Testimony of Randy Phelps, Ph.D.
Deputy Executive Director for Professional Practice
American Psychological Association
April 9, 2008
Chairman Akaka and distinguished members of the committee, I am Dr. Randy Phelps, Deputy Director for Professional Practice of the American Psychological Association ("APA"), the largest association of psychologists, with more than 148,000 members and affiliates engaged in the study, research, and practice of psychology. The APA appreciates the opportunity of testifying before you today on behalf of our member psychologists who are dedicated to serving the very pressing needs of our country's veterans. VA's need for the health and mental health, primary care, research, and other, often unique, services that psychologists provide has perhaps never been greater.
Over 200,000 homeless veterans will be sleeping on America's streets tonight. Worse yet, Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veterans are becoming homeless faster than their predecessors. After Vietnam, it took 9 to 12 years for veterans' circumstances to deteriorate to the point of homelessness. Today, the high incidence of Post Traumatic Stress Disorder (PTSD) and traumatic brain injury (TBI) will contribute to increased homelessness unless dramatic measures are taken to mitigate this trend. Other issues for service members and their families are repeated deployment, National Guard and Reserve deployment, women in combat and the extended duration of the Global War on Terrorism (GWOT).
More than one million service members in the Active and Reserve components of the military have been deployed in OIF/OEF; more than 449,000 of those have been deployed more than once. Of the troops returning from deployment, 31% of Marines, 38% of Soldiers, and 49% of National Guardsmen report psychological symptoms. This doesn't take into account those making multiple deployments or the psychological needs of their families.
There were 686,306 OIF and OEF veterans who separated from active duty service between 2002 and December 2006 who were eligible for Department of Veterans Affairs (DVA) care; 229,015 (33%) of those accessed care at a DVA facility. Of those 229,015 veterans who accessed care since 2002, 83,889 (37%) received a diagnosis of or were evaluated for a mental disorder, including PTSD (39,243 or 17%), non-dependent abuse of drugs (33,099 or 14%), and depressive disorder (27,023 or 12%).
Psychologists' Roles within Healthcare Systems
Psychologists are unique professionals in terms of their training and skill sets. No other mental health profession requires as high a degree of education and training in mental health as psychology. Accredited doctoral programs in clinical, counseling and other health services psychology involve a median of seven years of training beyond an undergraduate degree. Psychologists are licensed, independent practitioners with specialized clinical and research skills.
Psychologists provide a holistic approach to mental health care with their keen understanding of how the mind and the body interact. Our members include the specially trained neuropsychologists who understand those disorders of perception, memory, language, and behavior that result from brain injury, an essential skill in dealing with the new generation of veterans returning from theater in large numbers with Traumatic Brain Injuries (TBI).
Psychologists' skills in program development, team building, research/outcome and program evaluation, and in assessment and treatment interventions equip psychologists to be leaders in planning and providing a coordinated service approach. This includes models and practices of care that encompass inpatient, partial hospitalization and outpatient services including Community Based Outpatient Clinics (CBOC), psychosocial rehabilitation programs, homeless programs, geriatric services in the community, residencies and the home.
Psychologists initiate and evaluate innovative programs, such as tele-mental health services. They go beyond the provision of service to initiate, plan and evaluate the efficacy of such services and their clinical and cost benefits.
Recruitment of Psychologists in VHA
It is critical to note that VA is already the single largest employer of psychologists in the nation, and has been for many years. However, VA continues to recognize the need to increase its psychology staffing numbers in response to ever-increasing needs for services to veterans. For example, the Veterans Health Administration's (VHA) provision of mental health services to veterans has skyrocketed from 1996 to 2006, going from 565,529 veterans served to 934,925 and rising. In response, VHA has hired more than 800 new psychologists since 2005; thereby, increasing the number of GS11 thru 15 psychologists and surpassing its 1995 high of approximately 1,800 psychologists.
The APA applauds VA for its tremendous and serious recent efforts to increase psychology staffing levels, such that there are now approximately 2,400 psychologists employed by VA nationwide across the GS-11 to GS-15 levels. However, that is a very recent accomplishment. It was not until 2006 that psychology staffing levels exceeded those of 1995 levels. Moreover, the vast majority on new psychologist hires in VHA are younger, lesser experienced psychologists who have come into the system at the GS-13 level or below. In contrast, as of the end of 2007, the number of GS-14s in the entire system nationally was essentially the same as it was in 1995, at approximately 130 GS-14 psychologists. Of additional concern to the APA is that the number of GS-15 psychologists nationally as of the end of 2007 (approximately 50) was still considerably lower than the number of GS-15s in 1995.
VA has also recognized and capitalized on the fact that the best source of recruiting new psychologists has been the Department's own training system. Over the past two years, approximately 75% of all new psychologist hires have been prior VA trainees. And, VA is rapidly increasing its funding of psychology training. In the 2008-2009 training year, VA has added approximately 60 new psychology internship positions and 100 new postdoctoral fellowship positions, spending approximately $5 million to do so. This will bring the total psychology training positions to approximately 620 per year nationwide.
Retention of the Psychology Workforce
Here is the dilemma: while the VA is employing more psychologists than ever, VA's advancement and retention policies continue to be driven by outdated and overly- rigid personnel and retention systems. In addition to hiring new staff, the VA needs to retain those existing psychologists who are qualified, possess specialized skills, and are already institutionalized within the system. These psychologists are vital to service provision because of their professional expertise and knowledge of the system and its resources. However, there are several glaring obstacles to retention, covered in some detail below.
Lack of Uniform Leadership Positions
Since 1995, independent mental health discipline services at most facilities have been replaced with interdisciplinary Mental Health Service Lines. As a result, there has been a decrease in the number of discipline chiefs across the system. Interdisciplinary management within mental health services can have advantages in terms of cross-discipline coordination of care and clearer accountability at the individual program level. However, the dissolution of discipline specific services has left a clear leadership gap in terms of professional practice accountability, guidance on the proper use of professional skills, and promotion and oversight of profession specific staff and pre-licensure training. For Psychology, this problem is further complicated by the fact that the lack of recognized psychology discipline leadership at many facilities translates into a significant lack of oversight, structure and support for the growing number of psychologists working in non-mental health areas such as primary care, geriatrics, and Home & Community Based Care (HBPC), among others.
In 2002, the VA remedied this situation for Social Work with the appointment of a Social Work Executive at each facility that lacked an independent Social Work Service (VHA Directive 2002-029). The creation of the Social Work Executive position has been highly effective in ensuring the integrity of Social Work practice and training within an inter-disciplinary management structure. Since 2003 there have been efforts to create an analogous Psychologist Executive role. However, at present, Psychology remains the only major mental health discipline without an officially designated leader in every medical center. While the number of "Chief Psychologists" is now increasing, a far more prevalent position is the "Lead Psychologist", a position which is all too frequently unrecognized at the level of additional pay for additional responsibilities.
Inequitable Access to Key Leadership Positions
Nor are psychologists represented equitably in the all levels of leadership in the VA's healthcare delivery system. In 1998, the Under Secretary for Health (USH) attempted to correct this situation with the issuance of VHA Directive 98-018, later reissued in 2004 as VHA Directive 2004-004, which stated that "it is important that the most qualified individuals be selected for leadership positions in mental health programs regardless of their professional discipline."
Unfortunately, the only requirement within the Directive was that announcements of VA mental health leadership positions not contain language that restricts recruitment to a specific discipline. As a result, this Directive has had little practical impact on the appointment of highly qualified psychologists to VA mental health senior leadership roles, particularly at medical school affiliated VA facilities.
Implementation Problems in Hybrid Title 38
In late 2003, the Hybrid Title 38 system was statutorily expanded to provide psychologists and a wide range of other non-physician disciplines some of the same personnel and pay considerations as their physician counterparts. The Title 38 Hybrid is a combination of Title 38 and Title 5 provisions for non-physician health care professionals at the VA.
Historically, Title 38 was created to alleviate severe shortages of health care personnel, especially for physicians in VA, by reducing the bureaucratic red tape of the civil service recruiting and hiring system and the restrictive compensation practices inherent in Title 5.
Psychologists remain the only health care providers requiring the doctorate who are not included in Title 38. The Title 38 Hybrid was created to provide a middle ground solution for health care professionals that needed some of the same considerations as their physician counterparts. The hybrid model requires Professional Standards Boards to make recommendations on employment, promotion and grade for psychologists, and is still more subjective than a pure Title 38 program; unlike Title 38 where professionals are hired, promoted and retained based solely on their qualifications.
The implementation of the new Title 38 Hybrid boarding process on the number of GS-14 and 15 psychologists is currently very mixed. Many Psychologist leaders from facilities throughout the country have reported that their facilities and Veterans Integrated Service Networks (VISN) have denied GS-14 and 15 promotions that have been recommended by the national boarding process. Even more frequent are reports of facilities and VISNs that have delayed or refused to forward boarding packets to the national board and/or have refused to reveal the results of the national board action. This leaves the psychologists in question with considerable leadership responsibilities, but with little or no recourse regarding their boarding status and consequent grade level.
Informational missteps and technical problems have also plagued the national psychology boarding process. An unknown, but apparently significant, number of boarding packets have been adversely affected by incorrect information provided by local human resource (HR) officials regarding the required format and content of the packets. This has resulted in the submission of a number of packets that may have described GS-14 or above responsibilities, but that were unable to be boarded at that level due to packet content errors.
Of particular concern are reports that a number of psychologists throughout the country were instructed by their facilities to only submit special achievements occurring during the previous three years, despite the fact that Psychology Boards were authorized to consider achievements throughout the psychologists' VA careers for the one-time Special Advancement for Achievement. This meant that significant and creditable achievements occurring earlier in the psychologists' VA careers would never have an opportunity to be considered for a Special Advancement for Achievement (SAA).
On March 7, 2007, instructions were sent from the VA Central Office (VACO) to the field that eliminated the national cap on GS-14 psychologists. This was a beneficial step that has removed one of the reasons often cited by local and VISN management for failure to approve justified grade increases to the GS-14 level.
However, the same set of instructions tied the award of GS-15 psychology positions to the facility's level of complexity. Per these instructions, only psychologists at complexity level 1A facilities are eligible for promotion to GS-15. Senior psychologist leaders at non-1A facilities, regardless of the scope and complexity of their actual duties and regardless of the question of whether they meet the VA's own qualification standards for GS-15 would be ineligible for promotion to that grade level. In addition, complexity 1A facilities without current GS-15 psychologists would need to petition VACO for an increase in their GS-15 ceiling should the boarding process recommend, and the facility management concur, in moving a psychologist manager to the GS-15 level.
These new field instructions will accelerate the already steep decline in the number of GS-15 level psychologists. They will also create equity problems in that psychologists from non-1a facilities who supervise many programs and individuals will be ineligible for a GS-15, whereas facility complexity 1a psychologists with more limited supervisory responsibility will be eligible for the grade as long as they meet the minimum GS-15 requirements of the VA's Qualification Standard.
Part of the difficulty with these new instructions is that they treat psychologist promotion in a manner that is characteristic of Title 5. Dissimilar positions are compared against one another according to some overarching standard of complexity. Typically, in the case of psychologists, the comparison is made to the grade level of the Associate Director.
As doctoral level Title 38 Hybrid clinicians, it would be more appropriate to treat the issue of psychologist promotion as being similar to the Title 38 process. In this approach, the full performance level (GS-13) is defined by the journeyperson clinical responsibilities. Additional administrative and program management responsibilities warrant higher grade levels, provided that these additional responsibilities meet established scope and complexity requirements for those levels. This is essentially the approach that was taken in the VA's own Qualification Standard for Psychology.
The decline in the availability of upper grade level positions presents VA with a serious recruitment and retention issue. As psychologists come to believe that there is little possibility for advancement, regardless of the level or complexity of responsibilities, fewer high potential psychologists will be willing to accept positions of greater responsibility. In addition, high potential trainees whom the VA would like to recruit will increasingly see VA as a "dead end" for their careers and will be attracted to other career options that offer more potential for advancement.
Thank you for this opportunity to provide testimony today on behalf of the American Psychological Association. We stand ready to assist with the Committee's work to further improve recruitment and retention of psychologists to assist in providing care to this nation's honored veterans.
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