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Manpower substitution in mental health service delivery Macpherson, Elinor Carol 1988

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MANPOWER SUBSTITUTION IN MENTAL HEALTH SERVICE DELIVERY By ELINOR CAROL MACPHERSON B.A., Stanford University, 1964 M.A., University of I l l i n o i s , 1969 Ph.D., University of I l l i n o i s , 1971  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE STUDIES Department of Health Care and Epidemiology Health Services Planning and Administration Program  We accept this thesis as conforming to the required  standard  THE UNIVERSITY OF BRITISH COLUMBIA  May 1988 ©Copyright:  E l i n o r Carol Macpherson, 1988  In p r e s e n t i n g  t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f the  requirements f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make it  f r e e l y a v a i l a b l e f o r reference  and study.  I further  agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying o f t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the head o f my department o r by h i s o r h e r r e p r e s e n t a t i v e s .  Iti s  understood t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l gain  s h a l l n o t be allowed without my  permission.  Department  of  H e a l t h Care and Epidemiology  The U n i v e r s i t y o f B r i t i s h 2075 Wesbrook P l a c e Vancouver, Canada V6T 1W5 Date  April  22, 1988  Columbia  written  ii ABSTRACT The  study developed  manpower s u b s t i t u t i o n  a model f o r p r o j e c t i n g p o t e n t i a l economies  from  among the four core mental health professions and  applied the model t o a proposed s u b s t i t u t i o n s i t u a t i o n which would s u b s t i t u t e psychologists f o r p s y c h i a t r i s t s i n the d e l i v e r y of a proportion of present private practice  ( f e e - f o r - s e r v i c e ) p s y c h i a t r y services i n B r i t i s h  The model i d e n t i f i e s three c o n t r o l l i n g v a r i a b l e s :  Columbia.  treatment s u b s t i t u t a b i l i t y  (TS), p r a c t i c e p r i v i l e g e constraints (PPC), and r e l a t i v e payment rates (RR). In the model, TS and PPC are conceptualized as determining the estimated s u b s t i t u t a b l e share of costs (SSC%);  RR, i n combination with the values  derived f o r SSC%, i s then used t o estimate p o t e n t i a l cost savings (CS%).  Two  conditions were defined f o r each of the three c o n t r o l l i n g v a r i a b l e s i n order to provide a range of possible values f o r SSC% and CS%. For reasons of data a v a i l a b i l i t y , data were obtained from the Manitoba Health Services Commission f o r p r i v a t e p r a c t i c e p s y c h i a t r y services f o r FY 1984 and estimates of SSC% calculated.  These estimates were then applied to B.C. Medical S e r v i c e s  Commission d a t a Calculations  f o r FY 1984, and p r o j e c t e d v a l u e s of CS% c a l c u l a t e d .  were made both  f o r a l l services  and f o r the subset o f  psychotherapy s e r v i c e s , which accounted f o r 80 percent of the larger set of services.  The r e s u l t s of the study i n d i c a t e d considerable p o s s i b i l i t i e s f o r  manpower s u b s t i t u t i o n , ranging from 35 to 70 percent f o r a l l services and 40 to 75 percent f o r psychotherapy s e r v i c e s . while  salaried  However, the study a l s o found that  psychologists offered the p o s s i b i l i t y  savings, a f ee-f o r - s e r v i c e arrangement suggested savings.  of s u b s t a n t i a l cost  virtually  no  potential  Projected values of CS% f o r the s a l a r i e d a l t e r n a t i v e were 20 to 40  percent f o r a l l services and 15 to 30 percent f o r psychotherapy services but i n the f e e - f o r - s e r v i c e a l t e r n a t i v e , only 4 to 8 percent f o r a l l services and 4 t o 7 percent f o r psychotherapy s e r v i c e s .  Licensure and market r i g i d i t i e s  which might pose b a r r i e r s to implementation were evaluated  and  a review of  p r o f e s s i o n a l t r a i n i n g standards (TS), l i c e n s u r e standards (PPC), and alternatives  (RR)  i n d i c a t e d that the projected economies could be  with no necessity f o r modifications i n e x i s t i n g arrangements. present  almost no  b a r r i e r s to  economies  from  the  funding achieved  PPC appear to  proposed  manpower  s u b s t i t u t i o n and those b a r r i e r s which are presented by TS and RR l i m i t a t i o n s still  allow  considerable  opportunities  for  i n t e r v e n t i o n i n achieving  economies appear to be relative  p o t e n t i a l f o r economies.  i n the  effectiveness  pharmacotherapy).  The  of  and  Thus, the  greatest  enhancing the  projected,  exploration of r e l a t i v e payment r a t e s  t r e a t m e n t methods  (e.g.,  psychotherapy  study concludes with a discussion of f a c t o r s  outside the boundaries of the model but which impinge, nonetheless, f e a s i b i l i t y of the proposed s u b s t i t u t i o n and makers to address. centres  was  The  suggested as  fall,  e x i s t i n g network of B.C. a possible mechanism f o r  and vs. lying  upon the  n e c e s s a r i l y , to p o l i c y community mental health the  d e l i v e r y of  s u b s t i t u t a b l e share of p r i v a t e p r a c t i c e psychiatry s e r v i c e s .  the  iv TABLE OF CONTENTS Page ABSTRACT  i i  LIST OF TABLES  vii  LIST OF FIGURES  viii  ACKNOWLEDGEMENT  ix  CHAPTER ONE: 1 .1 1 .2 1.3 1.4 CHAPTER TWO:  INTRODUCTION  1  Objective Rationale Concept of Manpower S u b s t i t u t i o n Structure  1 2 6 8  MODEL FOR PROJECTING POTENTIAL ECONOMIES  10  FROM MENTAL HEALTH MANPOWER SUBSTITUTION CHAPTER THREE:  THE EFFECTIVENESS OF PSYCHOTHERAPY  24  CHAPTER FOUR:  THE PROFESSIONAL TRAINING STANDARDS  35  4.1 4.2 CHAPTER FIVE:  A c c r e d i t a t i o n & Training Program Standards P r o f e s s i o n a l Training Programs Compared THE PROFESSIONAL LICENSURE STANDARDS  35 56 61  5.1 5.2 5.3  P r o f e s s i o n a l Licensure Standards Professional Practice Privileges Licensure Standards & P r a c t i c e P r i v i l e g e s Compared  61 67 73  5.4  P o t e n t i a l P r a c t i c e P r i v i l e g e s f o r Psychologists  79  THE PROFESSIONS COMPARED AS PSYCHOTHERAPISTS  86  Perceived Clinical Clinical Patterns  86 90 93 97  CHAPTER SIX: 6.1 6.2 6.3 6.4 6.5  Credibility Attitudes Effectiveness of P r a c t i c e  • Professions as Psychotherapists  Compared  101  CHAPTER SEVEN:  SUBSTITUTION S THE TREATMENT OF MENTAL DISORDERS  104  CHAPTER EIGHT: 8.1  METHODOLOGY Estimating Substitutable Share of Services and Costs P r o j e c t i n g Cost Implications of Manpower Substitution  135 137  8.2  152  V  TABLE OP CONTENTS (cont.) Page CHAPTER NINE: 9.1 9.2 CHAPTER TEN:  RESULTS AND ANALYSIS  166  Estimated Substitutable Share of Services and Costs Projected Cost Implications of Manpower Substitution  166  DISCUSSION AND CONCLUSION  206  190  FOOTNOTES  225  BIBLIOGRAPHY  228  APPENDIX  245 Appendix Appendix Appendix Appendix  A: B: C: D:  The P r o f e s s i o n a l Training Standards The P r o f e s s i o n a l Licensure Standards Data The P r o f e s s i o n a l Payment Schedules  246 279 292 302  vi LIST OF TABLES Page TABLE I .  Comparison of Training Programs i n the Four Core Mental Health Professions a t B r i t i s h Columbia Universities  36  TABLE I I .  Program Elements: Program  U.B.C. Psychiatry  Training  41  TABLE I I I .  Program Elements: T r a i n i n g Program  S.F.U. C l i n i c a l Psychology  46  TABLE IV.  Program Elements: Douglas College P s y c h i a t r i c Nursing T r a i n i n g Program  48  TABLE V.  Program Elements: Program  54  TABLE V I .  Licensure Standards f o r Mental Health Professions i n B r i t i s h Columbia  62  TABLE V I I .  P r a c t i c e P r i v i l e g e s f o r Mental Health Professions i n B r i t i s h Columbia  69& 70  TABLE V I I I .  S u b s t i t u t i o n and the Treatment of Mental Disorders  105  TABLE IX.  Four Scenarios f o r Estimating S u t s t i t u t a b l e Share and P r o j e c t i n g Cost Implications of Manpower S u b s t i t u t i o n  139  TABLE X.  Estimates of Treatment S u b s t i t u t a b i l i t y  142  TABLE XI.  Estimates of P r a c t i c e P r i v i l e g e Constraints  145  TABLE X I I .  Age/Sex Population D i s t r i b u t i o n f o r Manitoba and B r i t i s h Columbia (June 1, 1984)  154  U.B.C. S o c i a l Work Training  TABLE X I I I .  D i s t r i b u t i o n of Mental Disorders Diagnosed f o r Patients Discharged from P s y c h i a t r i c and General Hospitals i n Manitoba and B r i t i s h Columbia (FY 1982)  155  TABLE XIV.  Fee Schedule Structure f o r P s y c h i a t r i s t s B i l l i n g Medical Plans i n Manitoba and B r i t i s h Columbia ( A p r i l , 1985)  156  TABLE XV.  Payment Rates f o r P s y c h i a t r i s t s and Psychologists i n B r i t i s h Columbia (1985)  162  TABLE XVI.  Estimated E f f e c t of Treatment S u b s t i t u t a b i l i t y on P o t e n t i a l f o r Manpower S u b s t i t u t i o n (Private P r a c t i c e Psychiatry B i l l i n g s t o MHSC: FY 1984)  167& 168  vii LIST OF TABLES (cont.) TABLE XVII.  Estimated E f f e c t of P r a c t i c e P r i v i l e g e Constraints on P o t e n t i a l f o r Manpower S u b s t i t u t i o n (Private P r a c t i c e Psychiatry B i l l i n g s t o MHSC: FY 1984)  TABLE XVIII.  Substitutable Share of P r i v a t e P r a c t i c e Psychiatry 176& Services and Costs: Estimated Combined E f f e c t of 177 Treatment S u b s t i t u t a b i l i t y (TS) and P r a c t i c e P r i v i l e g e Constraints (PPC) on P o t e n t i a l f o r Manpower S u b s t i t u t i o n ( P r i v a t e P r a c t i c e Psychiatry B i l l i n g s to MHSC: FY 1984)  TABLE XIX.  P r i v a t e P r a c t i c e Psychiatry Psychotherapy Services 181 and Costs i n Manitoba and B r i t i s h Columbia (FY 1984)  TABLE XX.  Substitutable Share of P r i v a t e P r a c t i c e Psychiatry 183& Psychotherapy Services and Costs: Estimated Combined 184 E f f e c t of Treatment S u b s t i t u t a b i l i t y (TS) and P r a c t i c e P r i v i l e g e Constraints (PPC) on P o t e n t i a l f o r Manpower S u b s t i t u t i o n (Private P r a c t i c e Psychiatry B i l l i n g s t o MHSC: FY 1984)  TABLE XXI.  Summary of Estimated Separate and Combined E f f e c t 188& of Treatment S u b s t i t u t a b i l i t y (TS) and P r i v a t e 189 P r i v i l e g e Constraints (PPC) on P o t e n t i a l f o r Manpower S u b s t i t u t i o n ( P r i v a t e P r a c t i c e Psychiatry B i l l i n g s to MHSC: FY 1984)  TABLE XXII.  Cost Implications of Manpower S u b s t i t u t i o n f o r P r i v a t e P r a c t i c e Psychiatry Services: Projected Combined E f f e c t of Treatment S u b s t i t u t a b i l i t y , P r a c t i c e P r i v i l e g e Constraints, and R e l a t i v e Payment Rate on P o t e n t i a l Economies (Private P r a c t i c e Psychiatry B i l l i n g s t o BCMSC: FY 1984)  1 94& 195  TABLE XXIII.  Cost Implications of Manpower S u b s t i t u t i o n f o r P r i v a t e P r a c t i c e Psychiatry Psychotherapy Services: Projected Combined E f f e c t of Treatment S u b s t i t u t a b i l i t y , P r a c t i c e P r i v i l e g e Constraints, and R e l a t i v e Payment Rate on P o t e n t i a l Economies (Private P r a c t i c e Psychiatry B i l l i n g s t o BCMSC: FY 1984)  199& 200  TABLE XXIV.  R e l a t i v e Payment Rates f o r the Four Core Mental Health Professions i n B r i t i s h Columbia (1987)  217  171  Vlll  LIST OF FIGURES Page FIGURE 1.  V e r t i c a l D i s t r i b u t i o n of P r o f e s s i o n a l Manpower to Meet Mental Health Needs  11  FIGURE 2.  Horizontal D i s t r i b u t i o n of P r o f e s s i o n a l Manpower to Meet Mental Health Needs  12  FIGURE 3a.  Model of P o t e n t i a l Economies from Mental Health Manpower S u b s t i t u t i o n : Estimating Substitutable Share of Costs  15  FIGURE 3b.  Model of P o t e n t i a l Economies from Mental Health Manpower S u b s t i t u t i o n : P r o j e c t i n g Cost Implications of Manpower S u b s t i t u t i o n  16  FIGURE 4.  Model f o r P r o j e c t i n g P o t e n t i a l Economies from Mental Health Manpower S u b s t i t u t i o n : Matrix Format  18& 19  FIGURE 5a.  Estimated E f f e c t s of Treatment S u b s t i t u t a b i l i t y (TS) and P r a c t i c e P r i v i l e g e Constraints (PPC) on Substitutable Share of Costs f o r Mental Health Manpower S u b s t i t u t i o n  FIGURE 5b.  Projected E f f e c t s of Treatment S u b s t i t u t a b i l i t y (TS), 192 P r a c t i c e P r i v i l e g e Constraints (PPC) and R e l a t i v e Payment Rate (RR) on Cost Implications of Mental Health Manpower S u b s t i t u t i o n  174  ix ACKNOWLEDGEMENT  I would l i k e  t o express my very  great  appreciation  t o my  Committee Chairman, Dr. Morris Barer, D i r e c t o r , D i v i s i o n of Health  Thesis Services  Research and Development, U n i v e r s i t y of B r i t i s h Columbia, f o r h i s supervision of  this  research  project.  Dr. B a r e r has made h i m s e l f  available for  c o n s u l t a t i o n over a two year period and I have found h i s advice, and most p a r t i c u l a r l y h i s emphasis on excellence, would also l i k e  both h e l p f u l and challenging. I  t o thank the members of my Thesis  Committee, Dr. Morton  Beiser, Professor, Department of P s y c h i a t r y , U n i v e r s i t y of B r i t i s h Columbia, and  Mr. Jonathan  Lomas, A s s o c i a t e  Professor,  Department  of C l i n i c a l  Epidemiology and B i o s t a t i s t i c s , McMaster U n i v e r s i t y , f o r t h e i r encouragement and c r i t i c i s m .  I have been most appreciative of the e f f o r t s Dr. Beiser and  Mr. Lomas have made t o share t h e i r expertise i n t h e i r respective f i e l d s with me.  For t h e i r f i n a n c i a l support of t h i s p r o j e c t , I would f u r t h e r l i k e t o  extend my thanks to the National Health  Research and Development Program,  Health and Welfare Canada, and t o my parents, Mr. and Mrs.  J.H. Macpherson.  As w e l l , f o r t h e i r assistance with t e c h n i c a l aspects of the p r o j e c t , I would l i k e t o thank Mr. Alan H o l t s l a g , Senior S t a t i s t i c a l Analyst, Manitoba Health Services  Commission, Mr. J i m Henderson, L i b r a r i a n , Woodward  L i b r a r y , Mr. Barney Herring, Tetrad Matovich,  Bio-Medical  Computer A p p l i c a t i o n s Ltd., Ms. Tracey  Research A s s i s t a n t , and Mr. Ron S i z t o , Computer  Department of Health Care & Epidemiology.  Consultant,  Furthermore, f o r t h e i r  personal  patience and encouragement, I would l i k e t o thank Ms. Rose Matovich and Mr. Jack Cooper. Mrs.  F i n a l l y , I would l i k e t o express my very great appreciation t o  Lorraine Davidson f o r her exceptional c l e r i c a l s k i l l s i n designing and  typing the manuscript.  CHAPTER ONE  INTRODUCTION  1.1  OBJECTIVE The  objective of the present t h e s i s p r o j e c t i s t o develop a model  of manpower s u b s t i t u t i o n i n mental health s e r v i c e d e l i v e r y .  The t h e s i s  attempts t o e s t a b l i s h a range of f e a s i b l e s u b s t i t u t i o n s among the four core mental health professions: nursing, and s o c i a l work.  p s y c h i a t r y , psychology, p s y c h i a t r i c  I t takes p r i v a t e p r a c t i c e psychiatry as i t s  s t a r t i n g p o i n t and i n v e s t i g a t e s the p o s s i b i l i t i e s f o r s u b s t i t u t i o n among the  four professions.  The study places  emphasis on a comparison of  psychiatry and psychology, as the t r a i n i n g and l i c e n s u r e standards f o r these two p r o f e s s i o n s  are the most s i m i l a r .  I t concludes with an  examination of the i m p l i c a t i o n s of the manpower s u b s t i t u t i o n model f o r the cost of mental health s e r v i c e d e l i v e r y i n the Canadian context, with p a r t i c u l a r reference t o B r i t i s h Columbia.  2 1.2  RATIONALE As mental health services are c u r r e n t l y d e l i v e r e d i n North America, there are four core mental health professions: p s y c h i a t r y , psychology, p s y c h i a t r i c nursing, years,  and p s y c h i a t r i c s o c i a l work.  changing p e r c e p t i o n s  o f mental d i s o r d e r s  Over the past 30 and t h e i r  proper  treatment have b l u r r e d the r o l e s of the mental health professions. the s t a r t of t h i s t r a n s i t i o n p e r i o d , with three-quarters  At  of a l l care  episodes occurring on an i n p a t i e n t b a s i s , p r o f e s s i o n a l r o l e s were q u i t e stereotyped:  p s y c h i a t r i s t s t r e a t e d p a t i e n t s , psychologists  t e s t s , nurses dispensed medication, plans  (Blum & R e d l i c h , 1980).  administered  and s o c i a l workers made  discharge  P r e s e n t l y , with three quarters  of a l l  care episodes occurring on an outpatient basis and with a wider range of conditions considered  appropriate  f o r treatment, there appears t o be a  more e g a l i t a r i a n d i s t r i b u t i o n of f u n c t i o n s , (McGuire, 1981).  Trebilcock  and Shaul (1983) have noted that the market f o r mental health s e r v i c e s is  very  lightly  regulated;  administration of medication,  with  the exception  of p r e s c r i p t i o n and  e x c l u s i v e r i g h t s t o p r a c t i c e a r e not  recognized and, at most, c e r t a i n p r o f e s s i o n a l t i t l e s are reserved by law to c e r t a i n groups.  Blum & Redlich, studying patterns of p r a c t i c e i n a  range o f C o n n e c t i c u t  mental h e a l t h  s e t t i n g s , found a sharing of  treatment functions such as i n d i v i d u a l and group psychotherapy by a l l mental health professions.  Also i n the U.S., Webb (1970) examined the  s e v e r i t y of mental health problems i n p a t i e n t s of p s y c h i a t r i s t s and psychologists i n p r i v a t e p r a c t i c e and found no s i g n i f i c a n t d i f f e r e n c e s . S i m i l a r l y , Taube, B u r n s , and K e s s l e r  (1984) found no s i g n i f i c a n t  d i f f e r e n c e s i n the rate of p a t i e n t h o s p i t a l i z a t i o n f o r U.S. p r i v a t e p r a c t i c e p s y c h i a t r i s t s and psychologists.  McGuire (1980) examined the  d i s t r i b u t i o n of p s y c h i a t r i s t s and psychologists i n U.S. community mental  3 health centers  and found that 85 percent of the variance  could be a t t r i b u t e d t o interchangeable severity  of d i a g n o s i s  and r a t e  i n staffing  professional inputs;  again,  of h o s p i t a l i z a t i o n d i d not d i f f e r  significantly. The present author (Macpherson, 1983) has addressed the reasons f o r t h i s overlap of f u n c t i o n among mental health professions, developing the t h e s i s that the overlap  occurs f o r two reasons.  F i r s t , because the  study of human behaviour includes both psychological and p h y s i o l o g i c a l elements, much of the knowledge base of the four core mental health professions i n t e r t w i n e s .  Second, because neither the absolute  r e l a t i v e effectiveness of the various  a l t e r n a t e therapies  nor the  f o r mental  disorders has been d e f i n i t i v e l y demonstrated, no s i n g l e p r o f e s s i o n has been able  t o l a y claim t o e x c l u s i v e expertise nor have the s e v e r a l  professions been able t o agree on a d i s t r i b u t i o n of e x c l u s i v e e x p e r t i s e . In  common p a r l a n c e ,  "profession" i s considered  c e r t a i n occupations such as law and engineering. (1972) and Larson  synonymous with  However, Johnson  (1977), approaching the concept of p r o f e s s i o n a l i s m  from a s o c i o l o g i c a l perspective, conclude that a profession i s not an occupation  but rather  a means of c o n t r o l l i n g an occupation  and that  therefore the key t o p r o f e s s i o n a l i z a t i o n i s t o c o n s t i t u t e and c o n t r o l a market f o r a p a r t i c u l a r form of expertise.  Larson p o s i t s that i n  e s t a b l i s h i n g p r o f e s s i o n a l monopoly, the c r u c i a l i n t e r v e n i n g  variable  between expertise and market c o n t r o l i s "cognitive exclusiveness," i . e . , p r o p r i e t a r y r i g h t s t o a body of knowledge. has  Hence, the present author  argued that as a r e s u l t of t h e i r common knowledge base and t h e i r  i n a b i l i t y t o c l e a r l y e s t a b l i s h the e f f e c t i v e n e s s of treatment, no s i n g l e mental health profession has been able t o e s t a b l i s h s u f f i c i e n t c o g n i t i v e exclusiveness t o gain monopoly c o n t r o l over the market f o r mental health  4 services.  Indeed, i n B r i t i s h Columbia current l e g i s l a t i o n s p e c i f i c a l l y  authorizes both medical p r a c t i t i o n e r s and psychologists to diagnose and t r e a t mental disorders.  Furthermore, B.C. Mental Health Branch p o l i c y ,  with the i n t r o d u c t i o n of a new management information system, requires a l l s t a f f t o provide a DSM-III (APA, 1980) designation f o r each c l i e n t , with  the proviso  classification  that  non-licensed  rather than a diagnosis  treatment of mental disorders  professionals (Copley,  a r e making a  1985).  Hence, t h e  does not appear t o f i t neatly i n t o any  s i n g l e p r o f e s s i o n a l b a i l i w i c k ; several professions  appear t o have a  l e g i t i m a t e claim t o expertise and, as a consequence, t o a share of the market f o r mental health s e r v i c e s . The  issue  of t h e e f f e c t i v e n e s s of t h i s expertise needs to be  addressed f u r t h e r , f o r there i s no gain to be made from a s u b s t i t u t i o n e f f o r t i f the treatment provided i s i t s e l f i n e f f e c t i v e . whether one subset of treatments,  The question of  psychotherapy, i s e f f e c t i v e has been  the subject of intense, even acrimonious, debate (Bergin 1971; Bergin & Lambert, 1978; Casey & Berman, 1985; Eysenck, 1952, 1965, 1966, 1978; G a l l o , 1978; G a r f i e l d , 1983; Luborsky, Singer & Luborsky, 1975; M e l t z o f f & Kornreich,  1970; P a r l o f f , 1978; Rachman, 1973; Smith & Glass, 1977;  Smith, Glass, & M i l l e r ,  1981; Wilson & Rachman, 1983).  The O f f i c e of  Technology Assessment (OTA, 1980), i n i t s paper "The E f f i c a c y and Cost Effectiveness  of Psychotherapy," provides  present state of knowledge. l i t e r a t u r e contains  a balanced summary of the  OTA concludes that the c u r r e n t l y a v a i l a b l e  a number of good q u a l i t y research  studies  and a  number of meta-analyses of these studies which f i n d p o s i t i v e outcomes f o r psychotherapy.  A more comprehensive discussion of the e f f e c t i v e n e s s  of psychotherapy i s presented i n Chapter Three.  5 Thus a l t h o u g h health  research  on  p r o f e s s i o n a l s u b s t i t u t i o n i n mental  services d e l i v e r y involves the  caveat that we  have no  truly  adequate operational d e f i n i t i o n of q u a l i t y of s e r v i c e , examinations of present patterns considerable  of s t a f f i n g and  patterns  s u b s t i t u t i o n occurs and  of p r a c t i c e i n d i c a t e  that  suggest the p o s s i b i l i t y f o r s t i l l  further s u b s t i t u t i o n . Given the range of reimbursement rates across four  core mental health professions, the i m p l i c a t i o n i s that  the  greater  cost e f f e c t i v e n e s s could be achieved i n the d e l i v e r y of mental health services.  In B r i t i s h Columbia, a comparison of 1987  p r o v i n c i a l salary  and s e s s i o n a l rates i l l u s t r a t e s t h i s reimbursement d i f f e r e n t i a l . payments  f o r p s y c h i a t r i s t s range  psychologists  from $35,000 to  from  $66,000 t o  Salary  $83,000 , f o r 1  $48,000 , f o r p s y c h i a t r i c nurses from 2  $27,000 to $34,000 , and f o r p s y c h i a t r i c s o c i a l workers from $26,000 to 3  $35,000^.  Sessional rates  (3 1/2  hours) f o r p s y c h i a t r i s t s range from  $211 to $273 , and f o r psychologists from $92 to $155 . 1  5  Nevertheless, although s u b s t i t u t i o n may d e s i r a b l e , the  market f o r health  be t e c h n i c a l l y f e a s i b l e and  services i n general  and  f o r mental  health services•as a subgroup appears to leave much of that f e a s i b i l i t y as no more than p o t e n t i a l .  Evans (1984) reviewed a s e r i e s of studies  which suggest that i n Canada and the United States reductions of as much as 40 percent of t o t a l expenditures could be achieved without loss of q u a l i t y on  dental s e r v i c e s , pharmaceutical dispensing,  goods through r a t i o n a l i z a t i o n of production personnel. primary  Lomas and care  practitioners. disturbed  Stoddart  physician  and  ophthalmic  and use of l e s s expensive  (1985) found that 40 to 90 percent of  office  visits  could  be  delegated  to nurse  In a study of agencies p r o v i d i n g services to emotionally  c h i l d r e n , Macpherson  (1982) found  that  while  patient  populations, p a t i e n t / s t a f f r a t i o s , and treatment programs were s i m i l a r ,  6 costs  d i f f e r e d considerably,  i n large measure as a function  s a l a r i e s , with the yearly cost per  of  staff  c h i l d ranging from $4,000 i n a u n i t  s t a f f e d by teachers, teacher aides, and c h i l d care workers to $15,000 i n a u n i t s t a f f e d by possibility  of  t e a c h e r s and substitution  reimbursement r a t e s , there may of mental health  psychologists. and  the  Hence, g i v e n  existence  of  a  the  range  of  be room f o r more cost e f f e c t i v e d e l i v e r y  services p a r a l l e l to the p o t e n t i a l i n other areas of  health service d e l i v e r y .  1.3  CONCEPT OF MANPOWER SUBSTITUTION Although s u b s t i t u t i o n i s the term commonly employed i n of how  discussions  we might economize i n s e r v i c e d e l i v e r y by the use of l e s s c o s t l y  personnel, s u b s t i t u t i o n should not  be taken to imply that l e s s c o s t l y  personnel are n e c e s s a r i l y l e s s w e l l t r a i n e d to perform tasks considered substitutable.  Perhaps a l l o c a t i o n rather than s u b s t i t u t i o n would be  more apt designation than considering with  f o r the process we are addressing.  " j u n i o r " personnel, Lomas (1986) has  s e r v i c i n g of  that  need might be  suggested that we  begin  our  services and then examine  how  apportioned so  assigned i n the most c o s t - e f f e c t i v e manner.  that  services  rather  than as  tasks  are  Thus, f o r example, i f a  s i t u a t i o n of unmet needs were perceived, i t would be s h o r t a g e of  Hence, rather  s u b s t i t u t i o n as the replacement of "senior" personnel  enquiry with the need f o r mental health the  a  necessarily  regarded as  a shortage of  a any  p a r t i c u l a r type of p r o f e s s i o n a l input (McGuire, 1980). Using t h i s  approach, McGuire provides an  excellent  s u b s t i t u t a b i l i t y i n mental health service d e l i v e r y . economists  distinguish  two  types  of  of  McGuire notes that  substitutability:  a b i l i t y i n production and s u b s t i t u t a b i l i t y i n demand.  analysis  substitut-  In meeting mental  7 health s e r v i c e needs, s u b s t i t u t a b i l i t y i n production  would be s a i d t o  e x i s t i f a l t e r n a t e p r o f e s s i o n a l inputs could be used t o produce the same p r o f e s s i o n a l output.  For example, any of the four core mental health  professions may be equally s k i l l e d i n conducting intake interviews or d e l i v e r i n g psychotherapy at a mental health  facility.  Likewise,  a  general medical p r a c t i t i o n e r and a psychologist working together may be able t o provide the same s e r v i c e as a p s y c h i a t r i s t working alone i n a correctional institution.  S u b s t i t u t a b i l i t y i n demand would be s a i d t o  e x i s t i f d i f f e r e n t p r o f e s s i o n a l inputs produced d i f f e r e n t outputs which were nevertheless for  instance,  considered by consumers t o meet the same need.  mental h e a l t h  clients  may  Thus,  judge psychotherapy and  pharmacotherapy equally e f f e c t i v e i n r e l i e v i n g anxiety s t a t e s . McGuire presents  a u s e f u l elaboration of the concept of s u b s t i t u t -  a b i l i t y i n production by d i s t i n g u i s h i n g between simple s u b s t i t u t i o n and complex s u b s t i t u t i o n .  In simple s u b s t i t u t i o n , P r o f e s s i o n a l I does the  same t h i n g as P r o f e s s i o n a l I I .  In complex s u b s t i t u t i o n Combination I of  workers can accomplish the same task as Combination I I of workers; that is,  many  inputs  a r e used i n c o m b i n a t i o n w i t h  one another i n the  production of services and s u b s t i t u t i o n takes the form of changes i n the combination of inputs. The present research p r o j e c t focusses s p e c i f i c a l l y on the p o t e n t i a l f o r s u b s t i t u t a b i l i t y i n the production  of p r i v a t e p r a c t i c e p s y c h i a t r y  services i n the Canadian context.  The study i s designed t o compare the  tasks  health  of one t y p e  of mental  worker,  fee-for-service  p s y c h i a t r i s t s , with the tasks of another, psychologists. in  principle,  substitution  capable  Hence, i t i s ,  of i d e n t i f y i n g p o s s i b i l i t i e s  i n t h e production  of these s e r v i c e s .  p r o j e c t s the p o t e n t i a l f o r cost savings  f o r simple  The study then  from such a s u b s t i t u t i o n .  In  8 more general terms, the present research p r o j e c t discusses the p o t e n t i a l f o r both s u b s t i t u t a b i l i t y i n production and s u b s t i t u t a b i l i t y i n demand across a l l four core mental health professions, addresses p o s s i b i l i t i e s f o r both simple and complex s u b s t i t u t i o n and examines the p o t e n t i a l f o r cost  savings which might r e s u l t from such a r e a l l o c a t i o n of s e r v i c e  delivery.  1.4  STRUCTURE To accomplish t h i s i n v e s t i g a t i o n of s u b s t i t u t i o n p o s s i b i l i t i e s the study develops a model f o r p r o j e c t i n g p o t e n t i a l economies from mental health manpower s u b s t i t u t i o n and applies that model t o what i s presently f e e - f o r - s e r v i c e p s y c h i a t r i c p r a c t i c e i n B r i t i s h Columbia.  The study  deals with the d i r e c t costs of s e r v i c e p r o v i s i o n and does not examine r e l a t i v e effectiveness  or i n d i r e c t costs.  investigates' the f o l l o w i n g three  In three steps,  the study  questions:  1•  Which services present the p o s s i b i l i t y for s u b s t i t u t i o n ?  2.  What would be the projected cost i m p l i c a t i o n s of implementing such s u b s t i t u t i o n s ?  3.  What l i c e n s u r e and market r i g i d i t i e s would need t o be changed f o r implementation?  The  remainder  of t h e t h e s i s  Chapter Two presents a discussion which can be conceptualized differentials  i s organized i n t o nine  chapters.  of the model of s u b s t i t u t a b i l i t y ,  i n matrix form and used t o p r o j e c t  f o r manpower s u b s t i t u t i o n i n mental h e a l t h  cost  service  d e l i v e r y under current and h y p o t h e t i c a l t r a i n i n g , l i c e n s u r e and funding arrangements.  In the matrix,  the f i r s t  axis  contains  treatment  s u b s t i t u t i o n p o s s i b i l i t i e s , the second axis contains p r a c t i c e p r i v i l e g e p o s s i b i l i t i e s , the t h i r d a x i s contains  r e l a t i v e payment p o s s i b i l i t i e s ,  9 and  the  c e l l s indicate  p o l i c y options. and  p r o j e c t e d cost d i f f e r e n t i a l s under d i f f e r i n g  Chapters Three through Seven address the f i r s t question  examine the p o s s i b i l i t i e s f o r simple s u b s t i t u t i o n .  These chapters  document the r e l a t i o n s h i p between, on the one hand, treatment p r a c t i c e s , t r a i n i n g standards, l i c e n s u r e  standards, and  on the other hand, s u b s t i t u t i o n p o s s i b i l i t i e s . attempt to provide q u a n t i t a t i v e  practice privileges,  Chapters Eight and Nine  answers to both the  questions, examining s u b s t i t u t i o n p o s s i b i l i t i e s and under v a r i o u s  treatment  and the r e s u l t s of the study. and presents a discussion s u b s t i t u t i o n arrangements•  first cost  s u b s t i t u t a b i l i t y , practice  r e l a t i v e payment conditions.  and,  and  second  implications  privilege,  and  These two chapters present the methodology Chapter Ten addresses the t h i r d question  of the p o l i c y i m p l i c a t i o n s of these p r o j e c t e d  10 CHAPTER TWO MODEL FOR PROJECTING POTENTIAL ECONOMIES FROM MENTAL HEALTH MANPOWER SUBSTITUTION  In considering the f e a s i b i l i t y of manpower s u b s t i t u t i o n i n the d e l i v e r y of mental health s e r v i c e s , I have suggested that i t may be more u s e f u l t o conceptualize mental health needs as being a l l o c a t e d rather than s u b s t i t u t e d among the professions and that where more than one profession can e f f e c t i v e l y perform the treatment f u n c t i o n , the d e l i v e r y of that s e r v i c e could reasonably be a l l o c a t e d t o the l e a s t expensive personnel.  P r e v i o u s l y , when treatment  was d e l i v e r e d p r i m a r i l y on an i n p a t i e n t b a s i s , i t was probably more accurate to consider  manpower d i s t r i b u t i o n as h i e r a r c h i c a l , as i l l u s t r a t e d i n Figure  1, with " j u n i o r " professions s u b s t i t u t i n g at times f o r "senior" professions. In t h i s s i t u a t i o n , the j u n i o r profession supporting  may indeed have functioned  r o l e and t o s u b s t i t u t e the j u n i o r p r o f e s s i o n  in a  f o r the senior  p r o f e s s i o n might have been a cheaper but second-best a l t e r n a t i v e , a trade-off of economy f o r competence.  However, with treatment p r e s e n t l y  delivered  p r i m a r i l y on an outpatient b a s i s , the documentation on p r o f e s s i o n a l t r a i n i n g standards and p r o f e s s i o n a l l i c e n s u r e standards and the l i t e r a t u r e r e l a t i v e effectiveness of the d i s c i p l i n e s possibility  of considerable  flexibility  corresponding s a c r i f i c e i n q u a l i t y .  as psychotherapists  on t h e  suggest the  i n manpower a l l o c a t i o n w i t h o u t a  Perhaps a h o r i z o n t a l conceptualization  of manpower d i s t r i b u t i o n , as suggested by Lomas (1986) and i l l u s t r a t e d i n Figure  2, might be a more h e l p f u l t o o l i n considering  treatment functions among d i s c i p l i n e s .  the a l l o c a t i o n of  In the h o r i z o n t a l c o n f i g u r a t i o n , the  professions have some s k i l l s i n common and some s k i l l s which are unique. the present context, we are addressing which might  In  that area of convergence of s k i l l s  permit more than one p r o f e s s i o n t o d e l i v e r  some of the services  11  FIGURE 1 VERTICAL DISTRIBUTION OF PROFESSIONAL MANPOWER TO MEET MENTAL HEALTH NEEDS  x XXX  PROFESSION  xxxxx xxxxxxx xxxxxxxxx xxxxxxxxxxx xxxxxxxxxxxxx .xxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx  JROFESSION  ASSESSMENT  PROFESSION  TREATMENT  FOLLOWUP  12  FIGURE 2 HORIZONTAL DISTRIBUTION OF PROFESSIONAL MANPOWER TO MEET MENTAL HEALTH NEEDS  MENTAL HEALTH NEEDS  MENTAL HEALTH PROFESSIONS  RELATIONSHIP  13 presently provided by p r i v a t e p r a c t i c e psychiatry and the p o s s i b l e economies which might be achieved. The  model used f o r p r o j e c t i n g p o t e n t i a l economies from mental health  manpower s u b s t i t u t i o n i n t h i s t h e s i s , i s based on the premise that controlling  variables  substitution: constraints  determine  treatment (PPC),  the cost  implications  substitutability  and r e l a t i v e payment  three  of manpower  (TS), practice p r i v i l e g e rate  (RR).  Treatment  s u b s t i t u t a b i l i t y r e f e r s t o the degree t o which the p r o f e s s i o n a l t r a i n i n g standards  f o r the four  overlapping  core mental h e a l t h professions  s k i l l s i n the treatment of mental disorders.  create  areas of  Practice p r i v i l e g e  c o n s t r a i n t s r e f e r s t o the degree t o which the extant p r o f e s s i o n a l l i c e n s u r e standards and informal p r a c t i c e p r i v i l e g e s f o r the four professions areas of overlapping  service delivery.  create  R e l a t i v e payment rate r e f e r s t o the  degree t o which the funding arrangements f o r the p r o f e s s i o n a l groups create p o s s i b l e savings i n personnel costs. The model proceeds i n two stages. the  estimation  In the f i r s t stage, the model permits  of the p o t e n t i a l f o r manpower s u b s t i t u t i o n , that  s u b s t i t u t a b l e share of present services and costs.  i s , the  In the second stage,  costs or p r i c e s are a p p l i e d t o the r e s u l t s of the f i r s t stage, t o p r o j e c t the p o t e n t i a l cost d i f f e r e n t i a l s from such a manpower s u b s t i t u t i o n . Figures  3a and 3b present the model i n graphic form.  In Figure 3a, TS  and PPC have been designated as the h o r i z o n t a l and v e r t i c a l axes, Axis I and Axis  I I r e s p e c t i v e l y , of the diagram.  have been conceptualized manpower  substitution.  The separate e f f e c t s of TS and PPC  as each c o n t r i b u t i n g t o t h e p o s s i b i l i t i e s f o r Hence, t h e g r e a t e s t  p o t e n t i a l f o r manpower  s u b s t i t u t i o n i s hypothesized t o occur i n the lower right-hand  c o r n e r of  Figure 3a, a t that point i n the convergence of the values of TS and PPC where the majority of treatment expenditures are f o r treatments with the greatest  14 overlapping of p r o f e s s i o n a l for  services with  skills  (highest treatment  s u b s t i t u t a b i l i t y ) and  t h e g r e a t e s t overlapping of service  practice privilege constraints).  delivery  (lowest  I n Figure 3b, TS, PPC, and RR have been  diagrammed as the three axes of a cube, as Axis I , Axis I I , and Axis I I I respectively,  and t h e i r separate  e f f e c t s have been conceptualized as each  contributing  to the p o s s i b i l i t i e s  f o r economies from such  substitution.  Hence, as i l l u s t r a t e d i n Figure 3b, the greatest p o t e n t i a l f o r economies i s hypothesized  t o occur  i n t h e lower  conditions of overlapping p r o f e s s i o n a l  front  right-hand  corner, when the  s k i l l s , overlapping service  delivery,  and savings i n personnel costs converge a t t h e i r maximum values. The f i r s t stage of the model and the second stage of the model stand i n the f o l l o w i n g r e l a t i o n s h i p t o each other.  In the f i r s t stage, although the  values of both TS and PPC may suggest considerable p o t e n t i a l f o r manpower s u b s t i t u t i o n , economies from s u b s t i t u t i o n w i l l a r i s e i n the second stage only if  the values of RR a l s o o f f e r the p o s s i b i l i t y of s i g n i f i c a n t savings i n  personnel  costs.  Likewise, while i n the second stage the values of RR may  suggest the p o s s i b i l i t y of considerable economies from s u b s t i t u t i o n , i f i n the f i r s t stage the values of e i t h e r TS or PPC severely l i m i t the scope of such s u b s t i t u t i o n , then, again, the p o t e n t i a l  f o r economies from manpower  s u b s t i t u t i o n w i l l be severely l i m i t e d as w e l l . Figure 4 presents i n matrix format a further e l a b o r a t i o n of the model t o permit  quantification  of the e f f e c t s  manpower s u b s t i t u t i o n s i t u a t i o n .  of TS, PPC, and RR f o r a s p e c i f i c  The matrix format proceeds i n two stages,  p a r a l l e l t o the graphic format of Figures 3a and 3b.  In the f i r s t stage, as  i n Figure 3a, Axis I and Axis I I represent the c o n t r o l l i n g v a r i a b l e s TS and PPC.  When t h e c o n d i t i o n s defined t o TS and PPC are q u a n t i f i e d  on the  appropriate axes as values of TS% and PPC%, the model formulae permit the c a l c u l a t i o n of the e f f e c t s  of TS  and  PPC  on  manpower  substitution  IS  FIGURE 3a MODEL OF POTENTIAL ECONOMIES FROM MENTAL HEALTH MANPOWER SUBSTITUTION: ESTIMATING SUBSTITUTABLE SHARE OF COSTS  AXIS I 7. OF COSTS FOR SUBSTITUTABLE TREATMENTS  « a co W H H t-l M < Z « 05 H W 01  CO  X  <  o w u w o w W CO  w  > PS « o  tn  Ui CO H CO H  o  o o < CJ  OS  Pu  o  100  16  FIGURE 3b MODEL OF POTENTIAL ECONOMIES FROM MENTAL HEALTH MANPOWER SUBSTITUTION: PROJECTING COST IMPLICATIONS OF MANPOWER SUBSTITUTION  17 possibilities.  The s e p a r a t e  effects  of TS and PPC on t h e p o t e n t i a l  formanpower s u b s t i t u t i o n can be c a l c u l a t e d using the model Formulae A - D and Formulae E - H r e s p e c t i v e l y . of  The model Formulae I - L permit the c a l c u l a t i o n  t h e combined e f f e c t of TS and PPC on t h e p o t e n t i a l f o r manpower  s u b s t i t u t i o n , o r , i n other words, the s u b s t i t u t a b l e share of services and costs.  The values of the s u b s t i t u t a b l e share of costs (SSC$ & SSC%) are  then entered i n the c e l l s of the f i r s t stage of the matrix.  To i l l u s t r a t e  the matrix format using the s u b s t i t u t a b l e share of costs as an example, the d o l l a r value of the s u b s t i t u t a b l e share of costs (SSC$) i s c a l c u l a t e d by m u l t i p l y i n g the values of TS% and PPC% f o r each s e t of combined TS/PPC conditions possible  by the present costs, TS c a t e g o r y  as broken  and PPC c a t e g o r y  down i n t o the costs f o r each  combination  (PC$(TS&PPC)).  The  percentage of the s u b s t i t u t a b l e share of costs (SSC%) i s then c a l c u l a t e d by d i v i d i n g SSC$ by the t o t a l costs of present services  (TPC$).  In the second stage of the matrix model, as i n Figure 3b, Axes I , I I , and  I I I again represent the c o n t r o l l i n g v a r i a b l e s TS, PPC, and RR. I n the  matrix format, when the values f o r TS%, PPC%, and RR% are i n d i c a t e d on the approximate  axes, the model Formulae 0 - Q permit the c a l c u l a t i o n of the  combined e f f e c t of TS, PPC, and RR on the cost i m p l i c a t i o n s of the proposed manpower s u b s t i t u t i o n .  In the second stage, the combined e f f e c t of TS and  PPC on the p o s s i b i l i t i e s f o r manpower s u b s t i t u t i o n are collapsed single  terms SSC$ and SSC%.  The p r o j e c t e d costs of a l t e r n a t e  i n t o the service  arrangements (CA$) are c a l c u l a t e d by m u l t i p l y i n g the t o t a l costs of present s e r v i c e arrangements (TPC$) by the percentage of the s u b s t i t u t a b l e share of costs (SSC%) and the r e l a t i v e payment rate (RR%).  The projected d o l l a r value  of cost savings (CS$) can then be c a l c u l a t e d by subtracting CA$ from SSC$. The percentage of cost savings (CS%) i s c a l c u l a t e d by d i v i d i n g CS$ by TPC$. These  values f o r CA$, CS$, and CS% are then  entered  i n the c e l l s of the  18  FIGURE 4  MODEL FOR PROJECTING POTENTIAL ECONOMIES FROM MENTAL HEALTH MANPOWER SUBSTITUTION: MATRIX FORMAT  ESQMKEIM5 SUBSCTTUTABLE SHARE OF COSTS PntfnHfll for MFmpnwpr Substitution (Etarnnlae A — M) PRESENT SERVICE ARRANGEMENTS Present Costs TPC$ PC$(TS&PPC)  AXIS II (PPC) Practice Privilege Constraints PPC%  AXIS I (TS) Treatment Substitutability TS% SSC$ = PC$(TSSPPC) x TS% x PPC%  ssc% = ssc$/rpc$  PRaiM:riNG COST iMPT.TcarrroNS OF MANPOWER s t B s n m n c N  BahpnHal Ccet Differentials (Etarnnlae N — S) ALTEraJATE SERVICE ARRANGEMENTS AXIS III (RR) Alternate Funding Arrangements Relative Payment Rates RR% RR% = ARS/PRS  AXIS I (TS) Treatment Substitutability TS% AXIS n  (PC)  Practice Privilege Constraints PPC%  CA$ = TPC$ x SSC% x RR% CS$ = SSC$ - CA$ CS% = CS$/TPC$  19 FIGURE 4 (Continued) TPC$ = Total present costs ($) PC$(TS&PPC) = Present costs by TS and PPC category combinations ($) SSC$ = Substitutable share of costs ($) SSC% = Substitutable share of costs (%)  PR$ = AR$ = CA$ = CS$ = CS% =  Present payment rate ($) Alternate payment rate ($) Total costs of alternate services ($) Cost savings ($) Cost savings (%)  TS% = Treatment substitutability (%) PPC% = Practice privilege constraints (%) RR% = Relative payment rate (%)  20 second stage of the matrix f o r the various and RR.  conditions defined f o r TS, PPC,  I t may be of i n t e r e s t t o note that per c a p i t a costs can a l s o be  c a l c u l a t e d (Formulae M and R) both f o r stage one (PCap$) and f o r stage two (CapA$) of the model and entered i n the c e l l s of the matrix as w e l l .  These  values of per c a p i t a cost can then be compared across the two stages of the model and a l s o with the t o t a l per c a p i t a costs  (TCap$).  The model formulae and the d e f i n i t i o n s of formulae terms are summarized below: I.  MODEL FORMULAE:  Formulae i n bold type are indicated i n Figure 4.  CONTROLLING VARIABLES (Axis I ) (Axis I I ) (Axis I I I )  TS = Treatment s u b s t i t u t a b i l i t y PPC = P r a c t i c e p r i v i l e g e c o n s t r a i n t s RR = R e l a t i v e payment rate  ESTIMATING SUBSTITUTABLE SHARE OF SERVICES AND COSTS Estimating E f f e c t of TS on P o t e n t i a l f o r Manpower S u b s t i t u t i o n : (Formula (Formula (Formula (Formula  A) B) C) D)  ETSS# ETSS% ETSC$ ETSC%  = = = =  PS#(TS) x TS% ETSS#/TPS# PC$(TS) x TS% ETSC$/TPC$  Estimating E f f e c t of PPC on P o t e n t i a l f o r Manpower S u b s t i t u t i o n : (Formula (Formula (Formula (Formula  E) F) G) H)  EPPCS# EPPCS% EPPCC$ EPPCC%  = = = =  PS#(PPC) x PPC% EPPCS#/TPS# PC$(PPC) x PPC% EPPCC$/TPC$  Estimating Substitutable Share of Services and Costs: (Formula (Formula (Formula (Formula (Formula  I) J) K) L) M)  SSS# SSS% SSC$ SSC% PCap$  = = = = =  PS#(TS&PPC) x TS% x PPC% SSS#/TPS# PC$(TS&PPC) x TS% x PPC% SSC$/TPC$ SSC$/Pop#  PROJECTING COST IMPLICATIONS OF MANPOWER SUBSTITUTION Estimating R e l a t i v e Payment Rate: (Formula N)  RR%  = AR$/PR$  21 P r o j e c t i n g Costs and Cost Savings of Alternate Service Arrangements; (Formula 0) (Formula P) (Formula Q)  CA$ CS$ CS%  = TPC$ x SSC% x RR% = SSC$ - CA$ = CS$/TPC$  (Formula R)  CapA$ = CA$/Pop#  Estimating S u b s t i t u t a b l e Share of Costs f o r Second Data Set: (Formula S) II.  SSC$X = TPC$X x SSC%  DEFINITION OF TERMS TERMS WITH VALUES DERIVED FROM EXISTING DATA Controlling Variables: TS% = PPC% = RR% = PR$ AR$  Treatment s u b s t i t u t a b i l i t y (percent) P r a c t i c e p r i v i l e g e c o n s t r a i n t s (percent) R e l a t i v e payment rate (percent) = Present payment rate ( d o l l a r s ) = A l t e r n a t e payment rate ( d o l l a r s )  Population: Pop# = Population (number) Present Services and Costs: TPS# PS#(TS) PS#(PPC) PS#(TS&PPC)  = = = =  TPC$ PC$(TS) PC$(PPC) PC$(TS&PPC)  = = = =  TCap$ TPC$X  T o t a l present services (number) Present services by TS categories (number) Present services by PPC categories (number) Present services by TS and PPC category combination (number)  T o t a l present costs ( d o l l a r s ) Present costs by TS categories ( d o l l a r s ) Present costs by PPC categories ( d o l l a r s ) Present costs by TS and PPC category combinations (dollars) = T o t a l per c a p i t a costs ( d o l l a r s ) = T o t a l present costs f o r second data s e t ( d o l l a r s )  TERMS WITH VALUES DERIVED FROM MODEL FORMULAE Estimating E f f e c t of TS on P o t e n t i a l f o r Manpower S u b s t i t u t i o n : ETSS# ETSS% ETSC$ ETSC%  = = = =  Effect Effect Effect Effect  of TS of TS of TS of TS  f o r s e r v i c e s (number) f o r s e r v i c e s (percent) f o r costs ( d o l l a r s ) f o r costs (percent)  Estimating E f f e c t of PPC on P o t e n t i a l f o r Manpower S u b s t i t u t i o n  22 EPPCS# = E f f e c t of PPC f o r s e r v i c e s (number) EPPCS% = E f f e c t of PPC f o r s e r v i c e s (percent) EPPCC$ = E f f e c t of PPC f o r costs ( d o l l a r s ) EPPCC% = E f f e c t of PPC f o r costs (percent) Estimating S u b s t i t u t a b l e Share of Services and SSS# SSS% SSC$ SSC% PCap$  = = = = =  Costs;  S u b s t i t u t a b l e share of s e r v i c e s (number) Substitutable share of services (percent) S u b s t i t u t a b l e share of costs ( d o l l a r s ) S u b s t i t u t a b l e share of costs (percent) Present per c a p i t a costs of s u b s t i t u t a b l e share of costs (dollars)  Estimating R e l a t i v e Payment Rate; RR% = R e l a t i v e payment rate  (percent)  P r o j e c t i n g Costs and Cost Savings of Alternate Service Arrangements: CA$ CS$ CS%  = T o t a l costs of a l t e r n a t e services ( d o l l a r s ) = Cost savings ( d o l l a r s ) = Cost savings (percent)  CapA$ = Per c a p i t a costs of a l t e r n a t e s e r v i c e s ( d o l l a r s ) Estimating S u b s t i t u t a b l e Share of Costs f o r Second Data Set: SSC$X = S u b s t i t u t a b l e share of costs f o r second data set ( d o l l a r s ) To  summarize, the above model f o r p r o j e c t i n g p o t e n t i a l economies from  mental health manpower s u b s t i t u t i o n i s a p p l i e d i n the present study to potential  manpower  substitution situation  which would  substitute  psychologists i n the d e l i v e r y of some of the services presently provided private practice psychiatrists. project  the  p o t e n t i a l cost  a  by  Thus, i n t h i s case, the model i s u t i l i z e d to savings  from  s u b s t i t u t i n g an  alternate  p r o f e s s i o n a l group f o r the present p r o f e s s i o n a l group i n the d e l i v e r y of a set of mental health arrangement.  services whose boundaries are  defined  As w e l l , the model i s a p p l i e d , with appropriate  t o p r o j e c t the  cost savings  f o r the  subset  of  by  a  funding  modifications,  psychotherapy  services.  Although the model i s u t i l i z e d i n the present study to p r o j e c t cost savings, i t might equally w e l l be used to p r o j e c t cost increases.  Further, although  only two conditions were defined f o r each of the c o n t r o l l i n g v a r i a b l e s , the model does not l i m i t the p o s s i b l e values which might be assigned t o TS%, PPC% and RR%.  Likewise,  although comparisons are made across two p r o f e s s i o n a l  groups, comparisons might a l s o be c a r r i e d out across several  professional  groups, o r , a l t e r n a t i v e l y , w i t h i n a s i n g l e p r o f e s s i o n a l group.  F i n a l l y , the  boundaries of the set of services encompassed by the proposed s u b s t i t u t i o n can be defined by any of a number of d i f f e r e n t c r i t e r i a ; i n t h i s case, the boundaries are d e l i m i t e d by the funding arrangement  f o r the l a r g e r set of  services and by type of treatment f o r the subset of psychotherapy s e r v i c e s . However, o t h e r examples  of boundary  criteria  might include p a r t i c u l a r  l i c e n s u r e arrangements or p a r t i c u l a r c l a s s i f i c a t i o n s of mental disorders.  24 CHAPTER THREE  THE EFFECTIVENESS OF PSYCHOTHERAPY  Psychotherapy services c o n s t i t u t e the majority of the services d e l i v e r e d by p r i v a t e p r a c t i c e p s y c h i a t r i s t s i n the two present  study.  The  data  on  p s y c h i a t r i s t s f o r f i s c a l year 1984 that the claims  j u r i s d i c t i o n s examined i n the  fee-for-service billings  Thus, i n order  e s s e n t i a l to document that a l l four  professions  l i c e n s e d to provide do  not  However, i n order  differ  76.0%  of  core mental h e a l t h  effectiveness  as  of  services, i t i s professions  psychotherapy services and  in their  and  to e s t a b l i s h the f e a s i b i l i t y  manpower s u b s t i t u t i o n f o r p r i v a t e p r a c t i c e p s y c h i a t r y  t r a i n e d and  by  i n Manitoba and B r i t i s h Columbia i n d i c a t e  f o r psychotherapy services c o n s t i t u t e d 80.4%  t o t a l claims r e s p e c t i v e l y .  submitted  that the  are four  psychotherapists.  to make statements about possible cost savings  manpower s u b s t i t u t i o n i n mental health service d e l i v e r y , we  through  must f i r s t  be  able to make statements about the effectiveness of that s e r v i c e .  Drummond  (1980) makes t h i s point  and  i n the  context  of  medical  technology  the  p r i n c i p l e i s equally true f o r mental health technology: "Economic a p p r a i s a l the assessment of economic a p p r a i s a l a p p r a i s a l upon which  r e l i e s p a r t l y on medical a p p r a i s a l f o r changes i n h e a l t h s t a t e . Therefore, can o n l y be as good as the m e d i c a l i t i s superimposed (p.45)."  S i m i l a r l y , Barer (1982) has  made the point that economic evaluation hinges  c r i t i c a l l y upon t e c h n i c a l evaluation. With regard  to manpower s u b s t i t u t i o n f o r p u b l i c l y funded s e r v i c e s , i t  can be argued that i f a treatment does no good, e i t h e r i t should not be given at a l l or i f s o c i e t y deems i t should be offered regardless, then a l l o c a t i o n of manpower on the basis of expertise i s i r r e l e v a n t and the treatment should  be provided by the l e a s t expensive personnel.  Likewise, i f a treatment does  good, then a l l o c a t i o n should be on the basis of expertise and i f expertise can  be shown t o be equal,  expensive personnel.  the treatment should  be provided  by the l e a s t  F i n a l l y , i f two treatments do equal good, consumers  could be o f f e r e d a choice regardless of cost or consumers could be o f f e r e d the l e a s t expensive treatment; i n e i t h e r case, as i n the preceding  example,  a l l o c a t i o n should be on the basis of expertise and i f expertise can be shown to be equal, treatment should be provided  by the l e a s t expensive personnel.  I f some consumers decide t o purchase s e r v i c e s p r i v a t e l y , then they w i l l no doubt weigh t h e c h o i c e s  of t r e a t m e n t , p r i c e , and ambience o f f e r e d by  professionals i n private practice. The  two p r i n c i p a l  treatments  offered  f o r mental  disorders are  psychotherapy and pharmacotherapy, e i t h e r alone or i n combination. earlier,  exclusive  As noted  r i g h t s t o p r a c t i c e psychotherapy are not recognized;  however, the r i g h t t o p r a c t i c e pharmacotherapy has been r e s e r v e d medical p r o f e s s i o n .  t o the  In considering the f e a s i b i l i t y of manpower s u b s t i t u t i o n  f o r s e r v i c e s presently d e l i v e r e d i n p r i v a t e p r a c t i c e p s y c h i a t r y , we need t o address the circumstance that p s y c h i a t r i s t s are permitted psychotherapy and pharmacotherapy, p s y c h o l o g i s t s permitted permitted  t o p r a c t i c e only  t o p r a c t i c e both  and s o c i a l  workers a r e  p s y c h o t h e r a p y , and p s y c h i a t r i c nurses are  t o p r a c t i c e psychotherapy and the a d m i n i s t r a t i o n / m o n i t o r i n g  psychotropic medications but not t h e i r p r e s c r i p t i o n .  of  Thus, i n examining the  p o s s i b i l i t y of simple s u b s t i t u t i o n , the onus i s on the i n v e s t i g a t o r t o make the case that f o r a t l e a s t some of the mental disorders t r e a t e d i n p r i v a t e p r a c t i c e p s y c h i a t r y , the e f f e c t i v e n e s s of p s y c h o t h e r a p y greater than the e f f e c t i v e n e s s of pharmacotherapy. outcome l i t e r a t u r e  on the absolute  i s equal t o or  This chapter reviews the  e f f e c t i v e n e s s of psychotherapy,  which  i n d i c a t e s that psychotherapy can indeed be an e f f e c t i v e treatment f o r some  26 mental d i s o r d e r s .  Chapters Four and Five document the t r a i n i n g standards and  l i c e n s u r e standards which permit a l l four core mental health professions to p r a c t i c e psychotherapy.  Chapter S i x reviews, the l i t e r a t u r e  comparing  r e l a t i v e e f f e c t i v e n e s s of the four professions as psychotherapists. Seven concludes the introductory chapters w i t h an  examination  the  Chapter of  those  services which have the p o s s i b i l i t y f o r s u b s t i t u t i o n ; the chapter reviews the outcome l i t e r a t u r e  on the r e l a t i v e  effectiveness  of psychotherapy  and  pharmacotherapy and discusses the r e l a t i o n s h i p between treatment p r a c t i c e and the f e a s i b i l i t y of manpower s u b s t i t u t i o n . In a consideration of the effectiveness of psychotherapy, there are two elements which require r e f l e c t i o n . i s meant by psychotherapy.  F i r s t , there i s the d e l i m i t a t i o n of what  A frequently c i t e d d e f i n i t i o n of psychotherapy i s  that of Meltzoff and Kornreich (1970): "Psychotherapy i s taken to mean the informed and p l a n f u l a p p l i c a t i o n of t e c h n i q u e s d e r i v e d from e s t a b l i s h e d p s y c h o l o g i c a l p r i n c i p l e s , by persons q u a l i f i e d through t r a i n i n g and experience to understand these p r i n c i p l e s and to a p p l y these t e c h n i q u e s w i t h the i n t e n t i o n of a s s i s t i n g i n d i v i d u a l s to modify such p e r s o n a l c h a r a c t e r i s t i c s as f e e l i n g s , values, a t t i t u d e s , and behaviors which are judged by the t h e r a p i s t to be maladaptive or maladjustive (p.6)." Second, t h e r e i s the method of determining when effectiveness has demonstrated. provide  been  Since s i n g l e studies of psychotherapy outcomes u s u a l l y do not  sufficient  "weight of evidence," such judgments are u s u a l l y made  through l i t e r a t u r e reviews, box-score analyses, or meta-analyses  of studies  reported i n the l i t e r a t u r e . The  procedure  of box-score a n a l y s i s begins with the s e l e c t i o n of a  population of research studies. criteria  and  excludes  methodology or which classifies  process  T y p i c a l l y , the reviewer e s t a b l i s h e s c e r t a i n  s t u d i e s which  are not  sufficiently  are o t h e r w i s e i n a p p r o p r i a t e . variables  ( e . g . , "yes,"  "no,"  The  rigorous i n  reviewer  "equivocal").  then The  d i s t i n c t i o n between the l i t e r a t u r e review and the box-score a n a l y s i s i s not sharply  drawn; however, i t i s the more e x p l i c i t  d e s c r i p t i o n of s e l e c t i o n  c r i t e r i a which d i f f e r e n t i a t e s the box-score technique.  S t i l l , the box-score  a n a l y s i s has been c r i t i c i z e d as s i m p l i s t i c and permitting, too much l a t i t u d e f o r i n d i v i d u a l judgement.  Most importantly, i t does not have the capacity t o  include strength of treatment e f f e c t i n i t s a n a l y s i s . Meta-analysis f o r determining  employs s t a t i s t i c a l techniques f o r aggregating  data and  r e l a t i o n s h i p s between causal v a r i a b l e s and treatment outcomes  (usually q u a n t i f i e d ) .  Studies  are coded on a set of v a r i a b l e s that are  thought t o be r e l a t e d t o outcomes.  These measures are l a t e r c o r r e l a t e d with  the outcomes and used as the basis f o r organizing outcome r e s u l t s i n terms of aspects of the studies. The e a r l i e s t review of psychotherapy outcome studies was Eysenck's work (Eysenck, 1952).  S e l e c t i n g 24 research s t u d i e s , which included 8,053 cases  of psychotherapy with neurotic p a t i e n t s , Eysenck d i v i d e d the studies i n t o two groups, p s y c h o a n a l y t i c  therapy  and  eclectic  therapy.  To  assess  e f f e c t i v e n e s s , Eysenck developed a r a t i n g scale of improvement f o l l o w i n g therapy.  In the e c l e c t i c therapy group, he c a l c u l a t e d an improvement rate of  64 p e r c e n t w i t h i n two y e a r s .  I n the psychoanalytic  therapy group, he  c a l c u l a t e d an improvement r a t e of 44 percent w i t h i n two years.  He then  compared t h e s e  One  outcome rates against  two no-treatment groups.  no-  treatment group was provided by data from a study by Denker (1946); Denker's data  consisted  of insurance  company records  on 500 i n d i v i d u a l s who had  submitted mental d i s a b i l i t y claims and been t r e a t e d by general p r a c t i t i o n e r s . Denker  found  that  within  one y e a r ,  without  r e c e i v i n g any  specific  psychotherapy, 44 percent had returned t o work and that w i t h i n two years, an additional  27 p e r c e n t had r e t u r n e d  t o work.  On t h e b a s i s  of these  comparisons, Eysenck concluded that the no-treatment improvement rate  was  28 approximately the same as that of the e c l e c t i c treatment groups and that the p s y c h o a n a l y t i c improvement rate was  inferior  t o that of the  no-treatment  groups• Eysenck's review e l i c i t e d a number of important a r t i c l e s c r i t i q u i n g h i s work.  Luborsky  (1954) noted that i t was  conclusions since i t was  d i f f i c u l t t o evaluate Eysenck's  not c l e a r what was  done i n each of the studies.  M e l t z o f f and Kornreich(1970) pointed out that Eysenck's c o n t r o l data f o r the e f f e c t s of treatment were drawn from non-randomly selected c o n t r o l groups, whose subjects may  have been more or l e s s troubled and dysfunctional than  t h o s e who  psychotherapy.  sought  suggested that Denker's  study was  Furthermore, M e l t z o f f not a true no-treatment  and Kornreich group i n t h a t  p a t i e n t s were provided with sedatives, reassurance, and a placebo type of treatment.  Bergin (1971)  argued  that  Eysenck  c a t e g o r i z i n g of the studies and i n the way reanalyzed  the d a t a used  i n Eysenck's  made e r r o r s  in his  he handled the data.  Bergin  review  had  and  improvement rate f o r the psychoanalytic treatment group.  found  a  different  In a d d i t i o n , Bergin  c a l c u l a t e d a d i f f e r e n t remission rate f o r the no-treatment groups and judged that only about 30 percent of the p a t i e n t s would have recovered had there been no psychotherapy.  In a general evaluation of Eysenck's r e p o r t , Bergin  concluded that global statements about the effectiveness of psychotherapy were meaningless and suggested that one must analyze s p e c i f i c therapies f o r s p e c i f i c problems. The  c o n t r o v e r s y c o n t i n u e d as Eysenck  updated h i s o r i g i n a l research  (Eysenck, 1966); he acknowledged many of the methodological problems of h i s e a r l i e r report and c i t e d 11 a d d i t i o n a l studies.  Although Eysenck stood by  h i s o r i g i n a l conclusion, he found supportive evidence f o r at l e a s t one type of p s y c h o t h e r a p y , the behavioral approach However, he was  of systematic d e s e n s i t i z a t i o n .  again c r i t i c i z e d for. s e l e c t i v e l y  reviewing the  literature  29 since  by t h a t  time there  were a t l e a s t 70 c o n t r o l - g r o u p  s t u d i e s of  psychotherapy, most of which Eysenck ignored. Meltzoff and Kornreich made an important  departure from e a r l i e r reviews  by c l a s s i f y i n g studies of psychotherapy outcome by methodological  adequacy.  In t h e i r category of "adequate" research designs, they included studies which used a c o n t r o l group c o n d i t i o n and adequate outcome measures.  In their  "questionable" category, they included studies with c o n t r o l groups that may not  have been comparable, that used poor outcome measures, or that used  inadequate a n a l y s i s procedures. control-group  studies.  According  Their review  included approximately  t o Smith, Glass, and M i l l e r  tabulated the r e s u l t s of M e l t z o f f and Kornreich's c o n t r o l l e d studies y i e l d e d p o s i t i v e r e s u l t s . r e l a t i o n s h i p between research percent  of t h e a d e q u a t e l y  compared t o only 33 percent  100  (1981), who  review, 80 percent of the  They a l s o found a p o s i t i v e  q u a l i t y and p o s i t i v e f i n d i n g s .  Thus, 84  designed studies y i e l d e d p o s i t i v e r e s u l t s as of the questionable  and Kornreich made a noteworthy methodological  studies.  Although M e l t z o f f  innovation, the same c r i t i c i s m  can be made of t h e i r work that Bergin made of Eysenck's work, that i s , that no  statements can be made regarding what s p e c i f i c psychotherapy  techniques  are e f f e c t i v e with which p a r t i c u l a r p s y c h o l o g i c a l problems. Bergin, as noted above, r e c a l c u l a t e d Eysenck's treatment remission rates and found a number of discrepancies. of psychotherapy outcome. and 15 t o be equivocal.  In a d d i t i o n , Bergin reviewed 52 studies  He judged 22 t o be p o s i t i v e , 15 t o be negative,  On the basis of these analyses and h i s r e a n a l y s i s of  Eysenck's data, Bergin concluded that psychotherapy has moderately p o s i t i v e results. Rachman (1973), a frequent c o l l a b o r a t o r of Eysenck, then reanalyzed and c r i t i q u e d Bergin's  work.  He disallowed a number of studies because t h e  subjects were c l a s s i f i e d as delinquent or psychosomatic rather than n e u r o t i c .  Rachman analyzed  23 studies which he s e l e c t e d as appropriate  e f f e c t i v e n e s s of  "verbal" psychotherapy.  to assess the  Of these s t u d i e s , Rachman found  only one that provided t e n t a t i v e evidence of p o s i t i v e r e s u l t s and f i v e that produced negative  results.  Smith et a l . (1981) have c r i t i c i z e d Rachman on  the grounds that he s e l e c t i v e l y chose studies to review which would support his  bias.  Rachman excluded 17 studies f o r a v a r i e t y of reasons; of  only two showed negative e f f e c t s .  these,  Smith et a l . a l s o c r i t i c i z e d Rachman f o r  s e l e c t i v e exclusion of studies on methodological  grounds; they argued that he  should  procedure and  have followed M e l t z o f f and  well-designed  with  Kornreich's  the poorly-designed  studies  compared  the  to determine whether they  y i e l d e d d i f f e r e n t kinds of conclusions. Luborsky, Singer, and Luborsky (1975) used a box-score a n a l y s i s , ranking each study on a f i v e - p o i n t s c a l e of research q u a l i t y . study  r e s u l t s as  showing s i g n i f i c a n t l y  They then categorized  better r e s u l t s f o r the  group, f o r the comparison group, or no s i g n i f i c a n t d i f f e r e n c e .  treatment  Luborsky et  a l . analyzed 33 studies i n which psychotherapy treatment groups were compared with no-treatment c o n t r o l groups.  Of these, 20 studies had treatment groups  that d i d s i g n i f i c a n t l y better than no-treatment groups and no d i f f e r e n c e between the groups.  The  13 studies showed  authors found no instances  i n which  the c o n t r o l group d i d s i g n i f i c a n t l y better than the treatment group.  There  have been no substantive c r i t i c i s m s of t h e i r work and i t has been supported by other  reviews.  Parloff  (1978) undertook  an  exceedingly  comprehensive r e v i e w  of  psychotherapy outcome studies f o r the National I n s t i t u t e of Mental Health i n which studies were organized general  f i n d i n g was  (psychotherapies  p r i m a r i l y by d i s a b l i n g conditions.  that p a t i e n t s  treated with  psychosocial  Parloff's therapies  that do not use drug treatments) showed s i g n i f i c a n t l y more  improvement than untreated p a t i e n t s .  Furthermore, studies which c o n t r o l l e d  31 f o r placebo e f f e c t s found changes a s s o c i a t e d w i t h treatment to be greater than changes a s s o c i a t e d with placebo. Eysenck, Rachman, Bergin, and there  i s c l e a r evidence  P a r l o f f a l s o concluded, along with  to some extent M e l t z o f f and K o r n r e i c h , t h a t  that behaviour-based  therapies are e f f e c t i v e f o r  s p e c i f i c conditions. Smith  and  Glass  outcome s t u d i e s ;  ( 1977)  conducted  they undertook  a meta-analysis of  to i d e n t i f y  and  psychotherapy  c o l l e c t a l l studies that  tested the e f f e c t s of d i f f e r e n t types of therapy, r e l a t i n g the s i z e of e f f e c t to the c h a r a c t e r i s t i c s of the therapy (e.g., diagnosis of p a t i e n t , of t h e r a p i s t ) and of the study. effect signs,  From 375 s t u d i e s , the authors computed 833  several studies y i e l d i n g  outcome or a t more than one  training  effects  time a f t e r  on more than one  therapy.  magnitude of e f f e c t - or " e f f e c t s i z e " - was  The  definition  the mean d i f f e r e n c e  type  of  of  the  between  t r e a t e d and c o n t r o l subjects d i v i d e d by the standard d e v i a t i o n of the c o n t r o l group: (*t -  x ) c  ES = S  The  results  of  the  C  analysis  indicated  t h a t the  psychotherapies  represented by the a v a i l a b l e outcome evaluations move the average c l i e n t from the 50th to the 75th p e r c e n t i l e . effect  of  type  of  therapy..  Smith  and Glass then i n v e s t i g a t e d  They grouped  studies into  ten  types  the of  psychotherapy and computed Hays' <*;^, which r e l a t e s the c a t e g o r i c a l v a r i a b l e "type of therapy" to the q u a n t i t a t i v e v a r i a b l e " e f f e c t s i z e . "  They found CJ^  to have a value of .10, i n d i c a t i n g t h a t the 10 therapy types accounted f o r 10 percent of the variance i n e f f e c t s i z e .  Smith and Glass concluded t h a t the  r e s u l t s of research s t u d i e s demonstrate the b e n e f i c i a l e f f e c t s of c o u n s e l l i n g and psychotherapy  but t h a t "despite the volumes devoted  to the t h e o r e t i c a l  differences  among d i f f e r e n t  schools of psychotherapy  (p. 692)," r e s e a r c h  r e s u l t s demonstrate n e g l i g i b l e d i f f e r e n c e s . Despite the extensive and c a r e f u l nature of t h e i r work, the c r i t i q u e s of Smith and Glass were not long i n coming.  Eysenck  (1978) h e l d true to h i s  o r i g i n a l course, s t a t i n g : " I would suggest that there i s no s i n g l e study i n existence which does not show serious weaknesses, and u n t i l these are overcome I must r e g r e t f u l l y r e s t a t e my conclusions of 1952, namely that there s t i l l i s no acceptable evidence of t h e e f f i c a c y of psychotherapy (p.517)." G a l l o (1978) has made a more thorough c r i t i c i s m and r a i s e d some i n t e r e s t i n g methodological  points.  Gallo  notes  that  Smith  and G l a s s '  two major  conclusions, that psychotherapy i s e f f e c t i v e and that psychotherapy types are e q u a l l y e f f e c t i v e , were drawn using somewhat d i f f e r e n t a n a l y s i s techniques. He s u g g e s t s  that  i f t h e same a n a l y s i s  t e c h n i q u e s were used  comparisons one might come t o very d i f f e r e n t conclusions.  i n both  G a l l o computes a )  2  f o r e f f e c t i v e n e s s of psychotherapy i n order t o make a comparison w i t h Smith and Glass's computation of types.  CJ ^ f o r d i f f e r e n t i a l e f f e c t i v e n e s s of therapy  Both values are approximately .10.  G a l l o then argues t h a t when put  i n t o the same u n i t of a n a l y s i s , that i s , the percentage of variance i n the dependent v a r i a b l e t h a t can be accounted f o r by the independent v a r i a b l e s , the s i z e of the e f f e c t of psychotherapy i n general i s of e x a c t l y the same s i z e as the d i f f e r e n t i a l e f f e c t of therapy type.  G a l l o ' s conclusion t h a t the  same 10 percent of variance accounted f o r cannot be taken as evidence f o r the b e n e f i c i a l e f f e c t of psychotherapy, on the one hand, and as evidence f o r the lack  of a d i f f e r e n t i a l  effect,  on the other hand, seems a j u s t i f i a b l e  criticism. I t i s of i n t e r e s t t o note that Smith and G l a s s , l i k e Eysenck  (1966),  found t h a t b e h a v i o r a l therapy techniques tended t o produce greater change on outcome measures than non-behavioral techniques.  In a rece"nt meta-analysis  of the effectiveness of psychotherapy with c h i l d r e n , Casey and Berman (1985) produced r e s u l t s s i m i l a r to those of Smith and Glass. that treated c h i l d r e n achieved outcomes about deviation  better  than untreated c h i l d r e n and  Casey and Berman found  t w o - t h i r d s of a s t a n d a r d that behavioral treatments  appeared to be more e f f e c t i v e than non-behavioral treatments. As i n the case of Smith and Glass, Casey  and  Berman q u a l i f y the apparent s u p e r i o r i t y of  behavioral treatments with the comment that when differences i n the types of outcomes measures are c o n t r o l l e d , t h i s f i n d i n g of r e l a t i v e l y greater e f f e c t s i z e s f o r behavioral therapies i s considerably diminished. I t i s apparent that the discussion of the effectiveness of psychotherapy has generated much heat and some l i g h t .  As an example of the acrimony which  developed, Eysenck t i t l e d h i s c r i t i q u e of Smith and Glass' meta-analysis "An Exercise i n Mega-Silliness" referred  t o Eysenck's  1952  (Eysenck, 1978), while Smith and Glass and  1965  articles  as  (1977)  "tendentious d i a t r i b e s  (p.684)." Leaving aside such p e r s o n a l i z a t i o n s of the arguments f o r and against the effectiveness of psychotherapy, l e t us conclude the present discussion  by  turning to the e x c e l l e n t review by the O f f i c e of Technology Assessment,  a  research arm of the United States Congress, i n i t s paper "The E f f i c a c y and Cost Effectiveness of Psychotherapy"  (OTA,  1980).  The OTA  f i n d s that, on  balance, the c u r r e n t l y a v a i l a b l e l i t e r a t u r e contains a number of good q u a l i t y research studies which f i n d p o s i t i v e outcomes f o r psychotherapy.  However,  they a l s o suggest that s t i l l better research on psychotherapy can be done and that a more d e f i n i t i v e meta-analysis may have to await the completion of such new  research.  In t h e i r view, the p r i n c i p a l d i f f i c u l t y with the  current  l i t e r a t u r e i s that, while a host of f a c t o r s have been i d e n t i f i e d as important to psychotherapy outcomes, the r o l e of these factors  (e.g., c h a r a c t e r i s t i c s  of the p a t i e n t , t h e r a p i s t , s e t t i n g ) has not been assessed i n a d e f i n i t i v e  34 way.  In other words, the t e c h n i c a l l i m i t a t i o n of the psychotherapy outcome  l i t e r a t u r e i s that psychotherapy evaluations, u n l i k e the evaluations of new drugs, need to pay as much a t t e n t i o n to the conditions of treatment as to the treatment i t s e l f , and that t h i s phenomenon has not yet been completely and satisfactorily  studied.  Granting  these r e s e r v a t i o n s ,  OTA  concludes i t s  consideration of the effectiveness of psychotherapy as f o l l o w s :  "In summary,  OTA f i n d s that psychotherapy i s a complex - yet s c i e n t i f i c a l l y assessableset of technologies.. e f f e c t s (p.5)."  I t also f i n d s good evidence of psychotherapy' s p o s i t i v e  35 CHAPTER FOUR  THE PROFESSIONAL TRAINING STANDARDS  4.1  ACCREDITATION AND TRAINING PROGRAM STANDARDS In  developing a framework w i t h i n which  t o compare the t r a i n i n g  standards of the four core mental h e a l t h p r o f e s s i o n s , I have used two sources:  accreditation  standards  of the n a t i o n a l  or p r o v i n c i a l  a c c r e d i t a t i o n bodies and curriculum o u t l i n e s from the B r i t i s h t r a i n i n g programsprograms.  Columbia  Table I presents a comparison of the four t r a i n i n g  In a d d i t i o n , the t e x t provides descriptions and a tabular  summary of the t r a i n i n g program f o r each of the four professions (see Tables I I , I I I , IV, & V). identify  those  In each t r a i n i n g program, I have attempted t o  g e n e r a l core  elements  which  form  the t h e o r e t i c a l  underpinnings of the p r o f e s s i o n and those c l i n i c a l core elements r e l a t e t o mental h e a l t h p r a c t i c e .  Furthermore,  i n order t o compare  c l i n i c a l core elements across programs, I have separated elements four  content  areas:  assessment/diagnosis,  psychotherapy, and pharmacotherapy.  pathology  into  theory,  In the case of courses which deal  with more than one of these content areas, I have broken  i  which  the c r e d i t  u n i t s down i n t o p a r t i a l c r e d i t s and assigned the p a r t i a l c r e d i t s t o the appropriate content area.  Thus, f o r example, I have determined t h a t  courses i n i n t e r v e n t i o n contain elements of pathology, assessment, and, sometimes, pharmacotherapy, as w e l l as a psychotherapy  element.  The  f i g u r e s i n Table I are meant t o imply a range and t o give the reader an idea of the r e l a t i v e rather than the absolute weight t r a i n i n g programs give t o the various program elements.  that the four The a n a l y s i s  i n d i c a t e s only the minimum s p e c i f i e d requirements and while i t i s under-  TABLE I Conparison of Training Programs i n the Four Core Mental Health Professions at British Columbia Universities  PROGRAM ELEMENTS  PROFESSION PSYCHIATRY  1  prerequisite Degree M.D. Program Length Course Work General Care Clinical Core Pathology Assessment General Psychometric Psychotherapy Pharmacotherapy Research Methods Total Major Paper Research Projects Comprehensive Examination Clinical Experience  PSYCtaJOGY  PSYCH. NURSING  SOCIAL WORK  B.A.  Secondary  2 Yrs Post-sec.or B.A.  2 years (21 months) Basic Psych. 28.5 9.5  3 years (18.5-26 months)  2  4 years 5 - 7 years (44 months) (56-78 months)  3  1  10.0  17.0  8.5  8.0  4.0  15.0  12.5 2.0 14.5 4.5 2-0  2.0 9.0 5.0  4.0  6.0  7.5 3.0  12.0  54.0 units  13.0  10.5 28.5 28.0 56.5 units  -  48.0 units  -  -  58.5 units yes 1.5 units  -  yes  -  yes  5852 hours  ^University of British Columbia ^Siiron Fraser University ^Douglas College  54.0 units  15.0  -  2344 hours  1288 hours  990 to 1440 hours  37 stood that students can and do take advantage of opportunities f o r more extensive course work and c l i n i c a l u n s p e c i f i e d elements here.  experience, I have not included such  Where a c c r e d i t a t i o n standards and curriculum  o u t l i n e s have s p e c i f i e d the number of hours of c l i n i c a l have used that f i g u r e .  experience,  I  Where such f i g u r e s have not been a v a i l a b l e , I  have used interviews with program administrators and curriculum o u t l i n e information on program length and number of days worked; I have then estimated the hours of c l i n i c a l  experience  assuming a 7.5 hour work day  and disregarding s t a t u t o r y h o l i d a y s . In developing the comparison of t r a i n i n g programs, i t was necessary t o d e l i m i t the t r a i n i n g program e n t i t y ,  that  i s , t o separate  the  p r e r e q u i s i t e s f o r the t r a i n i n g program from the t r a i n i n g program i t s e l f . In preparing  the comparison presented  i n Table I , I have used t h e  curriculum o u t l i n e d i s t r i b u t e d by the p a r t i c u l a r program t o i d e n t i f y the t r a i n i n g program b o u n d a r i e s requirements  i n the t e x t .  and have d i s c u s s e d  the p r e r e q u i s i t e  In the case of the p s y c h i a t r y  training  program, the p r e r e q u i s i t e requirements of an M.D. degree and a h o s p i t a l internship  c o n s t i t u t e a very  considerable  amount of p r i o r  Hence, I have, described the p r e r e q u i s i t e t r a i n i n g experiences detail  i n t h e appendix  (see Appendix A.1.c).  training. i n some  In the case of the  p s y c h i a t r i c nursing program, I have included the e n t i r e two-year program i n the comparison.  A case might be made that since the f i r s t year of  t r a i n i n g i s e x c l u s i v e l y devoted t o basic nursing s k i l l s , the f i r s t year, like  t h e M.D.  prerequisite.  degree  and i n t e r n s h i p , should  be c o n s i d e r e d  a  However, the curriculum o u t l i n e considers the two years  as a s i n g l e e n t i t y and so I have adopted the same convention.  In the  s e c t i o n on t r a i n i n g i n p s y c h i a t r i c nursing and i n the accompanying t a b l e (see  Table  I V ) , I have d i s t i n g u i s h e d between the basic nursing and  38 p s y c h i a t r i c d i v i s i o n s of the program.  I n the case of the s o c i a l work  t r a i n i n g program, the B.S.W. degree i s s u f f i c i e n t f o r employment i n s o c i a l welfare agencies i n B r i t i s h Columbia; however, the M.S.W. degree i s the entry settings.  l e v e l requirement f o r p r a c t i c e i n mental health  service  Hence, I have considered the B.S.W. and M.S.W. programs taken  together as the standard t r a i n i n g program f o r s o c i a l workers p r a c t i c i n g i n the mental health f i e l d . I t i s apparent that any comparison across t r a i n i n g programs must be a q u a l i f i e d one.  First,  as noted i n the preceding  paragraph,  each  t r a i n i n g program s p e c i f i e s d i f f e r e n t p r e r e q u i s i t e requirements and hence, each p r o f e s s i o n experiences.  comes t o t r a i n i n g w i t h  a d i f f e r e n t s e t of  Second, while comparison i s p o s s i b l e because the t r a i n i n g  programs share some common program elements, s i m i l a r m a t e r i a l i s covered i n varying degrees of depth.  However, i t i s hoped that the o b j e c t i v e of  the present comparison, which i s t o a s s i s t i n the determination extent  of the  t o which manpower s u b s t i t u t i o n i s f e a s i b l e i n the d e l i v e r y of  private practice psychiatry judicious consideration  s e r v i c e s , can be adequately a c h i e v e d i f  i s given  t o the s i m i l a r i t i e s  and d i f f e r e n c e s  among the four t r a i n i n g programs; the discussion a t the end of t h i s s e c t i o n on p r o f e s s i o n a l t r a i n i n g standards attempts t o provide  such a  consideration.  T r a i n i n g i n Psychiatry Psychiatry t r a i n i n g i s a post-M.D. program leading t o q u a l i f i c a t i o n as  a medical s p e c i a l i s t  i n psychiatry  Physicians and Surgeons of Canada.  with  t h e Royal College of  The n a t i o n a l a c c r e d i t a t i o n body f o r  Canadian psychiatry t r a i n i n g programs i s , again, the Royal College of Physicians  and Surgeons  of Canada.  The RCPSC "Specialty T r a i n i n g  39 Requirements i n P s y c h i a t r y "  (RCPSC, 1983)  phrase the o b j e c t i v e of  the  graduate t r a i n i n g program i n psychiatry as f o l l o w s : "...the t r a i n i n g of a medical s c i e n t i s t who i s expert i n the a p p l i c a t i o n of r e l e v a n t m e d i c a l , s u r g i c a l , b i o l o g i c a l , p s y c h o l o g i c a l , and s o c i a l f a c t o r s to the diagnosis, treatment, and management of p s y c h i a t r i c disorders. At the end of t r a i n i n g , the graduate must be capable of assuming therapeutic management i n the most e f f e c t i v e and e f f i c i e n t manner. I t i s thus necessary for the t r a i n e e to have adequate definable knowledge, s k i l l s and a t t i t u d e s that w i l l enable the f u l f i l l m e n t of the above general objectives....[and, as well] s k i l l s i n w o r k i n g c o l l a b o r a t i v e l y w i t h o t h e r mental h e a l t h workers.... [and] s p e c i a l s e n s i t i v i t y to the consequences of such f a c t o r s as poverty, d i s c r i m i n a t i o n , v i o l e n c e , and disrupted family l i f e (p.1)." Stated b r i e f l y , the goal of p s y c h i a t r i c residency programs i s t o t r a i n "experts  i n the  disorders. training.  bio/psycho/social  model"-) of the treatment of mental  A c c r e d i t a t i o n standards s p e c i f y a minimum of  four  years'  Three of these years must be spent i n a c l i n i c a l p s y c h i a t r i c  experience, and at l e a s t two of the three years must be i n an i n t e n s i v e l e a r n i n g experience p r o v i d i n g basic  clinical  experience and  didactic  instruction.  The a d d i t i o n a l two years should permit a wider choice f o r  the  and  trainee  allow  subspecialty area.  c o m p l e t i o n of  two  years  of  training in a  In a l l cases, at l e a s t two of the four years must be  spent i n adult p s y c h i a t r y .  The basic c l i n i c a l experience must include a  minimum of one year i n a general h o s p i t a l s e t t i n g , with experience i n both  the  i n p a t i e n t and  outpatient  u n i t s , and  opportunities  p a r t i c i p a t e i n community medicine and c r i s i s management.  to  In a d d i t i o n ,  the basic c l i n i c a l experience should include experience i n psychosomatic medicine and  with p s y c h o g e r i a t r i c  opportunities professionals.  to  work  with  p a t i e n t s ; i t should  other  medical  and  also  mental  offer health  As w e l l , the basic c l i n i c a l experience must include s i x  months, and p r e f e r a b l y one year, of experience i n the comprehensive care  40 and r e h a b i l i t a t i o n of both acute and long-term psychotic p a t i e n t s and a minimum of two years of supervised psychotherapy experience with a d u l t , c h i l d , and  adolescent  patients.  f o l l o w i n g content areas: of  the  D i d a c t i c i n s t r u c t i o n must cover  h i s t o r i c a l trends i n p s y c h i a t r y , c o n t r i b u t i o n s  b i o l o g i c a l , p s y c h o l o g i c a l , and  patterns  of  genetics, research  disease,  theories  normal and and  the  of  s o c i o - c u l t u r a l sciences,  p e r s o n a l i t y and  basic  psychopathology,  abnormal psychosexual development, p s y c h i a t r i c  research  methods, p s y c h i a t r i c s y n d r o m e s ,  r e t a r d a t i o n , psychophysiological  reactions  to  i l l n e s s , p s y c h i a t r i c assessment, p s y c h i a t r i c emergencies, methods  of  treatment  d i s o r d e r s , psychosocial  mental  (pharmacotherapy, behavior m o d i f i c a t i o n ,  psychotherapies,  s o c i a l t h e r a p i e s ) , and s p e c i a l t y areas ( c h i l d and adolescent, and  a d m i n i s t r a t i v e , g e r i a t r i c and  Canadian or U.S. clerkship  may  forensic psychiatry).  medical schools who fulfill  one  of  community  Graduates of  have had an undergraduate c l i n i c a l  the  required  y e a r s of  training in  psychiatry by t a k i n g one year of s p e c i a l t y i n t e r n s h i p i n p s y c h i a t r y or medicine (preferably i n c l u d i n g neurology and psychiatry) i n an approved residency  program.  (For a more d e t a i l e d o u t l i n e of  standards f o r p s y c h i a t r y  t r a i n i n g programs, please  accreditation  r e f e r to Appendix  A.1.a(1) and Appendix A.1.a(2).) The U n i v e r s i t y of B r i t i s h Columbia i n Vancouver, B r i t i s h Columbia, o f f e r s a psychiatry t r a i n i n g program accredited by the Royal College of Physicians  and  Surgeons of  Canada  (see  Table  II).  Prerequisite  requirements are a degree i n medicine, a one-year h o s p i t a l i n t e r n s h i p , successful  completion  of  the  Medical  Council of Canada Q u a l i f y i n g  Examination, s a t i s f a c t o r y performance i n a s e r i e s of interviews  with  members of the Department of P s y c h i a t r y , and e l i g i b i l i t y f o r temporary registration  with the  College  of  Physicians and  Surgeons of B r i t i s h  TABLE I I program E l e m e n t s :  U.B.C. P s y c h i a t r y T r a i n i n g  PROGRAM Research Methods  Course Work  General Core pathology  500 501 502 503 504 505 507 508 510 518 520 523 524 525 528 531 532 533 538 540 541 542  Orientation Path/Exam. Interview Psychotherapy Pharmacotherapy R e s r c h . Methods Psychotherapy Group T h e r a p y Neurology Group T h e r a p y Social Psychotherapy Psychotherapy Behav. T r e a t . Group T h e r a p y Child C l i n . Neurol. Geriatric Group T h e r a p y Psychometric Sex I s s u e s Forensic  (2) (2) (2) (2) (2) (2) (4) (2) (4) (2) (4) (4) (4) (2) (2) (2) (2) (2> (2) (2) (2) (2)  ELEMENTS C l i n i c a l Core Psychotherapy Assessment General PSi y c h o m e t r i c  Pharmacotherapy  *  2.0 1.0  1. 0 2. 0 2. 0 2.0  2.0 1.0  1. 0  2. 0 2. 0  0.5  0. 5  1. 0  1.0 1.0 0.5 0.5 0.5 0.5 0.5 0.5  1. 0 1. 0 0. 5 0. 5 0. 5 0. 5 0. 5 0. 5  2. 0 2. 0 1. 0 1. 0 0. 5 0. 5 0. 5 1. 0  0.5 0.5  0. 5 0. 5  4-0 4.0  0.5 0.5 0.5  2. 0  12. 5 TOTAL 54.0 UNITS C l i n i c a l Experience Tutorial 220 hours Rotation 5280 hours On C a l l 352 hours TOTAL 5852 HOURS  Program  2.0  10.0  8.5  0. 5 0. 5  0.5 0.5  14. 5  4.5  2. 0 14.5  2  3  4  U.B.C. c o u r s e c r e d i t d e s i g n a t i o n s have been t r a n s f o r m e d i n t o s e m e s t e r u n i t s . ^Assuming 1.25 h o u r s p e r week f o r an 11 month y e a r f o r f o u r y e a r s . ^Assuming 7.5 hours p e r day a t f o u r days p e r week f o r an 11-month y e a r f o r f o u r y e a r s . A s s u m i n g O n - C a l l one day p e r week, c a l l e d e i g h t h o u r s p e r month f o r an 11 month y e a r f o r f o u r y e a r s . 1  4  42 Columbia.  As noted above, the student entering the psychiatry t r a i n i n g  program has  completed f o u r  years  of  t r a i n i n g i n m e d i c i n e and  an  internship.  At the U n i v e r s i t y of B r i t i s h Columbia, the undergraduate  t r a i n i n g can  include  10-15  semester u n i t s  of  course w o r k / c l i n i c a l  experience i n p s y c h i a t r y . As w e l l , i f students take both the  fourth-year  c l e r k s h i p and the s p e c i a l t y i n t e r n s h i p i n p s y c h i a t r y , these experiences may  s u b s t i t u t e f o r one year of residency  training.  The psychiatry t r a i n i n g program requires four years f o r completion and has both a c l i n i c a l experience component and a d i d a c t i c i n s t r u c t i o n component, which continue f o r the length of the program. the d i d a c t i c i n s t r u c t i o n component, the program reserves week f o r classroom i n s t r u c t i o n ; students t y p i c a l l y courses i n each of three terms.  of  the  patient,  psychological measurement.  one  take two  drugs  and  somatic  treatments,  and and  behavioral  c h i l d psychiatry.  t h i r d year,  courses include s o c i a l p s y c h i a t r y , c l i n i c a l  psychiatry,  g e r i a t r i c psychiatry, sexual  courses, one  three  In the second year, courses include research  treatments i n p s y c h o l o g i c a l c o n d i t i o n s , and  year, two  to  each  psychopathology, i n t e r v i e w  methods i n p s y c h i a t r y , n e u r o l o g i c a l bases of human behavior,  f o r e n s i c psychiatry.  day  In the f i r s t year, required courses  include o r i e n t a t i o n t o p s y c h i a t r y , examination  To accommodate  issues  the  neurology i n  i n psychiatry,  In the f o u r t h year, as w e l l as i n each i n psychotherapy and one  In  and  preceding  i n group, m i l i e u , and  m a r i t a l psychotherapies are given (numbered successively f o r each year). In a d d i t i o n , e l e c t i v e c o u r s e s psychiatry,  theories  behavior physiology,  and  i n the  province  e t i o l o g y , problems of  and  functions  cerebral function,  neurochemistry, advanced psychopharmacology,  development and l e a r n i n g are o f f e r e d .  of  and  43 The  clinical  p r i n c i p a l of which  experience  component t a k e s  a number ^>of  are the residency r o t a t i o n assignments.  forms, Students  work s i x months i n each placement with two weeks holidays at the end of 1  each r o t a t i o n , making an 11-month working year.  Students work i n t h e i r  r o t a t i o n placement four days per week, t y p i c a l l y a minimum 7.5 hour day. In a d d i t i o n , students are on c a l l about one day i n seven; c a l l s u s u a l l y require a minimum of two hours and can r e q u i r e as much as s i x - eight hours t o complete. settings:  Rotation placements  are a v a i l a b l e i n a v a r i e t y of  general h o s p i t a l , c h i l d r e n ' s h o s p i t a l , and t e a c h i n g - h o s p i t a l  acute and outpatient f a c i l i t i e s , c h i l d and  family c l i n i c ,  extended  and  outpatient care, behavior  therapy s e r v i c e s , and sexual medicine u n i t .  There i s a l s o a r o t a t i o n  care, adolescent  inpatient  a v a i l a b l e t o Prince George, a northern c i t y , which may weeks t o two months. the t u t o r i a l .  The  geriatric  extend from two  c l i n i c a l experience component a l s o i n v o l v e s  Each student i s assigned to a psychotherapy  tutor.  The  emphasis i n the f i r s t year i s on t a k i n g a f u l l developmental h i s t o r y and formulating  a treatment  plan.  In s u c c e e d i n g years, students  are  encouraged t o undertake long-term psychotherapy with one or two p a t i e n t s under the s u p e r v i s i o n of the t u t o r .  Students meet with the t u t o r  1-1  1/2 hours per week and a new t u t o r i s assigned each year. In  a d d i t i o n t o the d i d a c t i c i n s t r u c t i o n and  clinical  experience  elements of the p s y c h i a t r y t r a i n i n g program, students are encouraged but not r e q u i r e d to become i n v o l v e d i n c l i n i c a l  research; t h i s may  take  various forms, such as a s s i s t i n g a c l i n i c a l supervisor, w r i t i n g up  an  unusual case f o r p u b l i c a t i o n , or designing and managing a small research study.  L a s t l y , a l l students p a r t i c i p a t e i n study groups, which  them t o p r e p a r e  f o r the  RCPSC examinations  medical s p e c i a l i s t i n p s y c h i a t r y .  for qualification  assist as  a  (For a more d e t a i l e d o u t l i n e of the  44 U n i v e r s i t y of B r i t i s h Columbia Psychiatry t r a i n i n g program, please r e f e r t o Appendix A.1.b.)  T r a i n i n g i n Psychology C l i n i c a l psychology  t r a i n i n g i n the majority of t r a i n i n g programs  i n North America f o l l o w s what i s c a l l e d the Boulder Model, a r t i c u l a t e d at a conference  at Boulder, Colorado,  i n 1949,  psychologists as a p p l i e d p r a c t i t i o n e r s funding and academic o r g a n i z a t i o n s .  when the t r a i n i n g of  became a p r i o r i t y  for  U.S.  The Boulder Model recommends t h a t  c l i n i c a l psychologists should be competent both as academic researchers and as p r o f e s s i o n a l c l i n i c i a n s .  C l i n i c a l psychology t r a i n i n g i s a post-  baccalaureate program leading to the degree of Doctor (Ph.D.).  The  national accreditation  of  Philosophy  body f o r Canadian  clinical  psychology t r a i n i n g programs i s the Canadian P s y c h o l o g i c a l A s s o c i a t i o n . A c c r e d i t a t i o n standards s p e c i f y three years of f u l l - t i m e course work i n s c i e n t i f i c and p r o f e s s i o n a l standards  and e t h i c s , research design  and  methodology, s t a t i s t i c s , p s y c h o l o g i c a l measurement, h i s t o r y and systems, and  substantive content.  biological,  General  cognitive/affective,  i n d i v i d u a l bases of behavior. range of assessment and bases. M.A.  core  content  must i n c l u d e  the  social/developmental as w e l l as  the  C l i n i c a l core courses must encompass the  i n t e r v e n t i o n techniques  and t h e i r t h e o r e t i c a l  Research t r a i n i n g requires execution of research p r o j e c t s at the and  Ph.D.  levels.  C l i n i c a l t r a i n i n g requires a minimum of  hours of practicum experience, i n c l u d i n g 250 experience  and  125  600  hours of d i r e c t s e r v i c e  hours of formally scheduled  s u p e r v i s i o n , and  1600  hours of i n t e r n s h i p experience, which can be taken f u l l - t i m e i n one year or  h a l f - t i m e i n two  years.  (For  a  more d e t a i l e d  outline  of  45 accreditation  standards  for c l i n i c a l  psychology  t r a i n i n g programs,  please r e f e r t o Appendix A.2.a.) Simon F r a s e r U n i v e r s i t y i n Burnaby, B r i t i s h Columbia, clinical  psychology  t r a i n i n g program a c c r e d i t e d  by  the  offers a American  Psychological A s s o c i a t i o n and p r o v i s i o n a l l y accredited by the Canadian Psychological are a B.A.  Association degree,  (see Table I I I ) .  24 semester  Prerequisite  requirements  c r e d i t s i n the experimental areas of  psychology, a s t a t i s t i c s course, and s a t i s f a c t o r y scores on the Graduate Record Examination. M.A.  Students are permitted three years t o complete  degree and four years t o complete the Ph.D.  11 months per year.  degree.  Students work  The program does not o f f e r a "terminal" M.A.  i n c l i n i c a l psychology; rather, students receive a master's psychology  and  are  then  admitted t o the Ph.D.  the  program i n  degree  degree i n clinical  psychology. In complete  the M.A. two  portion  of  t h e program, students are required  of the three general core courses  c o g n i t i v e / a f f e c t i v e , and  i n the  biological,  social/developmental bases of behavior, three  courses i n research design, and a course i n p e r s o n a l i t y theory. student must a l s o complete f i v e core c l i n i c a l courses: i n d i v i d u a l assessment techniques techniques  (two semesters).  c l i n i c a l placements:  (two  semesters),  The  psychopathology, and  intervention  As w e l l , the student must complete  three  i n d i v i d u a l assessment practicum (two semesters; 60  hours), i n t e r v e n t i o n practicum  (two semesters;  practicum (four months f u l l - t i m e ; 600 hours). must complete an M.A.  to  85 hours), and summer In a d d i t i o n , the student  thesis.  In the f i r s t year of the Ph.D.  program, students take t h e i r t h i r d  general core course, a course i n e t h i c s and p r o f e s s i o n a l i s s u e s , courses i n advanced t o p i c s ( c l i n i c a l  two  assessment, c l i n i c a l i n t e r v e n t i o n ,  1  TABLE III Program Elements :  S.E.U. C l i n i c a l  Psychology T r a i n i n g Program  PROGRAM ELEMENTS Research General Methods Core  Course Work  C l i n i c a l Core Assessment  Pathol ogy  General 600 601 602 744 770 806 807 819 820 822 824 910 911  (5) (5) (5) (3) (3) (3) (3) (2) (6) (6) (3) (5) (5)  B i o l . Bases Cog/Aff.Bases Dev/Soc.Bases Pathology Personallty Adv.Assess. Adv.tnterven. Ethics/Prof. Assessment Intervention Clin.Res.Des. Res.Design Res.Design  Psychometric  5.0 5.0 5.0 3.0 3.0 3.0 0.5  0.5  1.5  1.5  2.0  2.0 6.0 3.0  3.0 5.0 5.0 2.0  TOTAL  54.0 WITS  Research Projects M.A. Thesis Ph.D. Thesis TOTAL  12.0 u n i t s 36.0 u n i t s 48.0 UNITS  Comprehensive Exam yes C l i n i c a l Experience Psychometric Assess. 60 Psychotherapy 84 Practicum 600 Internship 1600 TOTAL 2344  Psychotherapy  13.1  17.0  8.0  9.0 11.0  5.0  hones; hours' hours hours HOURS  ^Assuming 2 hours per week f o r 12 weeks i n the f i r s t semester and 3 hours per week f o r 12 weeks i n the second semester. ^Assuming 4 hours per week for 12 weeks i n the f l t s t semester and 3 hours per week f o r 12 weeks i n the second semester.  47 program evaluation,  or i n d u s t r i a l psychology), and the comprehensive  examination on the previous three years' materialyears of the Ph.D. program, students are required d i s s e r t a t i o n and an i n t e r n s h i p  In the succeeding t o complete a Ph.D.  (one year f u l l - t i m e or two years h a l f -  time; 1600 hours).  (For a more d e t a i l e d o u t l i n e of the Simon Fraser  University  psychology  clinical  t r a i n i n g program, p l e a s e  refer to  Appendix A.2.b.)  T r a i n i n g i n P s y c h i a t r i c Nursing P s y c h i a t r i c nursing t r a i n i n g i s a post-secondary program leading t o the degree of Diploma of Associate i n P s y c h i a t r i c Nursing. nursing t r a i n i n g programs are accredited bodies  following  guidelines  Psychiatric  by the p r o v i n c i a l r e g i s t r a t i o n  developed  i n association  Psychiatric  Nurses Association  of Canada.  psychiatric  nursing t r a i n i n g program i s accredited  with  the  In B r i t i s h Columbia, the  P s y c h i a t r i c Nurses A s s o c i a t i o n of B r i t i s h Columbia.  by the Registered In Canada, t r a i n i n g  programs are a l s o a v a i l a b l e i n A l b e r t a , Saskatchewan, and Manitoba and t h e s e programs are accredited,  respectively,  by the PNAA, SPNA, and  RPNAM. A c c r e d i t a t i o n standards specify a program length of 20 months of classroom i n s t r u c t i o n and c l i n i c a l placements.  The minimum acceptable  requirement f o r t h e o r e t i c a l i n s t r u c t i o n i s 750 hours, which must include a minimum of 225 hours of basic nursing and 450 hours of p s y c h i a t r i c nursing, i n c l u d i n g accreditation  36 hours r e l a t i n g t o mental r e t a r d a t i o n .  (For the  standards f o r p s y c h i a t r i c nursing programs, please r e f e r  t o Appendix A.3.a.) Douglas C o l l e g e i n New Westminster, B r i t i s h Columbia, o f f e r s  a  p s y c h i a t r i c nursing t r a i n i n g program accredited by the RPNABC (see Table IV).  The  objective of the program i s  t o t r a i n graduates who w i l l be  TABLE IV  Program E l e m e n t s :  Douglas C o l l e g e P s y c h i a t r i c N u r s i n g T r a i n i n g  PROGRAM C o u r s e Work  NUR NUR NUR NUR NUR NUR NUR NUR NUR BIO BIO PSV PNU PNU PNU PNU PNU PNU PNU PNU COM  100 102 103 200 202 203 300 303 304 103 20 3 100 450 460 550 551 555 560 570 650 170  (4 0) (1 5) (1 5) (4 0) ( 1 5) (1 5) (4 0) (3 0) (1 5) (3 0) (3 0) (3 0) (5 0) (3.0) (2 0) (2 5) (2 0) (3 0) (1 5) (3 0) (3 0)  Nur.Theory pharmacology Interaction Nur. T h e o r y Pharmacology Interaction Nur. T h e o r y Interaction H e a l t h Promo. Physiology Physiology psychology Theory A d u l t I n d i v . Therapy T h e o r y Men.Ret. Care Men.Ret. Care E l d e r l y Group T h e r a p y Leadership Psy.Nur.Theory prof. Writing  4 1 1 4 1 1 4 3 1 3 3  Psych. Nursing  56.5 UNITS  C l i n i c a l Experience Basic Nursing Laboratory 168 h o u r s Placement 465 h o u r s Psych. Nursing Placement 285 h o u r s p r e c e p t o r s h i p 370 h o u r s TOTAL 12BB HOURS  Clinical  Pathology  Assessment  Core  Psychotherapy  Pharmacotherapy  0 5 5 0 5 5 0 0 5 0 0 3 0 1 0  1 5 1 0 3 0  1.0  1.0 0.5 0.5 0.5 0.5 0.5  1.0 0.5 0.5 0.5 0.5 0.5  1.0 2.0 0.5 1.0 0.5 2.0  0.5  0.5  0.5  0.5  4.0  4.0  7.5  3.0  0.5 0.5 0.5  9 5  28 5 TOTAL  ELEMENTS  G e n e r a l Core Basic Nursing  Program  38.0  49 able  t o provide  s a f e , comprehensive p s y c h i a t r i c n u r s i n g  care t o  i n d i v i d u a l s i n acute and long-term p s y c h i a t r i c , p s y c h o g e r i a t r i c , mental r e t a r d a t i o n , extended and intermediate care s e t t i n g s .  I t i s expected  that the graduate w i l l be able t o u t i l i z e beginning leadership s k i l l s i n delegating, organizing, and c o o r d i n a t i n g nursing care a t the nursing team l e v e l . in  I t i s not expected that graduates w i l l be able t o f u n c t i o n  s p e c i a l t y areas such as c h i l d , adolescent, f o r e n s i c , and community  care s e t t i n g s without a d d i t i o n a l t r a i n i n g .  I t i s understood that while  i n some other provinces and i n the United States, more advanced t r a i n i n g programs i n p s y c h i a t r i c nursing are a v a i l a b l e , i n B r i t i s h Columbia the p s y c h i a t r i c nursing program prepares beginning p r a c t i t i o n e r s . order  t o work i n s p e c i a l t y areas,  graduates w i l l  Thus, i n  need i n t e n s i v e i n -  s e r v i c e t r a i n i n g by the employer i n the s p e c i f i c job placement and/or upgrading t o the degree of Bachelor of Science i n Nursing (B.S.N.) with a  s p e c i a l t y i n p s y c h i a t r y o r a B.A. degree i n one of the s o c i a l  sciences.  I t i s t h i s l a t t e r q u a l i f i c a t i o n of a B.S.N, or B.A. degree  which i s u s u a l l y r e q u i r e d f o r employment i n the senior p s y c h i a t r i c n u r s i n g p o s i t i o n s i n community mental h e a l t h psychiatric  centres.  However,  nurses with the basic Diploma degree are a l s o presently  employed i n j u n i o r p o s i t i o n s i n mental h e a l t h  centres  i n British  Columbia; hence, I have documented p s y c h i a t r i c nursing t r a i n i n g only t o the l e v e l of the Diploma degree. P r e r e q u i s i t e requirements f o r the Douglas College program are a secondary degree ("C" average with two Grade 11 or Grade 12 science courses), I n d u s t r i a l F i r s t A i d C e r t i f i c a t e or both CPR and F i r s t A i d C e r t i f i c a t e s , medical satisfactory  chest  assessment showing adequate p h y s i c a l h e a l t h , X-ray,  current  immunization  c e r t i f i c a t e , and  s a t i s f a c t o r y performance on the Douglas College entrance  examinations.  50 The program requires two  f u l l years of s i x consecutive semesters  (21  months) t o complete. The  first  year i s taken i n common with students i n the general  nursing program and provides a foundation f o r the second year, concentrates on t r a i n i n g s p e c i f i c t o p s y c h i a t r i c nursing. year, students take three semesters  of  courses  In the f i r s t  i n nursing theory,  i n t r o d u c i n g students t o the nursing care of the w e l l a d u l t and e l d e r l y , as w e l l settings.  as  Students  adults i n medical,  surgical,  a l s o take three semesters  which  and  acute  of courses  the care  i n nursing  i n t e r a c t i o n s , which focus on communication approaches w i t h p a t i e n t s i n these same care s e t t i n g s , i n c l u d i n g i n t e r v i e w i n g , p a t i e n t teaching, and group process s k i l l s .  As w e l l , students take two semesters of courses  i n pharmacology and anatomy/physiology  and one semester  introductory psychology and h e a l t h promotion.  of courses i n  C l i n i c a l experience i s  provided i n each semester through a nursing laboratory, where students must master s e l e c t e d nursing s k i l l s  before p r a c t i c i n g  s e t t i n g s , and through c l i n i c a l placements  i n the  care  f o r a t o t a l of 645 hours of  c l i n i c a l experience. In  the  second  nursing theory, which diagnostic techniques  y e a r , students take f i v e  courses  introduce students t o p s y c h i a t r i c  c l a s s i f i c a t i o n s , psychopathology, (psychotherapy  and pharmacotherapy),  d e a l i n g w i t h the  psychiatric  care  legal  semester  and  clinical  The f i r s t theory  of a d u l t s i n acute  s e t t i n g s , requires one  terminology,  assessment, i n t e r v e n t i o n  i s s u e s , and p r o f e s s i o n a l r o l e s and r e s p o n s i b i l i t i e s . course,  i n psychiatric  t o complete  and  long-term  and the  three theory courses, d e a l i n g with the care of the mentally and the e l d e r l y , each r e q u i r e a half-semester t o complete.  next  handicapped The  final  i n t e n s i v e one-week course i n p s y c h i a t r i c nursing theory brings together  51 the m a t e r i a l i n the preceding courses and focusses on the r o l e of the p s y c h i a t r i c nurse as a change agent w i t h i n the mental h e a l t h s e r v i c e d e l i v e r y system.  I n addition/ students take two courses i n p s y c h i a t r i c  nursing i n t e r v e n t i o n ; these courses prepare  the student  t o provide  i n d i v i d u a l and group c o u n s e l l i n g t o p a t i e n t s i n i n s t i t u t i o n a l s e t t i n g s . As w e l l /  students take one course i n leadership, which prepares the  student t o f u n c t i o n i n the r o l e of program coordinator i n a v a r i e t y of treatment m o d a l i t i e s and as a head nurse.  Clinical  experience i n  p s y c h i a t r i c nursing p r a c t i c e i s r e q u i r e d i n each semester. c l i n i c a l experience provides 195 hours psychiatric setting. of  The f i r s t  of p r a c t i c e i n an acute a d u l t  The second c l i n i c a l experience provides 90 hours  practice i n geriatric  and p s y c h o g e r i a t r i c s e t t i n g s .  The t h i r d  c l i n i c a l experience, the preceptorship, provides 370 hours of f u l l - t i m e p r a c t i c e i n one of the various types of mental h e a l t h s e t t i n g s f o r which t h e i r t r a i n i n g has prepared the students. of  (For a more d e t a i l e d o u t l i n e  the Douglas College p s y c h i a t r i c nursing t r a i n i n g program,  please  r e f e r t o Appendix A.3.b.)  T r a i n i n g i n S o c i a l Work There are three degree programs i n s o c i a l work t r a i n i n g i n Canada, the Bachelor of S o c i a l Work, the Master of S o c i a l Work, and the Doctor of  S o c i a l Work. The B.S.W. and M.S.W. degrees are considered more  appropriate f o r students wishing t o pursue s o c i a l work p r a c t i c e and the D.S.W. i s considered more appropriate f o r students wishing t o pursue an academic career.  As noted above, I have chosen t o consider the B.S.W.  and M.S.W. programs together as the t r a i n i n g program standard f o r s o c i a l workers  practicing  i n t h e mental  health f i e l d .  The n a t i o n a l  a c c r e d i t a t i o n body f o r Canadian s o c i a l work t r a i n i n g programs i s the  52 Canadian Association of Schools of S o c i a l Work.  Rather than enforce a  s i n g l e curriculum model, the CASSW has made a more general statement of standards i n the b e l i e f that t h i s approach w i l l encourage the c r e a t i v i t y of  i n d i v i d u a l schools.  attached  Thus, proportionately  greater  importance i s  t o a c l e a r statement of program objectives  and curriculum  design by schools seeking a c c r e d i t a t i o n .  The a c c r e d i t a t i o n standards  s t a t e the c e n t r a l p h i l o s o p h i c a l requirement f o r program a c c r e d i t a t i o n as follows: "Schools s h a l l infuse s o c i a l work values and e t h i c s i n t o the c u r r i c u l u m , i n c l u d i n g f i e l d p r a c t i c e . More s p e c i f i c a l l y , s c h o o l s a r e e x p e c t e d t o promote a p r o f e s s i o n a l commitment t o o p t i m i z e t h e d i g n i t y and p o t e n t i a l o f a l l people. To t h i s end, schools are expected t o provide e d u c a t i o n e n a b l i n g professional a c t i o n t o remove obstacles t o s o c i a l f u n c t i o n i n g and t o eliminate i n e q u a l i t y . " 2 A c c r e d i t a t i o n standards f o r the B.S.W. t r a i n i n g program s p e c i f y that the graduate w i l l  be prepared f o r general p r a c t i c e -  The curriculum  must  o f f e r the student opportunities t o become f a m i l i a r with the development of Canadian s o c i a l welfare i n s t i t u t i o n s , the h i s t o r y of the of  s o c i a l work, t h e v a l u e s  problems, and the u t i l i z a t i o n intervention.  and assumptions associated of s c i e n t i f i c  profession with  social  methods i n p r o f e s s i o n a l  The t r a i n i n g program must include  a field  practice  component which r e f l e c t s the school's objectives and which prepares f o r professional practice.  A c c r e d i t a t i o n standards f o r the M.S.W. program  specify that entering students must be able to demonstrate competence a t the  B.S.W. l e v e l .  emphasizing the  Studies a t the M.S.W. l e v e l should be focussed,  r e l a t i o n s h i p among s o c i a l work problems,  approaches, s o c i a l s e r v i c e context.  systems, and t h e s o c i a l and p o l i t i c a l  The t r a i n i n g p r o g r a m  opportunities  intervention  must p r o v i d e  field  placement  which demand an advanced l e v e l of p r o f e s s i o n a l judgement  53 and i n t e r v e n t i o n s k i l l s .  (For a more d e t a i l e d o u t l i n e of a c c r e d i t a t i o n  standards f o r s o c i a l work t r a i n i n g programs, please r e f e r t o Appendix A. 4.a. ) The U n i v e r s i t y of B r i t i s h Columbia i n Vancouver, B r i t i s h Columbia, o f f e r s s o c i a l work t r a i n i n g programs accredited by the CASSW at both the B. S.W.  and the M.S.W. l e v e l s (See Table V).  The School of S o c i a l Work  states the o b j e c t i v e s of the B.S.W. program as "to provide students with the  knowledge and s k i l l s necessary t o beginning p r o f e s s i o n a l p r a c t i c e i n  s o c i a l work r o l e s at the i n d i v i d u a l , family and small group or community level  [and] t o prepare s e l e c t e d students f o r entry i n t o more advanced  p r o f e s s i o n a l studies at the graduate l e v e l . " 3 The B.S.W. program i s o f f e r e d i n three formats:  a two-year (16  months) undergraduate program f o r students without a B.A. degree, a oneyear (8.5 months) graduate program f o r students with a B.A. extensive s o c i a l work employment, and a two-year  degree and  (16 months) graduate  program f o r students with a B.A. degree but minimal previous s o c i a l work employment.  P r e r e q u i s i t e requirements f o r the undergraduate B.S.W.  program are completion of the f i r s t two years of the B.A. program with a minimum 65 p e r c e n t a v e r a g e ,  12 semester  behavioral sciences, and a s t a t i s t i c s degree requirement). program  units  i n the s o c i a l and  course (optional  prerequisite,  P r e r e q u i s i t e requirements f o r the graduate B.S.W.  a r e a B.A. degree,  24 semester  units  i n t h e s o c i a l and  behavioral sciences, a s t a t i s t i c s course, and s a t i s f a c t o r y performance on the Faculty of Arts E n g l i s h Composition Tests.  Degree requirements  for the undergraduate and graduate B.S.W. programs are the same w i t h the exception that undergraduate students must complete an a d d i t i o n a l 15 semester u n i t s i n the s o c i a l and behavioral sciences.  TABLE V  Program E l e m e n t s :  PROGRAM ELEMENTS Research General Methods Core  COURSE WORK B.S.W. Program 300 (6) 310 ( 6 ) 320 (6) 336 (3) 400 ( 3 )  Pathology  410 o r 415 ( 6 ) M.S.W. Program 512 (6) 522 ( 6 ) 542 (6) 552 ( 6 ) 560 ( 6 ) TOTAL  Cdn. S o c . S e r . Intervention R e s e a r c h Meth. S o c i a l Problems Cdn. S o c . S e r . Intervention Health Problems Can. H l t h . S e r . Intervention R e s e a r c h Meth. Intervention 5B.5 UN ITS  R e s e a r c h P r o j e c t - 320  1.5 u n l t a  M a j o r Paper  yes  Comprehensive Exam  yes  Clinical  U.B.C. S o c i a l Work T r a i n i n g  Program  C l i n i c a l Core Psychotherapy Assessment  6.0 1.5  3.0  1.5  3.0  1. 5  1.5  3.0  1. 5  1.5  3.0  15. 0  6-0  12.0  1. 5 4.5 3. 0 3.0 1. 5 6. 0 6.0 6.0  10.5  15.0  Experience  B.S.W. {1 y e a r ) B.S.W. (2 y e a r ) M.S.W. TOTAL 4  2  3  510 h o u r s 960 h o u r s 4B0 h o u r s 990-1440 BOORS  'u.B.C. c o u r s e c r e d i t d e s i g n a t i o n s have been t r a n s f o r m e d i n t o s e m e s t e r u n i t s . A s s u m i n g 7.5 h o u r s p e r day a t 2 d a y s p e r week f o r 8.5 months. A s s u m i n g 7.5 h o u r s p e r day a t 2 days p e r week f o r 16 months A s s u m i n g 7.5 h o u r s p e r day a t 2 days p e r week f o r 8 months.  2  3  4  1  55 Students i n the B.S.W. program are r e q u i r e d t o take three general core courses i n s o c i a l work theory. of  Canadian  social  These courses review the s t r u c t u r e  s e r v i c e s , examining  s o c i a l i s s u e s , the t r a n s l a t i o n of t h i s  the l e g i s l a t i o n r e l a t i n g t o legislation f i r s t  into  social  p o l i c y and then i n t o s o c i a l programs, and f i n a l l y , the impact of these s o c i a l programs on the i n d i v i d u a l .  Using a systems model, students  study the i n t e r a c t i o n s between the s o c i a l context and the i n d i v i d u a l , i d e n t i f y i n g the values which u n d e r l i e s o c i a l p o l i c y  development.  As  w e l l , students must take two courses i n s o c i a l work research methods and complete a small research p r o j e c t . course  i nsocial  pathology,  The c l i n i c a l core courses i n c l u d e a  which  examines the dynamics of human  behavior w i t h i n s o c i a l systems, f o c u s s i n g on p a r t i c u l a r s o c i a l problems such as divorce, i l l n e s s , and poverty.  Students are a l s o r e q u i r e d t o  complete three courses i n s o c i a l work i n t e r v e n t i o n , l e a r n i n g assessment techniques  and i n t e r v e n t i o n  strategies.  The c l i n i c a l  experience  component of the program requires the student t o work two days per week i n a c l i n i c a l , placement. complete  510 hours  undergraduate Instruction.  Students  i n the one-year graduate  program  of F i e l d I n s t r u c t i o n and students i n the two-year  and graduate  programs  complete  960 hours  of F i e l d  (For a more d e t a i l e d o u t l i n e of the U n i v e r s i t y of B r i t i s h  Columbia B.S.W. s o c i a l work t r a i n i n g program, please r e f e r t o Appendix A.4.b(1).) The complete.  M.S.W. program r e q u i r e s t e n months of f u l l  The M.S.W. p r e r e q u i s i t e requirement i s a B.S.W. degree.  program o f f e r s a problem-centered three concentrations: needs. practice  time work t o  curriculum through  The  a choice among  f a m i l y needs, h e a l t h needs, and socio-economic  Within the concentration, the student then chooses among four specializations:  direct  practice,  social  p l a n n i n g and  56 community work, s o c i a l a d m i n i s t r a t i o n , and research.  For purposes of  the present comparison, I have assumed t h a t the student planning t o work i n mental h e a l t h s e r v i c e s e t t i n g s would be most l i k e l y t o choose the health needs concentration with a d i r e c t p r a c t i c e s p e c i a l i z a t i o n .  Given  t h i s assumption, the student would be r e q u i r e d t o take two general core courses i n s o c i a l work theory, s i m i l a r t o the s o c i a l work theory courses at  the B.S.W. l e v e l but d e a l i n g s p e c i f i c a l l y with health care p o l i c y ,  f i n a n c i n g , and d e l i v e r y .  S i x c l i n i c a l core courses are required.  Two  courses present s o c i a l pathology theory, analyzing t h e o r i e s on h e a l t h and  illness  selected  as these a f f e c t s o c i a l work i n t e r v e n t i o n  h e a l t h problems  f o r their  and s t u d y i n g  s o c i a l work i m p l i c a t i o n s .  Two  courses present methods of s o c i a l work d i r e c t p r a c t i c e and two courses present  further  s p e c i a l i z a t i o n i n d i r e c t p r a c t i c e techniques  student's i n t e r e s t area. research  methods  examination.  As w e l l , students must take two courses i n  and complete  The c l i n i c a l  i n the  a major paper  and comprehensive  experience component o f t h e s o c i a l  work  t r a i n i n g program requires the student t o work two days per week i n a clinical  placement  f o r e i g h t months, p r o v i d i n g s t u d e n t s  approximately 480 hours of c l i n i c a l experience. o u t l i n e of the U n i v e r s i t y  of B r i t i s h  with  (For a more d e t a i l e d  Columbia M.S.W. s o c i a l  work  t r a i n i n g program, please r e f e r t o Appendix A.4.b.(2).)  4.2  PROFESSIONAL TRAINING PROGRAMS COMPARED I t i s apparent from the review of p r o f e s s i o n a l t r a i n i n g  standards  and p r o f e s s i o n a l t r a i n i n g programs presented i n Tables I - V and i n the t e x t , that a l l the t r a i n i n g programs provide both d i d a c t i c  instruction  and c l i n i c a l experience i n the treatment of mental d i s o r d e r s .  However,  the programs vary i n the emphasis they place on treatment modes, p a t i e n t  57 p o p u l a t i o n s , and treatment s e t t i n g s . well-trained  i n somatic  classification.  treatments  P s y c h i a t r i s t s are p a r t i c u l a r l y and  i n psychiatric  diagnostic  Psychologists receive a great deal of t r a i n i n g i n  normal p s y c h o l o g i c a l processes and i n c r i t i c a l a n a l y s i s of methodology. S o c i a l workers are t r a i n e d t o view themselves and t h e i r c l i e n t s i n a social  context and t o develop s o c i a l s o l u t i o n s t o s o c i a l  Psychiatric  nurses  problems.  are t r a i n e d t o intervene d i r e c t l y w i t h mentally  disordered and handicapped  patients i n i n s t i t u t i o n a l settings.  Thus,  while the t r a i n i n g programs overlap i n some respects, they d i f f e r i n others.  Let us begin by examining the p o i n t s of most extreme divergence  and then gradually move toward those areas of s i m i l a r i t y which are of concern t o us i n the present context. Each of the professions comes from a d i f f e r e n t t r a d i t i o n .  For  example, comparing p s y c h i a t r y and psychology, psychiatry's development has been much more r e l a t e d t o s e r v i c e d e l i v e r y than t o research, and psychology's has been the reverse.  This d i f f e r e n c e i s r e f l e c t e d i n the  f i g u r e s i n Table I where we can see the r e l a t i v e l y greater weight given i n the p s y c h i a t r y t r a i n i n g program t o psychotherapy,  pharmacotherapy,  and c l i n i c a l experience and the r e l a t i v e l y greater weight given i n the psychology t r a i n i n g program to research methods and research experience. Differences a l s o occur i n the choice of assessment  techniques.  Both  programs devote considerable time t o assessment, however, psychiatry's emphasis i s toward c l i n i c a l c l a s s i f i c a t i o n while psychology's emphasis is  toward  behavioral analysis;  likewise,  p s y c h o l o g i s t s spend  p r o p o r t i o n a t e l y l e s s time l e a r n i n g p a t i e n t examination s k i l l s and more time l e a r n i n g the a d m i n i s t r a t i o n and tests.  i n t e r p r e t a t i o n of  psychometric  K i e s l e r (1979) presents an i n t e r e s t i n g commentary on how  these  58 differences  manifest  themselves  when comparing  the a t t i t u d e s  of  p s y c h i a t r i s t s and psychologists toward s e r v i c e review: "I think i t i s f a i r t o say t h a t p s y c h i a t r i s t s have b u i l t t h e i r review system on the t r a d i t i o n a l medical one. The t r a d i t i o n a l medical one i s a r e t r o s p e c t i v e review system based on the assumption t h a t there are a c c e p t e d and t r a d i t i o n a l s t a n d a r d s and methods of p r a c t i c e . P s y c h i a t r i s t s ' o r i e n t a t i o n i s t o weed out some s m a l l percentage of people and/or p r a c t i c e s not meeting those standards. I have no argument w i t h t h i s ; i t i s p e r f e c t l y plausible. But p s y c h o l o g i s t s ' ideas about standards of review are much more l i k e l y t o be e i t h e r concurrent or prospective. A p s y c h o l o g i s t dwells l e s s on whether the method i s t r a d i t i o n a l l y accepted and more on whether t h e method worked. In t h i s view, t h e p r o f e s s i o n a l should s t a t e i n advance of treatment what the p a t i e n t ' s problem i s , what treatment i s recommended, and what s p e c i f i c a l l y i s p r e d i c t e d t o be the outcome of the treatment. I t i s rather s c i e n t i f i c and e v a l u a t i v e , but p s y c h o l o g i s t s see t h i s as a review. I t i s more of a review of a system of treatment than i t i s a review of an i n d i v i d u a l p r a c t i t i o n e r . When d i s c u s s i n g the i d e a l P r o f e s s i o n a l Standards Review O r g a n i z a t i o n (PSRO), conversations between a p s y c h i a t r i s t and a psychologist can become q u i t e animated because they are r e a l l y t a l k i n g about q u a l i t a t i v e l y d i f f e r e n t types of review . (p.33)." S o c i a l work's emergence as. a p r o f e s s i o n comes from a t r a d i t i o n of advocacy  f o r the s o c i a l l y  disadvantaged.  Through i t s g e n e r a l  core  c o u r s e s , the  s o c i a l work t r a i n i n g program places heavy emphasis on  knowledge of  social  relatively analyzing  systems.  g r e a t e r time the  social  The  clinical  core  courses  devote  to s o c i a l pathology courses concerned  context  of  individual  problems  and  with  devote  r e l a t i v e l y l e s s time t o assessment courses concerned with techniques f o r i n d i v i d u a l assessment.  In the area of research methods, the s o c i a l work  t r a i n i n g program places almost as much emphasis on research methods as does the psychology t r a i n i n g program; however, the i n t e r e s t i s more i n the q u a l i t a t i v e  research models rather than the q u a n t i t a t i v e models  favored by psychology and, although a research p r o j e c t i s r e q u i r e d , the  59 t h r u s t i s more toward understanding how t o use research f i n d i n g s than on producing research The  itself.  profession  d i r e c t care "keepers."  of p s y c h i a t r i c nursing comes from a t r a d i t i o n of  givers i n mental i n s t i t u t i o n s ,  f o r many y e a r s c a l l e d  However, as the concept of the asylum changed t o that of the  h o s p i t a l , the p r o f e s s i o n of p s y c h i a t r i c nursing developed; the B r i t i s h Columbia p r o v i n c i a l mental h o s p i t a l graduated i t s f i r s t  c l a s s of  p s y c h i a t r i c nurses i n 1932. With the community mental health movement, there has been an exodus of p a t i e n t s from the large i n s t i t u t i o n s and an accompanying greater  demand on p s y c h i a t r i c nurses f o r independent  p r a c t i c e and therapeutic rather than c u s t o d i a l s k i l l s . nursing  t r a i n i n g program r e f l e c t s  nurses  will  function  both  this  expectation  as d i r e c t care  The p s y c h i a t r i c  that p s y c h i a t r i c  givers  under  medical  supervision and as independent change agents i n the considerable  weight  given i n the f i r s t year t o basic nursing s k i l l s and the emphasis w i t h i n the second year on psychotherapy i n t e r v e n t i o n techniques. Granting four  these d i f f e r e n c e s i n the t r a d i t i o n s and t r a i n i n g of the  core mental health p r o f e s s i o n s ,  indicate  t h a t there  the data summarized i n Table I  i s a l s o a great  deal of s i m i l a r i t y .  A l l four  professions receive d i d a c t i c i n s t r u c t i o n i n pathology, assessment, and psychotherapy  and a l s o c l i n i c a l  mentally disordered. to  function  experience i n the treatment of the  The t r a i n i n g programs prepare a l l four professions  as p s y c h o t h e r a p i s t s :  p s y c h i a t r i s t s , p s y c h o l o g i s t s , and  s o c i a l workers as independent p r a c t i t i o n e r s across psychiatric circumstances. professions  nurses  as i n d e p e n d e n t  a l l s e t t i n g s and  p r a c t i t i o n e r s i n selected  The t r a i n i n g program data i n d i c a t e that none of the four  can c l a i m p r o p r i e t a r y r i g h t s t o the body of knowledge and  e x p e r i e n c e which  prepares  the student  t o become  a practicing  60 psychotherapist. l i c e n s u r e standards  In the f o l l o w i n g two  chapters, we  w i l l examine the  granting p r i v i l e g e s or imposing l i m i t a t i o n s on  f o u r p r o f e s s i o n s as psychotherapists  and  then review  the  comparing t h e i r r e l a t i v e e f f e c t i v e n e s s as psychotherapists.  the  literature  61 CHAPTER FIVE  THE PROFESSIONAL LICENSURE STANDARDS  Chapter Five presents  a review of p r o f e s s i o n a l l i c e n s u r e standards  p r o f e s s i o n a l p r a c t i c e p r i v i l e g e s f o r the four core mental health in  the province  of B r i t i s h Columbia.  and  professions  P r o f e s s i o n a l l i c e n s i n g standards are  summarized i n Table VI and p r o f e s s i o n a l p r a c t i c e p r i v i l e g e s are summarized i n Table V I I . and  The  chapter concludes with a comparison of l i c e n s u r e standards  p r a c t i c e p r i v i l e g e s among the  four p r o f e s s i o n s  and  a discussion  of  l e g i s l a t i o n i n other j u r i s d i c t i o n s which has granted more extensive p r a c t i c e p r i v i l e g e s to psychologists than i s presently the case i n B r i t i s h Columbia. In d i s c u s s i n g p r o f e s s i o n a l l i c e n s u r e standards, between l i c e n s u r e s t a t u t e s  and  I have drawn a d i s t i n c t i o n  registration statutes.  In  licensure  l e g i s l a t i o n , a profession i s given the power to c o n t r o l t i t l e , to define the scope of p r a c t i c e , and  to  enforce  exclusive  practice privileges.  In  r e g i s t r a t i o n l e g i s l a t i o n , the p r o f e s s i o n i s given the power to c o n t r o l t i t l e and to define p r a c t i c e but not to enforce e x c l u s i v e p r a c t i c e p r i v i l e g e s .  5.1  PROFESSIONAL LICENSURE STANDARDS Psychiatry In B r i t i s h Columbia, p s y c h i a t r i s t s are l i c e n s e d under the P r a c t i t i o n e r s Act (R.S.B.C. 1979, c Physicians  and  Surgeons of  254).  British  members (s.29(1), s.4, s.48,  The act gives the College of  Columbia  r e g i s t e r members, to e s t a b l i s h a code of  Medical  (CPSBC) the power t o  e t h i c s , and  s.50, and s.51).  to  discipline  TABLE VT  Licensure Standards Far Mental Health Professions in British Qoluibla  PROFESSuTi PSYCHIATRIC NURSItG fui*i r>\ n)-f*r\ TVJ Body Registered Psychiatric Board of Registration Nurses Association of far Social Workers of British Columbia tlie Province of B.C. Itajilrud Anmrtaf nd Society British Columbia AssociNone Hriemtitp None None ation of Social Workers htelical Practitioners Psychologists Set Unrses (Registered Sncial Workers (RegisInginlariae Act Act (R.S.B.C. 1979, (R.S.B.C., 1979, Psychiatric) Act tration) Act (R.S.B.C. c. 254) c. 342) (R.S.B.C. 1979, c. 301) 1979, c. 389) Title Fellow of the Royal Col-• Psychologist or Registered Psychiatric Registered Social legs of Physicians and Registered Psychologist Nurse (R.P.N.) Worker (R.S.W.) Surgeons of Canada, Physician and Surgeon Control of Title Yes Yes Yes Yes (limited) $500 for each day of Fine far I l l e ^ l Use of Title $500 contravention $2,000 $50 Practice htedicine Psychology Psychiatric Nursing Social Work Yes Independent Practice Yes Yes Yes Yes Definition of Practice Yes Unspecified Unspecified Control of Practice Yes None None None Qiixcpractxirs, Dentists, Physicians, Registered Naturopaths, OptomeProfessions, Academic Exempted Professions trists, Pharmacists, Psychologists, Unspecified Unspecified podiatrists. Psycholo- Government Employees gists, Nurses Yes Dade of Ethics Yes Yes Yes Disciplinary powers: r e Meabers yes Yes Yes Yes Offence Act (R.S..B.C. Prosecution for Illegal 1979, c. 304) Fine and/ None None None Practice or Imprisonment Procedure Degrees i n Rarttfllrr of Specialty Residency Doctoral Degree i n Diplcina of Associate Social Work or Master Credentials •Raining i n Psychiatry Psychology in Psyciiiatric Nursing of Social Mark or CneYear Full Time Employment in Social Work Specialty Examination Examination in the Pro- RPMABC Registration Examination in Psychiatry fessional practice of Examination Itoiie Psychology Royal CollegE: of Physi- Association of State Registered psychiatric Examining Body cians and Surgoons of Psychology Boards Nurses Association of None Canada British Coluihia Written Examination Yes Yes Yes None Oral Examination Yes Yes None None PSYCHXAlRf College of Physicians and Surgeons of British Colmbia  PSYCHOLOGY British Columbia Psychological Association  SOCIAL WORK Associated Professional Social Workers of British Columbia None  (Proposed) Board of Social Work Examiners  None (Proposed) Social Work Act  None  None None  Social Worker Licensed Social Worker licensed Clinical S.W. Licensed S.W. Spedalist Yes ON  None Social Work Yes Unspecified None  Unspecified  $500 Social Work Yes Yes None Physicians, Attorneys, Psychologists, Clergy, Other professional Groups  Yes Yes  Yes Yes  None  None  Degrees in Bachelor of Social Work or (taster of Social Work  Degrees in Bachelor of Social Work or Master of Social Work  Private Practice Examination  Rajuired but unspecified  Associated Professional Social Workers of British Coluiiiia None Yes  Board of Social Work Examiners Unspecified Unspecified  The a c t gives the CPSBC the power t o define the scope and c o n t r o l the p r a c t i c e of medicine.  Under the a c t , the CPSBC has the power t o  f i n e i n d i v i d u a l s who attempt t o obtain l i c e n s u r e f r a u d u l e n t l y (s.82) and to l a y charges under the Offence Act (R.S.B.C unlicensed (s.83). and  i n d i v i d u a l s who p r a c t i c e  or o f f e r  1979, c  305) against  to practice  Hence, the a c t gives the CPSBC c o n t r o l of the t i t l e s  Surgeon"  and " M e d i c a l  requirement f o r p r a c t i c e .  P r a c t i t i o n e r " and makes  medicine "Physician  licensure  a  However, although the act i s quite powerful  i n that i t permits the CPSBC t o define the scope of p r a c t i c e , the a c t a l s o includes an exemption s e c t i o n l i s t i n g other r e g i s t e r e d e n t i t l e d t o p r a c t i c e t h e i r professions practicing  professions  without being considered t o be  m e d i c i n e ; of p a r t i c u l a r relevance here are the sections  exempting psychologists  ( s . 7 3 ( i ) ) and nurses (s.73(m)).  In order t o  become l i c e n s e d as a p s y c h i a t r i s t i n B r i t i s h Columbia, the applicant must present t o the CPSBC proof of the necessary academic c r e d e n t i a l s (M.D. degree, i n t e r n s h i p ,  and residency  s a t i s f a c t o r y performance on the required  t r a i n i n g ) and evidence of  examinations (Medical  Council  of Canada Q u a l i f y i n g Examination i n the s p e c i a l t y of p s y c h i a t r y ) . (For s t a t u t o r y references, please r e f e r t o Appendix B.1.)  Psychology In  British  Psychologists  Columbia, p s y c h o l o g i s t s  Act (R.S.B.C. 1979, c. 342).  are r e g i s t e r e d  under the  The a c t gives the B r i t i s h  Columbia Psychological A s s o c i a t i o n (BCPA) the power t o r e g i s t e r members, to e s t a b l i s h a code of e t h i c s , and t o d i s c i p l i n e members s.6(1)(d), and s.9).  The a c t s p e c i f i e s that psychologists  (s.6(1)(a), are e n t i t l e d  to p r a c t i c e independently of the supervision of a medical p r a c t i t i o n e r (s.15).  The a c t gives the BCPA c o n t r o l of the t i t l e s "Psychologist" and  64 "Registered  Psychologist"  (s.16(2)) and  the t i t l e i l l e g a l l y  the power to f i n e i n d i v i d u a l s  who  use  for  employment or p r i v a t e p r a c t i c e when the  The  act provides a d e f i n i t i o n of the p r a c t i c e of psychology (s.1) the  (s.16(5)).  BCPA the  R e g i s t r a t i o n i s a requirement title  i s used  (s.16(1)).  does not  give  practice.  The act includes an exemption s e c t i o n p e r m i t t i n g p r a c t i c e by  other r e g i s t e r e d professions, University  Act  power to enforce exclusive  academic psychologists  (R.S.B.C. 1979,  c-  419),  and  control  but  employed under the  employees of  a g e n c i e s where q u a l i f i c a t i o n s i n p s y c h o l o g y  of  condition  of  In order to become r e g i s t e r e d as a psychologist  in  B r i t i s h Columbia, the applicant must present to the BCPA proof of  the  employment (s.18).  required academic c r e d e n t i a l s c l i n i c a l internship  (1600  are  a  government  (Ph.D. degree i n psychology),  hours), and  s a t i s f a c t o r y performance on  Examination i n the P r a c t i c e of P r o f e s s i o n a l Psychology. references, please r e f e r t o Appendix  supervised  (For  the  statutory  B.2.)  P s y c h i a t r i c Nursing In B r i t i s h Columbia, p s y c h i a t r i c nurses are Nurses (Registered gives the Registered  P s y c h i a t r i c ) Act  r e g i s t e r e d under the  (R.S.B.C. 1979,  c  301).  The  act  P s y c h i a t r i c Nurses Association of B r i t i s h Columbia  (RPNABC) the power to r e g i s t e r p s y c h i a t r i c nurses, to e s t a b l i s h a code of e t h i c s , and to d i s c i p l i n e members (s.6(1), s.7(1)(a), and The  act gives the RPNABC c o n t r o l of the t i t l e  "Registered  s.7(1)(b)). Psychiatric  Nurse" and of the abbreviation  "R.P.N." (s.12(1)) and the power to f i n e  i n d i v i d u a l s who  illegally  use  the  title  (s.12(2)).  The  act does not  give the RPNABC the power to define the scope of p r a c t i c e or to c o n t r o l p r a c t i c e ; hence, i t i s the case that Registered Nurses, who R.P.N, academic c r e d e n t i a l s or r e g i s t r a t i o n , are frequently  may  not have  employed i n  65 p s y c h i a t r i c nursing p o s i t i o n s .  However, r e g i s t r a t i o n i n some branch of  n u r s i n g i s a requirement f o r employment as a p s y c h i a t r i c  nurse and  a l t h o u g h maintenance of r e g i s t r a t i o n has not been a condition of continued employment, i t i s expected t h i s l a t t e r circumstance w i l l be changed s h o r t l y psychiatric  (Stewart, 1986).  In order t o become r e g i s t e r e d  nurse i n the province of B r i t i s h Columbia, the applicant  must present proof of the necessary academic c r e d e n t i a l s Associate  as a  i n Psychiatric  satisfactorily  Nursing)  on the w r i t t e n  t o t h e RPNABC  (Diploma of and p e r f o r m  examination s e t by the RPNABC.  (For  statutory references, please r e f e r t o Appendix B.3.)  S o c i a l Work In B r i t i s h Columbia, s o c i a l workers may become r e g i s t e r e d under the S o c i a l Workers  (Registration)  gives the B r i t i s h  Act (R.S.B.C. 1979, c. 389).  Columbia Association  The a c t  of S o c i a l Workers (BCASW) the  power t o r e g i s t e r s o c i a l workers, t o e s t a b l i s h a code of e t h i c s , and t o d i s c i p l i n e members ( S o c i a l Workers (Registration) Reg.  45/69, s.1(2), s.2(2)(c),  and s.6).  Act Regulations, B.C.  The a c t g i v e s  t h e BCASW  c o n t r o l of the t i t l e "Registered S o c i a l Worker" and of the abbreviation "R.S.W." (B.C. Reg.45/69, s.1(3)) and the power t o f i n e i n d i v i d u a l s who use the t i t l e i l l e g a l l y  (R.S.B.C. 1979, c. 389, s.5).  The a c t s p e c i f i e s  that no r e g i s t e r e d s o c i a l worker, who does not hold an M.S.W. degree, may e s t a b l i s h a p r i v a t e p r a c t i c e . However, r e g i s t r a t i o n i s not a requirement f o r employment and hence,  this  meaningless.  power  to register  and t o c o n t r o l  title  i s largely  The B r i t i s h Columbia p r o v i n c i a l government h i r e s  individuals into positions  many  with the c l a s s i f i c a t i o n of " S o c i a l Worker"  who have no t r a i n i n g i n s o c i a l work but who may have a bachelor's degree  66 i n a s o c i a l science or who have t r a i n e d as teachers, p s y c h i a t r i c nurses, or  master's degree l e v e l p s y c h o l o g i s t s .  establish a private  practice  As w e l l ,  i n d i v i d u a l s may  i n s o c i a l work without being  registered.  Furthermore, the BCASW i t s e l f , while i n d i c a t i n g that a B.S.W. or M.S.W. degree are s a t i s f a c t o r y  credentials  i n d i v i d u a l s with no p r o f e s s i o n a l  f o r r e g i s t r a t i o n , also  registers  t r a i n i n g i n s o c i a l work but who have  had one year of f u l l t i m e employment i n a s o c i a l work p o s i t i o n . As  a result  of t h i s  circumstance,  a second  organization  representing s o c i a l workers, the Associated P r o f e s s i o n a l  S o c i a l Workers  of B r i t i s h Columbia (APSWBC), has formed an i n t e r e s t group t o lobby f o r a l e g i s l a t i v e a c t which would t r u l y give s o c i a l workers c o n t r o l of t i t l e and require p r o f e s s i o n a l  t r a i n i n g f o r the designation of s o c i a l worker.  The APSWBC i s incorporated under the Society Act (R.S.B.C. 1979, c 390) and i t s stated objectives  include the recognition  and maintenance "as a  minimal acceptable standard of education f o r s o c i a l work p r a c t i c e , the completion of a u n i v e r s i t y degree i n s o c i a l work [and the]  l i c e n s i n g of  p r o f e s s i o n a l s o c i a l workers f o r the p r o t e c t i o n of the profession public"  1  established (APSWBC, credentials  Although  t h e APSWBC has no s t a t u t o r y  and the  powers, i t has  a r e g i s t e r , a code of e t h i c s , and d i s c i p l i n a r y procedures 1981).  The requirement f o r membership i s presentation of  i n d i c a t i n g the applicant  holds a B.S.W. or M.S.W. degree.  The APSWBC has proposed the S o c i a l Workers Act, which would e s t a b l i s h a Board of S o c i a l Work Examiners w i t h workers, t o e s t a b l i s h  t h e power t o r e g i s t e r  a code of e t h i c s ,  and t o d i s c i p l i n e members  ( S o c i a l Workers Act (proposed), s.7(7), s.7(9), and s.12)). would c o n t r o l  the t i t l e  specialty t i t l e s ,  social  The a c t  of " S o c i a l Worker" and would e s t a b l i s h  four  " S o c i a l Worker," "Licensed S o c i a l Worker," "Licensed  67 C l i n i c a l S o c i a l Worker," and "Licensed S o c i a l Work S p e c i a l i s t " , (s.5 and s.8), each r e q u i r i n g successively experience.  higher  q u a l i f i c a t i o n s i n t r a i n i n g and  For example, requirements  f o r r e g i s t r a t i o n as a S o c i a l  Worker would be a B.S.W. degree, s a t i s f a c t o r y  performance on an  examination set by the Board, and employment under the s u p e r v i s i o n of a Licensed S o c i a l Worker, while f o r r e g i s t r a t i o n as a Licensed S o c i a l Work S p e c i a l i s t , the a p p l i c a t i o n would need an M.S.W. or D.S.W. degree, f i v e years post-graduate would p r o v i d e practice  experience, and t o pass the examination.  a d e f i n i t i o n of p r a c t i c e  The act  (s.5) but would not  (s.19); however, i t would specify t h a t i n d i v i d u a l s  control  seeking t o  e s t a b l i s h a p r i v a t e p r a c t i c e i n s o c i a l work must have the designation of Licensed S o c i a l Work S p e c i a l i s t (s.15(1)).  The act would give the Board  of Examiners the power t o f i n e i n d i v i d u a l s who used any of the t i t l e s illegally practice  (s.18(1)) and t o f i n e i n d i v i d u a l s who established illegally  (s.18(3)).  (For statutory  a private  references, please r e f e r  t o Appendix B.4.a, Appendix B.4.b, and Appendix B.4.c.)  5.2  PROFESSIONAL PRACTICE PRIVILEGES Psychiatry In  British  practitioners,  Columbia, p s y c h i a t r i s t s  are independently  practice  legally liable,  q u a l i f i e d by the courts as expert witnesses.  as independent  and are f r e q u e n t l y  As medical p r a c t i t i o n e r s ,  p s y c h i a t r i s t s are among the professions reimbursed on a f e e - f o r - s e r v i c e basis through p a i d through formal  the p r o v i n c i a l medical insurance plan as w e l l as being sessional  statutory  and s a l a r i e d  recognition,  practitioners,  psychiatrists  Psychiatrists  have been  enjoy  granted  funding arrangements.  again  i n their  role  a number of p r a c t i c e hospital  admission  Through  as m e d i c a l privileges.  and discharge  68 p r i v i l e g e s (Hospital Act Regulations, B.C. Reg. 289/73) and p r e s c r i b i n g privileges granted  (Medical P r a c t i t i o n e r s A c t ) .  P s y c h i a t r i s t s have a l s o been  t h e power t o diagnose and t r e a t mental disorders  (Medical  P r a c t i t i o n e r s A c t ) , t o commit i n d i v i d u a l s t o a mental h o s p i t a l Health Act, R.S.B.C. 1979, c  (Mental  256), and the power t o declare i n d i v i d u a l s  mentally incompetent (Patients Property Act, R.S.B.C. 1979, c. 313). As medical p r a c t i t i o n e r s , p s y c h i a t r i s t s are included Infants Act (R.S.B.C. 1979, c the treatment of a minor.  with d e n t i s t s  i n the  196) requirements f o r parental consent t o  In a d d i t i o n , the evidence of p s y c h i a t r i s t s i s  s p e c i f i c a l l y recognized i n statutes dealing with f i t n e s s t o drive (Motor Vehicle Act, R.S.B.C. 1979, c- 288), f i t n e s s t o stand t r i a l and c r i m i n a l insanity  (Criminal  Code Act, R.S.C. 1970, c.34), and f i t n e s s t o stand  t r i a l and d i s p o s i t i o n of j u v e n i l e offenders (Young Offenders Act, S.C. 1980-81-82-83, c  110). As w e l l , i n B r i t i s h Columbia, p s y c h i a t r i s t s are  charged through the Forensic Psychiatry Act (R.S.B.C. 1979, c  139) w i t h  the assessment and care of the c r i m i n a l l y insane.  Psychology In  British  Columbia, p s y c h o l o g i s t s  p r a c t i t i o n e r s , are independently  legally  liable,  q u a l i f i e d by the courts as expert witnesses. recognition,  practice  as independent  and a r e  Through formal  frequently statutory  psychologists have been granted the power t o diagnose and  t r e a t mental disorders  (Psychologists  of psychologists i s s p e c i f i c a l l y f i t n e s s t o drive  (Motor Vehicle  Act).  In a d d i t i o n , the evidence  recognized i n statutes  with  Act) and f i t n e s s t o stand t r i a l and  d i s p o s i t i o n of j u v e n i l e offenders (Young Offenders A c t ) . are recognized i n p o l i c y decisions  dealing  Psychologists  r e q u i r i n g psychometric t e s t r e s u l t s ,  such as a u t h o r i z a t i o n of e l i g i b i l i t y  for special  education  programs  TABLE VII  P r a c t i c e P r i v i l e g e s f o r Mental H e a l t h P r o f e s s i o n s  Psychiatry  PROFESSION Psychology Psychiatric Nursing  Yes Yes Yes  Yes Yes Yes  Yes Yes Yes  Yes Yes Yes  Yes Yes Yes Yes  No Yes Yes Yes  Ho No No Yes  No No No Yes  PRACTICE PRIVILEGE  General  i n B r i t i s h Columbia  S o c i a l Work  Recognition  Independent P r a c t i c e o f P r o f e s s i o n Independently L e g a l l y L i a b l e Expert Witness S t a t u s Payment Status T h i r d Party Payment Government Private Carriers S e s s i o n a l Payment S a l a r i e d Payment  vc  F o r a a l Statutory Recognition D i a g n o s i s and Treatment P s y c h o l o g i s t s Act of Mental Disorders T R . S . B . C . 1 9 7 9 , c. 3 4 2 ) Medical P r a c t i t i o n e r s Act (R.S.B.C. 1 9 7 9 , c. 2 5 4 ) Care o f the C r i m i n a l l y F o r e n s i c P s y c h i a t r y Act Insane (R.S.B.C. 1 9 7 9 , c. 1 3 9 ) Treatment o f Minors Infants A c t P a r e n t a l Consent (R.S.B.C. 1 9 7 9 , c. 1 9 6 ) Required H o s p i t a l Admission and H o s p i t a l A c t Discharge P r i v i l e g e s (R.S.B.C. 1 9 7 9 , c. 1 7 6 ) P r e s c r i b i n g P r i v i l e g e s Medical P r a c t i t i o n e r s Act (R.S.B.C. 1 9 7 9 , c. 2 5 4 ) Commitment Mental H e a l t h A c t (R.S.B.C. 1 9 7 9 c. 2 5 6 ) Incompetency Patients Property Act (R.S.B.C. 1 9 7 9 , c. 3 1 3 ) Evidence C i t e d Motor V e h i c l e Act F i t n e s s t o Drive (R.S.B.C. 1 9 7 9 , c. 2 8 8 ) F i t n e s s t o Stand C r i m i n a l Code A c t (R.S.C. 1 9 7 0 , c. 3 4 ) Trial C r i m i n a l Code Act Criminal Insanity (R.S.C. 1 9 7 0 , c. 3 4 ) F i t n e s s t o Stand Young O f f e n d e r s Act T r i a l and D i s p o s i t i o n (S.C. 1 9 8 0 - 8 1 - 8 2 - 8 3 , c. 1 1 0 )  Yes  Yes  No  No  Yes  No  No  No  Yes  No  No  No  Yes  No  No  No  Yes  No  No  No  Yes  No  No  No  Yes  No  No  No  Yes Yes  Yes No Yes(proposed) No Yes(proposed  No No Yes(proposed) No Yes(proposed)  No No Yes(proposed) No Yes(proposed)  Yes  No  No  Yes  Yes  TABLE V I I ( C o n t i n u e d )  Practice Privileges  f o r Mental  Health Professions i n B r i t i s h  Columbia  NO  NO  No  Yes  No  NO  No  Yes  NO  NO  NO  Yes  NO  NO  NO  Yes  NO  NO  NO  Yes  NO  No  Yes  Yes  NO  NO  No  Yes  NO  NO  Yes  Yes  Yes  NO  NO  Yes  NO  No  NO  Yes  Yes  Yes  NO  Yes  No  Yes  No  No  No  No  NO  Yes  Yes  Yes  Yes  Yes  Informal Statutory Recognition Statutory Responsibilities Adoption  Adoption Act (R.S.B.C. 1979, c. 4) C h i l d P a t e r n i t y and Paternity Determination Support A c t (R.S.B.C. 1979, c . 49) L i c e n s i n g of Mental Community C a r e F a c i l i t y H e a l t h B o a r d i n g Homes A c t (R.S.B.C. 1979, c . 57) Child Protection Apprehension F a m i l y and C h i l d S e r v i c e s Guardianship A c t (R.S.B.C. 1979, c . 119) D i s p u t e d Custody Family R e l a t i o n s Act (R.S.B.C. 1979, c. 121) B r e a c h o f Order i n Forensic Psychiatry Act Council Patients (R.S.B.C. 1979, c. 139) G u a r a n t e e d A v a i l a b l e Income Eligibility for Comfort Allowance Need A c t (R.S.B.C. 1979, c 158) Commitment ( T h i r d Mental Health A c t Signatory) (R.S.B.C. 1979, c. 313) Incompetence ( r e g a r d - P a t i e n t s P r o p e r t y A c t i n g Managing A f f a i r s ) (R.S.B.C. 1979, C 313) Young O f f e n d e r s A c t Guardian i n Court Proceedings (S.C. 1980-81-82-83, c . 110)  Policy Responsibilities E l i g i b i l i t y Decisions • S o c i a l W e l f a r e Programs f o r t h e M e n t a l l y Retarded S p e c i a l E d u c a t i o n Programs f o r t h e L e a r n i n g D i s a b l e d and M e n t a l l y R e t a r d e d Placement i n M e n t a l H e a l t h o r P s y c h o G e r i a t r i c B o a r d i n g Home A d m i n i s t r a t i o n S u p e r v i s o r s o f C.C.T. and C.M.H.C. O u t p a t i e n t T r e a t m e n t F a c i l i t i e s  71 for  t h e l e a r n i n g d i s a b l e d and mentally  retarded  s o c i a l welfare programs f o r the mentally  and e l i g i b i l i t y f o r  retarded.  P s y c h i a t r i c Nursing In B r i t i s h Columbia/ p s y c h i a t r i c nurses are independently l e g a l l y l i a b l e and have been c a l l e d by the courts as expert witnesses.  Although  as nurses/ p s y c h i a t r i c nurses perform some of t h e i r duties i n response to the w r i t t e n and verbal orders  of p s y c h i a t r i s t s , p s y c h i a t r i c nurses  are i n c r e a s i n g l y coming t o be considered independent p r a c t i t i o n e r s . In B r i t i s h Columbia, when p s y c h i a t r i c nurses are employed i n Community Care Teams or Community Mental Health loads  and a r e n o t under  psychiatrist  (Stewart,  Centres,  statutory 1986).  they carry t h e i r  own case  o b l i g a t i o n to consult  Typically, i n their  with  a  employment  s i t u a t i o n s , team members work i n c o n s u l t a t i o n with one another, with the psychiatrist administering plan,  p r e s c r i b i n g medication i n j e c t i o n s , monitoring  and p r o v i d i n g psychotherapeutic  and t h e p s y c h i a t r i c nurse  medication,  formulating  a  i n t e r v e n t i o n (e.g. l i f e  t r a i n i n g , supportive c o u n s e l l i n g , psychotherapy). p s y c h i a t r i s t s are not employed as c l i n i c a l  care skills  In CCT's and CMHC's,  supervisors and only r a r e l y  as a d m i n i s t r a t i v e supervisors; however, there are a number of instances in  which p s y c h i a t r i c nurses a c t as a d m i n i s t r a t i v e supervisors.  regard t o l e g a l l i a b i l i t y , p s y c h i a t r i c nurses are more frequently held  independently  legally  liable  With being  f o r t h e i r p r a c t i c e performance.  P r e v i o u s l y , when p s y c h i a t r i c nurses were almost e x c l u s i v e l y employed i n large i n s t i t u t i o n s , p l a i n t i f f s u s u a l l y sued the i n s t i t u t i o n and perhaps the  attending  physician.  However, as the a s p i r a t i o n s of nurses f o r  independent p r a c t i c e have grown, there has been a corresponding growth in  s u i t s against  nurses.  The RPNABC r e q u i r e s  members t o purchase  professional  liability  insurance  through  their  r e g i s t r a t i o n fees.  Informal s t a t u t o r y r e c o g n i t i o n has been granted t o p s y c h i a t r i c nurses i n the power t o r e h o s p i t a l i z e p a t i e n t s released from the f o r e n s i c h o s p i t a l for  v i o l a t i o n s of release conditions  (Forensic Psychiatry Act) and t o  act as the t h i r d signatory when no r e l a t i v e i s a v a i l a b l e f o r commitment orders (Mental Health A c t ) •  S o c i a l Work In B r i t i s h practitioners,  Columbia,  social  workers p r a c t i c e as independent  are independently l e g a l l y  q u a l i f i e d as expert witnesses.  liable,  and a r e f r e q u e n t l y  Informal s t a t u t o r y r e c o g n i t i o n has been  granted t o s o c i a l workers across  a wide range of s t a t u t e s .  workers have been granted the power t o enforce  Social  the laws d e a l i n g with  adoption (Adoption Act, R.S.B.C. 1979, c.4), c h i l d p r o t e c t i o n (Family & C h i l d Services  A c t , R.S.B.C. 1979, c  119), and l i c e n s i n g of mental  health and p s y c h o g e r i a t r i c boarding homes (Community Care F a c i l i t y A c t , R.S.B.C. 1979, c- 57).  As w e l l , s o c i a l  workers have been  r e s p o n s i b i l i t i e s under the statutes dealing with p a t e r n i t y ( C h i l d P a t e r n i t y & Support Act, R.S.B.C. 1979, c disputes (Family Relations Act, R.S.B.C. 1979, c  given  determination  49), c h i l d custody  121), and appearing as  guardian i n court proceedings f o r c h i l d r e n - i n - c a r e charged as j u v e n i l e offenders As granted  (Young Offenders Act.) i n the case of p s y c h i a t r i c nurses, s o c i a l workers have been t h e power t o r e h o s p i t a l i z e f o r e n s i c p a t i e n t s  (Forensic  Psychiatry Act) and t o a c t as the t h i r d signatory on commitment orders (Mental Health A c t ) .  S o c i a l Workers have a l s o been granted the power t o  determine e l i g i b i l i t y  f o r comfort allowances  Income Need A c t , R.S.B.C. 1979, c  (Guaranteed A v a i l a b l e  158) and t o act as the second  73 signatory i n determination  of mental incompetency i n f i n a n c i a l matters  (Patients Property Act)• S o c i a l Workers are recognized  i n a number of p o l i c y d e c i s i o n s , f o r  example, the a u t h o r i z a t i o n of e l i g i b i l i t y f o r placement i n mental health or p s y c h o g e r i a t r i c boarding homes and e l i g i b i l i t y programs f o r the mentally frequently  designated  retarded,  for social  welfare  and are a l s o the d i s c i p l i n e most  as a d m i n i s t r a t i v e  supervisors  f o r CMHC's i n  B r i t i s h Columbia.  5.3  LICENSURE STANDARDS AND PRACTICE PRIVILEGES COMPARED With regard t o p r o f e s s i o n a l l i c e n s i n g standards f o r the four core mental health professions applies only while  i n B r i t i s h Columbia, l i c e n s u r e  legislation  t o medical p r a c t i t i o n e r s (and hence t o p s y c h i a t r i s t s ) ,  registration legislation  nurses, and s o c i a l workers.  applies t o p s y c h o l o g i s t s , p s y c h i a t r i c  Thus, i n theory, psychiatry has the power  to c o n t r o l p r a c t i c e while the other professions do not.  However, as we  have seen i n the d i s c u s s i o n of p r o f e s s i o n a l t r a i n i n g standards, a l l four professional  disciplines  psychotherapy with  mentally  receive disordered  t r a i n i n g i n assessment and clients.  I n examining t h e  r e l a t i o n s h i p between p r o f e s s i o n a l t r a i n i n g standards, and  on the one hand,  p r o f e s s i o n a l l i c e n s u r e standards and p r a c t i c e p r i v i l e g e s , on the  other,  we see that p s y c h i a t r y  does not maintain  monopoly over p r a c t i c e as other  the same degree of  medical p r a c t i t i o n e r s .  For example,  when we compare the Medical P r a c t i t i o n e r s Act and the Psychologists Act, we f i n d that both p s y c h i a t r y  and psychology have been authorized t o  diagnose and t r e a t mental disorders:  74 Medical P r a c t i t i o n e r s Act s.72(2) For the purposes of and without r e s t r i c t i n g the g e n e r a l i t y of s u b s e c t i o n (1)/ a person p r a c t i c e s medicine who (b) diagnoses, or o f f e r s t o diagnose, a human disease, ailment, deformity, defect or i n j u r y , or who examines or advises on, or o f f e r s t o examine or advise on, the p h y s i c a l or mental c o n d i t i o n of a person. s.73 For the purposes of s e c t i o n 72, a person does not p r a c t i c e or o f f e r t o p r a c t i c e medicine who ( i ) p r a c t i c e s psychology while r e g i s t e r e d under the Psychologists Act. Psychologists Act s. 1 In t h i s Act . . . " p r a c t i c e of psychology i n c l u d e s " (b) t h e a p p l i c a t i o n of methods and p r o c e d u r e s of i n t e r v i e w i n g , c o u n s e l l i n g , psychotherapy, behavior therapy, behavior m o d i f i c a t i o n , hypnosis, research; or (c) the c o n s t r u c t i o n , a d m i n i s t r a t i o n , and i n t e r p r e t a t i o n of t e s t s of mental a b i l i t i e s , a p t i t u d e s , i n t e r e s t s , o p i n i o n s , a t t i t u d e s , emotions, p e r s o n a l i t y characteri s t i c s , motivations and psychophysiological characteri s t i c s and the assessment or diagnosis of behavioral, emotional and mental d i s o r d e r f o r a f e e o r reward, monetary or otherwise. s.15 Nothing i n t h i s Act e n t i t l e s a person t o p r a c t i c e medicine w i t h i n the meaning of s e c t i o n 72 of the Medical P r a c t i t i o n e r s Act, but, notwithstanding that s e c t i o n , a r e g i s t e r e d psychologist i s c e r t i f i e d t o carry on the p r a c t i c e of psychology without supervision by a medical practitioner. Thus, by s t a t u t e , neither profession treatment or diagnosis,  nor can e i t h e r p r o f e s s i o n  p r a c t i c e under the supervision of the other. initiatives,  has e x c l u s i v e c o n t r o l over be r e q u i r e d t o  S i m i l a r l y , through p o l i c y  both s o c i a l workers and p s y c h i a t r i c nurses have  been  authorized t o provide assessments of p a t i e n t s ; i n a memorandum t o CMHC d i r e c t o r s , the Executive Director of Mental Health Services f o r B r i t i s h Columbia issued the f o l l o w i n g d i r e c t i v e regarding assessment p r a c t i c e : "Re: DSM-III C l a s s i f i c a t i o n : As you know, we have introduced the DSM-III c l a s s i f i c a t i o n system A p r i l 1, 1985. When the new Management Information System f o r Mental Health Centres i s introduced, we w i l l r e q u i r e t h a t t h e DSM-III c l a s s i f i c a t i o n of each c l i e n t be recorded t o provide data on the types of problems our  75 s e r v i c e i s dealing with. A question has a r i s e n about n o n - l i c e n s e d p r o f e s s i o n a l s making DSM-III c l a s s i f i cations and whether t h i s may be a v i o l a t i o n of t h e M e d i c a l P r a c t i t i o n e r s A c t . We have received l e g a l a d v i c e t h a t t h e use of DSM-III as a c l a s s i f i c a t i o n system does not v i o l a t e the Medical P r a c t i t i o n e r s Act since that Act i s concerned with l i m i t i n g diagnosis and treatment t o medical p r a c t i t i o n e r s / or other l i c e n s e d practitioners. I t i s important t o s t r e s s that i t i s a DSM-III c l a s s i f i c a t i o n b e i n g made by n o n - l i c e n s e d p r o f e s s i o n a l s rather than a d i a g n o s i s . " 2  Likewise, p r o v i n c i a l government job d e s c r i p t i o n s f o r p s y c h o l o g i s t s , p s y c h i a t r i c nurses and s o c i a l workers i n CMHC's i n d i c a t e that a l l three professions  are expected  psychotherapeutic  to provide  both  assessment  and  i n t e r v e n t i o n i n the course of t h e i r employment:  "Licensed Psychologist 3/4: As p a r t o f a m u l t i d i s c i p l i n a r y team, provide assessment, treatment, and c o n s u l t a t i o n s e r v i c e s t o i n d i v i d u a l s , f a m i l i e s , groups and agencies; provide p s y c h o l o g i c a l t e s t i n g t o mental health c l i n i c s as r e q u i r e d . " 3  "Community Nurse 3: Under general d i r e c t i o n of team leader, t o f u n c t i o n independently with psychiatric c o n s u l t a t i o n a v a i l a b l e , as primary or co-therapist on mu 11 i - d i s c i p 1 i n a r y team t h a t p r o v i d e s crisis i n t e r v e n t i o n and/or longer term t r e a t m e n t t o b e h a v i o r a l l y or emotionally disturbed children, adolescents and t h e i r f a m i l i e s ; n u r s i n g assessments, i d e n t i f y i n g and implementing treatment plans; evaluating responses t o t h e r a p e u t i c r e g i m e s ; p a r t i c i p a t i n g i n v a r i o u s t r e a t m e n t m o d a l i t i e s , discharge planning and f o l l o w up. 1,4  " P s y c h i a t r i c S o c i a l Worker 4: Provide a wide range of s e r v i c e s t o catchment a r e a ; a s s e s s r e s o u r c e s / n e e d s , determine program p r i o r i t i e s ; p a r t i c i p a t e i n developing/implementing programs; p r o v i d e s e r v i c e s c r i s i s i n t e r v e n t i o n , assessments, case f i n d i n g f o r serious i l l n e s s , treatment p l a n n i n g and t h e r a p y f o r i n d i v i d u a l s , f a m i l i e s , groups u t i l i z i n g m o d a l i t i e s r e q u i r i n g advanced s k i l l s . " 5  Thus, while p s y c h i a t r y i s regulated under a l i c e n s i n g act and while the  social  work  nevertheless,  registration act i s e s s e n t i a l l y meaningless,  i n British  Columbia  a l l four  core  mental  health  76 professions are authorized to p r a c t i c e assessment and intervention  with  the  mentally  disordered  and  psychotherapeutic to  function  as  independent, l e g a l l y l i a b l e p r a c t i t i o n e r s . Although p r o f e s s i o n a l s from the various d i s c i p l i n e s may do  not  f u n c t i o n as  accountable t o  f u n c t i o n as a d m i n i s t r a t i v e supervisors, they  c l i n i c a l supervisors; r a t h e r , the professions  their  r e g i s t r a t i o n bodies  for their  standards  are of  practice. With  regard  to  practice  privileges, in British  Columbia,  p s y c h i a t r i s t s have been given the greatest degree of formal recognition. health  statutory  Psychiatry i s the only d i s c i p l i n e of the four core mental  professions  which  has  been  granted h o s p i t a l p r i v i l e g e s ,  p r e s c r i b i n g p r i v i l e g e s , and the power to make declarations of commitment and competency. informal  S o c i a l workers and p s y c h i a t r i c nurses have been given  recognition  i n commitment p r o c e e d i n g s i n that while  signatures must be those of medical p r a c t i t i o n e r s , the t h i r d  signature,  u s u a l l y that of a r e l a t i v e , i s i n p r a c t i c e provided by these l a t t e r disciplines  i f no  relative i s available-  proceedings d e a l i n g s o l e l y with  the  two  two  As w e l l , i n incompetency  management of  financial  affairs,  p o l i c y d i r e c t i v e s allow one of the two s i g n a t o r i e s to be a s o c i a l worker rather than a medical p r a c t i t i o n e r . Psychiatrists  a l s o have the  greatest  degree of r e c o g n i t i o n  f l e x i b i l i t y i n terms of funding arrangements. the p r o v i n c i a l medical insurance greatest opportunity well  as  the  Information  option  and  With r e c o g n i t i o n under  p l a n , p s y c h i a t r i s t s have by  f a r the  to engage i n f e e - f o r - s e r v i c e p r i v a t e p r a c t i c e as t o work i n s e s s i o n a l  or  s a l a r i e d situations.  from the Medical Services Plan of B r i t i s h Columbia f o r the  year 1980-81 i n d i c a t e d that 71 percent of payments to p s y c h i a t r i s t s were f e e - f o r - s e r v i c e , 15 percent s e s s i o n a l , and 14 percent s a l a r i e d .  77 Psychologists  are  reimbursed through both s e s s i o n a l and  funding arrangements with included  i n fee-for-service  insurance plan. private varied.  the p r o v i n c i a l government; they  There are  practice  and  f u n d i n g under the  fewer psychologists  f ee-f o r - s e r v i c e  A survey completed by  Association  (1981) found that  fulltime salaried positions  and  the 51.9 of  t h e i r time i n p r a c t i c e , and their  time i n p r i v a t e  c l i e n t s , psychologists arrangements w i t h  26.4  are  not  p r o v i n c i a l medical  than p s y c h i a t r i s t s i n  funding arrangements are  British  Columbia  those i n p r i v a t e  more  Psychological  percent of psychologists  percent were i n p r a c t i c e f u l l t i m e , 6.2  salaried  were i n  practice,  7.7  percent spent 25-75 percent of  percent spent l e s s than 25 percent of  practice.  In a d d i t i o n to d i r e c t fees from  i n p r i v a t e p r a c t i c e have f e e - f o r - s e r v i c e funding  Canada Employment and  Immigration, union  benefit  programs, employee assistance programs, the M i n i s t r i e s of Health, S o c i a l Services, and the Attorney General, and v i c t i m compensation programs. S o c i a l workers and  p s y c h i a t r i c nurses are  usually  s a l a r i e d s i t u a t i o n s ; neither p r o f e s s i o n a l group has s e s s i o n a l funding arrangements at the present time. and  employed  in  fee-for-service  or  Some s o c i a l workers  p s y c h i a t r i c nurses engage i n p r i v a t e p r a c t i c e with c l i e n t s paying  directly.  The  private practice situation i s similar for psychiatric  nurses, with the added circumstance that p s y c h i a t r i c nurses often prefer t o i d e n t i f y themselves as "counsellors" rather than as nurses. With regard to expert witness s t a t u s , p s y c h i a t r i s t s have once again been given the greatest degree of formal s t a t u t o r y r e c o g n i t i o n .  However  the court has the power to recognize any of the four core mental health professions c  116).  as expert witnesses under the Evidence Act The  (R.S.B.C.  evidence of p s y c h i a t r i s t s and psychologists  1979,  i s formally  recognized under the Motor Vehicle Act and the Young Offenders Act.  As  78 w e l l , p s y c h i a t r i s t s are f o r m a l l y recognized under the C r i m i n a l Code Act, in  proceedings  insanity.  The  dealing with fitness  to stand t r i a l  and  criminal  c o u r t s have been i n the p r a c t i c e f o r some time of  recognizing the evidence of p s y c h o l o g i s t s as w e l l i n these l a t t e r categories.  two  Hence, i n a White Paper c u r r e n t l y being c i r c u l a t e d by the  f e d e r a l government (Minister of J u s t i c e and Attorney General of Canada, 1986),  the p r o p o s a l has  been made to amend the C r i m i n a l Code Act  d e l e t i n g s p e c i f i c reference t o the evidence of medical p r a c t i t i o n e r s and leaving  discretion  completely  to the  bench i n q u a l i f y i n g  witnesses i n matters of f i t n e s s and i n s a n i t y . the  expert  The amendment would have  e f f e c t of l e g i t i m i z i n g the evidence p r e s e n t l y being provided  by  psychologists and would suggest greater l a t i t u d e f o r the q u a l i f i c a t i o n of s o c i a l workers and p s y c h i a t r i c nurses as expert witnesses as w e l l . With regard t o i n f o r m a l s t a t u t o r y r e c o g n i t i o n , i t would appear that s o c i a l workers have been granted the greatest r e c o g n i t i o n .  Under a wide  range of s t a t u t e s , s o c i a l workers have been charged with the enforcement of  legislation  or with the a u t h o r i z a t i o n of e l i g i b i l i t y  e s t a b l i s h e d through workers  legislation.  f o r programs  Many of the decisions which  social  are c a l l e d upon to make have profound e f f e c t s on the l i v e s of  i n d i v i d u a l s , most obviously i n the area of c h i l d p r o t e c t i o n ,  where  s o c i a l workers have been granted the power t o i n v e s t i g a t e complaints of c h i l d neglect and abuse, to apprehend c h i l d r e n , t o serve as guardians, and t o act as expert witnesses i n proceedings d e a l i n g with temporary  and  permanent wardship.  the  I t i s somewhat s t a r t l i n g ,  then,  given  s i g n i f i c a n c e of the r o l e s s o c i a l workers perform, that the p r o f e s s i o n of s o c i a l work i s so loosely regulated. To summarize, i n reviewing the s t a t u t e s and p o l i c i e s which document p r o f e s s i o n a l l i c e n s u r e standards  and p r a c t i c e p r i v i l e g e s , i t appears  79 that while there are many functions which are unique to each of the four core mental health professions, which overlap.  there  are a l s o a number of  functions  The p r i n c i p a l point of overlap which i s of concern to us  i n the present context i s the r e c o g n i t i o n of a l l four d i s c i p l i n e s as providers recognition  of  psychotherapy  of  services  and,  both p s y c h i a t r i s t s and  most p a r t i c u l a r l y ,  psychologists  as  the  empowered  by  s t a t u t e to diagnose and t r e a t mental disorders.  5.4  POTENTIAL PRACTICE PRIVILEGES FOR PSYCHOLOGISTS As the present study places p a r t i c u l a r emphasis on a comparison of psychiatry and psychology i n i t s development of a manpower s u b s t i t u t i o n model and i t s examination of the i m p l i c a t i o n s of the model f o r the  cost  of mental health  s e r v i c e d e l i v e r y , a more d e t a i l e d discussion of  the  s i m i l a r i t i e s and  differences i n the p r a c t i c e p r i v i l e g e s f o r these  two  professions seems i n order. three  categories:  general  Table VII divides p r a c t i c e p r i v i l e g e s i n t o r e c o g n i t i o n , formal  statutory  recognition,  and informal s t a t u t o r y r e c o g n i t i o n . With r e g a r d privileges  listed  substitution  to  informal  i n Table VII  in private  particular professional settings.  statutory do  practice  functions  recognition,  not  appear t o  the  bear  psychiatric services  occur mainly w i t h i n  practice  on  simple  as  these  institutional  However, with regard to general r e c o g n i t i o n , a l l the p r a c t i c e  p r i v i l e g e s l i s t e d i n Table VII do appear to bear on simple s u b s t i t u t i o n . P s y c h i a t r i s t s and psychologists  share the  same p r a c t i c e p r i v i l e g e s of  independent p r o f e s s i o n a l p r a c t i c e , independent l e g a l l i a b i l i t y , witness s t a t u s , t h i r d party payment by p r i v a t e c a r r i e r s , and and  s a l a r i e d payment arrangements with  psychiatrists  government.  have made f e e - f o r - s e r v i c e  funding  expert  sessional  However, agreements  while with  80 government/  psychologists  psychologists'  have  not.  Although  the p r o v i n c i a l  r e g i s t r a t i o n bodies have approached t h e i r  governments with proposals  respective  (BCPA, 1986), no p r o v i n c i a l government has  yet concluded a f e e - f o r - s e r v i c e arrangement with psychologists.  These  proposals have presented the case f o r the f e a s i b i l i t y of government feef o r - s e r v i c e coverage and I w i l l r e f e r t o these arguments i n Chapter Ten, when the l i c e n s u r e and market r i g i d i t i e s which would need t o be changed for  implementation  of s i m p l e  substitution for private  practice  psychiatry services are addressed. With  regard  t o formal  statutory  r e c o g n i t i o n , there  i s more  d i s p a r i t y than i s the case f o r e i t h e r informal s t a t u t o r y r e c o g n i t i o n or general  r e c o g n i t i o n i n the degree t o which the p r a c t i c e p r i v i l e g e s  granted t o the two professions bear on simple s u b s t i t u t i o n p o s s i b i l i t i e s for  private  practice  psychologists treatment  services.  share the same p r a c t i c e p r i v i l e g e s of d i a g n o s i s  f i t n e s s t o d r i v e , and expert  t o stand  However, while  trial,  regarding  c r i m i n a l i n s a n i t y , and j u v e n i l e  offenders.  p s y c h i a t r i s t s have been a c c o r d e d  an  formal  statutory  the requirement of  and t h e power t o commit and t o d e c l a r e  psychologists have not. bear d i r e c t l y  services.  statutes  consent t o t r e a t a minor, h o s p i t a l p r i v i l e g e s , p r e s c r i b i n g  privileges,  to  and  witness s t a t u s  r e c o g n i t i o n i n the care of the c r i m i n a l l y insane, parental  P s y c h i a t r i s t s and  of mental d i s o r d e r s , requirement t o report under  dealing with fitness  psychiatry  incompetent,  Two of these p r a c t i c e p r i v i l e g e s do not appear  on s u b s t i t u t i o n i n p r i v a t e p r a c t i c e p s y c h i a t r i c  The f i r s t , the care of the c r i m i n a l l y insane, takes place i n  appropriately  designated  agency which  contracts  services  with  p s y c h i a t r i s t s and psychologists i n accordance with the status of other p r a c t i c e p r i v i l e g e s . The second, the requirement of parental consent t o  81 t r e a t a minor, c o n s t i t u t e s practice matter  a r e s t r i c t i o n rather than an enhancement of  p r i v i l e g e s and, i n any case, i s a p r a c t i c e of p o l i c y ,  practitioners. privileges,  by n o n - m e d i c a l  as w e l l  observed, as a  as m e d i c a l  The remaining four p r a c t i c e p r i v i l e g e s , i . e . , h o s p i t a l  prescribing  p r i v i l e g e s , and the power t o commit and t o  declare incompetent, do appear t o bear on p r i v a t e p r a c t i c e . hospital  privileges  psychologists  health  Of these,  have been t h e p r i n c i p a l focus of attempts by  t o extend  formal  statutory  recognition.  psychologists have tended t o perceive h o s p i t a l p r i v i l e g e s  While  as f a l l i n g  w i t h i n t h e i r competence and necessary t o t h e i r p r o f e s s i o n a l  practice,  they have not, f o r the most p a r t , perceived p r e s c r i b i n g p r i v i l e g e s as within  t h e i r expertise  or as necessary t o t h e i r p r a c t i c e ;  therefore,  they have pursued the former with vigour and persistence but have almost e n t i r e l y ignored the l a t t e r .  With regard t o the power t o commit and t o  declare incompetent, these two p r a c t i c e p r i v i l e g e s appear t o be l e s s contentious and t o flow more e a s i l y and, sometimes, as a matter of course once the hurdle of h o s p i t a l p r i v i l e g e s has been overcome. In discussing  h o s p i t a l p r i v i l e g e s , i t i s necessary t o d i s t i n g u i s h  between c l i n i c a l and s t a f f p r i v i l e g e s .  C l i n i c a l privileges refer to  a c t i v i t i e s such as admission, discharge, and the treatment of patients while s t a f f p r i v i l e g e s r e f e r t o membership on the medical s t a f f with the power t o vote, hold o f f i c e , and serve on committees. Streiner,  and Goodman  ( 1987) have recently  h o s p i t a l p r i v i l e g e s f o r psychologists i n Canada. percent of Canadian Psychological employees i n h o s p i t a l s ,  Association  a figure  Arnett,  Martin,  reviewed the status of They report that 10  members work as f u l l - t i m e  s i m i l a r t o U.S. s t a t i s t i c s .  With  regard t o s t a f f p r i v i l e g e s , the authors found that only two percent of the psychologists were f u l l  voting  members of t h e i r h o s p i t a l  medical  82 staff  associations.  With regard t o c l i n i c a l p r i v i l e g e s , the authors  found that 57 percent of the h o s p i t a l s d i d not r e q u i r e a physician's r e f e r r a l f o r p s y c h o l o g i c a l assessment or treatment t o be conducted but the  authors  were not aware  of any Canadian  hospitals  granting  independent admitting and discharge p r i v i l e g e s t o p s y c h o l o g i s t s .  Thus,  i t i s apparent that p s y c h o l o g i s t s i n Canada f u n c t i o n i n h o s p i t a l s w i t h r e s t r i c t e d treatment p r i v i l e g e s , very l i m i t e d s t a f f p r i v i l e g e s , and no admission or discharge p r i v i l e g e s . In the United States, Dorken, Webb, and Zaro  (1982), i n a survey  conducted i n 1980, found t h a t f o r p s y c h o l o g i s t s p r a c t i c i n g i n h o s p i t a l s 25 p e r c e n t had f o r m a l m e d i c a l  staff  privileges  (full,  associate,  c o n s u l t i n g , or courtesy membership) and 20 percent had formal c l i n i c a l p r i v i l e g e s ; f o r p s y c h o l o g i s t s w i t h c l i n i c a l p r i v i l e g e s , approximately 50 percent p r a c t i c e d independently of p h y s i c i a n r e f e r r a l but v i r t u a l l y none had  independent  admission or discharge p r i v i l e g e s .  However, as an  examination of statutes and h o s p i t a l and a c c r e d i t a t i o n standards and of recent developments both i n Canada and the United States shows, t h i s r e s t r i c t i o n of h o s p i t a l p r i v i l e g e s t o medical p r a c t i t i o n e r s appears t o be more t h e r e s u l t of convention than of a lack of f e a s i b i l i t y  in  extending h o s p i t a l p r i v i l e g e s t o non-medical p r a c t i t i o n e r s . In  the Canadian  context, we might f i r s t note that Arnett e_t a l .  comment that the standards f o r a c c r e d i t a t i o n of health care f a c i l i t i e s set f o r t h by the Canadian Council on H o s p i t a l A c c r e d i t a t i o n (1985) allow for s t a f f p r i v i l e g e s i n a s p e c i a l membership category f o r non-physician doctoral  scientists  Furthermore,  and others who q u a l i f y  i n B r i t i s h Columbia,  for c l i n i c a l  privileges.  the H o s p i t a l Act Regulations permit  the granting of treatment p r i v i l e g e s t o non-medical p r a c t i t i o n e r s under Section 4(3):  83 "The Board of a h o s p i t a l may, subject t o the approval of the M i n i s t e r , provide...for s e r v i c e or treatment t o be rendered t o a p a t i e n t by persons who are not members of the College of Physicians and Surgeons of B r i t i s h Columbia, provided that the r e s p o n s i b i l i t y f o r admitting the p a t i e n t t o the h o s p i t a l and discharging him therefrom and f o r the medical care of t h e p a t i e n t while he remains i n h o s p i t a l r e s t s with the member of the medical s t a f f of the h o s p i t a l who i s attending the s a i d patient." Accordingly,  t h e C h i r o p r a c t i c A s s o c i a t i o n of B r i t i s h  Columbia  r e c e n t l y made a p p l i c a t i o n t o the B.C H o s p i t a l A s s o c i a t i o n f o r h o s p i t a l treatment p r i v i l e g e s (Nixdorf,  1986).  However, the BCHA has so f a r  chosen t o r e s i s t the c h i r o p r a c t o r s ' request by i g n o r i n g Section 4(3) i n favour of a s t r i c t i n t e r p r e t a t i o n of Section 4(1): "... no person may attend or t r e a t p a t i e n t s i n a h o s p i t a l , or i n any way a v a i l h i m s e l f of t h e f a c i l i t i e s f o r medical p r a c t i c e i n a h o s p i t a l unless he i s a member i n good standing of the College of Physicians and Surgeons of B r i t i s h Columbia, who holds a v a l i d permit from the board t o p r a c t i c e medicine i n the h o s p i t a l and who has been appointed t o the medical s t a f f of that h o s p i t a l . " A t h i r d i n t e r e s t i n g circumstance has occurred i n A l b e r t a , where the M e n t a l Health admission, physicians  Act (R.S.A.  commitment,  1972, c.118) formerly  permitted  powers of  and d e c l a r a t i o n of incompetency t o l i c e n s e d  and r e g i s t e r e d t h e r a p i s t s  (s.29,  s.25, & s.35).  Those  e l i g i b l e t o become r e g i s t e r e d t h e r a p i s t s were p s y c h o l o g i s t s , r e g i s t e r e d nurses, p s y c h i a t r i c n u r s e s , and s o c i a l  workers who had been  enumerated by t h e i r r e g i s t r a t i o n bodies (s.6). these professions  d i d not have t h e i r  p l a c e , these powers were reserved  duly  However, because some of  i n d i v i d u a l r e g i s t r a t i o n acts i n  i n p r a c t i c e t o p h y s i c i a n s ; i n 1979,  the r e s t r i c t i o n was formalized when the Mental Health Act. (R.S.A. 1979, c.118) was amended and the reference t o r e g i s t e r e d t h e r a p i s t s was struck out (Wardell, 1986). In the United considerably  greater  States, where non-medical p r a c t i t i o n e r s have made inroads  i n t o the status quo, psychologists  have  84 pursued the granting of h o s p i t a l p r i v i l e g e s through both l i t i g a t i o n legislation. anti-trust  State p s y c h o l o g i c a l a s s o c i a t i o n s s u i t s agains.t  the  launched a s e r i e s  J o i n t Commission on  and of  A c c r e d i t a t i o n of  Hospitals (JCAH), a p r i v a t e , nonprofit corporation whose r e s p o n s i b i l i t y i s the establishment At the  and monitoring of h o s p i t a l a c c r e d i t a t i o n standards.  commencement of the  l i t i g a t i o n , JCAH standards d i d not  psychologists to p r a c t i c e independently i n h o s p i t a l s . Governors i s comprised of one  permit  The JCAH Board of  representative from the American  Dental  A s s o c i a t i o n , one p u b l i c member, and 20 representatives from the American College of Surgeons, American College of Physicians, American H o s p i t a l A s s o c i a t i o n , and  American Medical  Association  (Tanney, 1983).  Tanney  notes that among the evidence c i t e d by the p e t i t i o n i n g psychologists  was  a study completed by Dorken (1983), analyzing the u t i l i z a t i o n data f o r i n p a t i e n t p s y c h i a t r i c care under the insurance program f o r U.S. employees.  federal  For the year 1980, Dorken found that only 3.3 percent of the  i n p a t i e n t s e r v i c e s provided by p s y c h i a t r i s t s were f o r medical s e r v i c e s . The remaining 96.7 percent of a l l i n p a t i e n t services could have been and were provided  by e i t h e r a p s y c h i a t r i s t or a psychologist w i t h i n t h e i r  scope of p r a c t i c e .  The  courts and the Federal Trade Commission agreed  with the p s y c h o l o g i s t s ' argument that the d e n i a l of h o s p i t a l p r i v i l e g e s to  duly  enumerated h e a l t h  care providers  who  met  the  hospital p r a c t i c e c o n s t i t u t e d a h o r i z o n t a l boycott (Bailey,  1983).  As  standard  by  for  physicians  a r e s u l t , the JCAH backed away from i t s e a r l i e r  r e f u s a l to grant h o s p i t a l p r i v i l e g e s to psychologists and modified i t s standards to permit psychologists t o p r a c t i c e independently i n h o s p i t a l s i n those states having statutes guaranteeing t h i s  r i g h t to p r a c t i c e .  State psychological a s s o c i a t i o n s then pressed f o r the passage of enabling  legislation  and  in a  recent  review  of  their  this  progress,  85 Psychotherapy hospital  Finances  licensure  ( 1985)  that  24 j u r i s d i c t i o n s had  codes which p e r m i t t e d p s y c h o l o g i s t s  independent service providers Columbia  reported  i n hospital settings.  The D i s t r i c t of  (Health-Care and Community Residence F a c i l i t y ,  Home Care Licensure Act,  t o a c t as  Hospice/ and  D.C. Law 5-48, 30 D.C.R. 5778) provides a  u s e f u l example of the form and scope of t h i s l e g i s l a t i o n . "Section 8(c) No p r o v i s i o n of D i s t r i c t of Columbia Law . . . s h a l l p r o h i b i t q u a l i f i e d nurse a n e s t h e t i s t s , nurse midwives, nurse p r a c t i t i o n e r s , p o d i a t r i s t s , or psychologists as a c l a s s from b e i n g a c c o r d e d c l i n i c a l p r i v i l e g e s and appointed t o a l l categories of s t a f f membership a t those f a c i l i t i e s and a g e n c i e s t h a t o f f e r t h e type of s e r v i c e d e l i v e r e d by members of these classes and t h e i r p h y s i c i a n competitors. Notwithstanding any p r o v i s i o n of law t o the c o n t r a r y , c l i n i c a l p r i v i l e g e s t h a t may be a c c o r d e d t o psychologists i n c l u d e , but are not l i m i t e d t o , the f o l l o w i n g : admission, examination, c e r t i f i c a t i o n of mental i l l n e s s , treatment and treatment plan a u t h o r i z a t i o n , and discharge.". Thus, i t appears that i n a number of j u r i s d i c t i o n s i n the United States,  psychologists  have been g r a n t e d  a l l t h e formal  statutory  p r a c t i c e p r i v i l e g e s relevant t o p r i v a t e p r a c t i c e s u b s t i t u t i o n with the exception of p r e s c r i b i n g p r i v i l e g e s .  And, as we s h a l l see i n Chapter  Seven, a review of the l i t e r a t u r e comparing the r e l a t i v e effectiveness of  psychotherapy  proportion  and pharmacotherapy i n d i c a t e s that  of the mental disorders  a  considerable  seen by p s y c h i a t r i s t s i n p r i v a t e  p r a c t i c e s e t t i n g s can be t r e a t e d e f f e c t i v e l y with psychotherapy alone. As with the lack of f e e - f o r - s e r v i c e funding, I w i l l explore i n Chapter Ten whether the lack of h o s p i t a l p r i v i l e g e s f o r psychologists would c o n s t i t u t e a b a r r i e r to p r i v a t e p r a c t i c e s u b s t i t u t i o n .  i n Canada  86 CHAPTER SIX  THE PROFESSIONS COMPARED AS PSYCHOTHERAPISTS  I f we grant that a l l four core mental health professions, by v i r t u e of t h e i r t r a i n i n g and p r a c t i c e p r i v i l e g e s , provide psychotherapy s e r v i c e s , then the  next step  i n considering  the f e a s i b i l i t y  of simple  substitution for  p r i v a t e p r a c t i c e p s y c h i a t r y services would appear t o be t o address the issue of the r e l a t i v e e f f e c t i v e n e s s of these psychotherapy services when d e l i v e r e d by d i f f e r e n t d i s c i p l i n e s . similarities  Chapter S i x reviews the l i t e r a t u r e i n v e s t i g a t i n g  and d i f f e r e n c e s  i n the perceived  e f f e c t i v e n e s s , and patterns  credibility,  clinical  attitudes,  clinical  of p r a c t i c e of the four  professions  i n an attempt t o determine whether they d e l i v e r psychotherapy  services of comparable q u a l i t y w i t h i n comparable time periods t o comparable sets of presenting  conditions.  In presenting  this  review, there  caveat that the studies which compare c l i n i c a l effectiveness have some methodological  deficiencies.  placebo group as a c o n t r o l c o n d i t i o n .  None of the s t u d i e s  i s the  (Section 6.3) has used a  Hence, the evidence does not permit  the stronger conclusion that the four core professions do not d i f f e r i n t h e i r e f f e c t i v e n e s s but rather only the somewhat weaker conclusion that there i s no evidence  that  the four  professions  do d i f f e r  i n t h e i r e f f e c t i v e n e s s as  psychotherapists.  6.1  PERCEIVED CREDIBILITY Perceived  c r e d i b i l i t y can be examined from the perspective of the  c l i e n t s ' views of the p r o f e s s i o n a l s or the p r o f e s s i o n a l s ' views of each other.  Taking the f i r s t  perspective,  Gravitz  and Gerton  (1977)  interviewed 100 adults on the s t r e e t i n Washington, D.C. and asked them  87 t o rank an a l p h a b e t i c a l l i s t i n g of ten mental health d i s c i p l i n e s f o r prestige.  In descending order,  follows:  p s y c h i a t r i s t , psychoanalyst,  pastoral  counsellor,  marriage  subjects  ranked t h e p r o f e s s i o n s psychologist,  counsellor,  as  counsellor,  psychiatric  nurse,  paraprofessional worker, p s y c h i a t r i c s o c i a l worker, and s o c i a l worker. In a second study, Trautt  and Bloom (1982) asked  144 undergraduate  students t o r a t e a d e s c r i p t i o n of a mental health p r o f e s s i o n a l t i t l e d p s y c h i a t r i s t , c o u n s e l l o r , or p s y c h o l o g i s t , a l l with doctoral degrees, on various dimensions of a t t r a c t i o n and c r e d i b i l i t y . for t i t l e  A significant result  was found on w i l l i n g n e s s t o recommend the t h e r a p i s t t o a  f r i e n d and r e s u l t s approaching s i g n i f i c a n c e were found f o r perceived safety and f o r w i l l i n g n e s s t o seek treatment oneself.  The pattern of  these r e s u l t s was i d e n t i c a l ; the " p s y c h i a t r i s t " c o n s i s t e n t l y was r a t e d higher  than the "counsellor," who i n turn was rated higher  "psychologist."  than the  The p s y c h i a t r i s t d i f f e r e d s i g n i f i c a n t l y  from the  psychologist but d i d not d i f f e r s i g n i f i c a n t l y from the counsellor nor was  there  a significant  psychologist. university  difference  A l p e r i n and B e n e d i c t  between t h e c o u n s e l l o r (1985) randomly  assigned  and 180  students t o r a t e e i t h e r p s y c h i a t r i s t s , p s y c h o l o g i s t s , or  s o c i a l workers on an 85-adjective they were t o discuss  c h e c k l i s t and t o i n d i c a t e how l i k e l y  seven problem areas with  the person.  On the  a d j e c t i v e c h e c k l i s t , the l a r g e s t d i f f e r e n c e occurred between perceptions of p s y c h i a t r i s t s and s o c i a l workers. to be s i g n i f i c a n t l y reserved,  more studious,  The p s y c h i a t r i s t s were perceived clever, i n t e l l e c t u a l , a n a l y t i c ,  and d u l l than the s o c i a l workers, while the s o c i a l workers  were perceived  t o be s i g n i f i c a n t l y more warm, c h e e r f u l ,  enthusiastic,  s o c i a b l e , and a p p r e c i a t i v e  Psychologists  were perceived  energetic,  than the p s y c h i a t r i s t s .  t o be s i g n i f i c a n t l y  more s t u d i o u s  and  88 c l e v e r than the s o c i a l workers, while the s o c i a l workers were rated as significantly  more c h e e r f u l  and  active  than  the  psychologists.  Psychologists were the p r o f e s s i o n a l s the subjects i n d i c a t e d they would be most l i k e l y to consult f o r help with the majority of t h e i r problems. Taking the second perspective, Schindler, Berren, and B e i g e l (1981) sent a questionnaire  to p s y c h i a t r i s t s , psychologists,  s o c i a l workers,  and nurses i n various mental health s e t t i n g s and asked them to evaluate how  large a r o l e p s y c h i a t r i s t s and psychologists played i n 11 everyday  activities,  how  competent the  a c t i v i t y , and how the  activity.  two  professions  were to perform  the  much r e s p o n s i b i l i t y each should have i n c a r r y i n g out With r e g a r d  to present  role,  p s y c h i a t r i s t s rated  themselves as having primary r e s p o n s i b i l i t y f o r a l l a c t i v i t i e s t e s t i n g , psychotherapy, and c o u n s e l l i n g .  except  Other p r o f e s s i o n a l s supported  these judgments, however, t h e i r r a t i n g s of r e s p o n s i b i l i t y assigned psychologists  were  generally  higher  than  the  ratings  that  to the  p s y c h i a t r i s t s gave psychologists.  Psychologists perceived p s y c h i a t r i s t s  as  f o r program coordination,  being  p r i m a r i l y responsible  management, and  t e s t i f y i n g as  expert  witnesses,  while  reserving  themselves r e s p o n s i b i l i t y f o r t e s t i n g , psychotherapy, and In  the  remaining  categories  of  intake  screening,  supervision and t r a i n i n g , and c o n s u l t a t i o n and education,  medication to  counselling. diagnostics, psychologists  b e l i e v e d they had as much r e s p o n s i b i l i t y as p s y c h i a t r i s t s . In terms of  competence, p s y c h i a t r i s t s rated themselves as  more competent than p s y c h o l o g i s t s  to  carry  out  eight  of  being  the  11  a c t i v i t i e s and perceived psychologists as more competent than themselves only i n conducting p s y c h o l o g i c a l t e s t i n g . as  more competent t o  c a r r y out  nine  Psychologists saw  of the  11  themselves  activities,  saw  no  d i f f e r e n c e i n t e s t i f y i n g as an expert witness, and viewed p s y c h i a t r i s t s  89 as more competent only i n the area of medication management.  The other  p r o f e s s i o n a l s saw no d i f f e r e n c e i n competency between the two f o r s i x of the a c t i v i t i e s /  saw psychologists as more competent i n psychotherapy/  c o u n s e l l i n g , and t e s t i n g ,  and p s y c h i a t r i s t s  as more competent i n  diagnostics and medication managementIn considering i d e a l r o l e , p s y c h i a t r i s t s they  should  have  responsibility  strongly believed t h a t  f o r a l l the a c t i v i t i e s  psychotherapy,  c o u n s e l l i n g , and t e s t i n g .  psychiatrists  should have primary  except  Psychologists b e l i e v e d that  responsibility  management, t h a t psychologists should take primary  only f o r medication responsibility for  psychotherapy,  c o u n s e l l i n g , and t e s t i n g , and that the two should share  responsibility  f o r the remaining  activities.  The other p r o f e s s i o n s  generally agreed that p s y c h o l o g i s t s should have equal r e s p o n s i b i l i t y f o r intake screening, psychotherapy,  program coordination, s u p e r v i s i o n and  t r a i n i n g , c o n s u l t a t i o n and education, s t a f f i n g d e c i s i o n s , and t e s t i f y i n g as an expert witness. Newman, Carney, and Sharon (1978) i n v e s t i g a t e d r e f e r r a l preferences among p s y c h i a t r i s t s , counsellors.  psychologists, social  workers,  and p a s t o r a l  Subjects were given two case h i s t o r i e s , one designed t o  represent neurosis and the other t o represent p s y c h o s i s , and subjects t o i n d i c a t e whether they would t r e a t themselves the choice was t o r e f e r ,  they  were asked  professions i n order of preference.  or r e f e r .  a list  P s y c h i a t r i s t s were ranked  followed by p s y c h o l o g i s t s , s o c i a l workers, marriage), and layman-volunteer.  t o rank  asked If  of s i x first,  counsellors ( p a s t o r a l and  90 6.2  CLINICAL ATTITUDES Studies i n v e s t i g a t i n g the c l i n i c a l a t t i t u d e s of the various mental health professions f i n d that d i f f e r e n c e s do appear between professions as  a f u n c t i o n of t h e o r e t i c a l o r i e n t a t i o n and perceived  general  r o l e of " c l i n i c i a n "  r o l e but the  appears t o override many other  factors,  producing many s i m i l a r i t i e s . Abramowitz, Schwartz and Roback (1977) i n v e s t i g a t e d the e f f e c t s of professional d i s c i p l i n e c l i n i c a l reactions.  and e x p e r i e n c e  Subjects  i n group p s y c h o t h e r a p i s t s  1  were 100 members of the American Group  Psychotherapy A s s o c i a t i o n and were p s y c h i a t r i s t s , p s y c h o l o g i s t s , o r s o c i a l workers.  A d e t a i l e d c l i n i c a l p r o f i l e of an outpatient i n group  therapy was mailed t o prospective clinical  impression  subjects and they were asked t o rate  and t h e r a p y  responses  t o the c l i e n t .  The  i n v e s t i g a t o r s found that more experienced t h e r a p i s t s , r e g a r d l e s s discipline,  tended  t o be more s t r i n g e n t  i n evaluating  adjustment, more p e s s i m i s t i c about prognosis,  of  l e v e l of  and more d i r e c t i v e i n  therapeutic approach. Bernstein and Lecomte (1982) examined the e f f e c t of c l i e n t gender, t h e r a p i s t gender, t h e r a p i s t p r o f e s s i o n , and t h e r a p i s t l e v e l of t r a i n i n g on  the d i a g n o s t i c , prognostic,  and p r o c e s s  expectancies  t h e r a p i s t s p r i o r t o c o u n s e l l i n g with a s p e c i f i c c l i e n t .  h e l d by  Subjects were a  randomly selected sample which included  167 p s y c h o l o g i s t s , 306 s o c i a l  workers, 320 c o u n s e l l o r s ,  M.A.  165 e n t e r i n g  students, and 142 completing M.A. students.  counselling/psychology  Subjects were sent a c l i e n t  d e s c r i p t i o n t i t l e d e i t h e r "Marie" or "Thomas" and asked t o complete an inventory as i f they were going t o see the c l i e n t i n treatment. i n d i c a t e d that c l i e n t  gender produced no s i g n i f i c a n t  Results  differences.  However, t h e r a p i s t gender produced a s i g n i f i c a n t e f f e c t i n that male  91 therapists Contrary  expected  to  to  be  more d i r e c t i v e than female t h e r a p i s t s .  Abramowitz  et  a l . ( 1977),  professional  t h e r a p i s t s expected to be  the  authors  found  that  l e s s d i r e c t i v e than student  t h e r a p i s t s but d i d r e p l i c a t e the tendency of experienced t h e r a p i s t s to be The  more p e s s i m i s t i c about prognosis three professions  expected to be  the  d i f f e r e d on  than less-experienced only  most d i r e c t i v e and  one  dimension;  therapists. counsellors  s o c i a l workers the  l e a s t with  psychologists f a l l i n g between but not s i g n i f i c a n t l y d i f f e r e n t from the other  two  groups.  The  authors  speculate  that the  differences i n  expected d i r e c t i v e n e s s between more- and less-experienced t h e r a p i s t s and between p r o f e s s i o n a l d i s c i p l i n e s was a f u n c t i o n of d i f f e r e n t t h e o r e t i c a l backgrounds i n t h e i r t r a i n i n g with the more d i r e c t i v e being t r a i n e d i n c o g n i t i v e therapies and the l e s s d i r e c t i v e i n c l i e n t - c e n t e r e d therapies. They note that the student group was more l i k e l y to have been t r a i n e d i n c o g n i t i v e therapies than the older t h e r a p i s t s as t h i s treatment method was  i n vogue i n t r a i n i n g i n s t i t u t i o n s  during  that  p a r t i c u l a r time  period. Similarly,  Harari  and  Hosey  (1979) found  p r o f e s s i o n a l groups which could apparently theoretical  schools  of  therapy.  differences between  be a t t r i b u t e d to  Subjects  differing  were 9 p s y c h i a t r i s t s , 9  p s y c h o l o g i s t s , and 9 s o c i a l workers at a community mental health i n the United States.  Subjects  centre  were given three b r i e f case h i s t o r i e s  representing three d i f f e r e n t diagnostic categories (obsessive compulsive neurosis,  anxiety  neurosis,  and  h y s t e r i c a l neurosis)  with  causation  a t t r i b u t e d e i t h e r to personal inadequacy, inadequate s o c i a l environment, or no  cause.  client's  Subjects  recovery.  were asked to estimate Results  indicated that  the prognosis  for  the  p s y c h i a t r i s t s gave  s i g n i f i c a n t l y better prognoses when the cause was personal  inadequacy,  92 s o c i a l workers when the cause was inadequate s o c i a l environment, while psychologists showed a tendency  toward better prognosis f o r personal  inadequacy but not t o the same degree as p s y c h i a t r i s t s .  Psychiatrists  a l s o gave a s i g n i f i c a n t l y better prognosis t o the h y s t e r i c a l neurosis clients.  The authors, as i n the previous study, speculate that because  the p s y c h i a t r i s t s  tended  t o be t r a i n e d  i n psychodynamic  therapy  emphasizing i n t r a p e r s o n a l v a r i a b l e s rather than i n t e r p e r s o n a l v a r i a b l e s , the p s y c h i a t r i s t s tended t o perceive the cases where personal inadequacy was t h e cause and h y s t e r i c a l neurosis was the diagnosis ( h y s t e r i c a l neuroses  are more frequently t r e a t e d psychodynamically while a n x i e t y  neuroses  are frequently  treated  b e h a v i o r a l l y ) as more amenable t o  treatment • Del Gaudio, S t e i n , Ansley, and Carpenter (1975) studied the degree to which the four core mental h e a l t h p r o f e s s i o n s perceived the community mental health movement as p o s i t i v e .  Subjects were 27 p s y c h i a t r i s t s , 14  p s y c h o l o g i s t s , 12 s o c i a l workers, and 12 nurses i n a community mental health centre i n the United States.  The i n v e s t i g a t o r s  e f f e c t s of p r o f e s s i o n a l t r a i n i n g and socio-economic support f o r community mental health ideology (CMHI). significant  effects  f o r both  professional  group  examined the  class  (SES) on  Results i n d i c a t e d and SES  level.  Psychologists and s o c i a l workers d i d not d i f f e r s i g n i f i c a n t l y from one another i n supporting CMHI but both groups were s i g n i f i c a n t l y p o s i t i v e than the other two groups. less  positive  than  Although nurses were s i g n i f i c a n t l y  p s y c h o l o g i s t s and s o c i a l  s i g n i f i c a n t l y more p o s i t i v e than p s y c h i a t r i s t s . SES  more  workers,  they  were  Subjects from higher  l e v e l s were found t o be l e s s p o s i t i v e i n t h e i r support of CMHI.  However, when t h e p r o f e s s i o n a l  groups  were compared h o l d i n g SES  93 constant/  the  differences  between the p r o f e s s i o n a l groups remained  highly significant. In  the  study  by Newman, Carney, and  Sharon  (1978) r e f e r r e d to  above, the subjects, which included 11 p s y c h i a t r i s t s , 17 p s y c h o l o g i s t s , and  18 s o c i a l workers, were given two  neurosis and one  case h i s t o r i e s , one  representing  representing psychosis, and asked to i n d i c a t e whether  they would t r e a t or r e f e r .  Results i n d i c a t e d that f o r the neurotic case  a l l groups, about 80 percent, p r e f e r r e d to t r e a t the c l i e n t but f o r the psychotic  case about  50  p r e f e r r e d to r e f e r , while  percent of psychologists 90 percent of  and p s y c h i a t r i s t s  s o c i a l workers p r e f e r r e d  to  t r e a t the c l i e n t .  6.3  CLINICAL EFFECTIVENESS Studies comparing the c l i n i c a l e f f e c t i v e n e s s of d i f f e r e n t groups of mental health p r o f e s s i o n a l s are  not  numerous, but  those which  are  a v a i l a b l e generally i n d i c a t e that f o r the s p e c i f i c tasks evaluated,  the  professions can provide equally competent s e r v i c e i n the same amount of time.  Returning  to the meta-analysis of psychotherapy outcome studies  r e f e r r e d to e a r l i e r , Smith & Glass of 375  (1977) report that i n t h e i r a n a l y s i s  studies using t h e r a p i s t s t r a i n e d i n p s y c h i a t r y , psychology, or  education,  no  differences  i n professional  effectiveness  emerged.  Likewise, Casey and Berman's (1985) meta-analysis of the e f f e c t i v e n e s s of psychotherapy with education,  or  sex  of  c h i l d r e n revealed the  that neither the  t h e r a p i s t was  significantly  experience, r e l a t e d to  treatment success. Looking at studies designed s p e c i f i c a l l y to compare one  profession  against another, r e s u l t s are s i m i l a r to those of the meta-analyses, with the  occasional  r e s u l t f a v o r i n g the  "junior" profession.  Knesper,  94 Pagnucco,  and  Wheeler  (1985) s t u d i e d  the  diagnostic  skills  p s y c h i a t r i s t s , p s y c h o l o g i s t s , and s o c i a l workers i n the United As part of a l a r g e r study greater  d e t a i l below, the  p s y c h i a t r i s t s , 2,917 were presented  of  States.  i n c l i n i c a l a c t i v i t i e s , to be reported i n i n v e s t i g a t o r s surveyed a sample of  p s y c h o l o g i s t s , and  1,585  s o c i a l workers.  3,239  Subjects  with four w r i t t e n vignettes from the DSM-III Case Book  and asked to judge s e v e r i t y l e v e l and s e l e c t the " c o r r e c t " diagnosis; no s i g n i f i c a n t d i f f e r e n c e s were found between groups. C l a v e l l e and Turner (1980) i n v e s t i g a t e d the a b i l i t y of three groups of mental health workers to make decisions i n an intake i n t e r v i e w as to whether  a  client  hospitalization.  was  suicidal,  needed  medication,  and  needed  The groups compared were 32 paraprofessionals ( t r a i n e d  as intake workers i n a community mental health centre on a U.S. post),  11  Subjects  social  workers  (M.S.W.), and  conducted a simulated  intake  13 p s y c h o l o g i s t s  interview.  Army  (Ph.D.).  Each c l i e n t  was  represented by a stack of index cards with the name of a c l a s s i f i c a t i o n of information on the f r o n t and the corresponding the back.  c l i e n t information on  Subjects began with standard i d e n t i f y i n g information and then  proceeded through the cards as they judged appropriate, in  the  three  categories,  and  rated  their  made decisions  certainty.  The  paraprofessionals and p r o f e s s i o n a l s showed equal consensus i n d e c i s i o n making.  The psychologists were the most confident i n t h e i r d e c i s i o n -  making but only when appropriate; they seemed to be able to d i s c r i m i n a t e better  t h a n the  paraprofessionals  ambiguous i s s u e s .  between the  c l e a r - c u t and  S o c i a l workers were more c o n f i d e n t  the  than  the  compared  the  paraprofessionals but l e s s confident than the psychologists. Similarly, effectiveness  of  Newson-Smith  and  s o c i a l workers and  Hirsch  (1979)  psychiatrists  i n evaluating  60  p a t i e n t s admitted to a London h o s p i t a l as attempted s u i c i d e s .  Patients  were interviewed f i r s t by a s o c i a l worker and then by a p s y c h i a t r i s t , both of whom were asked to carry out a c l i n i c a l assessment and f i l l a r a t i n g schedule at the  end  of the  interview.  Evaluations  out were  compared against a t h i r d interview conducted l a t e r the same day by research  p s y c h i a t r i s t , who  examinations.  administered  standardized  mental  S o c i a l workers and p s y c h i a t r i s t s showed a high l e v e l of  agreement with the standardized abnormality,  two  a  measures i n the  areas of p e r s o n a l i t y  presence of p h y s i c a l i l l n e s s , necessity f o r a p s y c h i a t r i c  opinion before discharge, and necessity to admit.  S o c i a l workers showed  more disagreement with the standardized measures i n r a t i n g the presence of mental i l l n e s s i n ambiguous s i t u a t i o n s , tending to rate i t as present more o f t e n than the p s y c h i a t r i s t s f o r those p a t i e n t s whose  standard  scale scores  on  further  workers'  original  suicide  fell  attempts  judgments as being indicated  that  i n the  middle range.  tended t o  s u p p o r t the  as v a l i d as  Follow-up social  data  those of p s y c h i a t r i s t s .  s o c i a l workers appeared to be  The  more s k i l l e d  results than  p s y c h i a t r i s t s at recommending support s e r v i c e s upon d i s c h a r g e .  the The  authors conclude that s o c i a l workers could undertake to deal with some or a l l of the attempted s u i c i d e intake r e f e r r a l s , with a p s y c h i a t r i s t a v a i l a b l e f o r consultations about urgent problems. P s y c h i a t r i c nurses have been the focus of several i n v e s t i g a t i o n s of t h e i r competence as t h e r a p i s t s .  Marks, Hallam, P h i l p o t t , and  Connolly  (1975) t r a i n e d f i v e p s y c h i a t r i c nurses i n an 18-month course to become behavioral t h e r a p i s t s with adult neurotic p a t i e n t s i n a London h o s p i t a l outpatient department. l e c t u r e s and  continued  T r a i n i n g began with two  weeks of  introductory  with small group l e c t u r e s throughout t r a i n i n g .  The t r a i n i n g program followed the apprenticeship model used i n t r a i n i n g  96 psychiatrists.  Trainees  observed t h e i r  supervisors  c a r r y i n g out  treatment and then gradually took over the therapeutic r o l e t o become the  p r i n c i p a l therapist.  Supervision  occupied  almost 50 percent  of  t r a i n e e s ' time at the s t a r t of t r a i n i n g but dropped to only a half-hour c o n s u l t a t i o n per  week when t h e r a p i s t s were seconded to h o s p i t a l s  years l a t e r .  P a t i e n t s presented  disorders,  sexual  hypochondriasis.  with phobic and  dysfunction,  stuttering,  at follow-up one,  s i x , and  i n v e s t i g a t o r s compared the r e s u l t s obtained outcome s t u d i e s  procedures. effective  obsessive-compulsive enuresis,  and  A l l p a t i e n t s were rated on target behaviors before  a f t e r treatment and  with  two  and  12 months l a t e r .  The  by the p s y c h i a t r i c nurses  i n v e s t i g a t i n g comparable b e h a v i o u r  therapy  They reported that the p s y c h i a t r i c nurses proved to be as  psychiatrists,  performing s i m i l a r  psychologists  and  medical  as  students  techniques.  Paykel, Mangen, G r i f f i t h ,  and Burns (1982) compared p s y c h i a t r i s t s  and p s y c h i a t r i c nurses i n the management of 71 adult neurotic p a t i e n t s seen at an assigned  outpatient  clinic  i n London.  to outpatient care by  v i s i t i n g by  The  p a t i e n t s were randomly  a p s y c h i a t r i s t at the  a p s y c h i a t r i c nurse.  clinic  P a t i e n t s were evaluated  or home every s i x  months f o r 18 months.  The  i n v e s t i g a t o r s found no d i f f e r e n c e s between  the  the  two  e f f e c t i v e n e s s of  modes of  s e r v i c e on  symptoms, s o c i a l  adjustment, or family burden; however, p a t i e n t s seen by the p s y c h i a t r i c nurses  showed  a  marked  reduction  p s y c h i a t r i s t s at the c l i n i c , had  i n outpatient  a higher  contacts  r a t e of discharge  c l i n i c , and reported greater s a t i s f a c t i o n with  treatment.  with  from the  97 6.4  PATTERNS OF PRACTICE In an attempt to determine the extent to which' each of the mental health p r o f e s s i o n s surveyed 586 nurses,  and  private  provides  p s y c h o t h e r a p y , Blum & R e d l i c h  p s y c h i a t r i s t s , p s y c h o l o g i s t s , s o c i a l workers, p s y c h i a t r i c mental health workers i n 25 treatment f a c i l i t i e s  p r a c t i c e i n south-central Connecticut.  Subjects  whether they spent at l e a s t one hour per week i n any activities: liaison  (1980)  i n d i v i d u a l therapy,  f o r p a t i e n t s , or  p r o v i d i n g services m  intake  and  in  were asked  of the f o l l o w i n g  group therapy,  family/couple  therapy,  evaluation.  A l l groups  reported  a l l categories, with the exception that no  were gathered f o r p s y c h i a t r i s t s i n the  last  two  data  categories.  The  professions provided i n d i v i d u a l , group, and family/couple therapy at the following  rates  psychologists  respectively:  (70%,  53%,  52%),  p s y c h i a t r i s t s (89%, social  workers  40%,  (84%,  59%),  49%,  63%),  p s y c h i a t r i c nurses (64%, 64%, 41%), and mental health workers (50%, 44%).  64%,  The authors comment that the sharing of the task of psychotherapy  among the p r o f e s s i o n a l groups represents a change i n the deployment of manpower.  They speculate that t h i s does not represent a r e t r e a t from  psychotherapy by p s y c h i a t r i s t s but rather an expansion of the functions of other  professions.  They suggest that the  greater  involvement of  nurses i n p r o v i d i n g psychotherapy f o r i n p a t i e n t s perhaps stems from the movement to replace c u s t o d i a l care with a more a c t i v e treatment program and,  s i m i l a r l y , the extensive involvement of psychologists and  workers  i n p r o v i d i n g psychotherapy f o r outpatients  considerable  expansion  of  professions tend to be h e a v i l y  outpatient  clinics,  social  i s t i e d to  where  these  the two  concentrated.  McGuire (1980) examined the d i s t r i b u t i o n of the core mental health d i s c i p l i n e s using employment data obtained  from n a t i o n a l p r o f e s s i o n a l  . 98 organizations,  the N a t i o n a l  I n s t i t u t e of Mental Health,  President's Commission on Mental Health.  and the 1978  McGuire found that the mix of  professions p r o v i d i n g mental health services across f a c i l i t i e s v a r i e d a great deal.  In h o s p i t a l s e t t i n g s , medical personnel ( p s y c h i a t r i s t s and  nurses) were more h e a v i l y used.  R e l a t i v e t o other groups, p s y c h i a t r i s t s  were most h e a v i l y used i n general h o s p i t a l s . such as f r e e - s t a n d i n g workers predominated.  clinics  In outpatient s e t t i n g s ,  and CMHC's, psychologists  and s o c i a l  The r a t i o of p s y c h i a t r i s t s t o psychologists (M.A.  and above), was very close t o 1:1 across a l l f a c i l i t i e s , but ranged from 3.17 f o r general h o s p i t a l s t o .57 f o r CMHC's t o .44 f o r free-standing outpatient c l i n i c s .  Psychotherapy i n p r i v a t e p r a c t i c e was dominated by  p s y c h i a t r i s t s and p s y c h o l o g i s t s ,  although s o c i a l workers a l s o  part of the p r i v a t e p r a c t i c e manpower pool. that time i n the United practice  States, there  McGuire reports that at  were about 10,000 FTE p r i v a t e  p s y c h i a t r i s t s and 6,000 t o 8,000 FTE p r i v a t e  psychologists.  formed  practice  Data f o r s o c i a l workers d i d not permit d e r i v a t i o n of an  FTE i n d i c a t o r , but McGuire notes that of the 8,500 s o c i a l workers doing some p r i v a t e p r a c t i c e , 2,000 worked more than 20 hours per week i n private  practice.  P s y c h i a t r i c nurses  represented  a very  small  percentage of p r i v a t e p r a c t i c e manpower, with fewer than 300 nurses i n e i t h e r f u l l - t i m e or part-time p r i v a t e p r a c t i c e . Knesper, Pagnucco, & Wheeler  (1985) studied  t h e case mixes of  p s y c h i a t r i s t s , p s y c h o l o g i s t s , and s o c i a l workers i n the United The  i n v e s t i g a t o r s d i s t r i b u t e d a questionnaire  each p r o f e s s i o n .  States.  t o a s e l e c t e d sample of  Therapists were i n s t r u c t e d t o choose p a t i e n t s f o r whom  they had provided d i r e c t treatment, defined as a s e r i e s of face-to-face professional consultation.  contacts  f o r therapy  rather  than  f o r evaluation or  Subjects were placed i n t o one of two groups; the f i r s t  99 group answered questions about the l a s t f i v e p a t i e n t s seen i n i n d i v i d u a l treatment and the second group answered questions p a t i e n t s d i s c o n t i n u i n g treatment. investigators  divided  Conditions:  mental  schizophrenia,  disorders) and LSC's (Less  about the l a s t f i v e  In analyzing the survey r e s u l t s , the disorders  major  i n t o MSC's  depressive  Severe C o n d i t i o n s :  (More  disorders, and manic anxiety  disorders,  neuroses, p e r s o n a l i t y d i s o r d e r s , and r e l a t i o n s h i p problems). that the LSC's dominated the case mix of a l l provider practice  settings.  psychiatrists  I n t h e case  saw t w i c e  psychologists  Severe  They found  groups i n a l l  of MSC's i n t h e CMHC  setting,  as many MSC's b u t h a l f as many LSC's as  and s o c i a l workers but f o r MSC's t r e a t e d i n h o s p i t a l  s e t t i n g s , the three provider groups d i d not d i f f e r appreciably i n case mix.  Taking  into  account  various  funding  and apportionment  arrangements, the authors conclude that i n l e s s organized simple  s u b s t i t u t i o n seems t o occur f o r LSC's, and i n more  settings, organized  s e t t i n g s , complex s u b s t i t u t i o n appears t o occur f o r MSC's as w e l l . Two studies have examined the s t a f f i n g patterns of CMHC's i n the United States ( P e r l s , winslow, & Pathak, 1980; McGuire, 1980) and have found that apportionment of p r o f e s s i o n a l s appears t o be determined not only by need f o r a p a r t i c u l a r d i s c i p l i n e , as one would expect, but a l s o by the preferences  of the d i r e c t o r s f o r one d i s c i p l i n e over another and  by economic considerations. centres  P e r l s et a l . surveyed 278 mental health  and compared the s t a f f i n g patterns  educational background of the d i r e c t o r . centres  The i n v e s t i g a t o r s found that  whose d i r e c t o r was a p s y c h i a t r i s t / p h y s i c i a n employed a  significantly centres  of the centres by type of  higher  median number of f u l l - t i m e  p s y c h i a t r i s t s than  whose d i r e c t o r was from another d i s c i p l i n e .  d i r e c t o r was a Ph.D.-level  psychologist  Centres whose  employed a somewhat  higher  100 median number of psychologists but not s i g n i f i c a n t l y so. tendency of c e n t r e  d i r e c t o r s t o employ more s t a f f  However, the of t h e i r  own  p r o f e s s i o n a l background d i d not hold f o r s o c i a l workers; centres with a p s y c h i a t r i s t as d i r e c t o r employed s i g n i f i c a n t l y more s o c i a l workers than centres whose d i r e c t o r s were from other p r o f e s s i o n a l backgrounds. McGuire (1980) i n v e s t i g a t e d patterns services  of s u b s t i t u t a b i l i t y  of p s y c h i a t r i s t s and psychologists  i n CMHC's.  f o r the  Using NIMH  survey data on s t a f f i n g f o r a sample week i n 1976, McGuire computed the r a t i o of a l l hours worked by p s y c h i a t r i s t s taken alone t o a l l hours worked by p s y c h i a t r i s t s and psychologists  taken together.  Carefully  c o n t r o l l i n g p o s s i b l e sources of confounding, McGuire examined the extent t o which the r e l a t i v e use of the two professions' attributed  to substitutability  services could be  between t h e two i n p u t s .  Results  i n d i c a t e d that as much as 85 percent of the variance i n the d i s t r i b u t i o n of  t h e two p r o f e s s i o n s  could be a t t r i b u t e d t o simple s u b s t i t u t i o n .  McGuire separated the independent v a r i a b l e s  i n t o four  "different  s u b s t i t u t a b i l i t y , " and  outputs,"  "ambiguous,"  "complex s u b s t i t u t a b i l i t y . "  "simple  In the f i r s t category,  categories:  d i f f e r e n t outputs,  McGuire found that the percentage of p a t i e n t s t r e a t e d on an i n p a t i e n t basis and the percentage of p a t i e n t s with more "severe" diagnoses had no s i g n i f i c a n t e f f e c t on r e l a t i v e rates of p s y c h i a t r i s t and psychologist staffing.  However, CMHC's i n catchment areas with more young residents  used s i g n i f i c a n t l y more p s y c h o l o g i s t s , with higher  and CMHC's i n catchment areas  incomes used s i g n i f i c a n t l y more p s y c h i a t r i s t s .  In the  second, ambiguous, category,  source of funds seemed t o have a powerful  e f f e c t on s t a f f i n g patterns.  Centres with a high l e v e l of grants and  payments from medicare, medicaid, and p r i v a t e insurance made r e l a t i v e l y heavier use of p s y c h i a t r i s t s . Conversely, centres which r e l i e d on fees  101 and centres based i n p r i v a t e p s y c h i a t r i c h o s p i t a l s made r e l a t i v e l y more use of psychologists. as  i n Perls  considerable  In the t h i r d category,  et a l . , the d i s c i p l i n e  simple  of the centre  substitutability, d i r e c t o r had a  e f f e c t on the r a t i o of p s y c h i a t r i s t s and psychologists.  A l l other d i r e c t o r s use fewer p s y c h i a t r i s t s and more psychologists than do p s y c h i a t r i s t d i r e c t o r s with the s i n g l e exception of other directors.  Also  i n this  regulatory  climate  significant effect.  category,  none of the v a r i a b l e s measuring  f o r psychologists  i n p r i v a t e p r a c t i c e had a  In the fourth category, complex s u b s t i t u t a b i l i t y , a  comparison was made of t h e r e l a t i v e psychologists  physician  with  use of p s y c h i a t r i s t s a n d  the r e l a t i v e use of a l l types of workers.  The  r e s u l t s i n d i c a t e d that i n centres where p s y c h i a t r i s t s and psychologists are  replaced  replaced.  by other  mental health workers, more psychologists are  Conversely, i n centres where work i s done with a heavier use  of p s y c h i a t r i s t s and p s y c h o l o g i s t s ,  psychologists  increase  percentage of the t o t a l work force more than do p s y c h i a t r i s t s .  their This  l a s t f i n d i n g suggests that when services are expanded, mental health workers p r o v i d i n g s e r v i c e s f o r which simple (such  substitution i s possible  as psychotherapy) are h i r e d and when services are contracted,  mental health workers p r o v i d i n g s e r v i c e s f o r which simple s u b s t i t u t i o n is  not p o s s i b l e  (such  as m e d i c a t i o n p r e s c r i p t i o n and review) are  retained.  6.5  PROFESSIONS AS PSYCHOTHERAPISTS COMPARED In summary, when the p u b l i c was asked t o rate the four professions i n terms of perceived  p r e s t i g e , p s y c h i a t r i s t s were c o n s i s t e n t l y given  the highest r a t i n g ; but when the professions were considered i n terms of desirability  as a p s y c h o t h e r a p i s t ,  subjects  were l e s s consistent,  102 sometimes c h o o s i n g  one  p r o f e s s i o n and  sometimes another.  When  two  d i s c i p l i n e s , p s y c h i a t r i s t s and p s y c h o l o g i s t s , were asked to r a t e each other's competence, they d i d not have a very high opinion of each other. The  other mental health workers, s o c i a l workers and  rated  the  two  disciplines,  nurses,  gave a more b a l a n c e d  p s y c h i a t r i s t s higher marks i n diagnostics and medication  who  view,  which reviewed c l i n i c a l  a t t i t u d e s of  giving  management and  psychologists higher marks i n psychotherapy, c o u n s e l l i n g , and Studies  also  testing.  psychotherapists  across d i s c i p l i n e s found that a t t i t u d e s v a r i e d more as a f u n c t i o n of the t h e o r e t i c a l school of psychotherapy, gender of the psychotherapists, years of p r o f e s s i o n a l experience comparing a t t i t u d e s toward  and  than of p r o f e s s i o n a l d i s c i p l i n e .  treatment  In  settings, specifically  the  community mental health movement, psychologists and s o c i a l workers were found to be the most p o s i t i v e and p s y c h i a t r i s t s l e a s t p o s i t i v e , nurses  falling  disciplines.  above  the  While t h i s  p s y c h i a t r i s t s but  below the  a t t i t u d e s , whether t o  other  r e s u l t might have been p r e d i c t e d  e x a m i n a t i o n of t r a i n i n g program emphases, another study t r e a t or  refer a psychotic  with  of  two  from  an  clinical  p a t i e n t , seems  s u r p r i s i n g i n i t s f i n d i n g that s o c i a l workers are f a r more l i k e l y  to  choose to t r e a t than are psychologists  we  consider living  that  the  services being  In studies of c l i n i c a l  unless  o f f e r e d might have been community  support systems, f o r which the  indeed make them the best-prepared  or p s y c h i a t r i s t s ,  s o c i a l workers' t r a i n i n g would  to r e t a i n the p a t i e n t .  e f f e c t i v e n e s s , i n v e s t i g a t o r s found  that  professions are most confident and accurate i n those functions f o r which they have received the most t r a i n i n g and have had the most  experience;  however, i n terms of absolute e f f e c t i v e n e s s , there i s no evidence that the  professions  differ  appreciably  e i t h e r as  diagnosticians  or  10 3 psychotherapists required  nor that the professions d i f f e r i n the amount of time  to d e l i v e r psychotherapy s e r v i c e s .  psychiatrists  In the study  and p s y c h i a t r i c nurses as psychotherapists  comparing  f o r chronic  neurotic outpatients, i t was found that c l i e n t s showed more improvement with supportive c o u n s e l l i n g i n t h e i r homes with a p s y c h i a t r i c nurse than with b r i e f medication checks at a c l i n i c r e s u l t could  with a p s y c h i a t r i s t , but the  c e r t a i n l y be as much a f u n c t i o n of the type of s e r v i c e  o f f e r e d as of the p a r t i c u l a r d i s c i p l i n e o f f e r i n g i t .  When  studies  i n v e s t i g a t i n g patterns of p r a c t i c e are reviewed, study r e s u l t s i n d i c a t e that a l l of the four core mental health psychotherapy across organized simple  disciplines  are p r o v i d i n g  a wide v a r i e t y of treatment s e t t i n g s .  In l e s s  s e t t i n g s , such as p r i v a t e p r a c t i c e and outpatient  clinics,  s u b s t i t u t i o n appears t o occur f o r LSC's and i n more  organized  s e t t i n g s , such as h o s p i t a l s , complex s u b s t i t u t i o n appears to occur f o r MSC's as w e l l .  Studies  of s t a f f i n g patterns  i n d i c a t e that while each  p r o f e s s i o n appears t o have s k i l l s which are unique t o that p r o f e s s i o n , there i s s u f f i c i e n t overlap i n s k i l l s across professions t h a t f a c t o r s such as funding arrangements and preferences as  of f a c i l i t y  w e l l as p r o f e s s i o n a l d i s c i p l i n e have a considerable  a l l o c a t i o n of s t a f f p o s i t i o n s .  administrators i n f l u e n c e on  104 CHAPTER SEVEN  SUBSTITUTION AND THE TREATMENT OF MENTAL DISORDERS  In assessing the f e a s i b i l i t y of simple s u b s t i t u t i o n i n p r i v a t e p r a c t i c e p s y c h i a t r y , we next consider the degree t o which treatment p r a c t i c e s permit s u b s t i t u t i o n of o t h e r mental currently  h e a l t h workers  d e l i v e r e d by p s y c h i a t r i s t s .  as p r o v i d e r s of s e r v i c e s  Chapter  Seven examines the common  patterns of treatment p r a c t i c e i n an attempt t o develop statements about the range of p o s s i b l e s u b s t i t u t i o n s .  Table V I I I presents i n o u t l i n e form the  accepted treatment modes and management modes f o r mental disorders and then r e l a t e s these treatment modes and management modes t o an estimate of simple substitution p o s s i b i l i t i e s .  I have used the ICD-9-CM c l a s s i f i c a t i o n  (WHO,  1978a) system rather than the DSM-III c l a s s i f i c a t i o n system because although the  latter  system  i s t h e one used  i n British  Columbia,  t h e former  c l a s s i f i c a t i o n system i s the one used i n Manitoba, which i s the source f o r the data used i n the a n a l y s i s of s u b s t i t u t a b l e share i n the present study. In using the term "treatment mode," my i n t e n t i o n i s t o i n d i c a t e whether a particular pharmacotherapy,  mental  disorder  i s typically  t r e a t e d using psychotherapy,  or a combination of psychotherapy and pharmacotherapy.  reviewing the treatment outcome l i t e r a t u r e ,  In  observing treatment p r a c t i c e s ,  and i n t e r v i e w i n g p r a c t i c i n g c l i n i c i a n s , I have t r i e d t o include the broadest range  of treatment p r a c t i c e s i n order t o encompass those instances where  conventional wisdom even i f not n e c e s s a r i l y e x p e r i m e n t a l e v i d e n c e m i l i t a t e against s u b s t i t u t i o n . bulimia (Diagnostic Code: considers  might  For example, i n the case of the treatment of  307) there i s a school of treatment theory which  b u l i m i a a depressive equivalent and recommends anti-depressant  medications as the treatment of choice; although the outcome l i t e r a t u r e does  TABLE V I I I  S u b s t i t u t i o n and t h e Treatment o f M e n t a l  DIAGNOSTIC (ICP-9-CH)  cone  Organic Psychotic Conditions (290-294) 290 291 292 293 294  Disorders  TREATMENT  MANAGEMENT  SIMPLE SUBSTITUTION  Psychotherapy Pharmacotherapy Cosfeined Favored Favored Favored  Single Therapy Therapist Teas  Low  S e n i l e & P r e s e n i l e Organic Psychoses A l c o h o l i c Psychoses Drug P s y c h o s e s T r a n s i e n t Psychoses Other O r g a n i c Psychoses  X X X X  X X X X  X X  X  X  X  X  X  X X X X  X X X X  X X  Moderate  High  X X  Other Psychoses (295-299) 295 296 297 298 299  S c h i z o p h r e n i c Psychoses A f f e c t i v e Psychoses Paranoid States Other Nonorganic Psychoses P s y c h o s e s with O r i g i n S p e c i f i c  X X  to  X X X  Childhood  X X X  Neurotic Disorders, Personality Disorders, and Other Nonpsychotic Mental Disorders (300-316) 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316  Neurotic Disorders Personality Disorders S e x u a l D e v i a t i o n s and D i s o r d e r s A l c o h o l Dependence D r u g Dependence Nondependent D r u g A b u s e Somatoform D i s o r d e r s S p e c i a l Symptoms NEC^ Acute Reaction t o Stress Adjustment Reaction N o n p s y c h o t i c D i s o r d e r s F o l l o w i n g B r a i n Damage D e p r e s s i v e D i s o r d e r NEC C o n d u c t D i s o r d e r NEC Emotional Disturbance of Childhood/Adolescence H y p e r k i n e t i c Syndrome o f C h i l d h o o d S p e c i f i c D e l a y s i n Development P s y c h o s o m a t i c D i s o r d e r s EC^  X X X  X  X X X X X X X X X  X  X X X  X  X X X  X X  X X  X X  X X X X X  X X X X X  X X  X X X  X X  X X X  X  x  x  X X X  X  X X X  X X  X  X  X  X  X  X X  X  X  X  X X  X X  X  X  X  X  X X  X X  X X X X X  X  X X  Mental Retardation (317-319) 317 318 319  M i l d Mental Retardation Other S p e c i f i e d Mental Retardation Unspecified Mental Retardation  X X X  Conditions Not Attributable to a Mental Disorder (V) V61 O t h e r F a m i l y C i r c u m s t a n c e s V62 O t h e r P s y c h o s o c i a l C i r c u m s t a n c e s V 6 3 - V71 M e d i c a l o r I n d e t e r m i n a t e P r o c e d u r e s  *NEC<  Not E l s e w h e r e  Classified  X  X  X  X  X X X  106 not f i n d evidence f o r the e f f e c t i v e n e s s of t h i s treatment mode i n reducing bulimic  binge-eating  pharmacotherapy  behavior  (Huon & Brown,  1984),  I have i n d i c a t e d  as a p o s s i b l e treatment mode f o r t h i s disorder.  On the other  hand, I have not included psychotherapy as a p o s s i b l e treatment mode where the outcome l i t e r a t u r e does not support i t s e f f e c t i v e n e s s .  This  has the  e f f e c t of making my p o t e n t i a l s u b s t i t u t i o n ranges extremely conservative. In using the term "management mode," my i n t e n t i o n i s t o i n d i c a t e whether a p a r t i c u l a r mental disorder i s t y p i c a l l y t r e a t e d by a s i n g l e t h e r a p i s t or by a therapy team.  Where I have i n d i c a t e d that a disorder might be t r e a t e d by a  s i n g l e t h e r a p i s t , i t has been my i n t e n t i o n t o c i t e those instances where i t i s common p r a c t i c e f o r a s i n g l e t h e r a p i s t t o be responsible f o r the treatment needs of a p a t i e n t e i t h e r i n an outpatient s e t t i n g or an i n p a t i e n t medical or other i n s t i t u t i o n a l s e t t i n g . Where I have i n d i c a t e d that a disorder might be treated  by a t h e r a p y team, i t has been my i n t e n t i o n t o include  instances responsible  where  a combination  of mental  health  workers  those  i s typically  f o r the treatment needs of a p a t i e n t e i t h e r i n an outpatient  s e t t i n g or an i n p a t i e n t p s y c h i a t r i c s e t t i n g ; however, I have meant t o exclude those treatment s i t u a t i o n s where a s i n g l e mental health worker i s responsible f o r the mental health treatment needs of a p a t i e n t as a member of a team of workers from outside the mental health d i s c i p l i n e s , such as non-psychiatric medical p r a c t i t i o n e r s , teachers, and welfare agency s o c i a l workers. I have assigned t h i s l a t t e r t h e r a p i s t management mode. the b r o a d e s t treatment  range  Instead,  category of treatment s i t u a t i o n t o the s i n g l e  As with treatment modes, I have t r i e d t o include  of management modes i n an attempt t o include  s i t u a t i o n s which  would  limit  the p o s s i b i l i t i e s  those  f o r simple  substitution. With  regard  t o the r e l a t i o n s h i p between treatment p r a c t i c e s and the  p o s s i b i l i t i e s f o r simple s u b s t i t u t i o n , consideration of the combinations of  107 treatment modes and  management modes which  appear  e x a m i n a t i o n of patterns of treatment p r a c t i c e l e v e l s of s u b s t i t u t i o n p o s s i b i l i t i e s : low  substitutability  t o emerge from  leads me  t o suggest three  "low," "moderate," and "high."  c a t e g o r y , I would  an  To the  suggest assigning those mental  disorders which are t y p i c a l l y t r e a t e d by a therapy team; given t h i s treatment situation, simple.  s u b s t i t u t i o n would n e c e s s a r i l y need t o be complex  rather than  Also t o the low s u b s t i t u t a b i l i t y category, I would suggest a s s i g n i n g  those disorders which can be t r e a t e d by a s i n g l e t h e r a p i s t but where the treatment of choice i s most commonly pharmacotherapy psychotherapy and pharmacotherapy; would  necessarily  substitutability  need  to  be  i n this  or a combination of  instance the s i n g l e  a psychiatrist.  To  therapist  the  moderate  category, I would suggest assigning those disorders f o r  which, depending upon the phase of the disorder or the s u b - c l a s s i f i c a t i o n of the  d i s o r d e r , psychotherapy and s i n g l e t h e r a p i s t are sometimes,  always, the favored treatment and management modes. substitutability  but not  F i n a l l y , t o the high  category, I would suggest assigning those disorders f o r  which psychotherapy and  single  therapist  are t y p i c a l l y  the  preferred  treatment and management modes. In the review of treatment p r a c t i c e s which f o l l o w s , I have chosen t o begin with the two mental  disorders  which  accounted f o r the  greatest  percentage of b i l l i n g s by p r i v a t e p r a c t i c e p s y c h i a t r i s t s to the Manitoba Health Services Commission  i n 1984, Neurotic Disorders ( D i a g n o s t i c  300) and Depressive Disorders (Diagnostic Code: outcome l i t e r a t u r e constitute  f o r t h e s e two  disorders  311).  i n greater  I w i l l review the detail  some 50 p e r c e n t of the costs of p r i v a t e p r a c t i c e  service delivery.  Code:  as  they  psychiatry  I then move to a discussion of two groups of disorders  which appear t o have a very low p o s s i b i l i t y f o r simple s u b s t i t u t i o n , Organic Psychotic Conditions ( D i a g n o s t i c  Codes:  290-294) and  Other  Psychoses  108 (Diagnostic Codes: practices  295-299).  I then conclude  for Personality Disorders  Nonpsychotic  Mental  Disorders  Retardation (Diagnostic Codes:  with a review of  ( D i a g n o s t i c Code:  ( D i a g n o s t i c Codes:  treatment  301),  302-316),  Other Mental  317-319), and Conditions Not A t t r i b u t a b l e to  a Mental Disorder (the s o - c a l l e d "V" Codes).  Depressive Disorder NEC  1  (Diagnostic Code:  311)  "States of depression, u s u a l l y of moderate but o c c a s i o n a l l y of marked i n t e n s i t y , which have no s p e c i f i c a l l y manicdepressive or other psychotic depressive features and which do not appear t o be associated with s t r e s s f u l events or other features s p e c i f i e d under N e u r o t i c D e p r e s s i o n [ D i a g n o s t i c Code: 300.4]." 2  Studies medication  which have compared the e f f e c t i v e n e s s of psychotherapy  generally f i n d that psychotherapy  medication.  McLean and  Hakstian  i s at l e a s t as e f f e c t i v e  (1979) randomly assigned  depressed c l i e n t s t o ten weeks of psychotherapy, (CBT), pharmacotherapy, or r e l a x a t i o n therapy  and  178  as  moderately  cognitive-behaviour  therapy  (treatment c o n t r o l c o n d i t i o n ) .  In a d d i t i o n to showing d i f f e r e n t i a l drop-out rates of 5 percent f o r CBT 26 t o 36 percent f o r the three other c o n d i t i o n s , r e s u l t s showed CBT  and  t o be  superior on nine out of ten measures at the end of treatment and marginally superior  at  the  three-month  follow-up.  Psychotherapy,  which  was  psychodynamic i n technique, performed most poorly on most outcome measures at both  evaluation periods and  there were no s i g n i f i c a n t d i f f e r e n c e s between  pharmacotherapy and r e l a x a t i o n therapy on any outcome measures. Blackburn, Bishop, Glen, Whalley, and C h r i s t i e (1981) and Blackburn Bishop  (1983) randomly assigned 64 depressed p a t i e n t s to c o g n i t i v e therapy,  antidepressant therapy, or a combination  of the two.  Subjects were t r e a t e d  e i t h e r i n general p r a c t i c e or i n a h o s p i t a l outpatient department. results  and  i n d i c a t e d greater  improvement on  The  a l l parameters with c o g n i t i v e  109 methods than w i t h p h a r m a c o l o g i c a l agents. treatment  was  symptomatic the  more  hospital  effective  The combination of both methods of  with  the  more  but  not  significantly  outpatients,  chronically  i l l and  more  more e f f e c t i v e  for  patients treated i n general practiceRush, Beck, Kovacs,  with  and  a n t i d e p r e s s a n t s and  cognitive rate:  therapy.  Hollon found  Again,  (1977) compared  significantly  t h e r e were  cognitive  psychotherapy  greater effectiveness  significant  differences  in  for  drop-out  5 p e r c e n t f o r t h e c o g n i t i v e psychotherapy group and 32 p e r c e n t f o r t h e  pharmacotherapy one-year  group.  Kovacs,  f o l l o w - u p with  the  Rush, Beck, and H o l l o n (1981) r e p o r t e d on Rush  c o g n i t i v e psychotherapy group was two  groups  had  been  were not maintained,  now  et  still  statistically  those  a l - (1977)  subjects.  Although  the  s u p e r i o r t o the m e d i c a t i o n group,  the  different.  However, t r e a t m e n t  intergroup differences  which  d i d occur  (i.e.,  t o o b t a i n a s c o r e over  gains always  f a v o r e d the c o g n i t i v e psychotherapy group, and the m e d i c a t i o n group was as l i k e l y t o r e l a p s e  a  twice  16 on the Beck D e p r e s s i o n  I n v e n t o r y a t some time d u r i n g the y e a r ) . As i n t h e B l a c k b u r n s t u d i e s , Murphy, Simons, W e t z e l , and Lustman  (1984)  found c o g n i t i v e psychotherapy t o be as e f f e c t i v e but not more e f f e c t i v e t h a n pharmacotherapy  in a  study  which  p s y c h o t h e r a p y , pharmacotherapy, or  cognitive  studies al. ,  by  and  patients,  psychotherapy  assigned p a t i e n t s  et  p l u s placebo-  a l . , concludes  cognitive  pharmacotherapy  psychotherapy  i n producing  either  c o g n i t i v e psychotherapy p l u s  B l a c k b u r n e t a l . , Kovacs  Rush  to  Williams  cognitive  pharmacotherapy,  (1984),  reviewing  e t a l . , McLean and H a k s t i a n , Murphy e t  that  for mildly  appears  change  on  to  be  to at  outcome  moderately least  as  measures  depressed  effective taken  at  t e r m i n a t i o n of treatment and appears, as w e l l , t o have the added advantage a lower drop-out r a t e and a lower r e l a p s e r a t e with  the o b s e r v a t i o n t h a t  the  f o r severely  as the of  He q u a l i f i e s h i s c o n c l u s i o n s  depressed p a t i e n t s ,  a combination  of  110 c o g n i t i v e psychotherapy  and pharmacotherapy  may  be  more e f f e c t i v e  than  c o g n i t i v e psychotherapy alone. Studies which have compared the e f f e c t i v e n e s s of combined treatment with psychotherapy alone or medication alone sometimes f i n d an a d d i t i v e e f f e c t and sometimes do not.  Beck, Hollon, Young, Bedrosian, and Budenz (1985) assigned  33 outpatients t o e i t h e r CBT or CBT plus pharmacotherapy.  Both groups showed  s t a t i s t i c a l l y s i g n i f i c a n t and c l i n i c a l l y meaningful decreases i n depressive symptoms.  No  d i f f e r e n c e s emerged between the two  magnitude of the decrease.  groups i n terms of the  The authors conclude that the a d d i t i o n of the  antidepressant medication d i d not improve the response obtained by CBT alone. Weissman, K a s l , & Klerman, (1976) studied 150 women who were f i r s t given 4 t o 6 weeks of medication treatment, then two months of medication treatment with e i t h e r weekly supportive psychotherapy or a b r i e f monthly i n t e r v i e w , and then s i x months of e i t h e r medication, placebo, or no medication. report  that medication  prevented  symptom r e t u r n but  The authors  d i d not  have a  d i f f e r e n t i a l e f f e c t on s o c i a l f u n c t i o n i n g ; psychotherapy, on the other hand, did not prevent symptom r e t u r n but d i d improve s o c i a l f u n c t i o n i n g . year follow-up, the r e s u l t s showed no medication and the psychotherapy  significant  In a one-  d i f f e r e n c e s between the  groups; however, the r e s u l t s are confounded  because the experimental conditions were no longer c o n t r o l l e d i n the f o l l o w up p e r i o d and p a t i e n t s sought a v a r i e t y of treatments. Weissman, P r u s o f f , and DiMascio medication and psychotherapy  In a second  (1979) again compared the e f f e c t i v e n e s s of  and the combination of the two.  96 outpatients randomly assigned f o r 16 weeks t o e i t h e r pharmacotherapy, p s y c h o t h e r a p y psychotherapy they  study,  Subjects were psychotherapy,  p l u s pharmacotherapy, or  nonscheduled  (patients were assigned t o a p s y c h i a t r i s t and were t o l d t h a t  should contact the t h e r a p i s t i f they  Results showed t h a t the c o m b i n a t i o n  felt  the need f o r treatment).  of a n t i d e p r e s s a n t s and  short-term  111 psychotherapy  was  more e f f e c t i v e than e i t h e r treatment  nonscheduled  psychotherapy;  alone or than  medication and psychotherapy  the  alone were about  equally e f f e c t i v e . Teasdale, F e n n e l l , Hibbert, and Amies (1984) assigned 34 p a t i e n t s t o treatment groups of medication alone or medication plus i n d i v i d u a l c o g n i t i v e therapy.  At  the  completion  therapy p l u s m e d i c a t i o n receiving  medication  of  treatment, p a t i e n t s r e c e i v i n g  were s i g n i f i c a n t l y  alone.  At  the  less  depressed  three-month  than  those  f o l l o w - u p assessment  c o g n i t i v e therapy plus medication p a t i e n t s no longer d i f f e r e d from the medication alone group.  cognitive  significantly  I t i s unfortunate that t h i s study d i d not  a l s o i n c l u d e a c o g n i t i v e therapy alone group. B e l l a c k , Hersen, and Himmelhoch (1981) randomly assigned 125  depressed  women t o four experimental c o n d i t i o n s : antidepressant alone, antidepressant plus  social  skills  training,  social  s k i l l s t r a i n i n g plus placebo,  psychotherapy  plus placebo.  statistically  s i g n i f i c a n t and c l i n i c a l l y meaningful changes i n symptoms but  that medication d i d not add  The authors found that each treatment  and  t o the e f f e c t i v e n e s s of  the  social  produced  skills  treatment.  In a d d i t i o n , the group r e c e i v i n g s o c i a l s k i l l s t r a i n i n g p l u s  placebo had  the lowest l e v e l  of a t t r i t i o n  (24 percent  compared w i t h  53  percent f o r the antidepressant alone group) and had the highest p r o p o r t i o n of p a t i e n t s who were s i g n i f i c a n t l y improved at the six-month follow-up. Conte, P l u t c h i k , Wild, and Karasu (1986) reviewed 11 c o n t r o l l e d studies reported between 1974 and 1984, i n c l u d i n g s e v e r a l of those already mentioned (Beck et a l . , 1985; B e l l a c k et a l . , 1981; Blackburn et a l . , 1981, 1983;  and  Murphy et a l . , 1984),  and  t o determine  whether combined p s y c h o t h e r a p y  pharmacotherapy i s superior t o e i t h e r treatment alone. approach quality  Using a s t a t i s t i c a l  t o analyze the f i n d i n g s of the s t u d i e s , the authors evaluated the of each study and assigned weights t o each outcome.  The  results  112 i n d i c a t e d t h a t the combined a c t i v e treatments (medication plus psychotherapy) were appreciably more e f f e c t i v e than placebo conditions but only s l i g h t l y and n o n - s i g n i f i c a n t l y superior t o psychotherapy alone or  pharmacotherapy alone.  F i n a l l y , t o conclude, i n a study which i n d i c a t e s that there may i n t e r a c t i v e e f f e c t between p e r s o n a l i t y Simons, Lustman, Wetzel, and Murphy  traits  and  be an  p r e f e r r e d treatment,  (1985) found a r e l a t i o n s h i p between  degree of learned resourcefulness as measured by the S e l f - C o n t r o l  Schedule  (SCS) and response to c o g n i t i v e psychotherapy or anti-depressant medication. In t h e i r study, 35 moderately  depressed p a t i e n t s were assigned t o e i t h e r a  c o g n i t i v e psychotherapy or an antidepressant pharmacotherapy c o n d i t i o n . r e s u l t s showed that both treatment.  groups improved  significantly  However, s u b j e c t s e n t e r i n g c o g n i t i v e  by  the  The  end  psychotherapy  of  with  r e l a t i v e l y high SCS scores d i d b e t t e r than subjects with low SCS scores while subjects  e n t e r i n g pharmacotherapy w i t h low SCS  scores d i d b e t t e r  than  subjects with high SCS scores. In the treatment of Depressive Disorder, t o summarize the review of outcome l i t e r a t u r e presented above, p s y c h o t h e r a p y , combined psychotherapy/pharmacotherapy  pharmacotherapy,  and  each appear to be more e f f e c t i v e than  placebo c o n d i t i o n s , but t h e i r r e l a t i v e and absolute effectiveness seem to be r e l a t e d t o the p a r t i c u l a r technique employed and t o the p a r t i c u l a r phase of the disorder being treated. behavior  therapy  psychotherapy.  appears  1979;  be  more e f f e c t i v e  than  other  types  of  (Catalan, Gath, Edmonds, & Ennis, 1984; G u l l i c k &  Weissman & Klerman,  produce a lower drop-out treatments have produced severely  to  mode, c o g n i t i v e  Anti-depressant medications appear t o be more e f f e c t i v e than  a n t i - a n x i e t y medications King,  With r e g a r d t o t r e a t m e n t  1977).  Psychotherapy  treatments tend t o  rate than pharmacotherapy treatments.  Combined  greater improvement i n some studies with the more  depressed p a t i e n t s but r e s u l t s are not c o n s i s t e n t f o r the  severely depressed p a t i e n t s .  F i n a l l y , there appears  t o be an  less  interaction  113 .between the p e r s o n a l i t y type of the p a t i e n t and the r e l a t i v e effectiveness of e i t h e r psychotherapy or pharmacotherapy. patients  diagnosed as  With regard  Depressive D i s o r d e r  are  to management mode,  typically  treated  in  an  outpatient s e t t i n g , u s u a l l y by a s i n g l e t h e r a p i s t , but o c c a s i o n a l l y , i f the c o n d i t i o n i s severe and/or there are s u i c i d a l features, the p a t i e n t may  be  treated  of  i n an  inpatient psychiatric setting.  Based on  t h i s pattern  treatment p r a c t i c e s , I would suggest that simple s u b s t i t u t i o n p o s s i b i l i t i e s f o r Diagnostic Code 311 be considered to f a l l i n the moderate range.  Neurotic Disorder  (Diagnostic Code:  300)  " N e u r o t i c D i s o r d e r s are mental d i s o r d e r s w i t h o u t any demonstrable organic basis i n which the p a t i e n t may have considerable i n s i g h t and has unimpaired r e a l i t y t e s t i n g , i n t h a t he u s u a l l y does not confuse h i s morbid subjective experiences and f a n t a s i e s with e x t e r n a l r e a l i t y . Behavior may be g r e a t l y a f f e c t e d a l t h o u g h u s u a l l y r e m a i n i n g w i t h i n s o c i a l l y a c c e p t a b l e l i m i t s , but p e r s o n a l i t y i s not disorganized. The p r i n c i p a l manifestations include excessive anxiety, h y s t e r i c a l symptoms, o b s e s s i o n a l and c o m p u l s i v e symptoms, and depression." 3  With regard to the treatment of the s u b - c l a s s i f i c a t i o n Phobic States, a number  of  modification  studies  and  reviews  studies  psychotherapy techniques and  techniques are  at  l e a s t as  studies  of  i n vivo  s i g n i f i c a n t improvement and  found  that  pharmacotherapy  treatments. exposure  have  behavior  cognitive behavior psychotherapy  e f f e c t i v e as  psychotherapy/pharmacotherapy controlled  of  Linden  and  combined  (1981) r e v i e w e d  f o r agoraphobia  and  reported  maintenance of improvement i n the majority  treated p a t i e n t s , with the lowest improvement rate reported S i m i l a r l y , Carney (1985) notes that recent  reviews of studies employing i n  complete treatment show s i g n i f i c a n t  which are maintained f o r four to nine years.  of  as 58 percent.  vivo exposure with agoraphobics have concluded that approximately 65 to percent of p a t i e n t s who  11  75  improvements,  However, the same reviews have  114 a l s o noted that due percent  of p a t i e n t s  t o the nature of the exposure treatments, up r e f u s e or f a i l  t o complete treatment.  to  30  Alternative  behavioral psychotherapy techniques o f f e r treatment options which might prove more p a l a t a b l e t o p a t i e n t s ; James, Hampton, and Larsen (1983) compared the e f f i c a c y of imaginal and i n vivo d e s e n s i t i z a t i o n techniques i n the treatment of  agoraphobics  and  found t h e two  procedures t o be equally  effective.  Likewise, W i l l i a m s , Turner, and Peer (1985) compared i n vivo exposure with a cognitive  b e h a v i o r psychotherapy technique (guided mastery  training)  and  found the l a t t e r t o be more e f f e c t i v e than the former i n the treatment of height phobics. Turning t o a consideration of pharmacotherapy  treatment, there are some  adherents of the use of a n t i - a n x i e t y medications (Marks, J . , 1985); however, there are other researchers who maintain that while a n t i - a n x i e t y medications may  have short-term p a l l i a t i v e value i n reducing anxiety, t h e i r  long-term  value should remain i n question because phobic symptoms have been observed t o return when medication i s discontinued combined  (Marks, I . ; 1983).  psy chotherapy/pharmacotherapy  researchers are again mixed.  With regard t o  t r e a t m e n t s , the  o p i n i o n s of  Z i n t r i n , K l e i n , and Woerner (1980) assigned 76  female agoraphobic p a t i e n t s to a combined imipramine and i n v i v o  exposure  c o n d i t i o n or t o a combined placebo and i n vivo exposure treatment c o n d i t i o n ; they found that the imipramine c o n d i t i o n was than the placebo c o n d i t i o n .  s i g n i f i c a n t l y more e f f e c t i v e  S i m i l a r l y , Mavissakalian, Michelson, and Dealy  (1983) t r e a t e d 18 agoraphobic p a t i e n t s with imipramine or imipramine plus i n v i v o exposure; they a l s o found s i g n i f i c a n t l y greater improvement on phobic measures i n the imipramine p l u s i n v i v o exposure condition.  On the other  hand, Marks, Gray, Cohen, H i l l , Mawson, Ramm, and Stern (1983) assigned 45 agoraphobic p a t i e n t s t o e i t h e r an i n v i v o exposure or a r e l a x a t i o n c o n d i t i o n and these two conditions were then combined with e i t h e r an imipramine or a  115 placebo c o n d i t i o n .  The i n v e s t i g a t o r s found that p a t i e n t s i n the i n v i v o  exposure c o n d i t i o n improved s i g n i f i c a n t l y  and maintained t h e i r gains  at a  one-year follow-up but that imipramine d i d not enhance the e f f e c t i v e n e s s of the  exposure c o n d i t i o n r e l a t i v e t o the placebo c o n d i t i o n .  At a two-year  follow-up of the same p a t i e n t s , Cohen, Monteiro, and Marks, (1984) found that about two-thirds of the p a t i e n t s who had improved remained improved but that there were now no s i g n i f i c a n t differences between any of the four treatment conditions. With regard  t o the treatment of the s u b c l a s s i f i c a t i o n of Obsessive-  Compulsive Disorders, psychotherapy treatment. patients  treatment alone  Results with  pharmacotherapy  the majority  of outcome s t u d i e s  have f o c u s s e d  on  or combined psychotherapy/pharmacotherapy  i n d i c a t e that psychotherapy i s e f f e c t i v e i n t r e a t i n g  obsessive  rituals  and t h a t  combined  psychotherapy/  may be h e l p f u l i n t r e a t i n g p a t i e n t s with ruminative thoughts  or p a t i e n t s who have a l s o been diagnosed with Depressive Disorder.  Marks,  Hodgson, and Rachman (1975) compared the e f f e c t i v e n e s s of i n v i v o exposure with  muscular  r e l a x a t i o n i n t h e treatment of 20 p a t i e n t s with  obsessive-compulsive r i t u a l s ; p a t i e n t s significant three-year  improvement a f t e r three follow-up  improvement.  i n the i n vivo  condition  chronic showed  weeks and maintained improvement at a  while p a t i e n t s i n the r e l a x a t i o n c o n d i t i o n showed no  In a review of 14 studies comparing the effectiveness of i n  v i v o exposure and r e l a x a t i o n t r e a t m e n t , Marks  (1981) found t h e former  treatment to be c o n s i s t e n t l y more e f f e c t i v e than the l a t t e r . Moving t o s t u d i e s opinions  of combined psychotherapy/pharmacotherapy, t h e  of i n v e s t i g a t o r s are mixed as t o whether pharmacotherapy has an  a d d i t i v e e f f e c t when combined with psychotherapy treatment.  Amin, Ban,  Pecknold, and Klingner (1977) assigned s i x p a t i e n t s with obsessive-compulsive neurosis  t o e i t h e r a clomipramine plus behavior therapy, clomipramine plus  116 simulated behavior therapy, or placebo plus behavior patients  i n the  clomipramine  greatest improvement.  therapy  condition;  plus behavior therapy condition showed the  Solyom and  Sookman ( 1977)  assigned 23 o b s e s s i v e -  compulsive p a t i e n t s to e i t h e r a clomipramine, i n v i v o exposure, or response prevention treatment condition. was  as  effective  prevention  as  The  i n v e s t i g a t o r s found that clomipramine  i n v i v o exposure  and more e f f e c t i v e than  i n r e d u c i n g r u m i n a t i v e thoughts  e f f e c t i v e than i n v i v o exposure Stern, Mawson, Cobb, and  but  clomipramine  i n reducing r i t u a l i s t i c  McDonald  (1980) t r e a t e d  response was  behaviors.  less Marks,  obsessive-compulsive  p a t i e n t s using e i t h e r an i n v i v o exposure or a r e l a x a t i o n condition combined with e i t h e r  a clomipramine  or placebo c o n d i t i o n ; r e s u l t s  indicated  that  clomipramine was e f f e c t i v e i n reducing depressive symptoms i n those p a t i e n t s who were s i g n i f i c a n t l y depressed at the s t a r t of treatment, however i t had no e f f e c t by i t s e l f on obsessive behaviors i n nondepressed p a t i e n t s and d i d not produce an a d d i t i v e e f f e c t when combined with i n v i v o exposure or r e l a x a t i o n . R e t u r n i n g t o the Marks l i t e r a t u r e on the r e l a t i v e  (1981) r e v i e w , the author  effectiveness  psychotherapy/pharmacotherapy  of psychotherapy  summarizes the and  with the conclusion that p a t i e n t s  obsessive r i t u a l i z e d behavior appear t o be  combined exhibiting  most r e s p o n s i v e t o i n v i v o  exposure and that p a t i e n t s e x h i b i t i n g obsessive ruminative thoughts appear t o be most responsive to combined Briefly  psychotherapy/pharmacotherapy.  reviewing the treatment of the s u b - c l a s s i f i c a t i o n s of Anxiety  States and Neurotic Depression, a number of studies of the treatment  of  Anxiety States i n d i c a t e that pharmacotherapy i s more e f f e c t i v e than placebo (e.g., Fyro, B e c k - F r i i s ,  & Sjostrand, 1974;  Goldberg  & Finnerty,  1979;  Pinosky, 1978) and that r e l a x a t i o n psychotherapy may be as e f f e c t i v e as a n t i anxiety medication i n reducing s e l f - r e p o r t e d anxiety i n p a t i e n t s with panic disorders  (Taylor, Kenigsberg,  & Robinson,  1982).  With regard t o the  117 treatment of Neurotic Depression, the l i t e r a t u r e reviewed i n the preceding section  on t h e t r e a t m e n t  judgments about combined  of D e p r e s s i v e Disorder may apply as w e l l t o  the effectiveness of psychotherapy, pharmacotherapy,  psychotherapy/pharmacotherapy  i n the treatment  and  of N e u r o t i c  Depression as most studies do not e x p l i c i t l y d i f f e r e n t i a t e between the two disorders  i n specifying  t h e i r p a t i e n t population.  p s y c h i a t r i s t p r a c t i c i n g i n Vancouver, empirical  Penfold, a f e m i n i s t  B.C., makes a strong t h e o r e t i c a l and  case f o r the use of psychotherapy  over pharmacotherapy  treatment of neurotic depression(Penfold and Walker, 1983).  i n the  She argues that  since most of the p a t i e n t s who are diagnosed w i t h the disorder are women i n d i f f i c u l t l i f e circumstances, teaching these women how t o cope with or change their  situations  should be more e f f e c t i v e i n producing long-term symptom  improvement than treatment w i t h a n t i - a n x i e t y or anti-depressant medications. As i n the case of Depressive Disorder, i n the treatment of Neurotic Disorders p s y c h o t h e r a p y , pharmacotherapy  pharmacotherapy,  each appear  and combined  t o be more e f f e c t i v e than placebo  although the r e s u l t s of outcome studies produce treatment  modes w i t h i n  psychotherapy/  particular  mixed  sub-classifications.  results  conditions f o r some  With regard t o  management mode, p a t i e n t s diagnosed with Neurotic Disorders are t y p i c a l l y t r e a t e d i n an outpatient s e t t i n g , u s u a l l y by a s i n g l e t h e r a p i s t .  Based on  t h i s p a t t e r n of treatment p r a c t i c e s , I would suggest that simple s u b s t i t u t i o n p o s s i b i l i t i e s f o r Diagnostic Code 300 be considered t o f a l l i n the moderate range.  Organic Psychotic Conditions (Diagnostic Codes: (Diagnostic Codes: 295-299)  290-294) and Other Psychoses  Organic Psychotic Conditions and Other Psychoses are t y p i c a l l y t r e a t e d in  the combined psychotherapy/pharmacotherapy  t r e a t m e n t mode and i n t h e  118 therapy team management mode, e i t h e r i n an outpatient s e t t i n g , an i n p a t i e n t p s y c h i a t r i c s e t t i n g , or a chronic care s e t t i n g .  In those instances where a  p a t i e n t might sometimes be s u c c e s s f u l l y managed by a s i n g l e t h e r a p i s t (Diagnostic Codes:  295-299),  psychotherapy/pharmacotherapy  because  the preference i s f o r the combined  treatment mode, the s i n g l e t h e r a p i s t  n e c e s s a r i l y need t o be a p s y c h i a t r i s t . p r a c t i c e s , I would suggest t h a t  would  Based on t h i s pattern of treatment  simple s u b s t i t u t i o n p o s s i b i l i t i e s f o r  Diagnostic Codes 290-294 and 295-299 be considered t o f a l l i n the low range. The diagnostic c l a s s i f i c a t i o n Organic Psychotic Conditions group  refers to a  of disorders which includes S e n i l e and P r e s e n i l e Organic Psychoses  (Diagnostic Code:  290), A l c o h o l i c Psychoses (Diagnostic Code:  291), Drug  Psychoses (Diagnostic Code: 292), Transient Psychoses (Diagnostic Code: 293), and Other Organic Psychoses (Diagnostic Code: the  first  three  conditions are t y p i c a l l y  294). P a t i e n t s s u f f e r i n g from  t r e a t e d i n an i n p a t i e n t s e t t i n g  during the acute phase of the disorder and then maintained i n a chronic care s e t t i n g when the disorder i s i n remission.  For p a t i e n t s with  Transient  Psychoses, which are u s u a l l y caused by some t o x i c , i n f e c t i o u s , metabolic, or systemic  disturbance,  t h e p a t i e n t i s often released from the i n p a t i e n t  s e t t i n g without the need f o r f u r t h e r care.  P a t i e n t s s u f f e r i n g from Other  Organic Psychoses, which are u s u a l l y caused by organic b r a i n damage due t o a l c o h o l abuse, Huntington's Chorea,  or s i m i l a r  disorders, are u s u a l l y  released e i t h e r t o an outpatient s e t t i n g or a chronic care s e t t i n g depending on the degree of impairment. Other  Psychoses  Schizophrenic (Diagnostic  r e f e r s t o a group  Psychoses  (Diagnostic  Code:  Code: 2 9 6 ) , P a r a n o i d States  Nonorganic Psychoses  (Diagnostic Code:  S p e c i f i c t o Childhood (Diagnostic Code:  of d i s o r d e r s  which  includes  2 9 5 ) , A f f e c t i v e Psychoses  (Diagnostic Code:  297), Other  298), and Psychoses w i t h  Origin  299). As noted above, p a t i e n t s are  119 typically  t r e a t e d by  a therapy  team i n an  inpatient psychiatric s e t t i n g  during the acute phase of the disorder and are then maintained  e i t h e r i n an  outpatient s e t t i n g or a chronic care s e t t i n g during remission.  P a t i e n t s are  typically  treated with  combined psychotherapy/pharmacotherapy, with  exception of some p a t i e n t s diagnosed with Paranoid States who able to f u n c t i o n adequately without  medication  (Ritzier,  the  are sometimes  1981).  For  the  Schizophrenic Disorders, an extraordinary amount of research has been devoted to the e f f e c t i v e n e s s of both the pharmacotherapy (Menuck & Seeman, 1985) the psychotherapy modes of treatment, therapy, and family therapy 1982;  L e f f , Kuipers,  Platman, 1983;  (Brady, 1984;  Berkowitz,  and Schooler,  Kazdin,  1982;  Goldstein & Doane,  Kirshner & Johnston, Paul  & Lentz,  1977;  Other Nonorganic Psychoses are u s u a l l y  l i f e experience;  i n remission the p a t i e n t  e i t h e r be released without the need f o r f u r t h e r care or be t r e a t e d by a  therapy Childhood the  F a l l o o n , 1986;  & Sturgeon, 1985;  1986).  a t t r i b u t e d to a recent traumatic may  i n c l u d i n g t o k e n economies, m i l i e u  Jacobs, Donahoe, & F a l l o o n , 1985;  1982;  and  team i n an outpatient s e t t i n g . r e f e r s to an exceedingly  s u b - c l a s s i f i c a t i o n s of  Childhood  Psychoses with O r i g i n S p e c i f i c to  large range of disorders, which includes  I n f a n t i l e Autism, Organic Brain Disease,  and  Schizophrenia; during remission p a t i e n t s are t y p i c a l l y released to  an outpatient or chronic care s e t t i n g and  managed by a therapy  team or a  s i n g l e t h e r a p i s t i n c o n s u l t a t i o n with a team of non-mental h e a l t h workers (Brady, 1984; Dudziak, 1982; Hung, 1977).  P e r s o n a l i t y Disorders (Diagnostic Code; Disorders (Diagnostic Codes: 302-316)  301)  and Other Nonpsychotic Mental  In considering the r e l a t i o n s h i p between patterns of treatment p r a c t i c e and p o s s i b i l i t i e s f o r simple s u b s t i t u t i o n f o r these mental disorders, I would suggest the disorders f a l l i n t o two  groups, those i n the moderate  range and  120 those i n the high range.  I w i l l begin with a discussion of those disorders  which appear t o f a l l i n the moderate range and then move t o a d i s c u s s i o n of those disorders which appear t o f a l l i n the high range. In the moderate range, three disorders with s i m i l a r treatment patterns are Alcohol Dependence (Diagnostic Code: Code:  303), Drug Dependence (Diagnostic  304), and Nondependent Drug Abuse (Diagnostic Code:  305). P a t i e n t s  diagnosed with Alcohol Dependence are sometimes i n i t i a l l y  t r e a t e d i n an  i n p a t i e n t s e t t i n g f o r d e t o x i f i c a t i o n ; some researchers have found that as an aid  t o the medical  i n t e r v e n t i o n s used i n d e t o x i f i c a t i o n ,  psychotherapy  (supportive counselling) treatment and pharmacotherapy treatment are equally effective  (Frecker, Shaw, Zilm, Jacob, S e l l e r s ,  Saletu, Grunberger, Mader, & Karobath, 1983).  & Degani,  1982; S a l e t u ,  Patients may then  continue  e i t h e r i n an i n p a t i e n t or an outpatient treatment s e t t i n g ; reviews of studies comparing the e f f i c a c y of i n p a t i e n t and outpatient treatment i n d i c a t e that with the exception  of d e t e r i o r a t e d p a t i e n t s who have no permanent home,  outpatient treatment i s as e f f e c t i v e as i n p a t i e n t treatment ( M i l l e r & Hester, 1986).  In the i n p a t i e n t s e t t i n g , management mode may be e i t h e r a  therapy  team or a s i n g l e t h e r a p i s t ; i n the outpatient s e t t i n g , p a t i e n t s are t y p i c a l l y t r e a t e d by a s i n g l e t h e r a p i s t alone or a s i n g l e t h e r a p i s t i n a s s o c i a t i o n with a team of non-mental h e a l t h  workers.  For the  majority  psychotherapy i s the treatment mode employed, which  of p a t i e n t s  includes  behavior  m o d i f i c a t i o n , c o g n i t i v e behavior, and family therapies (Brandsma & P a t t i s o n , 1985; Kaufman & P a t t i s o n , 1981; Litman & Topham, 1983; Orford, 1984; S o b e l l & S o b e l l , 1983; Wiens & Menustik, 1983); as w e l l , a minority of p a t i e n t s are maintained using 1983).  with pharmacotherapy or combined psychotherapy/ pharmacotherapy  medications  which block the metabolism of a l c o h o l (Litman & Topham,  121 For  patients  d i a g n o s e d with  Drug Dependence, patterns  of treatment  p r a c t i c e are s i m i l a r t o those f o r p a t i e n t s with Alcohol Dependence with the proviso  that a f t e r the i n i t i a l  d e t o x i f i c a t i o n phase, p a t i e n t s addicted t o  o p i o i d s , whether obtained through p r e s c r i p t i o n or i l l e g a l l y , frequently are maintained through pharmacotherapy or combined psychotherapy/pharmacotherapy with  s y n t h e t i c opiate medications.  anxiety or anti-depressant i n c r e a s i n g the l e v e l  Pharmacotherapy treatment w i t h  anti-  medications has not been found t o be e f f e c t i v e i n  of c l i e n t  functioning.  A g a i n , t r e a t m e n t mode i s  t y p i c a l l y a s i n g l e t h e r a p i s t i n a s s o c i a t i o n with a team of non-mental health workers  (Gawin & Kleber,  1984; Gossop, Bradley,  Rounsaville & Kleber, 1985;  Stang, & C o n n e l l , 1984;  Rush & Shaw, 1981; Tennant & Rawson, 1982). For  p a t i e n t s diagnosed with Nondependent Drug Abuse, psychotherapy i s t y p i c a l l y the treatment mode and s i n g l e t h e r a p i s t the management mode, sometimes i n a s s o c i a t i o n with Soghikian, The  a team of non-mental health workers  1979; Holroyd,  (Harrup, Hansen, &  1980).  remaining mental disorders which f a l l  i n t o the moderate range of  simple s u b s t i t u t i o n p o s s i b i l i t i e s have a heterogeneous pattern of treatment p r a c t i c e s with sometimes  the common denominator being  involve  the pharmacotherapy  that treatment p r a c t i c e s may  or combined  psychotherapy/  pharmacotherapy treatment modes as w e l l as the psychotherapy treatment mode and the therapy team as w e l l as the s i n g l e t h e r a p i s t management mode. Patients diagnosed with typically  present with  Somatoform Disorders  recurrent  (Diagnostic  Code:  306)  m u l t i p l e somatic complaints or symptoms  suggesting  n e u r o l o g i c a l disease  which have no basis i n a p h y s i c a l  process.  Although the treatment mode i s u s u a l l y p s y c h o t h e r a p y  disease and t h e  management mode s i n g l e t h e r a p i s t , I have suggested that treatment p r a c t i c e s for  t h i s mental disorder f a l l  i n the moderate rather than the high  because of the p o s s i b l e need f o r a d i f f e r e n t i a l medical/psychiatric  range  diagnosis  122 (Knesper, Pagnucco/ & Wheeler, 1985) and because p a t i e n t s frequently drop out of psychotherapy t o pursue medical i n t e r v e n t i o n s (Goodwin & Guze, 1984). S p e c i a l Symptoms NEC  (Diagnostic Code:  307) i s a category of mental  disorder which contains a number of s u b - c l a s s i f i c a t i o n s , i n c l u d i n g Anorexia, B u l i m i a , Enuresis, S t u t t e r i n g , and T i c s . Bulimia,  patients  are t y p i c a l l y  In the treatment of Anorexia and  t r e a t e d e i t h e r i n an i n p a t i e n t h o s p i t a l  s e t t i n g or an outpatient s e t t i n g by a s i n g l e t h e r a p i s t i n a s s o c i a t i o n with a team of non-mental  health  workers.  Reviews  of studies  comparing the  e f f e c t i v e n e s s of psychotherapy, pharmacotherapy, and combined psychotherapy/ pharmacotherapy  i n d i c a t e that psychotherapy i s r e l a t i v e l y  more e f f e c t i v e  (Elston & Thomas, 1985; Halmi, 1982, 1983a, 1983b; Herzog & Copeland, Huon & Brown, 1984), but because  there  are adherents to the l a t t e r  1985; two  treatment modes I have considered treatment p r a c t i c e s f o r the disorders t o be i n the moderate range of simple s u b s t i t u t i o n p o s s i b i l i t i e s . of Enuresis,  p a t i e n t s are t y p i c a l l y  In the treatment  t r e a t e d as o u t p a t i e n t s  by  a  single  t h e r a p i s t and behavior m o d i f i c a t i o n psychotherapy techniques have been found to  be  more  e f f e c t i v e than  psychotherapy/pharmacotherapy  either  (Mikkelsen  pharmacotherapy & Rapoport,  or  combined  1980; Netley,  Khanna,  McKendry, & Lovering, 1984; Wagner, Johnson, Walker, Carter, & Wittner, Wille,  1986).  I n t h e t r e a t m e n t of S t u t t e r i n g , treatment by a speech  t h e r a p i s t has been found to be more e f f e c t i v e than pharmacotherapy Kuhr, Cook, & James, 1981). from G i l l e s therapist  pharmacotherapy  the or  preferred  combined  Mohammad, & B a r r e t t ,  1978;  (Rustin,  In the treatment of T i c s , p a t i e n t s s u f f e r i n g  De La Tourette Syndrome are t y p i c a l l y with  1982;  treatment  treated  by  a  techniques being  psychotherapy/pharmacotherapy Thomas, Abrams, & Johnson,  single either  (Surwillo,  1971), however,  behavior m o d i f i c a t i o n psychotherapy techniques have been used i n p a t i e n t s who cannot t o l e r a t e medication (Tophoff, 1973).  Other forms of t i c s are u s u a l l y  123 t r e a t e d with  behavior m o d i f i c a t i o n  Sewall, 1974;  Schulman, 1974).  psychotherapy  techniques  (Knepler  P a t i e n t s diagnosed with Acute Reaction to Stress (Diagnostic Code: have been subject  to a traumatic  event/ such as  &  308)  rape, m i l i t a r y combat,  n a t u r a l d i s a s t e r , or catastrophic accident, and have subsequently developed c h a r a c t e r i s t i c symptoms which involve  reexperiencing  psychic  autonomic, d y s p h o r i c ,  numbing, and  complaints.  a  v a r i e t y of  the  traumatic or  cognitive  Depending upon the phase of the disorder, treatment may  i n p a t i e n t or  outpatient  pharmacotherapy, or  s e t t i n g and  may  employ e i t h e r the  event,  be i n an  psychotherapy,  combined psychotherapy/pharmacotherapy treatment modes  and the s i n g l e t h e r a p i s t or therapy team management modes. Patients  diagnosed w i t h  Organic B r a i n  Damage  S p e c i f i c Nonpsychotic  (Diagnostic  Code:  310)  Disorders  Following  show changes i n behavior  f o l l o w i n g damage to the f r o n t a l areas of the b r a i n ; there i s a diminution s e l f - c o n t r o l , f o r e s i g h t , c r e a t i v i t y , and not  concentration,  necessarily, a deterioration i n i n t e l l e c t  phase  of  the  disorder  anti-convulsant  and  or memory.  medication  may  frequently, In the be  of but  initial  used  as  a  p r o p h y l a c t i c measure to decrease b r a i n f u n c t i o n and thus reduce the p a t i e n t ' s experience of discontinued program.  The  the and  symptoms. the p a t i e n t  p a t i e n t may  In subsequent phases, medication i s u s u a l l y involved  i n a r e h a b i l i t a t i o n psychotherapy  be treated i n an i n p a t i e n t or outpatient s e t t i n g  depending upon the phase of the disorder s i n g l e t h e r a p i s t i n a s s o c i a t i o n with  and  treatment i s t y p i c a l l y  a team of  non-mental health  ( D i l l e r & Gordon, 1981; Grimm & B l e i b e r g , 1986; Kreutzer & Morrison, Disturbance of Code:  Emotions S p e c i f i c to Childhood/Adolescence  by  a  workers 1986).  (Diagnostic  313) i s an e x c e p t i o n a l l y broad diagnostic category, i n d i c a t i v e of the  circumstance that  diagnostic  systems are  l e s s well-developed f o r c h i l d r e n  than f o r a d u l t s .  Given the  d i v e r s i t y of the s u b - c l a s s i f i c a t i o n s included  124 w i t h i n t h i s d i s o r d e r , a l l of the treatment Since  reviews  of  s t u d i e s of the treatment  c h i l d r e n i n d i c a t e t h a t the psychotherapy therapist  management mode i s one  employed f o r t h i s Marchione,  and management modes are used.  disorder (Casey  of emotional  treatment  disturbances i n  mode and  the  of the patterns of treatment & Berman, 1985;  Michelson,  single practice  Mannarino,  Stern, Figueroa, & Beck, 1983; Millman, Schaefer, & Cohen,  1980;  P e l l i g r i n i & Urbain, 1985; S t e i n & Davis, 1982), I have suggested t h a t simple s u b s t i t u t i o n p o s s i b i l i t i e s f o r t h i s disorder be considered t o f a l l  i n the  moderate range. Hyperkinetic  Syndrome of  314)  i s an  extremely c o n t r o v e r s i a l diagnostic category both with regard t o the  proper  parameters f o r diagnosis and treatment.  Childhood  ( D i a g n o s t i c Code:  with regard t o the most e f f e c t i v e method of  There i s debate as t o whether h y p e r a c t i v i t y i s a true syndrome  because no  single  diagnostic  (Loney,  reliability  symptom or 1980;  group of symptoms has  Ross & Ross, 1982)  and  been i d e n t i f i e d  because s t u d i e s of  of diagnosis i n d i c a t e t h a t c l i n i c i a n s may  variously  as the  diagnose  c h i l d r e n with hyperactive behavior as Hyperactive Syndrome, Conduct Disorder, Emotional Disturbance, or Learning Disabled (Cannon & Comptom, 1980; & Sherman, 1983; Wender, 1983).  Shapiro  Treatment i s u s u a l l y i n the s i n g l e t h e r a p i s t  management mode, e i t h e r alone or i n a s s o c i a t i o n with a team of non-mental health  workers.  psychotherapy  Reviews  of  s t u d i e s comparing  and pharmacotherapy have found psychotherapy  more e f f e c t i v e than pharmacotherapy  practices,  considered possibilities.  to  fall  to be equally or  a f i r m p o s i t i o n i n the p a t t e r n of  I have suggested i n the  e f f e c t i v e n e s s of  ( F i r e s t o n e , K e l l y , Goodman, & Davey,  1981); however, as pharmacotherapy has treatment  the  moderate  t h a t H y p e r k i n e t i c Syndrome range  of  simple  be  substitution  125 Psychosomatic Disorders  (Diagnostic Code:  316) r e f e r t o conditions i n  which p s y c h o l o g i c a l f a c t o r s contribute t o the i n i t i a t i o n or exacerbation of a physical condition.  Common examples of p h y s i c a l conditions f o r which t h i s  category may be appropriate include asthma, obesity, migraine gastric ulcer.  P a t i e n t s may be t r e a t e d i n i n p a t i e n t h o s p i t a l s e t t i n g s or  outpatient s e t t i n g s , u s u a l l y by a s i n g l e t h e r a p i s t . psychotherapy treatment, such as biofeedback, intervention  headache, and  p a r t i c u l a r l y the techniques  Reviews of studies of of behavioral medicine  r e l a x a t i o n , deconditioning, assertiveness t r a i n i n g , and  t o increase  adherence t o m e d i c a l  procedures,  indicate  psychotherapy i s an e f f e c t i v e treatment f o r a number of s u b - c l a s s i f i c a t i o n s of  the disorder  1982).  (Agras,  1982; Blanchard,  1982; Conners, 1983; Pomerlau,  As i n the case of Somatoform Disorders, although  the treatment mode  i s u s u a l l y psychotherapy and the management mode s i n g l e t h e r a p i s t , I have suggested that treatment p r a c t i c e s f o r t h i s mental disorder be considered t o f a l l i n the moderate rather than the high range because of the p o s s i b l e need f o r a d i f f e r e n t i a l m e d i c a l / p s y c h i a t r i c diagnosis because p a t i e n t s may p r e f e r  (Knesper et a l . , 1985) and  t o pursue pharmacotherapy treatment and/or  a d d i t i o n a l medical i n t e r v e n t i o n s . To the high range of simple s u b s t i t u t i o n p o s s i b i l i t i e s , I have assigned f i v e disorders which are t y p i c a l l y t r e a t e d i n the psychotherapy treatment mode and the s i n g l e t h e r a p i s t management mode: P e r s o n a l i t y Disorders,  Sexual  Disorders, Adjustment Reaction, Conduct Disorder NEC and S p e c i f i c Delays i n Development. behavioral  Psychotherapy  techniques  supportive,  treatments include behavioral and c o g n i t i v e  and a l s o v e r b a l t e c h n i q u e s ,  such as t h e dynamic,  t r a n s a c t i o n a l , g e s t a l t , and r a t i o n a l emotive  P e r s o n a l i t y Disorders  (Diagnostic Code:  psychotherapies.  301) are considered  d i f f i c u l t to  t r e a t ; the o r i g i n of the disorders i s conceptualized t o be a coping strategy developed i n childhood t o deal with an emotionally  inadequate developmental  126 environment,  hence, the p a t i e n t i s often very well-defended  and  tends  become exceedingly anxious when attempting t o address the problem.  to  However,  i f the t h e r a p i s t i s s u c c e s s f u l i n gaining the p a t i e n t ' s t r u s t , any of s e v e r a l psychotherapy  techniques  have p r o v e d  Masterson, 1981; Numberg, 1984; S p i t z , Sexual  Disorders  mode but  (Buie & A d l e r ,  302)  includes a number of  treatment has proved  For P e d o p h i l i a , n e i t h e r psychotherapy  has  t o be  Offenders,  i f the  psychotherapy  an  effective  p a t i e n t has  treatment, which  not  usually  treatment. offended  In the  treatment  of  sub-  nor pharmacotherapy  In the case of Incest outside his/her  home,  includes behavior m o d i f i c a t i o n and  c o g n i t i v e behavior psychotherapy techniques and parenting s k i l l s , has improvement.  sub-  the p r i n c i p a l  whose e f f e c t i v e n e s s v a r i e s with the p a r t i c u l a r  classification. been found  1982,  1984).  (Diagnostic Code:  c l a s s i f i c a t i o n s f o r which psychotherapy treatment  effective  Impotence and  Frigidity,  brought behavior  m o d i f i c a t i o n and c o g n i t i v e behavior psychotherapy techniques, u s u a l l y grouped under the r u b r i c of sex therapy, have been found to be e f f e c t i v e  (Cooper,  1981; Kuriansky & Sharpe, 1981; Marks, 1981), and while there has been some research i n t o the use of testosterone with Impotence, t h i s has not been found to  be  an  effective  treatment  (Cooper,  1981).  I n the  treatment  of  Transvestism, E x h i b i t i o n i s m , and Sex Offenders, the usual treatment mode i s behavior m o d i f i c a t i o n and c o g n i t i v e behavior techniques; very r a r e l y , i n the case  of t h e  violent  rapist  who  has  proved  unresponsive  to a l l other  i n t e r v e n t i o n s , the medication provera may be used. Adjustment Reaction reaction  to  an  (Diagnostic Code:  identifiable  309)  r e f e r s to a  psychosocial stressor  bereavement, retirement, or f i n a n c i a l l o s s .  such  as  maladaptive divorce,  With these p a t i e n t s , t y p i c a l l y  the treatment strategy i s the use of supportive psychotherapy  t o a s s i s t the  p a t i e n t t o cope u n t i l the s t r e s s o r remits or the use of c o g n i t i v e behavior  127 psychotherapy or the verbal psychotherapies to a s s i s t the p a t i e n t to a t t a i n a new  l e v e l of adaptation i f the s t r e s s o r p e r s i s t s P a t i e n t s diagnosed with Conduct Disorder NEC  considered  difficult  to  motivate  psychotherapies ( R a n i e r i , 1984). causes of  the  (Anolik, 1983; Deisher,  disorder  i n an  Lane, 1980;  1983;  Rich,  suggested, ranging  312)  f o r p a r t i c i p a t i o n i n the  verbal  attempt to develop an  and  e f f e c t i v e treatment  Loeber & Dishion,  while  a number of  1983;  Paperny &  theories  have been  from the b i o l o g i c a l to the psychosocial, there has  much discouragement with the lack of e f f e c t i v e n e s s of the psychotherapy pharmacotherapy t r e a t m e n t s which have been attempted However, i n an  extensive  are  Much research has focussed on the probable  Loeber, 1982;  1982)  (Diagnostic Code:  review  of  (Clarke,  been and  1984).  treatment programs which have been  implemented with t h i s p a t i e n t population, Ross and Fabiano (1985) report t h a t c o g n i t i v e behavior psychotherapy techniques have proved the most e f f e c t i v e i n b r i n g i n g improvement. Specific  Delays i n Development  (Diagnostic  Code:  315)  r e f e r s to  d e f i c i t s such as d y s l e x i a , d y s c a l c u l i a , or language disorders i n an otherwise normal i n d i v i d u a l and are much more frequently diagnosed i n c h i l d r e n than i n adults because that i s the stage of development at which the disorder  on  academic f u n c t i o n i n g f i r s t  become apparent.  e f f e c t s of the T y p i c a l l y the  t h e r a p i s t t r e a t s the p a t i e n t i n a s s o c i a t i o n with a team of non-mental health workers, such as teachers  and  with the s o c i a l manifestations behavior m o d i f i c a t i o n and remedial education Wender, 1983).  family members, a s s i s t i n g with diagnosis of the disorder.  and  The usual treatment mode i s  c o g n i t i v e behavior psychotherapy techniques  (Cannon & Compton, 1980; Millman, Schaefer, & Cohen,  and 1980;  128 Mental Retardation (Diagnostic Codes: The  diagnostic c l a s s i f i c a t i o n  disorders:  317-319)  of Mental R e t a r d a t i o n  M i l d Mental Retardation (Diagnostic Code:  Retardation  (Diagnostic Code:  (Diagnostic Code:  319).  includes  three  317), Other S p e c i f i e d  318), and U n s p e c i f i e d M e n t a l  Patients diagnosed with M i l d Mental  Retardation Retardation  t y p i c a l l y l i v e i n the community, e i t h e r with t h e i r f a m i l i e s or i n a chronic care  setting.  techniques treated  Behavior  m o d i f i c a t i o n and s k i l l  are u s u a l l y the treatment  t r a i n i n g psychotherapy  mode employed.  Patients are r a r e l y  i n s p e c i a l i z e d i n p a t i e n t s e t t i n g s f o r the retarded unless  exhibit disruptive behaviors,  frequently unrelated  they  t o the r e t a r d a t i o n  c o n d i t i o n , which cannot be managed i n the usual f a c i l i t i e s f o r such problem behaviors,  such as the j u d i c i a l system or i n p a t i e n t p s y c h i a t r i c s e t t i n g s .  Patients are t y p i c a l l y managed by a s i n g l e t h e r a p i s t a c t i n g as consultant t o non-mental health workers or family members. Other  For p a t i e n t s diagnosed with  S p e c i f i e d R e t a r d a t i o n , which r e f e r s t o the s u b - c l a s s i f i c a t i o n s of  Moderate, Severe, and Profound Retardation, the goal of i n p a t i e n t treatment, for  those p a t i e n t s who do not require i n t e n s i v e nursing care or who do not  have i n t r a c t a b l e behavior problems, i s placement i n a chronic care s e t t i n g . The  p r e f e r r e d treatment  psychotherapy  mode i s behavior  techniques;  there  pharmacotherapy as a "chemical pharmacotherapy i s t y p i c a l l y ineffective  m o d i f i c a t i o n and s k i l l  i s an attempt  to avoid  training  the use of  s t r a i g h t j a c k e t " and combined psychotherapy/ employed only a f t e r psychotherapy has proved  or when t h e p a t i e n t a l s o s u f f e r s from psychosis.  i n p a t i e n t s e t t i n g , p a t i e n t s are t y p i c a l l y managed by a therapy  In the  team and i n  the outpatient s e t t i n g by a s i n g l e t h e r a p i s t a c t i n g as consultant t o a team of non-mental h e a l t h w o r k e r s .  With r e g a r d  t o p a t i e n t s diagnosed as  Unspecified Mental Retardation, i t i s d i f f i c u l t t o make statements about the treatment  and management modes employed i n these  instances  because t h e  129 category  i s indeterminate,  but I would suggest that the same patterns of  treatment p r a c t i c e hold f o r t h i s diagnostic c l a s s i f i c a t i o n as f o r M i l d Mental Retardation and Other S p e c i f i e d Retardation  (Hornby & Singh,  1983; Kazdin &  Matson, 1981; Matson & Gorman-Smith, 1986). In summary, when these disorders are t r e a t e d i n an i n p a t i e n t s e t t i n g , psychotherapy or combined psychotherapy/pharmacotherapy are t y p i c a l l y the treatment modes and therapy disorders  team the management mode employed.  are t r e a t e d i n an outpatient  When these  s e t t i n g , psychotherapy and s i n g l e  t h e r a p i s t are t y p i c a l l y the treatment and management modes employed, with the t h e r a p i s t a c t i n g as a consultant  t o a team of non-mental health workers.  Based on t h i s pattern of treatment p r a c t i c e s , I would suggest that the simple s u b s t i t u t i o n p o s s i b i l i t i e s f o r Diagnostic Codes 317-319 be considered t o f a l l i n the moderate range.  Conditions Not A t t r i b u t a b l e t o a Mental Disorder Diagnostic Codes: For  the disorders i n t h i s  disorders be considered  to f a l l  classification,  (V61-V71)  I have suggested that two  i n the high range of simple s u b s t i t u t i o n  p o s s i b i l i t i e s and that the remainder be considered t o f a l l i n the low range of  simple  substitution possibilities.  e i t h e r are indeterminate  Those disorders i n the low range  (thus not p e r m i t t i n g an estimate  of s u b s t i t u t i o n  p o s s i b i l i t i e s without f u r t h e r study) or involve medical procedures.  As i t i s  not p o s s i b l e t o make statements about treatment mode and management mode f o r these categories, I have omitted VIII.  i n d i c a t i o n i n the summary i n Table  The diagnostic codes I have suggested be assigned t o t h i s group are as  follows:  No Medical F a c i l i t y f o r Care (Diagnostic Code:  Not Done (Diagnostic Code: Code:  their  V64), Other Reasons f o r Consultation (Diagnostic  V65), Convalescence (Diagnostic Code:  (Diagnostic Code:  V63), Procedures  V66),  Follow-up Examination  V67), Administrative Encounter Diagnostic  Code:  V68),  130 General Medical Examination  (Diagnostic Code:  Suspected Condition (Diagnostic Code: accounted  V71).  f o r o n l y some $3,000 of the  V70),  and  Observation  of  As Diagnostic Codes V63-V71  approximately  $7.5  million  in  expenditures f o r p r i v a t e p r a c t i c e p s y c h i a t r y services (considerably l e s s than .01 percent) i n the data analyzed i n the present study, I have excluded them from consideration. The two disorders which I have suggested be assigned to the high range are Other Family Circumstances (Diagnostic Code: Circumstances  (Diagnostic Code:  V62).  V61) and Other Psychosocial  These conditions are t r e a t e d i n the  same manner as the other disorders i n the high range, t y p i c a l l y  i n the  psychotherapy treatment mode and the s i n g l e t h e r a p i s t management mode-  Other  Family Circumstances r e f e r s t o a range of s i t u a t i o n s , i n c l u d i n g p a r e n t - c h i l d c o n f l i c t , d i v o r c e , i n c e s t , bereavement, and family v i o l e n c e ; l i k e w i s e , Other Psychosocial Circumstances  a l s o r e f e r s t o a range  of s i t u a t i o n s ,  which,  although not r e s u l t i n g i n a mental d i s o r d e r , produce considerable s u f f e r i n g and d i s l o c a t i o n f o r the i n d i v i d u a l and his/her associates.  Psychotherapy  treatments can be d e l i v e r e d i n an i n d i v i d u a l , group, or family context and include behavior m o d i f i c a t i o n and c o g n i t i v e behavior techniques as w e l l the v e r b a l techniques  (Adler & Raphael,  1983;  Dulcan,  1984;  Jacobs, 1982; J e l l i n e k & S l o v i k , 1981; O'Shea & Phelps, 1985;  Holmes,  as  1985;  Schwartzberg,  1981; S i l v e r , Lubin, M i l l e r , & Dobson, 1981; S p i t z , 1984; Swanson & Biaggio, 1985; Wahler, & Fox,  1981).  To conclude, i n Chapters One through Seven I have attempted t o set the stage f o r the development of both q u a l i t a t i v e and q u a n t i t a t i v e answers t o the three questions the present study i s designed to i n v e s t i g a t e : 1.  Which services present the p o s s i b i l i t y f o r s u b s t i t u t i o n ?  2.  What would be the p r o j e c t e d cost i m p l i c a t i o n s of implementing such substitutions?  1 31 3.  What l i c e n s u r e and market r i g i d i t i e s  would need t o be changed f o r  implementation? In  Figure  2,  I have  allocation,  asserting  holds  skills  some  that  proposed a  pool  and s e r v i c e s  a  model  of mental  i n common  of mental health  health  manpower  and which  exists  therefore  p o s s i b i l i t y o f simple s u b s t i t u t i o n i n s e r v i c i n g mental h e a l t h  manpower which  o f f e r s the  needs.  I have  p r e s e n t e d a review o f l i t e r a t u r e and documents which i n d i c a t e s t h a t a l l f o u r core  mental  (Tables an  health  professions  VI and V I I ) t o p r o v i d e  are trained  (Tables  can p r o v i d e  time p e r i o d .  authorized  psychotherapy s e r v i c e s , t h a t psychotherapy i s  e f f e c t i v e treatment f o r a number o f mental  professions  I - V) and  disorders,  and t h a t  the f o u r  comparable p s y c h o t h e r a p y s e r v i c e s w i t h i n a comparable  As w e l l ,  I have  discussed  the p r a c t i c e p r i v i l e g e c o n s t r a i n t s  which l i m i t the a b i l i t y o f non-medical mental h e a l t h p r a c t i t i o n e r s t o p r o v i d e psychotherapy  services  i n some  examination o f p a t t e r n s of  simple  assigned  t o each  o f the mental  summarizing  (Table  VII).  Finally,  o f treatment p r a c t i c e , I have suggested  substitution possibilities  c l a s s i f i c a t i o n system In  settings  (Table  ("low,"  disorder  "moderate,"  diagnostic  codes  from  that a l e v e l  "high")  VIII).  the r a t i o n a l e f o r the p r e s e n t  i n v e s t i g a t i o n of p o s s i b l e  from manpower s u b s t i t u t i o n i n mental h e a l t h  delivery,  at this  represented economies  i n Figures should  expenditures with items  with  point  3a and 3b.  result  under  to high  treatment  low p r a c t i c e  rate  a significant  to return  As F i g u r e  conditions  a r e f o r the treatment  moderate  payment  like  o f mental  where  substitutability  personnel costs  the g r e a t e s t of  codes  I) and f o r t a r i f f  I I ) , a n d where t h e  for substitution (Axis  service  i n diagnostic  (Axis  (Axis  service  graphically  the m a j o r i t y  disorders  privilege constraints  over c u r r e n t  t o the model  3b i l l u s t r a t e s ,  o f the p r o f e s s i o n a l group proposed saving  c a n be  i n the ICD-9-CM  economies t o be d e r i v e d I would  an  III).  represents  Thus,  i f ,in  1 32 examining the b i l l i n g data f o r f e e - f o r - s e r v i c e that  the m a j o r i t y  of service  psychiatry  expenditures f a l l  p r a c t i c e , we f i n d  i n the areas of highest  treatment s u b s t i t u t a b i l i t y and lowest p r a c t i c e p r i v i l e g e c o n s t r a i n t s ,  and i f  the r e l a t i v e payment rates are advantageous, then there are r e l a t i v e l y more economies t o be g a i n e d  from p u r s u i n g  the i m p l e m e n t a t i o n  of manpower  substitution. Axes I and I I , when taken together, permit an estimate of p o t e n t i a l f o r manpower s u b s t i t u t i o n , services and costs. cases of possible  o r , i n o t h e r words,  the s u b s t i t u t a b l e  share of  As i l l u s t r a t e d i n Figure 3a, i f we consider the extreme conditions  f o r manpower s u b s t i t u t i o n ,  that  i s , the four  corners of the diagram, we can see that the upper left-hand corner represents a s i t u a t i o n where there i s v i r t u a l l y no p o t e n t i a l f o r economies from manpower substitution  because l i t t l e  or no p o s s i b i l i t y  e x i s t s and p r a c t i c e p r i v i l e g e constraints by  alternate  regulatory  professionals.  f o r treatment  substitution  severely r e s t r i c t service  delivery  An example where both such educational and  b a r r i e r s a r i s e occurs i n the p o s i t i o n of p s y c h i a t r i s t s as the only  mental health profession  q u a l i f i e d to prescribe  medication.  the upper right-hand corner, again, there i s l i t t l e substitution  because,  s u b s t i t u t a b i l i t y , practice substitution.  although  there  may  p o t e n t i a l f o r manpower  be c o n s i d e r a b l e  p r i v i l e g e constraints  Thus, f o r example, while  In the case of  still  treatment  prohibit  the t r a i n i n g of a l l four  health professions permits them to provide a range of services  condition  S i m i l a r l y , i n the lower left-hand  occurs, i n which p r a c t i c e  mental  i n hospital  s e t t i n g s , p s y c h i a t r i s t s are the only group which has been granted hospital privileges.  manpower  clinical  corner, the reverse  p r i v i l e g e constraints  do not r e s t r i c t  service d e l i v e r y but p o t e n t i a l f o r manpower s u b s t i t u t i o n ,is low because there are  few services  f o r which treatment s u b s t i t u t a b i l i t y i s p o s s i b l e .  Such a  s i t u a t i o n occurs i n the case of i n t e l l i g e n c e t e s t i n g f o r , while there are no  133 legal prohibitions psychologist The  against other professions  administering  these  tests,  are the only p r o f e s s i o n a l group t r a i n e d to provide t h i s s e r v i c e .  lower right-hand corner i l l u s t r a t e s  the case of maximum p o t e n t i a l f o r  manpower s u b s t i t u t i o n because treatment s u b s t i t u t i o n p o s s i b i l i t i e s are high and service d e l i v e r y i s not affected by p r a c t i c e p r i v i l e g e c o n s t r a i n t s . When A x i s  I I I i s added to the model, as i l l u s t r a t e d  i n Figure 3b,  p o t e n t i a l economies f o r such manpower s u b s t i t u t i o n can be projected. once again, the upper rear  left-hand  Thus,  corner of the diagram i n d i c a t e s  no  p o t e n t i a l f o r economies from manpower s u b s t i t u t i o n because not only are the possibilities  f o r manpower s u b s t i t u t i o n exceedingly low, but the costs of  replacement personnel equal those of e x i s t i n g personnel. front  right-hand  corner  illustrates  economies from manpower s u b s t i t u t i o n  Likewise,  the lower  the case of maximum p o t e n t i a l f o r f o r i t i s at this  convergence of the three c o n t r o l l i n g v a r i a b l e s manpower s u b s t i t u t i o n and the r e l a t i v e s a v i n g s  point  i n the  that the p o s s i b i l i t i e s f o r i n personnel  costs are  greatest. Thus, the p o t e n t i a l f o r economies from manpower s u b s t i t u t i o n increases i n somewhat of a fan-shape as we proceed from the upper rear left-hand corner to the lower f r o n t right-hand corner of Figure 3b. However, even i n the most extreme case of maximum p o t e n t i a l f o r economies from manpower s u b s t i t u t i o n , there are f a c t o r s which might l i m i t the f e a s i b i l i t y of manpower s u b s t i t u t i o n , for  example, whether s u b s t i t u t a b l e  trivial,  whether  impractical  services  are judged to be valuable or  s u b s t i t u t i o n of services  i s judged to be p r a c t i c a l or  and whether the cost savings from manpower s u b s t i t u t i o n a r e  judged to be of s u f f i c i e n t magnitude to warrant i n s t i t u t i n g changes i n the service  delivery  quantitative  system.  estimates  The remaining chapters w i l l of the p o t e n t i a l  s u b s t i t u t i o n under various conditions  attempt t o provide  f o r economies  from  manpower  of treatment s u b s t i t u t a b i l i t y , p r a c t i c e  1 34 p r i v i l e g e c o n s t r a i n t s , and r e l a t i v e payment rates, and to discuss q u a l i t a t i v e issues  which might a f f e c t  the p o t e n t i a l  s u b s t i t u t i o n i n mental health service  f o r manpower economies from such  delivery.  135 CHAPTER EIGHT  METHODOLOGY  Methodologically,  m e d i c a l manpower  s u b s t i t u t i o n studies  usually  i n v e s t i g a t e p o t e n t i a l gains i n cost effectiveness by f i r s t examining the skills  and p r a c t i c e p r i v i l e g e s required  under p a r t i c u l a r t a r i f f those t a r i f f  to d e l i v e r the procedures  items and then c a l c u l a t i n g p o t e n t i a l savings f o r  items which o f f e r the p o s s i b i l i t y of s u b s t i t u t i o n .  s t u d i e s , because there i s a one-to-one correspondence and  s p e c i f i c procedures,  treatment  billed  In these  between t a r i f f  items  the e f f e c t s on s u b s t i t u t i o n p o s s i b i l i t i e s o f  substitutability  and p r a c t i c e p r i v i l e g e c o n s t r a i n t s can be  evaluated with an examination of t a r i f f items alone.  However, i n the case of  p r i v a t e p r a c t i c e psychiatry s e r v i c e s , t a r i f f items are commonly designated as classes of s e r v i c e (e.g., o f f i c e v i s i t ) rather than as s p e c i f i c procedures. Hence, a l t h o u g h the e v a l u a t i o n  o f the e f f e c t s of p r a c t i c e p r i v i l e g e  constraints can proceed, as usual, from an examination of t a r i f f items, the evaluation of treatment s u b s t i t u t a b i l i t y must proceed from an examination of the treatment p r a c t i c e s associated with p a r t i c u l a r diagnostic codes; then the e f f e c t s of the two v a r i a b l e s can be examined i n combination to determine the s u b s t i t u t a b l e share of services and costs. While we are p r i n c i p a l l y concerned i n the present research p r o j e c t with substitution p o s s i b i l i t i e s Columbia,  since  f o rprivate practice psychiatry  the disaggregated B r i t i s h  Columbia  i n British  Medical  Services  Commission (BCMSC) data on expenditures f o r these services do not include d i a g n o s t i c code, i t has been necessary f o r methodological reasons to use data from  the Manitoba  d i a g n o s t i c code.  Health S e r v i c e s  Commission  (MHSC), which  do i n c l u d e  Thus, i n the i n i t i a l stages of the a n a l y s i s I have used the  1 36 Manitoba data to estimate the s u b s t i t u t a b l e share of services and costs as determined by the f i r s t two c o n t r o l l i n g v a r i a b l e s , treatment s u b s t i t u t a b i l i t y and p r a c t i c e p r i v i l e g e c o n s t r a i n t s .  I have then r e l a t e d the estimates of the  s u b s t i t u t a b l e share of costs derived from the MHSC data to the BCMSC data to p r o j e c t the cost i m p l i c a t i o n s of manpower s u b s t i t u t i o n f o r B r i t i s h private  practice  p s y c h i a t r y s e r v i c e s , introducing the t h i r d  Columbia  controlling  v a r i a b l e , r e l a t i v e payment r a t e . An a n a l y s i s was made of MHSC data f o r f i s c a l years 1982, 1983, and 1984, containing the b i l l i n g s by a l l medical p r a c t i t i o n e r s f o r the treatment of mental d i s o r d e r s , i n order to determine the consistency across years of the d i s t r i b u t i o n of b i l l i n g s across diagnostic codes. stage  were f o r a l l m e d i c a l p r a c t i t i o n e r s  p s y c h i a t r i s t s , because the former investigator  Data f o r t h i s v a l i d a t i o n  rather than s p e c i f i c a l l y f o r  data were a v a i l a b l e at no cost t o the  whereas the l a t t e r  data were not.  The data were i n the  f o l l o w i n g disaggregated format: Diagnostic Code x