Antonio E. Puente University of North Carolina Wilmington

Transcription

1 What the First Twenty Five Years in Mainland US Might Tell Us About the Future of Clinical Neuropsychology and Its Implication for the Development of the Specialty in Puerto Rico Antonio E. Puente University of North Carolina Wilmington Presentation Given in Honor of the Founding of the Puerto Rican Neuropsychological Association April 30, 2008 La Concha Hotel San Juan, Puerto Rico

2 Puerto Rico & Puente: A Brief History and a Long Past Surfing Trips in the 1970s APA s Visiting Psychologist Program Two Visits in the Early 1980s (Salud Mental) Caribbean Institute of Psychology/Carlos Albizu University/University of Puerto Rico Workshops in the Late 1980s (Montijo & Cabilla) Involvement in Research 1980s - WIST 2000s- Liza San Miguel

3 Outline Historical Context Current Panorama The Future

4 The Beginning of APA Model American Physiological Society Preliminary Meeting (# = 26) Worcester, Mass (Clark; July 8, 1892) First Official Meeting (# = 18) Philadelphia, PA (Penn; December 27, 1892)

5 APA Membership Year Doctorate M F M Masters F Bachelors M F

6 APA Membership by Division Approximately 150,000 members Approximately 55 different divisions Top three divisions are: Clinical Psychology (1945) Clinical Neuropsychology (1980) Independent Practice (1982)

7 APA Membership Trends Health Provider 70% & > Research & Teaching 20% & < Other 10%

8 The Professionalization of Psychology WWII and the VA System ( ) Licensing Laws ( ) Third Party Reimbursement ( ) Medicare Program (1990-present) Specialties in Psychology (2000-present)

9 Education in Professional Psychology Bachelors (4 years) Generic Introduction/Liberal Arts Masters (2 years) Intermediate Step Psychological Assistant/Associate (Supervision Required) Doctorate (5-7 years) PhD Vs PsyD; Boulder vs Vail Models of Training Definition of a Psychologist Definition of Clinical Psychology (C vs c) Post-Doctorate (2 years) Clinical Neuropsychology as a Specialty Continuing Education Half-Life of Doctorate Education = 8 years

10 What is Clinical Neuropsychology? Study and practrice of the relationship between brain and behavior, especially but not exclusively neurological patients A way of understanding behavior Monistic continuum from the biological to the mental so that it is impossible to decipher where one begins and the other ends Strong anchoring, possibly unidirectional, of biological principles (Wundt & James; Sperry) Breaks down behavior into lowest common behavioral domains but requires a Gestal of functionality to provide contextual meaning In practical terms, it requires a doctorate in (clinical?) psychology with post-doctorate training as minimum requirement

11 Organizations American Psychological Association (1892) Division of Clinical Neuropsychology (1980) National Academy of Neuropsychology(1975) International Neuropsychological Society ( 72) Other issues/groups; APA s First Specialty (1996) Board Certification (e.g., ABCN/ABPN; 1985) Licensure (e.g., Louisiana; 2000) Specialty Groups (e.g., Pediatrics; 2005) Psychometrist Registration (under review)

12 Publications Publications Books (Goldstein, 1974) Journals (IJCN; 1978) Trends Assessment (1970s) Rehabilitation (1980s) Forensic (1990s) Non-Mental Health (2000s)

13 Personnel Overall Trends/Zeitgeist Growth Patterns = Exponential Demographic Patterns = Male to Female Location Pattern = Academic to Clinical

14 Clinical Activities Assessment Fixed (Halstead-Reitan Vs. Luria-Nebraska) Vs. Flexible (Boston) Clinical (e.g., Dementia, Stroke, Head Injury) Educational (e.g., Learning Disability) Rehabilitation Cognitive Rehabilitation Forensic Disability (Social Security; Pension) Worker s Compensation Civil Criminal

15 Current Clinical Activities: Surveying the Specialty Brief History of Surveys Hartlage (1980s) DeLuca & Putnam (1990s) Current Survey Methodology Sweet & Peck (2000) Division 40 and NAN

16 Field of Doctoral Degree (All Doctoral Licensed Clinicians) Percent Clinical Couns. Neuro. School Ed. Psy. Comb.

17 Work Setting (All Doctoral Licensed Clinicians) Percent Private Practice Institution Comb. Other

18 Weekly Professional Activities by Organization Percent Clinical Pract. Teach. Research ($) Res. (No $) NAN D40 Both Unknown Non-Clin Admin.

19 Weekly Professional Activities by Organization Percent Supervision Forensic NAN D40 Both Unknown

20 Income by Work Setting (Doctoral Licensed Clinicians Working Full Time or Full Time+) $140,000 $120,000 $100,000 $80, $60,000 $40,000 $20,000 $0 Private (n=424) Institution (n=378) Comb. (n=358) Mean Median

21 Percentages of Reimbursement Sources (For All Doctoral Licensed Clinicians) Managed Care Medicare Indemnity Insur Self Pay CHAMPUS Public Aid Indigent Forensic

22 Minutes Time-Related Case Activities (All Doctoral Licensed Clinicians) Private Institution Cons Ref So Feedback Interp/Rep Scoring * Test Admin Rec Rev Interview Intake Hours billed: Private=11.1 (SD=5.0); Institution=8.2 (SD=3.3) * Only scoring is not significant between groups; covarying amount of forensic practice did not eradicate group differences

23 What Neuropsychology is Worth? Reimbursement & Current Procedural Terminology (CPT) American Medical Association Developed by Surgeons (& Physicians) in 1966 for Reimbursement Purposes 7,500 Discrete Codes US Federal Insurance Program; Medicare AMA Under License with CMS Benchmark from Which All Third Party Uses

24 Applications of CPT for Neuropsychology Total Possible Codes = 7,500 Possible Codes for Psychology = Approximately 40 to 60 Three Existing Paradigms 1. Psychiatry/Mental Health 2. Neurology 3. Medicine/Health

25 CPT: The Future of the Profession Typical Code for Psychological Services = Approximately $100 / hour Estimated Goals for Neuropsychological Assessment= Approx. $125 / hour Major Paradigm Shift- From Mental Health to Physical Health

26 The Future is Now Is Our History the Best Predictor for Our Future? My Own Personal Glimpse Into What Awaits Clinical Neuropsychology

27 Projected Specific Trends for Neuropsychology Income (depends on activity; if clinical) Expected Overall Significant Increase Public & Professional Recognition Physician Level Mental vs. Physical Health Face vs. Societal Value Clinical Paradigms Industrial vs. Boutique Health vs. Non-Health Health vs. Non-Health

28 Projected Overall Trends for Neuropsychology Catching up to Psychiatry Leaving Psychiatry Joining Medicine Leaving Medicine Moving Towards: Legal Sports Governmental Industrial

29 Anticipated Problems for Empirical Data Base Neuropsychology Continued Professional Infighting Personnel Issues Value to Society (face Vs. criterion validity)

30 The Potential Future of Neuropsychology in Puerto Rico Organization = Puerto Rico Psychological Association Puerto Rico Neuropsychological Association Hispanic Neuropsychological Associatoin National Academy of Neuropsychology American Psychological Association (40) Research = Translation & Standardization of Existing Instruments Development of New Instruments Development of Appropriate Normative Samples Practice = Government & Institution Based Private Practice Neuropsychology in Clinical Psychology Practice Clinical Neuropsychological Practice Education = Bachelor s Level Experiential Opportunities Mentoring and Course Selection Graduate Level Courses and Neuropsychology Tracts Internships Post-doctoral Fellowships Mentoring Younger Colleagues Interested in Clinical Neuropsychology Supervising Opportunities for Non-Neuropsychologists

31 The Potential Problems for Neuropsychology in Puerto Rico Personnel Who is a Clinical Neuropsychologist? Who Can Administer Neuropsychological Tests? Who Should Handle Neuropsychological Rehabilitation? Clinical Activities Limited Test Instruments in Spanish Poor to Non-Existent Normative Samples Does Neuropsychology End with Assessment? How Does All of the Preceding Interface with a Very Conservative Medical Establishment?

32 Overall Summary Continued Growth, Especially in the Professional Domains Expansion Beyond Mental Health, to Health, to Other Areas Vibrant & Robust Yet Difficult to Predict Its Trajectory

33 El Futuro Para Neuropsicologia en General, en el Nuevo Paradigmo = Cambio Para Ustedes en Puerto Rico = Muchisimo Mas Cambio Pero Muchisimas Mas Oportunidad