has become increasingly more time consuming. The most common progression involves four years of undergraduate education, followed by two years to obtain a master’s degree, and three to four years of study at the doctoral level. Next comes the internship/residency year and most commonly a year of postdoctoral supervision before the person is eligible for generic licensure as a psychologist. Individuals seeking a formal postdoctoral fellowship in a specialty tended to do so electively. Following licensure most clinical psychologists enter practice and rarely think about additional credentialing. Some will seek registration in Address correspondence to A. J. Finch, Jr., SHSS, The Citadel, 171 Moultrie Street, Charleston, SC 29409. E-mail: fincha@citadel.edu. the National Register of Health Service Providers or seek to obtain the Certificate of Professional Qualification (CPQ) offered by the Association of State and Provincial Psychology Boards. However, few have historically sought specialty certification in clinical psychology, despite the fact that Board Certification in Clinical Psychology has been available for more than 50 years through the American Board of Professional Psychology (ABPP). A BRIEF HISTORICAL CONTEXT OF BOARD CERTIFICATION The initial ABPP specialty boards came into existence in 1947 with the establishment of the American Board of Professional Examiners in Psychology, which was developed to ensure that an individual was qualified to perform the specialties of clinical and counseling psychology. Industrial/Organizational psychology was added a year or so later. In 1968, the name was changed to American Board of Professional Psychology to reflect the expanding roles performed by professional psychologists. Since that time, additional specialty areas have been developed and included under the ABPP umbrella. These include cognitive and behavioral, clinical child and adolescent, clinical health, clinical neuropsychology, forensic, family, group, school, rehabilitation, and psychoanalysis. Industrial psychology has expanded to reflect its broadening scope in organization and business activities. Additionally, many professional psychologists seek dual specialty certifications that reflect their professional work. Examples of these combinations include clinical child and forensic certification, clinical and cognitive and behavioral, counseling and group, or clinical neuropsychology and rehabilitation. This article will focus on board certification by ABPP in clinical psychology and clinical child and adolescent psychology. © 2006 American Psychological Association. Published by Blackwell Publishing on behalf of the American Psychological Association. All rights reserved. For permissions, please email: journalsrights@oxon.blackwellpublishing.com 254 As has been discussed by several authors (Nelson & Finch, 2005; Packard & Reyes, 2003), there is a relatively common progression in the development of a professional field of practice. In the early stages of the profession there is an apprenticeship model of training during which the aspiring practitioner studies and works closely with an established professional in the field. Gradually the preparation process becomes more formalized and the need for a more complex and standardized curriculum develops. Gradually accreditation is established to ensure professional guidelines for preparation for the profession. As the field develops and diversifies in its applications, increased specialization in the practice of the professional develops. With increased specialization, the need to establish a process for identifying and certifying specialists in the various fields develops. The history of medicine is a good example of this developmental process. The American Board of Medical Specialties currently lists 24 affiliated specialty boards that offer 38 specialty certificates and 87 subspecialty certificates. Board certification in the various specialty areas of medicine has developed and the days of “general or generic practice” have passed. Given this developmental process in medicine and other professional fields, why has the development of specialty certification been so slow in professional psychology? Is the field too narrow? Given the growing diversity in professional psychology exemplified by the growing number of divisions and organizations in the field, this seems unlikely. Is there a lack of interest in specialty in professional psychology? The opposite would appear to be true. Within the American Psychological Association (APA) there exists the Council for the Recognition of Specialties and Proficiencies in Professional Psychology (CRSPPP), established in 1995 as the organizational agent to implement the recognition of specialties. ABPP has always had a mechanism for the recognition of specialties. Later, the Council of Specialties was established in 1997 as a joint venture, initially sponsored by the APA and the ABPP, to represent and support the development and functioning of recognized specialties in professional psychology. Are there any benefits to board certification? If there are no benefits for seeking board certification, then it would be easy to understand why it is not more common. However, there are a number of benefits both for the individual psychologists and for the public. Board THE FUTURE OF CLINICAL PSYCHOLOGY • FINCH ET AL. certification is a safeguard for the public. With the increased complexity and specialization in the practice of psychology, the public cannot be expected to have knowledge of the requirements for someone to provide services in a particular area. Board certification by ABPP is a way to assure the public that psychologists have the education and experience to practice in a specific area and that they have been examined by peers in the area. The advantages of ABPP board certification for the individual psychologists also would appear to be clear. First, there are clear financial benefits with a considerable reduction in liability insurance for the board-certified psychologists. For military psychologists and those in the public health service, there is a salary bonus. In addition, board certification is a credential that facilitates one’s qualification as an expert witness. Another benefit of ABPP board certification is increased ease of mobility, as many states recognize ABPP. Similarly, being board certified by ABPP facilitates obtaining the CPQ. In addition to these and other benefits, there is the professional growth that occurs as a result of the exam process. It appears that the time is now for board certification in professional psychology and that ABPP may have simply developed at a time when it was not needed. In truth the role of ABPP has developed with the field. It was developed before widespread licensure and initially served to identify trained practitioners in the field. Following the development of licensure, the role of ABPP drifted to a more “elitist” position. Although this position was not by design, nor reality, it reflected the “perception” within the field. However, those days have passed and the position has been replaced by one much more in line with the American Board of Medical Specialties, and ABPP sees its role as providing examinations for properly trained psychologists in the emerging specialty areas. THE EXAMINATION PROCESS Examination for board certification in clinical psychology is offered by the American Board of Clinical Psychology (ABCP) and examination in clinical child and adolescent psychology is offered by the American Board of Clinical Child and Adolescent Psychology (ABCCAP). Both are member boards of ABPP and their examination processes are similar, as are all examinations under the ABPP oversight board. Each requires verification of credentials in the respective area, including licensure as a professional 255 psychologist. If the credentials are accepted, the candidate enters the second phase of the examination process and begins preparation of practice samples. The practice samples include two video samples of professional work of approximately 50 min each. One sample is an unrehearsed psychological assessment and the other sample is an unrehearsed intervention. Both samples are to be drawn from typical clinical practice within approximately six months prior to the submission. These video samples should reflect one’s competence and expertise (rather than exemplary situations) that depict his or her interactive style with clients drawn from the candidate’s typical practice. Many candidates seem to want to select unique, interesting, or unusual cases but both groups prefer cases drawn from the candidate’s typical practice. Such a practice sample allows the examination committee an opportunity to see the candidate at his or her best. A senior option for the clinical exam practice sample was developed in 1996 and later adopted by the Clinical Child and Adolescent Board. Candidates who are 15 or more years post licensure can elect to submit a practice sample that reflects their career contributions. Frequently these senior practice samples include professional publications in clinical psychology, treatment manuals, program manuals, a summary of professional practice, etc. The exam itself is identical and the criterion for a pass is the same for all candidates. Three specialists serve as the examination committee and review the samples. Both boards provide scoring criteria with passing and failing responses. If the practice samples meet and pass criteria, the candidate enters the oral examination stage. The oral exam is conducted by the same three examiners that have reviewed and passed the practice samples and takes approximately three hours. During the practice samples review and the oral examination, the committee is attempting to assess the candidate’s competencies in several domains. There are some minor variations in how these are described and those from the ABCCAP will be presented here. The examination process encompasses the following interrelated domains. Professional Knowledge The successful candidate understands patients/clients within their social context (family, school, and peers) and their problems with conceptual breadth and depth. This understanding involves having a definable set of CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • constructs or a theoretical orientation of sufficient complexity to allow a rich discussion that can be justified from the research and/or clinical literature. Successful candidates can critically evaluate the research and professional literature and discuss implications for their practice. They appreciate the limitations of their own competence and appropriately seek consultation, supervision, and continuing education. Assessment Competence The successful candidate chooses procedures appropriate for the referral needs and characteristics of the patient/ client. They interpret assessment data accurately and develop conclusions appropriately. Successful candidates will communicate results in a manner that leads to useful outcomes for diagnosis and treatment while minimizing the likelihood of misuse. Intervention Competence Successful candidates will effectively manage treatment contract issues (patient/client goals, boundaries of treatment, payment resources, etc.). They choose procedures that are appropriate for both the patient/client and the situation. Interventions are applied and documented skillfully. Successful candidates will assess intervention issues in a developmentally appropriate and contextually relevant manner. Interpersonal Competence with Clients The successful candidate relates in developmentally appropriate ways that enhance the effectiveness of services and minimize interference or disruption. The candidate will be aware of patient–therapist interpersonal issues, personal impact, strengths, weaknesses, and limitations as professionals—and they consistently manage these factors. Successful candidates will be sensitive to the welfare, rights, and dignity of their patients/clients, families, other professionals, and society as a whole. Ethical and Legal Standards and Behavior Successful candidates will demonstrate knowledge of ethical principles, professional practice standards, recordkeeping requirements, and legal standards. They effectively apply ethical principles, professional practice standards, record-keeping requirements, and legal standards in their clinical practice as well as in unique situations. V13 N3, FALL 2006 256 Commitment to the Specialty and Awareness of Current Issues Successful candidates will demonstrate active participation in the profession. They can thoroughly describe current issues facing the profession and their implications for patient/client welfare. Competence in Supervision and Consultation Successful candidates will demonstrate awareness of the activities involved in and the complexities of the supervisory relationship. They also understand the parameters for consultation and the limitations of their own training and competence. Following the completion of the oral exam, all practice sample material is returned and the candidate is dismissed without knowledge of the results of the examination. The committee members independently rate the candidate on each of the domains and assign a pass/fail rating based on the candidate’s performance during the oral examination. Two votes are required for a passing score. Successful candidates are notified by Central Office. Unsuccessful candidates receive a detailed explanation of the reasons for the committee’s decision. THE REWARDS OF PROFESSIONAL ABPP CERTIFICATION Sharing their professional work and having an opportunity to discuss their practice with recognized specialists in the THE FUTURE OF CLINICAL PSYCHOLOGY • FINCH ET AL. area is an experience too rare in professional lives. Most candidates report that the experience was a rewarding one and resulted in professional growth. In recognition of the growth and developmental nature of the process, successful candidates are granted 10 continuing education credits by ABPP, which is recognized as an approved provider by APA. As stated in previous publications that explain the ABPP process (Dattilio, 2002), now, more than ever, the growth and sophistication of our profession and its position of importance and credibility in the delivery of mental health, consulting, and behavioral medicine services demand full participation in a highquality, standardized, board certification process. REFERENCES Dattilio, F. M. (2002). Board certification in psychology: Is it really necessary? Professional Psychology: Research and Practice, 33, 54– 57. Nelson, W. M., III, & Finch, A. J., Jr. (2005). Board certification in professional psychology: A developmental passage. The San Francisco Psychologist, December, 5, 11, 13. Packard, T., & Reyes, C. J. (2003). Specialty certification in professional psychology. In M. J. Prinstein & M. D. Patterson (Eds.), The portable mentor: Expert guide to a successful career in psychology (pp. 191–208). New York: Plenum. 257 The Present and Future of Clinical Psychology in Private Practice clinical xxxxx· psychology: science and v13Published n3, xxxxxx All 3O 13 Blackwell Malden, Clinical CPSP © 0969-5893 riginal 2006 rightcomas-diaz American Psychology: USA Article reserved. Publishing For Psychological Science Inc permission, andpractice Association. Practice please ·email: journalsrights@oxon.blackwellpublishing.com. by 2006 Blackwell Publishing on behalf of the American Psychological Association. Lillian Comas-Diaz, Transcultural Mental Health Institute This article discusses clinical psychologists’ current concerns, challenges, and opportunities in private practice. The future of clinicians in independent practice is presented within two paradigms, namely, psychology I discuss clinical psychologists’ concerns, challenges, and opportunities in private practice. I arrange my remarks under two paradigms, namely, psychology as a health profession, and psychology as life enhancement. as a health profession, and psychology as life enhancement. Finally, the author argues that psychotechnology, corporate clinical psychology, and psychology as life enrichment will evolve within the future of clinical psychological independent practice. Key words: clinical psychology, independent practice, life consultant, life trainer, psychotechnology. [Clin Psychol Sci Prac 13: 273–277, 2006] INTRODUCTION I examine how clinical psychology is currently evolving in private practice in the United States. Additionally, I speculate how independent clinical psychology will advance in the future. Most of my observations are based on anecdotal data acquired during my tenure as 2005 president-elect and 2006 president of the American Psychological Association’s (APA) Division of Psychologists in Independent Practice. In this capacity, I enjoyed an “inside” view of clinical psychology in private practice. Access to numerous online lists discussions, communications with independent practitioners, and input provided by APA governance groups informed my observations. Moreover, my experience of over 25 years in the private practice of clinical psychology grounded my comments. Address correspondence to Lillian Comas-Diaz, Transcultural Mental Health Institute, Auburn, NSW 2144, Australia. E-mail: cultura@starpower.net. CURRENT CONCERNS OF CLINICAL PSYCHOLOGISTS IN PRIVATE PRACTICE Clinical psychologists are trained within the Boulder Model of scientist-practitioner. However, clinical psychologists in private practice expand this definition by adding business to the science and practice designation. Within this context, independent practitioners offer consumers a choice for psychological services under a capitalist economy. Clinicians are committed to provide effective and ethical psychological services t...
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