The Public Sector Psychologist With 2020 Vision

Thomas W. MillerUniversity of Kentucky

Patrick H. DeLeonFormer President, American Psychological Association

Robert D. MorganTexas Tech University

Walter E. PenkTexas A&M University Systems Health Science Center,

Central Texas VA Health Care System, andHarvard Medical School at Cambridge Hospital

Philip R. MagalettaFederal Bureau of Prisons

What will public sector psychology look like in the year 2020? Will public sector psychologists beprepared to meet the evolving challenges and service needs encountered during the next 20 years? Thepurpose of this manuscript is to identify common characteristics of public sector psychology across worksettings and describe the changing face of public sector psychology. Emphasis is placed on the drivingforces fueling changes to the field (i.e., changing health care delivery paradigms, growth in technologyand information systems, new levels of professional accountability, changing economic infrastructures,and shifts in clinical populations and points of interventions). In addition, a vision for the future of publicsector psychology is offered.

Keywords: psychology, public sector, future, visionary

Psychologists in the public sector respond to the needs of thepublic in areas such as psychological practice, research, training,and policy formation. Public sector psychologists represent a va-

riety of settings: community and state hospitals, criminal justice,police and public safety, Indian health services, veterans’ affairs,and other publicly funded organizations committed to public wel-

THOMAS W. MILLER received his doctorate from the State University ofNew York at Buffalo, is a diplomate of the American Board of ProfessionalPsychology in clinical psychology, and is a fellow of the AmericanPsychological Association, the American Psychology Society, and theRoyal Society of Medicine. He has been a tenured professor at the Uni-versity of Connecticut and the University of Kentucky College of Medicineand has been chief of service at the Department of Veterans Affairs. He hasconsulted internationally with the Russian government, the British Instituteof Psychiatry and Royal Ministry of Defense. Research areas includepost-traumatic stress disorder (PTSD), telehealth, life span issues. andstressful life events.PATRICK H. DELEON received his PhD from Purdue University and JD fromCatholic University of America. He is Former President of the AmericanPsychological Association, chief of staff to Senator Daniel Inouye, formereditor of Professional Psychology: Research and Practice and PsychologicalServices and recipient of several awards and commendations for his commit-ment and dedication to public service psychology.ROBERT D. MORGAN received his doctorate in 1999 from Oklahoma StateUniversity. He is associate professor of psychology and director of theAmerican Psychological Association-accredited doctoral program in coun-seling psychology at Texas Tech University. His public service and generalresearch interests include correctional mental health, forensic assessment,and training and professional development.WALTER E. PENK received his PhD from the University of Houston andcurrently holds appointments with Texas A&M University Systems HealthScience Center; Central Texas VA Health Care System; Harvard MedicalSchool, Cambridge Hospital; Edith Nourse Rogers Memorial VeteransHospital; and Boston University School of Medicine. Research interestsinclude evaluation of managed care in treatment of mental and medical

health outcomes, diagnosis and treatment of PTSD, program evaluation ofcase management in treating patients who are seriously mentally ill, anddesign, implementation, and evaluating effectiveness of supported employ-ment programs for persons with serious mental illness.PHILIP R. MAGALETTA earned his doctorate in clinical psychology from St.Louis University. He has been practicing correctional psychology for overa decade with the Federal Bureau of Prisons and currently serves theagency as the clinical training coordinator for the psychology servicesbranch. His areas of research include mental health and substance abuseservices delivery to incarcerated populations and organizational ap-proaches to behavioral sciences research in prisons.THE AUTHORS WISH TO ACKNOWLEDGE the support and assistance ofDolly Sadow, PhD; Bob Kerns, PhD; Steve Nisenbaum, PhD; KathleenMcNamara, PhD; Barbara Powell, PhD; Bob Goldberg, PhD; Bob Ax,PhD; Bob Gresen, PhD; Rod Baker, PhD; Robert Goldberg, PhD; KathyHarowski, PhD; Monica Roy, MS; Ed Nightengale; Terry Keane, PhD;Ken Klauck, PhD; Phil Laughlin, PhD; Bill Safarjan, PhD;Charlie Stenger, PhD; Jon Cummings, PhD; and other public sectorpsychologists for their inspiration in the preparation of this article. Inaddition, the assistance of Jill Livingston, MLS, Jean M. Miller, EdD,Brenda Frommer, Kaysie Campbell, and Betty Downing are appreci-ated.THE VIEWS EXPRESSED IN THIS ARTICLE are those of the authors only and donot necessarily reflect the policies or opinions of the Bureau of Prisons, theDepartment of Justice, the Department of Veterans Affairs, or the authors’academic affiliations.CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to ThomasW. Miller, College of Medicine/Psychiatry, 3470 Blazer Parkway, Universityof Kentucky, Lexington, KY 40509-1810. E-mail: tmiller@uky.edu

Professional Psychology: Research and Practice Copyright 2006 by the American Psychological Association2006, Vol. 37, No. 5, 531–538 0735-7028/06/$12.00 DOI: 10.1037/0735-7028.37.5.531

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fare. As in the private sector, public sector psychology is consis-tently changing. But what forces will likely drive change in publicsector psychology in the future?

Several driving forces in the future are likely to influencepsychologists working in the public sector (e.g., Miller, 1998).These are driving forces that will require research in clinicaleffectiveness and efficiency and best practices—the driving forcesmost likely to constitute domains of empirical validation worthy ofarchival preservation. These also are the forces most likely tostrongly impact structures and functions of public, tax-supportedagencies, and, therefore, a psychologist’s practice. These drivingforces include: (a) modifications in health care delivery paradigms;(b) the growth of technology and information systems; (c) newlevels of professional accountability; (d) changing economic in-frastructures; (e) shifts in clinical populations and points of inter-ventions; (f) credentialing; and (g) prescription privileges (seeTable 1).

Although these driving forces are likely to affect professionalpsychology in general, their impact probably will be more dra-matic for public sector psychology because these forces willchange the organizational structures, mechanisms of providingservices, modes of reimbursements, and clientele served by psy-chologists in the public sector. It is noted that “public sectorpsychologists focus exclusively on the most serious and persistentsocietal problems, the least advantaged and most disenfranchisedpatients, the most culturally diverse clientele, and the most diffi-cult work venues” (Nisenbaum, 2002/2003; p. 3). Furthermore,public sector psychologists practice in a variety of organizationalinfrastructures, each of which has a slightly different mission,developmental and evolutionary history, and each of which servespsychology to a slightly different population. Thus, public sectorpsychologists rely on flexibility and creativity to meet societal and

patient needs as these needs change in response to political, social,and economical forces.

It is not surprising, therefore, that public sector psychologists,more by default than by design, are frequently at the forefront ofprofessional guild issues. Division 18 (Psychologists in PublicService) of the American Psychological Association (APA), forexample, advocated and supported prescription privileges legisla-tion. Correctional psychologists, by necessity, have been forced tocreate innovative service delivery options (e.g., telehealth) as wellas expand their repertoire of services (e.g., prescription privileges)in response to increased incarceration of mentally ill offenders(Ditton, 1999) without parallel staffing increases (Boothby &Clements, 2000). Similarly, the Bureau of Indian Affairs mustbalance the impact of technology and Western medicine with thedelivery of traditional health care and psychological treatmentsbased on the influence of Shamanism and the cultural traditions ofvarious tribes. As a result, public sector psychologists have takenthe lead in testing core principles of evidenced-based practicesamong the poor, the disadvantaged, and the culturally different,thereby filling diversity gaps among the marginalized as noted inAPA’s 2005 policy to test efficacy and effectiveness of treatmentand rehabilitation across all demographic categories of the generalpopulation (Norcross, Beutler, & Levant, 2005).

Stated more provocatively, public sector psychologists are morelikely to be impacted by changes in social and political policiesthan are private sector psychologists. Public sector psychologistsmust adjust their practices to changes in political administrations,disasters (e.g., Hurricane Katrina), changes in fiscal priorities, stateand federal budget cuts, and to continually restructured servicedelivery organizations. Changing health care dynamics have trans-formed real lives into statistical lives, specialty care to primarycare, and clinician-centered delivery models to consumer-centered

Table 1Major Shifts: A 2020 Vision for Public Sector Psychology

Driving forces 20th century 21st century

Health care deliveryparadigms

Federal hospitals, prisons, state hospitals, governmentsystems and providers of services functionindependently

Public and private networks and alliances in clinical,science, research, and care delivery with teams ofspecialists in each network and shared servicesbetween government agencies

Technology and informationsystems

Paper records, government-developed record systems,mail, local network accessibility; paper files,intra-unit information systems

Electronic records, online support systems, electronicfiles, worldwide limited access to current networkaccessibility, virtual information on criminal justiceeducation and health and medicine records

Professional accountability Limited accountability for clinicians andadministrators with respect to competency skills,outcome effectiveness, accreditation reviews, selfstudy, and site visits for institutions

Networks of accountability through managed carealliances; clinicians and administrators work withgovernment programs, contract with private agenciesfor accountability and assessment of systems

Economic infrastructures Salaries with increments, merit pay, revenueexpandable to cover costs

Capitation and contracting focusing on cost; premiumsfor efficiency and expected outcomes

Clinical populations andpoints of intervention

Few incentives for prevention-based initiatives,wellness and health promotion limited

Wellness promotion through public policy initiativescontracting for prevention diagnostic evaluation,diagnostic genetics; patients receive incentive forprevention efforts and wellness monitors and healthpromotion adherence

Credentialing and licensure Credentialing waived in governmental institutionsproviding lower standards for practice

Public service sector requires benchmark standards forpractice and licensure mobility to provide network ofclinical service

Prescription privileges Domain of physicians, advanced practice nurses, andphysician assistants

Psychologists contribute to spectrum of therapeuticinterventions in public service through prescriptionprivileges

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care. Thus, the driving forces, which generally are public issuesoutside the field of psychology, are particularly relevant, becausepublic sector psychologists are most likely to be directly impactedby policy changes.

Driving Forces for Public Sector Psychology

The driving forces facing public sector psychology includemany of those that face the health care establishment. The NationalInstitute for Health Care Management (2003) and the NationalCommittee for Quality Health Care have enumerated the drivingforces for change in our society. Among them are shifts from aprovider driven paradigm of health care delivery to a more patient-centered model that is evidence-based, well coordinated, and pro-vides continuous care. The information system will shift from apaper-based model to an electronically based system linking publicsector hospitals, agencies, and health care alliances. The publicsector will see adversarial governmental regulation shift to a morecollaborative regulated system, resulting in overall cost decline.When one considers these trends along with the visionary projec-tions of the APA Policy and Planning Committee trends in theirpublication entitled “APA 2020: A Perfect Vision for Psychology”(Tars, 2005), there is evidence of the driving forces impactingpublic sector psychologists’ domain.

Changing Health Care Delivery Paradigms

We expect our health care system to fundamentally change overthe next 15 years. Accordingly, public sector psychologists mustcontinually reconsider how they may best add value to changes inthe delivery of health services (O’Neil & the Pew Health Profes-sions Commission, 1998). It is likely that there will be shifts fromtraditional models of delivery to networks of services, with someinvolving group contracting and integrated delivery systems.These shifts will force public sector psychology to explore andexamine ways in which the public service professional deliversand provides services to the global network of consumers. Theorganizational focus may shift from hospitals, independent prac-tices, and independent provider services to networks of services,physician and clinician-oriented group contracting and integrateddelivery systems. The structure on which health care is foundedwill change. For example, health care services are already deliv-ered less often on inpatient units than in community health carefacilities; services are even provided through the use of the Inter-net. Changes such as these will force public sector psychology toexplore and examine the ways in which the consultant may bestdeliver and provide services in the health care delivery network ofthe future.

Ultimately, changes in the delivery of health care will have aprofound impact on the culture of our public service professions.We are likely to witness several accommodations to our profes-sional identities. The first of these is globalization, which Trofino(1996) describes as advocating a holistic perspective, the ability tobridge cultural gaps, and becoming global in our learning andproblem solving approaches. Such globalization requires develop-ing a shared vision with consumers, competitors, researchers, andproviders—a shared vision being critical for health care delivery towork successfully. Individuals and organizations will need to focus

not on short-term profits but on long-term gains for public andcommunity good.

Knowing how to master change will be essential for success inprofessional identity. Leadership changes will be needed.“Systems-thinking” will surpass linear thinking. Integration ofprofessions and locales will increase, leading to an integratedunderstanding of problems and their solutions. Public sector ad-ministrators will lead an increasingly diverse workforce whereclinicians and researchers will become more integrated in thepublic service arena. And psychologists in the public sector willneed to be more flexible than ever, balancing their drives towardmore internality in loci of professional control, with demands forcooperation as a member of an interdisciplinary team. Simulta-neously, shifts from traditional models of care will create a needfor increased consumer education programs aimed at health pro-motion, wellness, and disease prevention; such programs willprovide services to business, medicine, health care, schools, vet-erans, prisoners, constituents of the public service sector, and tothe world community through distance learning technology(Miller, Miller, Burton, Sprang, & Adams, 2003).

Accelerated change and increasing complexity require an em-powered public sector workforce. Empowerment may be definedas self-direction, allowing psychologists to take responsibility andauthority for decisions that affect them. Empowerment permitsspeed in decision-making, allowing educators to collaborate freelyand promote creativity, quality, safety and a true liberation of thehuman spirit. Empowerment will support a new leadership para-digm for the 21st century. To actualize empowerment for bothpublic sector psychologists and their clientele, psychologists mustpursue funding for services. Public sector psychologists may needto compete for resources, including the resources to fund one’sposition—as many already do in independent practice and whenwriting applications for health services grants.

The multiskilled public sector psychologist who achieves a 2020vision will realize technical competencies that address complexsystems analysis in an indigenous user-friendly manner. Emergingmodels of differentiated practice now necessitate expert specialistswho provide educational services for the future. New alliances willbe forged with many disciplines, including health care, business,industry, and global educational initiatives. These empowered“knowledge specialists” will be increasingly self-directed, provid-ing clinical services to an interventional health care market place.

Growth in Technology and Information Systems

Information systems and technology now offer the advantagesof access, speed, and flexibility, which, in turn, accelerate learning,information gathering and integration, and global knowledge.Hand-held computers, for example, are revolutionizing public ser-vice psychology from data collection of health statistics, to mea-suring reactions of stress under battlefield conditions, to servingthe psychologist whose “office” may be a squad car, hostage/barricade negotiation van, or a command center.

The positive impact of technology is already established, andapplications are increasing and generalizing across all public sec-tor settings. Telehealth, using audio-visual technologies to provideservices long distance, is increasing in the workplace (Thomas &Hersen, 2002), in hospitals and rural clinics (Stamm, 2003), and incorrectional facilities (e.g., Lowes, 2001; Magaletta, Fagan, & Ax,

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1998; Magaletta, Dennery, & Ax, in press). Telehealth allows theseriously mentally ill to access services in a more expedientmanner and allows administrators more latitude to select serviceproviders.

Telehealth is growing quickly in health care, law enforcement,homeland defense, and in fighting a war on terrorism, as well as inpreparing for natural disasters and the human complexities thatcomplicate responses to natural disasters. Positive results in tele-health not only accrue from access but from information anddatabase storage. Such benefits can be found in all aspects ofpublic sector psychology, such as in corrections, where positiveresults are associated with marital and family therapy throughtelehealth, which brings those patients outside the correction fa-cility to those inside, buttressing social supports and familialinfrastructures.

Telehealth is not confined to therapeutic interventions alone.Brailer (2005), National Health Information Technology coordi-nator, has developed a strategic plan for building a national healthinformation structure for serving underserved rural and NativeAmerican populations. The Veterans Health Administration(VHA) has a long tradition of telehealth applications beginningseveral decades ago in developing the Mental Health Users Pack-age for automating scoring psychological testing. The VHA now ishost to the automated psychological test report, an evidence-basedanalysis of scores (see, e.g., the Butcher Report in Butcher, 2005).Other telehealth applications include the VHA’s National Post-Traumatic Stress Disorder Centers’ (www.ncptsd.org) Internet-and Web-based resources for public sector psychologists treatingsurvivors of trauma—the Published International Literature OnTraumatic Stress (PILOTS) Web site. This Web site providedprivate and public practitioners with crises debriefing methods inresponse to the terrorist attacks of September 11, 2001. Currently,PILOTS is one of the most widely accessed Web sites in responseto the disasters associated with Hurricane Katrina, which devas-tated the Gulf Coast in 2005.

Electronic records can now bridge and link multiple systemsthat host the marginalized populations that public sector psychol-ogists so often serve. It is now possible to track the impact ofpolicy decisions quickly, accurately, and efficiently. Imagine da-tabases with common data points that permit assess to completetreatment histories across and between systems at different pointsin time.

Toward this end, the Practice Directorate of the APA has takenthe lead in designing and implementing the infrastructure neces-sary to operationalize networking among practitioners (www.APApractice.org), as well as training practitioners to be HealthInsurance Portability and Accountability Act (HIPAA) compliant.What APA has done for psychologists in independent practice nowcan be transferred to psychologists in the public sector.

New technologies are not only transforming the process of howclinical information is categorized, stored, shared, and then com-municated, but new technologies such as CT scans, MRIs, andfMRIs now produce a new dimension, as distinguished from theprocessing of information. The content from new technologiesrequires new coding systems for classifying responses and linkingbehavioral and societal referents for new ways of cognitivelycomprehending the problems and opportunities of persons withwhom psychologists are working. Changes in technology willoccur at increasingly faster rates, expanding data about the con-

tents of minds and psychologists’ visions of how minds are chang-ing to cope with the additional challenges that new technologiescreate (Gardner, 2004).

Technological advances will also lead to increased educationalopportunities. Just as technology has led to the development oftelehealth, so too will technology change the process of continuingeducation. Although university-based education will remain thefoundation of psychological training, tele-education will becomeincreasingly popular, as faculty and students are able to receive—via telecommunication methods—specialized training and educa-tional sessions from experts in the field. Rather than reading achapter by an expert on a topic and then having a classroomdiscussion, tele-education will offer opportunities for interactingand discussing relevant issues directly with the experts in the field.Students will experience first hand the globalization of profes-sional psychology through mass teaching via satellite connections.In addition to traditional didactic training, students will be able toobserve or participate in clinical work with experts in the field.

New Levels of Professional Accountability

As new public sector paradigms emerge, accountability will beredefined. Controls against duplication and incompetence will berecognized. Networks of organizations and government programswill oversee and account for delivery of services. Concepts such ascontract accountability and tenure will be revisited often andregularly. New models in the public sector may take advantage ofstructuring a stepwise procedure for decision-making use carealgorithms or flowcharts (www.hhs.gov/healthit/). These flow-charts are designed to be clear, concise, and graphic to provide abasis for communicating a competent, standardized pathway fordelivery of health care (Miller, Suchinsky, Kraus, & Leukefeld,1997).

Managed care and other forces are demanding that providersstandardize their care and achieve uniformity in services, therebyguaranteeing that consumers of medical and mental health servicesreceive those services they have paid for. Toward this end, VHAmental health specialists have developed clinical guidelines andcurrently provide free access to such care algorithms on the VHAWeb site (www.mentalhealth@med.va.gov/guidelin.htm).

Once algorithms choice points are selected, care pathways thatassign and define a multidisciplinary team approach are generated.These pathways represent the alliance of multidisciplinary special-ists working together toward the common goal of meeting theneeds of both provider and consumer. Again, public sector psy-chologists will lead in (a) evaluating effectiveness of guidelineimplementation, and (b) designing and evaluating effectiveness ofmanual-based treatment approaches that form the standardized,uniform approach to each diagnostic category (see, e.g., Foa,Keane, & Friedman, 2000; Norcross, Beutler, & Levant, 2005).

Changing Economic Infrastructures

Economic conditions will likely impact shifts driven by capita-tion and contracts with financial incentives as well as maximizingcost effectiveness. The events of 9/11 have transformed not just thestructure of our society but also the way in which psychologistsnow function in our society; this is true particularly for thosepublic sector psychologists who long ago began to develop a set of

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skills to address both the physical and the psychological impact ofbioterrorism. Economic infrastructures currently are being createdto sustain legislation being developed by members of the UnitedStates Congress—under the umbrella of the domestic homelandprotection acts and the bioterrorism preparedness acts—and willinevitably transform the role of public sector psychologist byincreasing funding for counseling and training in disaster responseand improving ways of responding to public health emergencies(e.g., Hurricane Katrina).

For new agencies, which support much of the state-of-the-artbehavioral sciences research, new economic infrastructures andfunding streams may begin to appear. One possible source for suchfunding is the criminal justice system. With increasing numbers ofseriously mentally ill patients behind bars (Diamond, Wang, Hol-zer, Thomas, & Cruser, 2001), one must pause and question howthe research funding process will be impacted. The Center forMental Health Services and Criminal Justice Research, funded byNational Institute of Mental Health (NIMH), are now collaboratingto address these issues. This center provides an organizationalstructure that promotes and facilitates the scholarly work of pro-fessionals interested in studying the prevalence of mental illness incorrectional settings and developing methods of better measuringthe needs of offenders. Public sector psychologists must orientthemselves to competitively seek funds for health services researchand training.

Shifts in Clinical Populations and Points of Interventions

Public sector psychologists are experiencing unprecedentedshifts in the clinical populations served and the provision of mentalhealth interventions, which will necessitate a paradigm shift inpublic sector psychology. For example, there are currently2,000,000 inmates in state and federal prisons in the United States,two-and-a-half times as many as 15 years ago (1990) when only743,382 inmates were incarcerated (Sentencing Project, 2003).This drastic increase not only raises issues of overcrowding, butalso severely taxes the ability of correctional psychologists to meetthe mental health needs of incarcerated offenders. Currently, thelargest mental health system in the United States is the jail andprison system (Condelli, Bradigan, & Holanchock, 1997; Hodgins,1995; Steadman, Morris, & Dennis, 1995; Torrey, 1995), withnearly 20% of the prison population suffering from a severe mentalillness (Bureau of Justice Statistics, 1999). Thus, public servicepsychologists need to alter their services from rehabilitation to abasic mental health services model (Fagan, 2003), changing scopeof practice to incorporate a biopsychosocial model of services,including advocacy.

Shifts in demographics already are impacting all agenciesserved by public sector psychologists because our nation is aging.Currently, more than 13% of the nation’s population is 65 years ofage or older; by the year 2030, more than 20% of the populationswill be over the age of 65 (Qualls, Segal, Norman, Niederehe, &Gallagher-Thompson, 2002). As public sector psychologists con-tinue to see older clients in mental health agencies and correctionalsettings, therapeutic programming must be overhauled to addressthe special needs of geriatric clients.

The changes that public sector psychologists will experience bythe year 2020 are not limited to demographic and presentingproblems. The interventions themselves will require modification,

in response to the changing mental health needs of clients or theelimination of programs and services as a means of fiscal savings.Alternative community-based programs are now being developedto create new roles for psychologists in such services as casemanagement, supported employment, family and peer counseling,and supported housing.

Increasingly, public sector psychologists are developing skills toprevent medical disorders (such as AIDS, cancer, and obesity)while developing expertise in areas such as genetic counseling,pain management, enhancing treatment compliance, and sustainingmotivation for challenging treatments in medical settings. Not onlymust new efforts focus on prevention and treatment adherence inmedical settings but efforts must be increasingly rehabilitative,particularly in prison settings (e.g., Andrews, 1994; Andrews,Zinger, Hoge, Bonta, Gendreau, et al., 1990; Gendreau & Ross,1987). As demographics change in medical and prison popula-tions, effective treatment strategies must be identified throughresearch for alleviating symptoms and increasing functioning andcoping (e.g., Fagan, 2003). With increasing globalization, publicservice psychologists also will see increasingly diverse popula-tions; interventions, therefore, will need to transcend cultures witha focus on developing broad based applicable treatment models.

Licensure and Credentialing

One exciting aspect of working in the public sector is theopportunity to develop creative service delivery and training mod-els for the future. In many ways, what transpires within the publicsector dramatically shapes the environment for private sector prac-tice; the potential for great change definitely exists. Already, thepublic service delivery systems at the local, state, and federallevels are generally not constrained in practice by tradition orstates’ scope of practice laws. Within the federal system, bystatute, all health care practitioners must be licensed by a state(although not necessarily the state in which they are employed);however, the actual clinical functions they perform usually aredetermined by the rules and bylaws of the institutions that employthe health care practitioners. Clearly this flexibility allows forcreative applications of psychology and the behavioral sciences topatient and systems concerns. Events that are the result of naturalor human-engendered disasters, which are large in scale now,require that licensing and credentialing policies be changed so thatclinicians can be amassed across licensing jurisdictions and par-ticipate fully as first-responders. Such flexibility may be one of thelegacies of Hurricane Katrina.

Interestingly, over the years several national health policy com-missions, including the Pew Health Professional Commission,have raised serious questions about our society’s historical relianceupon state determination of health professional competence, whichshould not be confused with individual practitioner competence.As we enter the 21st century and begin to experience the unprec-edented impact of technology on health care practice and partic-ularly the exponential advances occurring within the communica-tions field (e.g., telehealth, e-pharmacy, and the development ofvirtual consultation and training systems), the former significanceof geographical limitations, including deferring to local customs,no longer is as relevant to determining quality care (or conditionsof employment).

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The Pew commissioners further observed that balancing thetensions between free choice by consumers and protection fromharm (i.e., the “public health hazard” allegations of organizedmedicine) formed the core of policy dilemmas (Finocchio, Dower,Blick, & Gragnola, 1998). Health care practitioners who are inter-ested in shaping their future practice environment should appreci-ate the policy significance that few elected officials possess firsthand expertise in the nuances of health care. In the 108th Congress(2003–2004), for example, there were five psychologists serving inthe U.S. House of Representatives. However, the dominant pro-fession of the elected congressional membership remains law,followed by business. These latter professions possess fundamen-tally very different perspectives (and values) than most, if not all,of the health care professions. As envisioned by Pew, practice actdecisions benefit from the strengths of state (and federal) legisla-tive activity and suffer from partisan politics, campaign contribu-tions, and professional lobbying. Even health care professionalspossess conflicting interests. On the one hand, although eachprofession has a valid interest in minimal restrictions, each alsobenefits from the anticompetitive aspect of regulation. And, as thecommissioners have noted, usually it is the professions—never thepublic or consumer advocates—that request regulatory changes topractice acts.

Many of the professions have adopted national standards forexamination, certification, and accreditation. However, practiceacts are still decided at the state level with little or no coordination.The differences among practice acts for single professions vary inmagnitude. “The benefits and necessity of many aspects of statepolicy-making and policy-enforcement are numerous. However,differences from state to state in practice acts for the healthprofessions no longer make sense” (Finocchio, Dower, Blick, &Gragnola, 1998, p. 25). Accordingly, the Pew health policy expertsrecommended that

Congress should establish a national policy advisory body that willresearch, develop and publish national scopes of practice and con-tinuing competency standards for state legislatures to implement. . . .The national policy advisory board . . . should develop standards,including model legislative language, for uniform scopes of practiceauthority for the health professions. These standards and modelswould be based on a wide range of evidence regarding the competenceof the professions to provide safe and effective health care. . . . (And)States should require that their regulated health care practitionersdemonstrate their competence in the knowledge, judgment, technicalskills and interpersonal skills relevant to their jobs throughout theircareers. (Finocchio, Dower, Blick, & Gragnola, 1998, pp. v–vii)

These are the policy positions endorsed by the federal governmentin administering its own health care facilities (i.e., Department ofDefense [DOD], the Department of Veterans Affairs [VA], andU.S. Public Health Service).

Prescription Privileges for Psychologists (RxP)

To appreciate, in a very concrete sense, the potential impact ofpublic sector creativity on the profession of psychology, one needonly to review the literature surrounding psychology’s quest forprescriptive authority. In November 1982 the California Office ofStatewide Health Planning and Development submitted a land-mark report to the California legislature entitled Prescribing and

Dispensing Pilot Projects. Under the state’s statutory health man-power demonstration authority, a series of nonphysician prescrib-ing and dispensing projects were conducted. Over one millionpatients were seen over a 3-year period. The principal teachingmethods used were lectures and seminars varying from 16 to 95hours. Fifty-six percent of the trainees possessed a bachelor’sdegree or higher. Noting that “none of the projects, to date, havereceived the intense scrutiny that these 10 prescribing and dispens-ing projects have received” (State of California, 1982, p. i), theresults were extraordinarily positive from a variety of clinical andhealth policy perspectives. How far has psychology come? At theAPA annual State Leadership Conference, Russ Newman reportedthat from 1986 to 2002, a total of 13 states had filed RxP legisla-tion, usually no more than one or two a year. In 2005, 12 states aresimultaneously pursuing legislation; Two states—New Mexicoand Louisiana—have passed legislation permitting prescriptionauthority for licensed, qualified psychologists.

The genuine and growing enthusiasm within psychology’s prac-titioner community for the RxP agenda is a direct result of theimpressive clinical accomplishments of the 10 DOD prescribingpsychopharmacology fellows (DeLeon, 2003; Dittman, 2004;Maxwell, 2004) and the realization that certain federal facilities arepresently being considered for RxP practicum cites. Psychologypostdoctoral fellows at Tripler Army Medical Center are currentlybringing RxP expertise to Hawaii’s rural community health cen-ters. Psychologists bring to the art and science of prescriptionauthority the biopsychosocial model, in which medication regi-mens are briefer, and behavioral interventions replace medicationswhen appropriate (Dittman, 2004; Maxwell, 2004).

The Institute of Medicine (IOM) was established in 1970, underthe charter of the National Academy of Sciences, which wasgranted by the Congress in 1863 to secure the services of eminentmembers of appropriate professions to examine policy mattersconcerning the health of the public. IOM reported that

education for the health professions is in need of a major overhaul.Clinical education simply has not kept pace with or been responsiveenough to shifting patient demographics and desires, changing healthsystem expectations, evolving practice requirements and staffing ar-rangements, new information, a focus on improving quality, or newtechnologies. (IOM, 2003, p. 1)

The report further envisioned a health care environment in which“(a) all health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasiz-ing evidence-based practice, quality improvement approaches, andinformatics” (IOM, 2003, p. 45). Where, we would rhetoricallyask, is there a better locus for such training than within the publicsector? The IOM’s call for competency-based education, a com-mitment to lifelong learning, interdisciplinary treatment, and mov-ing away from professionally isolated silo-oriented training mod-els is the future for all health care.

IOM experts urged that

the federal government should take steps immediately to encourageand facilitate the development of the information technology infra-structure that is critical to health care quality and safety enhancement,as well as to many of the nation’s other priorities, such as bioterrorismsurveillance, public health and research. Specifically, Congress shouldconsider potential options to facilitate rapid development of a nationalhealth information infrastructure. VHA, DOD, and IHS [Indian Health

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Services] should continue implementing clinical and administrativeinformation systems that enable the retrieval of clinical informationacross their programs and can communicate directly with each other.(IOM, 2002, pp. 14–15)

Government health care programs should vigorously pursue pur-chasing strategies that encourage the adoption of best practicesthrough the release of public-domain comparative quality data andthe provision of financial and other rewards to providers thatachieve high levels of quality.

Not only should health care delivery systems operated by the publicprograms continue to serve as laboratories for the development ofinnovative 21st-century care delivery models, but much greater em-phasis should be placed on the dissemination of finding and, in thecase of information technology, the creation of public-domain prod-ucts. (IOM, 2002, pp. 9–10)

Finally, when one looks at the beneficiary population that usesthe public system most frequently, another IOM finding becomesintriguing.

Trends in the epidemiology of health and disease and in medicalscience and technology have profound implications for health caredelivery. Chronic conditions (defined as never resolved conditions,with continuing impairments that reduce the functioning of individu-als) are now the leading cause of illness, disability, and death in theUnited States and affect almost half the U.S. population. (IOM, 2002,p. 45)

Take Home Messages

The profession of public sector psychology has a rich history ofdevelopment and implementation, understanding innovation, andadapting to change. To maintain success in the public sector,however, psychologists must have a vision for the future. Onemight ask, what does the public sector psychologist with 20/20vision see emerging over the next two decades? Below are severaltrends to consider.

• Public sector psychologists will require a cutting edge under-standing of the international marketplace economically, politically,ethically, and clinically because we have become a global societyand public sector psychology is now providing consultation to aworld marketplace through international telehealth.

• Public sector psychologists must have a holistic perspectiveand bridge the multicultural similarities and differences we havecome to realize among the various countries and cultures of theworld. For example, the Federal Bureau of Prisons currently in-carcerates inmates from all over the world. VA psychologists areproviding services to combat veterans who have engaged in vari-ous types of warfare all over the world. Specific consultations tothe post-traumatic stress disorder program at the Southamptonnaval facilities in England and the National Mental Health Re-search Centers across Russia have been documented with publicsector psychology in the United States (Miller, 1989). Clearly,given the service settings and clientele, psychologists working inthe public sector must maintain a holistic (worldly) perspective aswell as a healthy appreciation for cultural differences.

• Current testing and evaluation will be replaced by a complexanalysis system and networks that will analyze how genetic factorsinfluence psychological markers that result in thinking and behav-

ior. One need only consider the possible implications of medicaladvances such as stem cell research to understand that psychologyis changing. As new techniques are developed to prevent seriousillnesses, including mental illnesses, our evaluation methodologieswill change. Given the focus of public service psychology onevaluating (and treating) patients with severe mental illness(Nisenbaum, 2003), this sector will be greatly impacted by newtechnologies.

• Public sector psychologists will have to be multiskilled, in-formation specialists serving new alliances of consumers andcompetitors. Competition is alive and well in the private sector andis increasing in the public sector. Privatization of prisons, with afocus on revenue rather than treatment or rehabilitation, is oneexample of changing dynamics in the public sector. As the marketincreasingly drives services, psychiatric hospitals, prisons, andVAs will be competing with private industry to afford the bestpossible care for patients; public service psychologists, therefore,must invest in quality control and accountability.

Federal institutions, agencies and programs will develop newalliances with the private sector and partnerships like the VAhealth care delivery system that emerged and grew through thesecond half of the 20th century to a system-wide hospital network.By 2020, there will be a smaller network of medical centers and avoucher system for health care for veterans and nonveterans.Public sector psychologists will use virtual reality technology foreducation and psychological services in the public sector domain.Public sector psychologists have already been influential in tele-health services for inmates (Magaletta, Fagan, & Ax, 1998; Ma-galetta, Fagan, & Peyrot, 2000) and other underserved populations(Stamm, 2003). However, the use of technology to expand servicedelivery will be increasingly necessary.

These visionary concepts are areas in which the public sectorpsychologist can begin to address changes that are likely to occurduring the first quarter of the 21st century. Current and futureissues confronting psychologists who work in the public sector areincreasingly complex and varied in content. The public sectorpsychologist with 20/20 vision must have a clear vision for thefuture and the competency to adapt to change to the benefit ofscience and practice for the world’s consumers in the public sectorarena.

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Received January 25, 2005Revision received October 20, 2005

Accepted November 21, 2005 �

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