Sections of this column were adapted, with permission, from Levant, R., Reed, G., Ragusea, S., Stout, C., DiCowden, M., Murphy, M., Sullivan, F., & Craig, P (2001). Envisioning and accessing new roles for professional psychology. Professional Psychology: Research and Practice,32, 79-87. Copyright 2001 by the American Psychological Association. Adapted with permission.

     From my current vantage point as both a dean of a graduate school of psychology and an officer of the American Psychological Association, I have a unique opportunity to reflect on the evolution of professional psychology. The scope of psychological practice is expanding and diversifying into new areas -- areas where the distinction between applied scientist and professional practitioner begins to blur -- such as health psychology (and its related aspects such as psychology in primary care, psychoneuroimmunolgy, and applied psychophysiology), neuropsychology, rehabilitation psychology, forensic psychology, child and family psychology, multicultural psychology, geropsychology, business and industry consultation, and psychopharmacology. It cannot be emphasized enough that the future evolution of professional psychology will entail the development of roles that do not now exist - in health care, public sector care, the courts, the correctional system, schools, businesses, etc. - in the numbers that psychologists entered the role of outpatient therapists in the 1970s and 80s.

     In this column I want to highlight the new opportunities for expanding the roles of professional psychologists in psychological health care. I will first discuss the redefinition of psychology from specialty mental health care to primary health care and then take up the psychological management of disease and health.

Redefinition: From Specialty Mental Health Care to Primary Health Care


     One of the most important aspects of the evolving nature of professional practice: is the redefinition of psychology from specialty mental health care to primary health care. As a specialty profession of mental health care, we deal primarily with the people who self-identify as having psychological problems and who have access to a mental health specialist, which is just a fraction of those who need psychological services. As a primary health care profession we would be able to serve the much larger group of people who do not have access to mental health care or who do not identify their problem as psychological. To grasp this potential, please consider a few facts about health care: (1) The U.S. Department of Health and Human services has pointed out the seven top health risk factors-tobacco use, diet, alcohol, unintentional injuries, suicide, violence, and unsafe sex-are behavioral; (2) Seven out of the nine leading causes of death have significant behavioral components (McGinnis & Foege, 1993); (3) At least 50% (and maybe as much as 75%) of all visits to primary care medical personnel are for problems with a psychological origin (including those who present with frank mental health problems and those who somaticize) or psychological component (including those with unhealthy lifestyle habits such as smoking, those with chronic illnesses, and those with medical compliance issues); (4) .Moreover, there is a growing body of empirical evidence supporting the effectiveness of psychological interventions in ameliorating a wide range of physical health problems, including both acute and chronic disease affecting literally every organ system and encompassing pediatric, adult and geriatric populations. In addition to being clinically effective, these interventions are dramatically less expensive than alternative somatic interventions across a wide variety of illnesses and disorders, including cardiovascular disease, diabetes, traumatic brain injury, etc. (5) The vast majority of people receiving mental health treatment are cared for by medical professionals with minimal specific training in mental health.

     The Cartesian world view, which separates mental health from physical health, is breaking down, and as a result psychology has a tremendous opportunity to evolve into a premier primary health care profession. At the very least this would put psychologists on the front lines of health care, working collaboratively with physicians and nurses. The more visionary perspective is that health care should be reorganized so that psychologists serve as primary caregivers at the gateway to the health care system, functioning to diagnose and treat the more prevalent psychological problems, and referring to medical physicians when indicated. Psychological Management of Disease and Health

     Over the past several years, it has been a consistently predicted that psychology's potential contribution to the prevention, assessment, treatment, and management of acute and chronic illnesses will play an important role in the future development of the profession. Much of the work in health psychology-and a significant opportunity for the field of psychology in general-focuses on behavioral contributors to health and disease (Newman & Reed, 1996). Moreover, as noted, psychological interventions are effective and cost-effective in ameliorating a wide range of physical health problems. For example, data regarding the efficacy and cost-effectiveness of psychological interventions for chronic pain are so compelling that the National Institutes of Health (NIH) published a consensus statement calling for wider acceptance and use of behavioral treatments in conjunction with typical medical care (NIH, 1995). In primary care settings, medical utilization can be substantially reduced through the availability of behavioral interventions. Total ambulatory care visits have been shown to decrease an average of 17 percent, with even greater reductions when visits for specific illnesses such as asthma (49 percent) and arthritis (40 percent) are tracked (Sobel, 1994).

     All of this suggests a huge potential market for psychological services in health care systems. In order to access these opportunities, however, psychology must define itself as a health profession rather than as a mental health profession. In fact, the APA Board of Professional Affairs Work Group on Expanding the Role of Psychology in the Health Care Delivery System has recently called for a "figure-ground reversal" in professional psychology (APA, 2000). That is, rather than viewing itself as a mental health profession with health psychology representing a subset of its expertise, the group advocated a view of psychology as a health profession, with mental health as a subset of its expertise.

     Psychologists' core skills in assessment and treatment can be integrated with roles in supervision, administration, program design, program evaluation, and research. As a consequence, psychologists are uniquely positioned to assume a greater role in the management of both health and disease. Potential functions include coordinating complex interventions, assisting patients to evaluate and select among treatment options, helping people to make necessary lifestyle changes and to comply with complex and difficult treatment regimens, and providing treatment for coexisting psychological problems as well as the psychological and emotional reactions of patients, their families, and other health care providers. Further, our strong research background-a unique qualification of psychologists among health care professionals-prepares us to play key roles in the design, implementation, and evaluation of prevention, and intervention programs at the individual, system, and community level.

     A serious limitation on psychologists' ability to participate in integrated care has been the absence of payment mechanisms to reimburse psychological services within general health care settings. Psychologists have not been permitted to bill under procedure codes such as evaluation and management of medical disorders, patient education, and preventative services. As a consequence, they were forced to bill under mental health codes, which are often inappropriate, or to make arrangements with systems to bundle their services (e.g., using DRG or per diem methodologies). Moreover, psychologists frequently do not have access to reimbursement for services provided to patients related to non-psychiatric diagnoses, even when these services are well accepted clinically and are strongly supported by the empirical literature. However, the recent approval of the Health and Behavior codes for psychologists will begin to address these problems.

     Some of the more specific trends in health care also have implications for psychology. For example, information about genetic factors in a variety of diseases and disorders is rapidly becoming available, largely as a result of the Human Genome Project, and genetic testing is becoming increasingly common. Genetic testing will confront people with profound choices and decisions. Assisting people to evaluate the available information, make appropriate choices, and implement preventative programs are roles that psychologists may fulfill in the future (see Shiloh, 1996). The aging of our society will also present significant opportunities for psychologists to enter health and disease management in the geriatric area (see Haley, Salzberg, & Barrett, 1993; Qualls, 1998; Takamura, 1998). As a part of a large and growing interest in complementary or alternative medicine (see Eisenberg et al., 1998), Americans are increasingly consuming herbal and nutritional remedies for a variety of prevention and treatment purposes. As an aspect of their practice, psychologists can play a key role in helping consumers to evaluate the available empirical data about the effects and the effectiveness of these remedies.

     As always, I welcome your thoughts on this column. You can most easily contact me via email: (new address): levant@uakron.edu



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