Why join professional associations?

I am a clinical psychologist. I am not a member of the American Psychological Association (APA). I earned my PhD in 1980 and ended my APA membership more than 20 years later after time in both clinical practice and in executive roles within the managed behavioral healthcare industry. It seemed to me that the association had rejected the business side of healthcare, as if we had all embraced a calling, a noble profession, and not a business.

I raise this now because the APA has a new, existential set of challenges in front of it, and I will be evaluating membership in a professional organization along with hundreds of thousands of other behavioral healthcare professionals. A break from the customary is needed. Yet I am afraid that most psychologists and most association leaders are not ready for change. While I don’t pretend to understand the concerns of social workers, marriage and family therapists, licensed professional counselors and the like, I don’t think the issues they face are markedly different from those of psychologists.

We are fighting for professional advancement and hoping that the world sees our work as psychotherapists as valuable. Yet I have some bad news. Hope is not a strategy.

I would like to take credit for the phrase, “Hope is not a strategy,” but I must admit that I stole it from the title of a popular book on sales strategy. I would offer that psychotherapists should be reading more sales strategy books because whatever clinical job you currently enjoy, sales and marketing are in your future. Healthcare sales are in flux and the silent healthcare providers will be marginalized. We need organizations like the APA to offer realistic guidance in this environment. My experience with the APA is that they promote the professional value of psychologists in a tepid way—largely avoiding the question of biological solutions versus psychosocial solutions—and they ignore the marketplace realities faced by real psychologists. Maybe that has changed—as I stated earlier, I have not been a member for a very long time.

Promoting solutions

I should clarify a couple of basic points. I love the profession of psychology, and I want people who have devoted themselves to this field to succeed and prosper. At the same time, I also hate the arrogance of mental health clinicians who have long told people to trust them, based on nothing. While I did read much of Sigmund Freud’s work in my earlier years, my fundamental understanding is that he wanted his creative musings about individual patients to be taken as proof of something more universal. Not many serious researchers believe that today. Yet we still have people promoting solutions with marginal proof. I have long been an advocate for better data on clinical outcomes, but things are much more serious today. We will soon be solidifying how to regard and reimburse the behavioral healthcare field for the next decade.

This is a time for better political action rather than better research activity. We are faced with the realities of the post-ACA healthcare landscape, and we need leadership to guide us through the uncertainties of the future. There are few organizations to reach out to at such a time, and this article is a call to all professional organizations to address current realities in a way that they never have historically. It is a call for all behavioral healthcare professionals to realize that they can either become healthcare activists or accept whatever the richer healthcare professions decide is the best future course.

Most healthcare organizations with deep pockets care little about psychotherapy. They are too busy managing surgeries, medications and medical devices to worry about the trivial dollars expended upon psychotherapy. The headlines today criticize the exorbitant increases in pharmaceutical costs and rarely stop to consider the dramatic results achieved by psychosocial interventions.

For example, we have endless stories about opiate overdoses, and yet we rarely hear reports on how people with chronic pain can be significantly helped with interventions such as mindfulness and cognitive behavioral therapy. We are a society that is addicted to easy medical solutions, and one consequence is that we are suffering from those easy medical solutions. If you are advising a loved one, would you encourage opiates or psychological techniques? You will surely be challenged mightily if you advise against medication.

Should we wait for the preponderance of scientific evidence to demand that psychosocial interventions be adopted, and then wait for a few more generations of clinical specialists to insist that we actually implement those recommendations? That is the norm, but it is not acceptable in a time of crisis, if ever. Are we in a time of crisis? I would just offer that behavioral health disorders are the most expensive, most disabling, and most poorly diagnosed and treated among healthcare conditions today. However, since we have no silver bullets that are commanding large investments (as Prozac did decades ago, to no large effect), we are just watching a tsunami develop with no real answers about what to do after it hits.

We need to reimagine the role of professional organizations in healthcare. They must be more activist with a clear agenda for change, rather than simply collecting dues for a nominal role in the healthcare establishment. While I must state that my politics are progressive, liberal and certainly not in step with the current national leadership, my call to action is not along political party lines. I am not interested in partisan discussions. I am only interested in discussions that further the field of behavioral healthcare.

This article is a call to reorganize how behavioral healthcare professionals lobby those with power. The American Psychiatric Association is exempted here since its association with the pharmaceutical industry drives a very different narrative. Those organizations promoting psychotherapeutic interventions (whether in the individual session or within the facility-based treatment program) have no deep pocket supporters. Yet our clinical impact is significant, and we now must amplify our political impact.

The main question that presents itself from the foregoing arguments is how we become a more effective lobbying force for psychosocial interventions. One key technical answer is the statistic, Number Needed to Treat (NNT). We should be promoting this metric within every behavioral healthcare professional organization, especially the APA, which extols its excellence as a source of evidence-based findings.

I would suspect that few people reading this can define NNT. That is not a shortcoming in any way since it is not a commonly reported statistic, even though it is one that many scientists agree normalizes how we should compare how different healthcare interventions can be ranked on an objective basis. The NNT statistic answers the simple question of how many people need to be treated with an intervention until remission has been achieved. If 100 patients file through my office each day for a particular condition, and I cure every 50 versus every 5 patients, then that is a dramatic difference. And so, it should be clear that if the NNT is 50 or more, then the intervention is not impressive. Lower numbers are better, and numbers under 10 are great, which is where psychotherapy lands in these analyses.

This is not an argument for one political party over another, but rather for embracing scientific evidence over economic power. Psychotherapeutic interventions have limited economic resources, but vast scientific validity. This is a critical debate with enormous consequences for clinical professionals. It is possible to have an incredible NNT score of 3 (the common NNT score for psychotherapy) and yet still lose funding to organizations with solutions at double, triple or quadruple that score.

I would suggest that it is a new day for solidifying the political strength of organizations that embrace the power of psychosocial interventions. We have only a few years to establish our legitimacy, and then, more importantly, raise our primacy as healthcare providers. Actual psychotherapy conversations take place in an office, in private, with no one else knowing what was said. Now we need a loud, public conversation about healthcare, including behavioral healthcare, that demands we look beyond expensive solutions like drugs and surgery, and embraces cheaper, effective psychosocial solutions. Can the APA be a leader in that?

The Affordable Care Act recognized the treatment of mental health and addictive disorders as essential health services, and we can only guess/fear that the post-ACA world will sanction treatment for these disorders as non-essential, elective, supplemental and any other marginalized term that might apply. It is time for professional associations to enter the real world of business and politics in a way not seen to date. Patients need safe and effective treatments, and we have them.

This does not mean that those treatments, in the current political climate, will be adequately covered or approved for people with Medicare, Medicaid or commercial health insurance. Clinicians need to stand up for the reality that they have powerful treatments for behavioral healthcare patients, and they must advance a stronger argument for the funding of their work. I hope the APA and other professional associations can be loud voices in this advocacy. If so, I will become a paying member again.

Ed Jones, PhD, is senior vice president, strategic planning, for the Institute for Health and Productivity Management