| Friday at the APS Conference | | Date Created: Oct 01, 2004, 11:51 AM |
 First session I attended was a Professional Practice symposium looking at training and employment of psychologists and expected renumeration.
I was left with the same question I have been asking of my professional colleagues almost since I joined the APS:
If the Angel of Death came down and smote all registered psychologists, who would notice? And if they did, when would our disappearance be noticed?
Would a sufficient gap be left such that other health professionals couldn't fill that gap? Would our clients or patients go without services or care for long? I don't think so... again, the focus in this symposium was on the unique qualities of psychologists, but I still wonder what these may be. (This link takes you to a pdf examining the "uniqueness" of counselling psychology, cf. other fields)
What we do have going is that pscyhology is the principle discipline for the study of human behaviour, but beyond this, in the field of professional practice, I'm not so sure what we offer in the clinical or organisational or counselling domain that is unique... perhaps it's in the school and educational domain where testing needs good training, and can yield very usable results. Or child guidance and teacher consultation...
President's Keynote - Prof. Paul Martin
At 11am outgoing APS President Paul Martin gave his keynote address looking at Behavioural Health in Australia. He reminded us that health is more than the absence of disease or infirmity, as the World Health Organisation first noted in 1948.
He looked at Australians' risk factors which could come into the behavioural category, looking at dietary intake, alcohol consumption, smoking, physical acitvity, and obesity.
In looking at the Australian population, virtually all would benefit from a behavioural lifestyle change, whether it be "finetuning" or a "major overhaul".
Paul then moved on to his own research and models, beginning with some criticisms of current thinking.
Firstly, current models tend to be disease-specific, and focussing specific variables.
He mentioned some new risk variables such as depression, and social isolation for heart disease.
The next slide was so complex as to be unreadable. Fortunately, the following slides explaining his model in detail used much simpler bullet points.
These looked at sociodemographic factors, environmental factors such as air and water pollution, as well as road conditions, and other aspect of the "built" environment.
Genetic factors were mentioned next, then Paul moved on to discuss other health areas, such as breast cancer and the risk factors which could be described as average or above average to high risk.
Paul went on to review family history factors looking at degrees of relativity: first-degree, versus further-removed.
Slides about Behavioural and lifestyle factors followed, looking at day to day behaviours taken for granted as areas worthy of examination, such as sleep, and work style such as shift work.
"What sort of vision do we want?" was then asked, to achieve optimal health.
Many visions according to Paul are unrealistic, and do not take in to account individual differences, and psychological variations. Nor do they integrate the various domains in behaviour in a more holisitic fashion, taking into account individual differences.
He also mentioned looking at heredity factors, and tailoring programs according to the available evidence for any one individual. (Perhaps this is psychology's uniqueness - the ability to acknowledge and work with the uniqueness of individuals while also understanding larger group properties.)
What this means is that where there is contradictory evidence for certain substances such as alcohol, then each person's risk factors need to be considered given their history and vulnerability. That is, some research says one or two glass of wine a day is good for health, other studies suggest that some population ought to always abstain.
He concluded by asking if we need a new specialisation in behavioural health psychology, such as guiding choice-making about clients' health, including an understanding of genetics and physiology. This would include looking at the variables that could be called lifestyle measures, as well as "genetic literacy" such as first diagnosis of illnesses in relatives. (How ironic that in my intial Bachelor of Science degree at Monash I majored in Physiology and did 3rd year Genetics as well as Psychology).
Paul concluded with a review slide of new research directions, but these were word- heavy which he read - a bit of a downer for my liking.
He did finish with mentioning how the Internet could be of use for mass education of the community, and this certainly is something to be taken up in the future.
Questions were asked from the audience, but why the APS couldn't organise a roving mike in a huge auditorium is beyond me. There were microphones on the floor, and one was eventually used, thankfully.
Afternoon session: "It is the therapist who makes the difference: Bruce Wampold, University of Wisconsin.
This was the first "applied" session I attended.
Bruce is a small beared balding man with a very pleasant disposition, who reminded us of what Bill Clinton had said: "It's the economy, stupid".
For Bruce, "it's the therapist, stupid".
He spoke of being a Mathematics major, with a French minor, and so let us know some of his material to be presented would be quite statistical in nature. In between relating a funny story about being library-phobic in his undergaduate days!
Bruce then related the history of the gold standard for random controlled studies (RCT). The first use of randomised control studies began with educational studies and what sort of educational training experience would work best. Since education was run by white males utilising females to teach, it was thought teachers were easily exchangable (!)
Later studies in Agriculture also ignored the individual farmer in studies of crop outcomes. In Medicine, the placebo/control group design was the first empirical measure design, with the physician's capacities out of the picture.
Are the current published trials in health and psychology placing the therapist at the centre of the treatment process? According to Bruce, no. And he has recently published a book where he lays out his ideas and research.
In his research, he wants to estimate the variability of therapists within treatments. To do so, he gave some background as to how large-scale random controlled studies are conducted, especially with regard to design.
Bruce discussed test design, first focussing on Nested Designs.
NIMH studies on depression were the largest clinical trial using this design to compare CBT with IP (Interpersonal Therapy). Therapists expert in various interventions worked with a homogeneous patient population. Different experts, different treatments, same type of patient.
The Crossed Design is one where each therapist delivers the different treatment strategies. Now that's asking for trouble!
In nested designs, you control for therapist allegiance, but not for their skill.
In the crossed design, the "person" of the therapist is controlled, but other variables like allegiance (to therapy "brand"), skill and training is not controlled.
The NIMH nested data was re-analysed in his department, looking at the 2 psychotherapy components. How much variance was due to treatment modality versus therapist?
Using a variety of measures and checklists, what turned out? Treatment variance? 0%. Therapist variance: between 5-12% which is fairly large despite how they were selected, monitored and screened.
What about in practice?
Using California Managed Care data with 6000 patients, very little variance - 5%
Therapist divided by total variability reveals other factors too, since the patient variability is much more in practice compared to rigorous clinical trials.
Heterogeneity amongst practice clients is more the norm. But in this case, variability of diagnosis, degree, and experience is 0%. There was a very small medication effect, but small compared with therapist variance.
Group providers were superior to independent providers, perhaps due to more interactions with fellow professionals, or that better therapists go into group practices where their work is open to quality control procedures. Better therapists keep producing great outcomes no matter what the presenting situation or severity. Interesting!
And the top 60% of therapists produce an effect equal to Random Controlled Trials (RCT) in half the number of sessions. And drop-outs are higher in RCT.
So what makes an effective therapist? Drum-roll please!
"Er, well we really don't know".
Hmm... were we really surprised to hear this... or disappointed. This idea has been around for at least 50 years. This includes no adherence to a treatment protocol, and emphasis on relationship, and rationale adherence by the therapist.
So Cognitive-Behaviour Therapy, based on this data, has been oversold, as well as any slavish adherence to treatment manuals.
So.. most of the variability in outcome is due to therapist variability.
... and there should be freedom to choose type of therapy and therapist. Hmm, I wonder if employees who visit a contracted EAP get much choice?
Perhaps we should put more research monies into investigating therapist variables, rather than treatment variables, according to Bruce.
Late Afternoon Session: Psychologist involvement in Government Initiatives
APS staffers Lyn Littlefield and David Stokes spoke in this session about the various initiatives the Society was invoved with, linking it with government department, as well as other health associations.
The first was the MAHS (More Allied health Services) initiative linking medicos with allied health practitioners in rural and remote areas. The funding of $50 million went to Divisions of General Practice and the creation of new positions.
Ironically, 54 nurses were employed full-time, and then some 46 psychologists, with dieticians being 20. Other allied health professions scored lower.
So overall, psychologists did quite well, and doctors did seem to have a preference for treating mental health issues, preferring psychologists over other professions.
It seems a review of this program which is unlikely to continue has suggested it can be transferred to outer urban areas too.
An interesting outcome is the increased likelihood of psychologists being employed by doctors in their practices, albeit with doctors not necessarily rewarding psychologists appropriately.
Better Outcomes in Mental Health Care - this initiative has proven quite controversial for the Society with some practitioners complaining about the small rebate being offered. It is of course a partial payment only, with the patient expected to pick up the tab.
This was faciliated within GP Divisions for their training in mental health, to a cost of $120 million.
There are a number of committees "running the show" and APS representatives are on many of these committees.
Something like 19% of all GPs in Australia have been trained to the inital level, and many less trained to a more advanced level. Not a good uptake when you think of your chances of seeing a trained GP. Hopefully, those who undertook training now know when to refer to a psychologist. Training like this ought to let you know your own limitations!
Six sessions for patients with high frequency disorders with high co-morbidity present doesn't sound like much, but heck, it's a start. I just wonder what it conveys to the public about psychologists' abilities for a change process in a short contact span.
Lyn Littlefield spoke of the whole program being evaluated rather quickly, with raw data being reviewed. Some 10 sites with focus groups have been more intensively evaluated.
Self-evaluation is also underway in all sites, and the data is being looked at.
The APS survey of its members showed 250 members responding on why they did or didn't involve themselves in this project.
One of the big outcomes have been the increased referrals of "difficult" clients to psychologists, and an improvement of total numbers of appropriate referrals.
The issues of concern for psychologists was the low rate of payment, and in some cases, of exploitation of such cheap labour.
Medicare Plus: A limited initiative within an Enhanced Primary Care Plan with 5 sessions per patient per year, with a very small rebate and time allotment.
Other aspects that were discussed by David Stokes were the rather loose definition of "chronic", with unlimited patients seem. unspecified interventions but of a psychological nature fby dint of registration with the HIC, and no limits on the nature of the patients.
Downsides seem to be the amount of paperwork the project entails.
Looking to the future, David spoke of wishing to see sessions extended to the usual 50" hour, with a range of health conditions treatable.
Speaking politically, under a Coalition government the EPC will be continued, but under Labor a reform of Medicare may well see it change.
National Advisory Council on Suicide Prevention
Lyn Littlefield is on this council, created by Prime Minister and Cabinet in 2000, to co-ordinate a national approach to suicide prevention.
The highest incidence has moved up to the 25-35 group as part of a cohort effect since previously it was a younger group who would now be - if they survived - in this new age group.
Various projects cover prevention and resilience-building, as well as setting up committees on how the media reports mental illness and suicide.
A project called StigmaWatch has been commenced, and a new MindMatters project has become to provide resources for teachers, schools and students in secondary schools.
The resources include numerous booklets for teachers to work into the curriculum, and psychologists may be working with a MindMatters program using best practice in association with a Guidance and Counsellors organisation, within the education sector, where the main players are principlals and teachers.
A new MindMattersPlus works with higher risk students and doctors, since it's managed by the Division of General Practice. Something for psychologists to watch out for...
The question for the suicide initiatives is what psychologists might contribute given special skills the profession possesses.
Inclusive of:
clinical assessment
skills and resilience building
health promotion
psychoeduational in the community
parent support and training
workplace and organsational professional development.
Im summary, the APS needs to get out there and push to the Government what psychologists have to offer, rather than let other professional groups run the agenda.
Interesting the Australian newspaper will soon be designing a Mental health special lift out in a forthcoming edition - wonder if the APS will buy some space, since it now employs paid consultants to advice on media activities, something some longstanding members have performed honorarily for many years.
Another example of the APS becoming more professional in its dealings with external stakeholders in mental health and public opinion.
In all, a fairly full day with lots of meeting and greeting of old friends. A few wanted to chat about tomorrow's election results, and motions to be put to the AGM which may turn out to be a fiery affair. I have voted, and hold several proxies.
Most of those I spoke with believed the outgoing President Paul Martin has done a very good job for the last four years. Whether any of the candidates can improve is a question which really concerns many in the APS. |
|
|
|
