Psychology’s Perverse Vision

February 27, 2008

Instead of directing their sexuality towards a more conventional object, individuals with perversions deflect their desire elsewhere, be it towards special clothing, shoes, or more dangerously, even children. Professional . psychology, on a state and national level, displays a similarly perverse deflection in its objectives. Its proper aim of providing the highest possible quality services has been *misdirected by financial concerns. The profession emphasizes educating psychologists to “survive” by working with managed care companies (Murray, 1998) rather than aggressively finding alternatives; it passively allows the unregulated proliferation of new doctoral programs rather than improving existing ones; worse yet. it enthusiastically pursues the gravest perverse aim of professional psychology – the quest for prescription privileges (Sullivan, 1997)when so many psychologists lack proper training now.

So why has psychology’s vision become so distorted? Because over the course of its short history, economics has replaced ethics as the motivating force of the profession. Beginning during World War II. with the need for mental health practitioners to treat psychologically traumatized soldiers, clinical psychology emerged as the bastard child of medicine, relegated to a second-class position, but tolerated due to need. During the ensuing three decades, with much sweat and toil on the part of its leaders, psychology emerged as a distinct discipline. By the 1970s, it had gained considerable respectability. Psychologists’ expertise in provision of psychotherapy, and psychological and neuropsychological assessments, was well-established. Many psychologists practiced independently. Graduate schools excelled in training psychologists in these basic tasks.

Then, with the malignant spread of health maintenance organizations and preferred provider organizations, commonly referred to as the “industrialization of medicine,” the face of psychology rapidly changed. Issues of privacy and provision of sufficient treatment took the back seat to concerns about cost-cutting. The insidious descent into motivation by money over quality gained momentum. As psychologists panicked at loss of insurance reimbursement, their concern turned to self-preservation. By the late 1980s, some psychologists began seeking prescription privileges as a way of competing with medicine and working within the new time-limited, cost-controlled system. No matter how they packaged it, the prescription privilege movement reeked of hoped-for financial gain, not quality of care. Unaccredited schools began sprouting up. feeding like so many sharks on naive graduate students of psychology heading toward professional slaughter. Administrators and instructors in these schools were easily found in the ranks of underemployed psychologists.

Meanwhile, managed care spread like wildfire, further limiting length of treatment, restricting provider participation, requiring utilization review by less qualified professionals, and increasingly invading the privacy of treatment, thereby ruining it. It was then only a short trip to the dark collection of various recently published, particularly nauseating articles in the professional newsletters, screaming of rationalization, such as one recent gem in the APA Monitor (Galante, 1997) which described a psychologist’s discovery of how working for a managed care company, which she had previously viewed as “the enemy,” was rewarding. She writes, “I disagree with the view… that MCOs (Managed Care Organizations) denigrate, limit or dictate the profession of psychology. I believe providers have irrational attitudes and behaviors toward MCOs.”

Because it has been responding to market pressures rather than improving its services, professional psychology now hemorrhages credibility. The continued capitulation to managed care forces will lead to further limits on outpatient psychotherapy and greater erosion of confidentiality. Patients who would best be served by psychological interventions will increasingly be herded into cheaper but often less effective psychopharmacological interventions; those in need of psychological assessments will rarely receive them. Insufficient energy gets directed towards finding alternatives which are cost effective yet retain confidentiality and access to treatment.

The managed care problem at least receives active discussion in professional newsletters, and some degree of action, but one reads much less about the expanSion of, existing and new training programs. More doctoral level psychologists are graduating than ever before, despite an absence of internships or actual professional jobs. One recent doctoral level psychology graduate appeared in Playboy magazine (October 1997 issue). How many more will be driving taxicabs, working as waiters or functioning in other businesses? These trends tarnish the reputation of the field. For those who find work in psychology, their fees or salary will be reduced, as will respectability, as quality of services falls. The supply of psychologists already exceeds demand. The public will become increasingly aware of how many of the swollen training programs – many of which are motivated by profit rather than excellence – inadequately screen or train their graduates.

Finally, the inevitable failure of the prescription privileges effort will drain limited financial resources for political lobbying and weaken the profession in the eyes of other professional colleagues, not to mention the public.

As I argued in more detail in an earlier California Psychologist article (Karbelnig, 1995), psychologists already have a more than sufficient number of skills. The addition of applied psychopharmacology will only aggravate the fields’ identity crisis. Obtaining mastery in even one of the varied schools of psychotherapy, in performing psychological research, or in conducting psychological or neuropsychological evaluations already requires a lifetime of devotion. So why add another complex competency, which so greatly overlaps with medicine, when psychologists’ plates are already overflowing? The suggestion that prescription privileges are needed because rural America lacks sufficient psychiatrists lacks logic; it makes more sense to train rural primary care providers or nurse practitioners in provision of psychotropics. Better to leave the psychopharmacology to physicians who should be devoting their full-time energy to adjusting chemicals rather than providing psychological services. The time and energy wasted on seeking prescription privileges should be spent instead on dealing with managed care and improving training.

Perversions typically prove difficult to treat because of the gratification individuals find in the distorted object of desire. A compulsive, self-reinforcing pattern usually develops which ensures the continuation of the behavior. This is just the sort of dynamic that has possessed professional psychology. It has become entrenched in certain paths: Lobbying for prescription privileges when many psychologists are inadequately trained in their basic skills; training psychologists to work within a managed care system, which destroys the provision of meaningful psychotherapy, rather than aggressively promoting quality alternatives; and allowing graduate training programs in psychology to proliferate, many of them without APA accreditation, when higher standards for screening and training should be developed instead.

In cases of severe perversions, behavioral changes typically only follow major consequences, i.e. arrest or public exposure. If hope exists for the future of psychology, it sadly lies on a similar path. As the profession’s credibility plummets, the prescription privileges effort fails, and the number of unemployed psychologists reaches into the hundreds or thousands, perhaps only then will we be able to focus our attention on these three focal tasks: relinquishing the absurd push for prescription privileges, eliminating, replacing or severely controlling managed care in professional psychology, and greatly increasing the standards for professional education through better screening, training, and the elimination of unaccredited schooling.

References
Galante,V. (1997). Managed care is not the enemy. APA Monitor, 28(9).

Karbelnig,A. (1995). Prescription privileges:An iatrogenic disease for psychology. California Psychologist, 28(8).

Mad about Christina. (1997). Playboy, 44( I0).

Murray, B. (1998). Psychology trainers urged to update their programs. APA Monitor, 29( I).

Sullivan, M. (1997). Prescription privileges. The California Psychologist, 30(6). Califorma

Published as:
Karbelnig, A. (1998). Psychology’s Perverse Vision. The California Psychologist, 31(7), 24-25.

(Dr. Karbelnig, a past Member of the CPA Board of Directors and current Chair of the Ethics Committee of the San Gabriel Valley Psychological Association, practices psychoanalytic psychotherapy and forensic psychology in South Pasadena, California.)

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