AAP Newsletters

Well it’s finally over. The prelude to what will be the most important election of my lifetime ended last week. Now the more grueling trudge of a 5 month general election campaign begins. Amidst all the virtually unprecedented drama and thrills provided by 54 primaries and caucuses throughout the first half of 2008, an unforeseen phenomenon occurred. During the nominating process, psychology, at best only a small blip on the political radar screen previously, achieved a level of distinction in the election process which was heretofore nearly unimaginable. For the first time, from my perspective, psychology rose to play an influential role in two key areas of the election process.

First, there was no mistaking the fact that all the top Democratic candidates uncharacteristically sought consultation with psychology researchers for input about enhancing their appeal to voters. No doubt this grew from the fact that in at least the last two Presidential elections, the Bush team outfoxed the Ds. Second, psychological research has not only been recognized but is being closely examined and utilized by the Democratic hierarchy to shed light on the two most critical issues emerging during the long primary season, how the race and gender of candidates affects voters.

It really is a testament to how far psychology has come in politics that the darling of election campaign consultants in 2008 has been none other than one of our own psychologist colleagues. It’s true. Drew Westen, a professor of psychology at Emory University and author of a book called “The Political Brain: The Role of Emotion in Deciding the Fate of the Nation” has climbed in stature rapidly to become THE go-to consultant for many Democratic candidates including both Hillary and Barack.

Westen takes the unlikely position that the Democratic Party should, for the most part, forget about issues, policies, even facts, and instead focus on feelings. Now there’s a novel idea for a psychologist. “The Political Brain” takes a different tack than another recent popular political tome, “What’s the Matter With Kansas?” by Thomas Frank or Al Gore’s “Assault on Reason,” which try to explain voter behavior in terms of self-interest and factual analysis.

Westen’s message is the exact opposite. Franks and Gore explain why we should be more rational instead of why we should bring more passion into politics.

What he calls “the dispassionate view of the mind” which has guided Democratic thinking for 40 years is deeply flawed according to Westen. What decides elections, he maintains, are people’s emotional reactions, even if they don’t know it.

In his book, Westen describes an experiment he conducted in the fall of 2004 on committed Democrats and Republicans. Subjects had their brains scanned while they viewed slides containing pairs of contradictory statements from their favored candidate (George W. Bush or John Kerry). Confronted with the unwelcome contradictions, each subject’s network of neurons associated with distress and regulating emotions (the right frontal lobe, the insula and amygdala) lit up. But soon the subjects found ways to deny that there was any significant contradiction, and calm returned.

The neural circuits charged with regulation of emotional states seemed to recruit beliefs — even false ones — that would eliminate the distress each subject was experiencing as interpreted by Westen. Meanwhile, the reasoning centers of the brain — the part to which writers like Mr. Gore appeal — were quiet.

What’s more, the neural circuits responsible for positive emotions turned on as soon as the subject found a way to resolve the contradictions — reinforcing the faulty reasoning. Westen summed it up: “people think with the gut.”

Clearly, the 2008 campaign, thus far, has been subjected to more psychological analysis than one of Freud’s Vienna analysands. And, the good news is that psychology’s forecasts have held up very well. A cursory look at the data does seem to confirm that voters are driven more by emotions than by a rational, logical analysis of a candidate’s record and positions. Take, for instance, the fact that so many anti-immigration Republicans pulled the lever for McCain. Or the fact that Hillary’s well constructed, highly engineered tenpoint plans didn’t move voters as powerfully as Barack’s inspirational oratory. Also, unconscious motivations appear to be stronger than conscious ones, which might explain the impact of the growing and not so subtle role of racism and sexism in the campaign.

The literature on racism and sexism, some of which examines voting behavior, is most thought provoking, even if it lacks consistency. I wanted to subject myself to a couple of the measures currently being used to shed light on this area. So, I tested myself, online, using two instruments social psychologists have developed for assessing implicit associations regarding race. I took an on-line University of Chicago test twice because I didn’t like my first score which showed bias against black armed models. The second testing then revealed bias against the white armed models. Yes, I broke all the research design rules and possibly confirmed nothing more than the fact that I’m a researcher’s worst nightmare, and also my own defensiveness.

Try one of the tests at: http://backhand. uchicago.edu/Center/ShooterEffect/

You’ll probably find, as the majority of test takers do, that much to your surprise, you show bias as well. Most whites and many blacks are quicker to shoot blacks than whites, no matter how egalitarian they profess to be.

Harvard, too, posts a battery of psychological tests online. These creative implicit association tests purportedly demonstrate that a stunningly large proportion of people who honestly believe themselves to be egalitarian unconsciously associate good with white and bad with black.

Social psychologist, Susan Fiske at Princeton, known for her work on social cognition, stereotypes, and prejudice, says that inter-group biases are startlingly automatic. She argues that people categorize other people based on age, race, and gender in milliseconds and then have visceral responses to those categories in milliseconds, too.

Fortunately, it is believed that these responses can be modified. For example, a member of an athletic team that includes someone from a different racial or social group is much less likely to stereotype that person. And a person motivated by values of fairness or harmony may employ a more individuating kind of process to override the automatic response according to Fiske.

John Tooby, at UC Santa Barbara’s Center for Evolutionary Psychology, ran an experiment which put blacks and whites in sports jerseys as if they belonged to two basketball teams. People looking at the photos logged the players in their memories more by team than by race, recalling a player’s jersey color but not necessarily his or her race. Of note, only very rarely did people forget whether a player was male or female.

Tooby hypothesizes that we can make categorization by race go away, but we could never make gender categorization go away. Tooby further suggests that looking at the challenges that black and female candidates face in overcoming unconscious bias, based on the underlying psychology and anthropology, it may be just as, and possibly more difficult for a woman, though not impossible.

Now throw into this mix of these social psychology views, some lessons learned from the in vivo election process, and the picture becomes murkier and murkier.

Remember in January, when Obama handily defeated Clinton in the Iowa caucuses, and polls going into the New Hampshire primary had him running ahead of her by up to 13 points. Yet, when the returns came in from NH, Obama lost by three points. Some attributed this to flaws in the polling, but others attributed the wide disparity to an instance of the Bradley Effect. The Bradley Effect refers to an electoral phenomenon first identified in a 1982 California gubernatorial election. Tom Bradley, the popular mayor of Los Angeles, was the supposed frontrunner in an open race for the state’s top job. Polls showed the African-American Democrat running well ahead of the white Republican candidate, George Deukmejian. Much to everyone’s surprise, when the returns came in, Bradley lost by more than 50,000 votes.

The result made no sense. The gubernatorial election was one of the few Democratic losses in what was a good year for the Ds. Bradley was an able politician with a sound record. Analysts took a new look at the polls, which seemed to have been conducted appropriately and questioned themselves vigorously.

They ultimately hit on the notion that white voters, not wanting to be thought of as prejudiced against an African-American candidate, had told pollsters they were for Bradley when they had always intended to vote for Deukmejian.

This occurrence was to be seen again in 1989, when Virginians were electing a new governor. African-American Democrat Doug Wilder held a solid lead over white Republican Marshall Coleman – nine points in some polls. Yet, on election night, results showed him winning by less than one point.

In 1990, when African-American Democrat Harvey Gantt challenged white Republican incumbent Jesse Helms for a North Carolina Senate seat, polls had Gantt ahead by four to six percentage points. On election night, however, Helms prevailed by four points.

As if the specter of racism in the 2008 election is not distressing enough, we need to also consider the equally insidious role of sexism in this year’s biggest electoral contest. The conventional wisdom for most suggests that Barack Obama faced a higher bar than Hillary Clinton during the primary selection process, as racism is thought to be more potent than sexism, but research, as that suggested above, seems to suggest that this may not necessarily be true.

Public opinion polls show consistently that a substantial portion (9 out of 10) of the American public would vote for a qualified female presidential candidate. However, factor social desirability into these responses and we see a far different result. Using an unobtrusive measure called the “list experiment,” Matthew Streb, Barbara Burrell, Brian Frederick at Northern Illinois University, and Michael Genovese of Loyola Marymount University found in a 2006 study that public opinion polls are indeed exaggerating support for a female president. Roughly 26 percent of the public is “angry or upset” about the prospect of a female president.

The research findings indicate a significant percentage of survey respondents are hiding their true feelings, most probably to avoid the appearance of being sexist. The findings were consistent among both male and female respondents across several demographic groups. Perhaps the Bradley Effect may henceforth be referred to as the Bradley/Clinton Effect.

These kinds of measures give fuel to the argument that the unconscious is playing a political role this year. The evidence is substantial that Americans have unconscious biases both against blacks and against women in executive roles.

The challenge for women competing in politics or business is likely to be less misogyny than unconscious sexism: Americans don’t hate women, but they do frequently stereotype them as warm and friendly, creating a mismatch with the stereotype we hold of leaders as tough and strong. So voters (women as well as men, though a bit less so) may feel that a female candidate is not the right person for the job because of biases they’re not even aware of.

Nilanjana Dasgupta, a psychology professor at the University of Massachusetts at Amherst has written about the fact that subjects don’t have to be conscious of this prejudice and may consciously understand their belief as nothing more than a perception that the person in question simply isn’t a good fit for a tough leadership job.

Women now hold 55 percent of top jobs at American foundations but are still vastly underrepresented among political and corporate leaders — and one factor may be that those are seen as jobs requiring particular toughness. Our unconscious may feel more of a mismatch when a woman competes to be president or a C.E.O. than when she aims to lead a foundation or a university.

Women face a very difficult challenge: Those viewed as tough and strong are also typically perceived as cold and unfeminine. Many experiments have found that women have trouble being perceived as both nice and competent.

Hillary Clinton has been the poster child for this perspective. Hillary certainly was viewed by many as particularly cold and particularly uncaring. There is a reasonable case to be made that these perceptions are based precisely on the fact that she doesn’t fit the mold. Men are virtually immune from this problem.

But biases are not cast in concrete. Research subjects who were asked to think of a strong woman then showed less implicit bias about men and women. And students exposed to a large number of female professors also experienced a reduction in gender stereotypes.

A popular question making the rounds in these post-primary days is whether Hillary lost to Obama because sexism is worse than racism in this country. I, for one, don’t think so (I must disclose that I am a man). She lost, I think, because Barack ran a smarter, better organized campaign and possesses oratory skills that surpass even the best of the modern age (Kennedy, Reagan, and Bill Clinton). It is not my intent to diminish Hillary at all. Although her campaign didn’t resolve whether a woman who seems tough enough to withstand the rigors of a punishing campaign or run the military can also seem likable enough to get elected, she laid the vital groundwork for more women to throw their hats in the ring in the future.

Without question, both racism and sexism still rear their ugly heads in this country. The struggles of the primary season are not just Obama’s or Clinton’s, however. They are America‘s struggle. Obama has made it to the next level. His performance so far indicates that he is ready to wrestle with all the alligators, including explicit/conscious and implicit/ unconscious racism. Between Hillary’s and Barack’s campaigns, the two have done more than what appears on the surface. They succeeded in opening up the American political debate in a way that has been needed for a very long time. Moreover, psychology has played an important role in this process. I am confident that psychology’s role in helping to unravel the real issues driving racism and sexism in the 21st Century will continue to be of value for some time to come. And in the end, perhaps the impact of this presidential contest won’t be measured just in national policies, but also in progress in modifying our own unconscious thoughts and feelings about race and gender.

Summer 2008 Newsletter

The mental health parity bill finally has arrived in the U.S. Congress. The Senate passed its version of parity last year and the House passed its own version in mid-March. We are optimistic that the two chambers will be able to work out their differences and send a bill to the President shortly. We should be able to celebrate by summer. Is there anything left to tackle in the health care arena after parity? I’m just kidding. How about Medicare reimbursement for psychologists, or privacy issues, or even health care system overhaul in general for starters??? We are hard at work on those pernicious Medicare rate cuts, the problem that keeps on living. Since the political season is rife with Presidential candidates offering their ideas for solving the health care crisis, I thought it an opportune time to examine our national dilemma once again.

U.S. health care expenditures rose 6.7% in 2006, the government recently reported. According to the Centers for Medicare and Medicaid Services, total health care expenditures exceeded $2.1 trillion, or more than $7,000 for every American man, woman, and child. Medicare costs jumped a record 18.7%, driven by the new privatized drug benefit. Total health care spending, now amounting to 16% of the gross domestic product, is projected to reach 20% in just 7 years. Keep in mind that this figure will have grown by a whopping 65% since 1990.

This rate of relentless health care inflation has been attributed to many factors — the aging population, the proliferation of new technologies, poor diet and lack of exercise, the tendency of supply (physicians, hospitals, tests, pharmaceuticals, medical devices, and novel treatments) to generate its own demand, excessive litigation and defensive medicine, and tax-favored insurance coverage.

This phenomenon may well be attributable to something else. Changing demographics and medical technology pose a cost challenge for every nation’s system, but ours is the outlier. The extreme failure of the United States to contain health care costs results primarily from our unique, all-encompassing immersion in commercialization. The dominance of for-profit insurance and pharmaceutical companies, a new wave of investor-owned specialty hospitals, and profit-maximizing behavior even by nonprofit players surely act to raise costs and distort resource allocation. It is estimated that profits, billing, marketing, and the gratuitous costs of private bureaucracies siphon off $400 billion to $500 billion of the $2.1 trillion spent, but the more serious and most often less appreciated syndrome is the set of improper incentives produced by commercial dominance of the system.

Markets are said to optimize efficiencies. The “markets” mantra is the holy grail of the business community and the forces that oppose government intervention. I, personally, am normally a “markets” supporter. But despite widespread belief that competition is the key to cost containment, health care—with its third-party payers and its partly social mission—does not lend itself to market discipline. When presented with this fact pattern, it is not unreasonable to ask “why” health care doesn’t fit into market theory.

The private insurance system’s main techniques for holding down costs are: practicing risk selection, limiting the services covered as every psychologist knows (parity relief is on its way), constraining payments to providers which is another technique with which psychologists are all too familiar, and shifting costs to patients. But given the system’s fragmentation and perverse incentives, much costeffective care is squeezed out, resources are increasingly allocated in response to profit opportunities rather than medical or psychological need, many attainable efficiencies are not achieved, unnecessary health care is provided for profit, administrative expenses are high, and enormous sums are squandered in efforts to game the system. The result is a blend of over-treatment and under-treatment as well as escalating costs. Researchers calculate that between one-fifth and one-third of health care outlays do nothing to improve health.

Great health improvements can be achieved through basic public health measures and a population-based approach to wellness and medical care. But entrepreneurs do not prosper by providing these services, and those who need them most are the least likely to have insurance. Innumerable studies have shown that consistent application of standard protocols for conditions such as depression, anxiety, diabetes, asthma, and elevated cholesterol levels, use of clinically proven screenings such as annual mammograms, provision of childhood immunizations, and changes to diet, exercise, and alcohol and drug usage can improve health and prevent larger outlays later on.

Comprehensive, government-organized, universal health insurance systems are far better equipped to realize these efficiencies because everyone is covered and there are no incentives to pursue the most profitable treatments rather than those dictated by medical need. Although the populations of most countries that belong to the Organi – zation for Economic Cooperation and Development are older than the U.S. population, these countries have been far more successful at containing costs without compromising care.

Cost-containment efforts in this country have fallen heavily on primary care physicians, who have seen caseloads increase and net earnings stagnate or decline. A popular strategy among cost-containment consultants relies on the psychology of income targeting. The idea is that physicians have a mental picture of expected earnings—an income target. If the insurance plan squeezes their income by reducing payments per visit, doctors compensate by increasing their caseload and spending less time with each patient.

This false economy is a telling example of the myopia of commercialized managed care. It may save the plan money in the short run, but as any practicing physician can testify, the strategy has multiple self-defeating effects. A doctor’s most precious commodity is time—adequate time to review a chart, take a history, truly listen to a patient. You can’t do all that in 10 minutes. Harried primary care doctors are more likely to miss cues, make mistakes, and—ironically enough—order more tests to compensate for lack of handson assessment. They are also more likely to make more referrals to specialists for procedures they could perform more cost-effectively themselves, given adequate time and compensation. And the gap between generalist and specialist pay is widening.

A second cost-containment tactic is to hike deductibles and copayments, whose frank purpose is to dissuade people from going to the doctor. But sometimes seeing the doctor is medically indicated, and waiting until conditions are dire costs the system far more money than it saves. Moreover, at some point during each year, more than 80 million Americans go without coverage, which makes them even less likely to seek preventive care.

Defenders of commercialized health care contend that economic incentives work. And they do—but often in perverse ways. The privately regulated health care market is signaling pressured providers to behave more like entrepreneurs, inspiring some to defect to “boutique practices,” in which well-to-do patients pay a premium, providers maintain good incomes, and both get leisurely consultation time. It’s a convenient solution, but only for the very affluent and their providers, and it increases overall health care outlays.

A comprehensive national system is far better positioned to match resources with needs—and not through the so-called rationing of care. (It is the U.S. system that has the most de facto rationing—high rates of uninsurance, exclusions for preexisting conditions, excessive deductibles and copayments, and shorter hospital stays and physician visits.) A universal system suffers far less of the feast-or-famine misallocation of resources driven by profit maximization. It also saves huge sums that our system wastes on administration, billing, marketing, profit, executive compensation, and risk selection. When the British National Health Service faced a shortage of primary care doctors, it adjusted pay schedules and added incentives for high-quality care, and the shortage diminished. Our commercialized system seems incapable of producing that result.

Despite our crisis of escalating costs, dwindling insurance coverage, and deteriorating conditions of practice, true national health insurance that would not rely on private insurers remains at the fringes of the national debate. This reality reflects the immense power of the insurance and pharmaceutical industries, the political fragmentation and ambivalence of health care professionals, the intimidation of politicians, and the erroneous media images of dissatisfied patients in universal systems.

As mentioned above, the upcoming election is producing a number of proposals from the final three candidates. Are any of these plans sufficient to substantively change the system? Currently, we have been in a pattern of what appears to be exhausting all the alternatives. In my personal opinion, it remains to be seen how much exhaustion the health care system will suffer before we turn to national health insurance. Psychology has made great political gains in Washington so that we can be seen as genuine players in the creation of a national health system. However, we still have a way to go to insure that we will have a place at the table when the negotiations begin. Tell your friends to get involved. Support AAP, talk to your elected officials, become more politically active.

Spring 2008 Newsletter

It really wouldn’t be much of a reach to describe the current stalemate between the Senate and the House over mental health parity (MHP) as a blend of Shakespeare’s Hamlet and Camus’, The Myth of Sisyphus (madness is a central theme in Hamlet and perpetual frustration is the core theme of Sisyphus’ adult life). Simply stated, this legislation has evolved into a bewildering array of plots and subplots which now threaten its passage.

A cursory inspection of the ongoing negotiations concerning Senate bill 558 and House bill 1424, indicates that the predictable special interest players have assumed their traditional opposing positions: liberals against conservatives, employers against consumer groups, etc. These usual suspects, while certainly having an impact, are really only providing background noise to the process in this particular case.

If we drill down just a little deeper into the process, we get a better birds-eye view of the road to MHP upon which there are numerous barriers, boulders, and huge potholes that are causing major problems in enacting MHP and are confounding an already dicey situation.

One case in point involves Senator Ted Kennedy (DMA), one of the Senate bill’s sponsors. Senator Kennedy strongly opposes the House version of the MHP bill which his son, Rep. Patrick Kennedy (DRI) sponsors in the House of Representatives. Father against son, a dynamic with which psychologists are very familiar, typically elicits the sort of conflict one would hope would be absent in any area of public policy, but especially in the lawmaking arena. Here we have the forces of a father, a leader with 40 years of Senate experience and a reputation as a legislative pragmatist colliding with his son, a passionate idealist. I won’t even venture into exploring the family dynamics that lie herein, but use your clinical skills to fill in the blanks.

Add to the forgoing facts, a virtual treasure trove for family therapists, the fact that one chamber of the US Congress is fighting for bragging rights with the other and you have a script outline for an NBC Saturday Night Live episode. It is no secret that members of the large unwieldy House feel as if they deserve more respect than they receive, the proverbial Rodney Dangerfield effect (“I can’t get no respect”) in relation to the members of the august body of the Senate. Given their feelings of fierce institutional pride, members of the Senate, even in the best of times, disdain comparison with the House. The tension between the two chambers is older than the Capitol itself.

Interestingly, Republicans in the House have recently adopted a newfound genuine fondness for their Senate Republican brethren, since losing control of the House in 2006. This “fondness” is based on the Senate’s ability to scuttle legislation they, in the House, no longer are able to achieve. This is precisely the situation we are seeing concerning MHP today. The House MHP bill, while offering a couple of generous provisions beyond those of the Senate bill, would simply be dead on arrival in the Senate. The House has recently been forced to accept/swallow the Senate’s language on a number of bills including the Children’s Health Insurance Program (CHIP). Unfortunately, they are feeling the need to exert their autonomy and influence on the MHP bill resulting in very difficult negotiations.

A key to understanding all of this is the fact that in the Senate, to stop debate and to be able to vote on most measures, an agreement of 60 members is required; this is 10 more than a majority. The Senate has had razor thin majorities for the past 20 years and partisanship has never been more pronounced than at this point in time, so a 10-vote majority will require major compromises to even permit a vote to occur in the Senate. The bottom line is that Senate Republicans still have a lot to say about the way the trains are run in that chamber.

On these two issues, the family dynamics of the co-sponsors and the self-esteem/pride issues of the two Houses of Congress, the negotiations around MHP provide us with a textbook illustration of how the influence of politics classically intervenes into the legislative process: “politics” always trumps “substance” in lawmaking. Further, it underscores a basic axiom in lawmaking: facts, while usually a necessary ingredient in legislative advocacy work, are not often sufficient to prevail in the legislative process. The force of sheer politics reigns supreme there.

The above is the story within the story of MHP. Now take a look at a summary of the facts of the case as they stand in mid-December. A compromise parity bill by Senators Domenici, Kennedy and Enzi, S. 558, was passed by the U.S. Senate on September 18th. AAP and the APA Practice Organization (APAPO) strongly support this bill. The bill represents the culmination of a year-long effort in which the APAPO lobbying team was able to positively affect negotiations over the provisions of the bill by using the extensive knowledge they had acquired on the issue since the mid-1990s. APAPO influenced the negotiations to move in a very proconsumer direction. For the first time ever, employer and insurer organizations are backing a parity bill. The effect of this historic change is that conservative senators are far less likely to block the legislation now.

The Senate bill would extend to some 113 million Americans full parity protections similar to those that members of Congress and 8.5 million other Americans have had in the Federal Employees Health Benefits Program since 2001. The bill would close the remaining loopholes of day & visit limits, co-payments, deductibles and other ways in which health plans have discriminated against mental health. It will cover substance use disorders as well. An important feature which APAPO successfully inserted during the negotiation with the Senate and, significantly, was agreed to by both Senators and employers/insurers, was to extend parity to out-of-network (OON) services as well as in-network services. Moreover, the bill preserves the effect of state parity laws on the small and individual markets. When language on the preemption of state laws sought by parity opponents proved unacceptable to state officials in states with strong parity laws, APAPO assisted in the negotiations that led to its deletion. At present, the bill includes the HIPAA-like preemption that allows stronger state parity laws to prevail.

Across Capitol Hill, in the House, the parity bill by Reps. Kennedy and Ramstad, H.R. 1424, has drawn widespread support among House members. Reflecting the more liberal House, their bill is stronger with somewhat broader benefits than S. 558 in a couple of ways and thus draws the opposition of employers and insurers. H.R. 1424 requires coverage of the full DSM and payment for such treatment. Opponents of this broader coverage have sharpened their knives and are employing many tactics to create obstacles for this bill’s passage, including reviving the “jet lag” attack and raising concerns about the cost of endless treatment referred to as the “Woody Allen Syndrome” which confused lawmakers in prior Congresses. It would mandate an out-of-network option, instead of merely requiring parity if OON exists for mental health. It has an earlier effective date than S. 558 which results in higher costs. And, it requires plans to reveal their medical necessity criteria when care is denied and includes further limits on the use of managed care. These provisions are the main subject of negotiations with the Senate. To date, Senate sponsors have made it clear that these controversial House provisions will not be acceptable to the Senate for the reasons stated above.

H.R. 1424 has been approved by the Education & Labor Committee, Ways & Means Committee, and Energy & Commerce Committee. They each reported a slightly different bill so the three must be merged in the House Rules Committee. House lawmakers also are facing challenges in determining where to find the $4 billion in costs associated with the House bill to comply with Paygo rules. The PAYGO rule was created to ensure that neither mandatory spending nor tax legislation increases the deficit. To comply with PAYGO, new mandatory spending programs or tax cuts need to be offset by an equal amount of mandatory spending cuts and/or tax increases. Paygo rules require all legislation to be “deficit-neutral.”

All three of the House committees are expected to help find the $4 billion expense which the bill mandates. The House Ways and Means Committee is most likely to carry the heaviest load because it generally has the responsibility for raising the revenue required to finance the Federal Government. This would be all well and good except for the fact that MHP is not the only health matter which is demanding fiscal resolution at the moment. In fact, the Ways and Means Committee might use its health-related revenue raisers to offset a scheduled cut for physicians under Medicare which is also a critical item on psychology’s legislative agenda, rather than funding the MHP legislation. Lawmakers could also offset some cost by delaying the effective date of the mental health bill (house bill sets 1/1/08 vs. the Senate implementation of a year later). The Senate bill did not identify offsets. Any changes agreed on by the lawmakers in Conference Committee could be added as a manager’s amendment to the House bill before it reaches the floor.

As, I think, you will agree, there are a lot of cooks and a lot of ingredients that go into making this stew, and there are an equal if not greater number of cooks who can spoil it. AAP, APAPO and its coalition partners believe that the most prudent strategy currently is for the House to accept the Senate-passed bill. APAPO has been meeting with Legislative Staffers of Blue Dog Members of Congress (fiscally conservative Democrats who are important swing voters) to urge that they tell the sponsors of the House parity bill that S. 558 is a good bill and that the House should not load up H.R. 1424 with controversial provisions that will cause a deadlock with the Senate. But, so far, it has been slow going for many reasons as outlined above.

At this juncture, there appears to be only one way to get beyond the MHP impasse. With apologies to Jesse “Big Daddy” Unruh, who coined the term, “money is the mother’s milk of politics”, “compromise is the mother’s milk of lawmaking”. During November, House MHP sponsors Patrick Kennedy and Jim Ramstad (R-MN) met with Senate sponsors, Ted Kennedy and Pete Domenici (RNM) to discuss possible compromises. This has been an exceedingly delicate part of the negotiations. All of these players are heavily invested in and committed to MHP. Ramstad and Patrick Kennedy both have personal involvement in the mental health system as consumers. Domenici has a daughter with mental illness. Teddy Kennedy has been a proponent of mental health reform for his entire 40 year Senate career.

It is said that politics is “the art of the possible.” If Congress really wants to enact MHP or any bill for that matter, compromises can and will be made. Compromise lies at the heart of everything in Congress, with or without the threat of Presidential vetoes, as compromises need to be made within parties, between regional groups of members and even between a few stubborn members.

Sometimes the process can get ugly. During the Clinton administration, a dispute between the Republican Congress and the President on the appropriations bills led to a government shutdown. Non-essential government employees were sent home since the money wasn’t appropriated to pay them. Compromise prevailed and the employees were later paid.

The process can be painstaking and grueling in working toward the final goal (all the way to a veto and veto over-ride sometimes) in order for a compromise to take shape. A passionate commitment to a specific piece of legislation like MHP is hardly passionate if you compromise at the start. Your supporters probably would throw you out the window.

Passionate issues are all over Congress lately. The Iraq War, Children’s Health Insurance, and Stem Cell Research, just to name a few that are percolating. Ultimately, all the passion will be compromised, as it should be in a democracy, although compromise is not pleasant for anyone. In fact, it is rare to see both parties completely satisfied with a compromise on legislation. It is inherent to our legislative process. It is how the system works, the essence of a functioning democracy. Of course it could break down and passion could trump compromise (which happened once and resulted in a Civil War). That experience, plus our genuine ability to live with compromise has suited us well so far.

In closing, I fully reject Camus’ central argument in The Myth of Sisyphus which is that life itself is a futile struggle devoid of hope, and that our fate only seems horrible when we place it in contrast with something that would seem preferable. If we accept that there is no preferable alternative, then we can accept our fate without horror. In fact, with regard to the life of MHP, we have every reason to be optimistic that a substantial change will occur in the final law that will be enacted.

I am reasonably confident that we will see MHP enacted most probably in Spring 2008. We must continue to do our part to move the process along by letting our Congressional supporters know that we value their work through our support of their election campaigns. The subplots discussed earlier will ultimately be resolved over time and the details of MHP will be worked out so that we will finally see an end to the health insurance discrimination against those individuals with mental disorders in this country.

Best wishes for the New Year to all.

Winter 2008 Newsletter

Each year retailers begin their Christmas sales hype earlier and earlier. Now, as soon as the “back to school” sales end in August, we begin to see the first signs of Christmas. Primary Presidential elections are following suit in this regard. Many states now are considering holding their primary elections only days after we ring in the New Year. In only a few months, the 2008 election will be cruising along at full throttle. Despite the fact that this painfully lengthens the whole election process, in other ways this development should be good news for health care.

Aside from the war in Iraq, health care has been the most important issue for the American public in the early phase of the 2008 presidential campaign, ranking higher than both immigration and the economy. A New York Times/CBS News poll indicates that a majority of the U.S. population thinks that the federal government “should guarantee health insurance for all Americans,” particularly children. The poll confirms that Americans would be willing to pay higher taxes to make changes possible, although, like politicians, they disagree about whether participation in a national health care plan should be required and whether the government or private insurers would do a better job of providing coverage. This means that we in psychology must position ourselves to be key players in these debates to insure that mental health coverage and specifically psychological services are included in whatever health care plan will unfold in the future.

The next president of the United States will have tremendous impact on the health care system for many years and it is critical that he or she be well versed in matters pertaining to mental health. Elsewhere in this edition of Advance, two psychologists discuss their roles in the campaigns of two Presidential candidates.

It is instructive to analyze the fundraising results of the candidates at this point in the election in order to better appreciate the role of political money in the election process. During the first six months of 2007,the presidential candidates raised more than $265 million. This represents the fastest start to presidential fund-raising ever, according to the Center for Responsive Politics. The eventual Democratic and Republican nominees could each ultimately raise $500 million or more — record amounts. So far, however, only a small percentage of the contributions has come from people who are affiliated with the health sector or from political action committees (PACs) associated with the health sector. Of note, AAP does not become directly involved in supporting Presidential candidates, in large part, because the risk jeopardizing psychology’s lobbying activities for at least four years is too great if we found ourselves in the difficult position of having supported a losing candidate for President.

The Center for Responsive Politics analyzes campaign finance data reported to the Federal Election Commission and classifies contributions of $200 or more from individual donors or PACs into 13 sectors. The health sector includes doctors, drug companies, and hospitals, among other groups. For the first half of 2007, Democratic candidate Hillary Clinton, the leading fund-raiser, collected $63.1 million, of which 2.7% was from the health sector. Senator Barack Obama collected $58.9 million, 2.1% was from the health sector. Republican candidate Mitt Romney, the leading Republican fund-raiser, collected $44.4 million, including 3.1%, from the health sector. Rudolph Giuliani, raised $35.6 million, including 2.5%, from the health sector.

In total, Democratic presidential candidates raised a reported $60 million more than Republican candidates in the first 6 months of the 2-year 2008 election cycle. Democrats raised a total of $3.9 million from the health sector, and Republicans $3.1 million, figures that are consistent with the Democrats’ overall lead in the race for money.

Traditionally, the financial sector — banks, insurance companies, and the real estate industry — has been the largest source of funds for presidential and congressional races, followed by lawyers and lobbyists and then ideological and single-issue groups. The financial sector contributed $338.9 million to federal candidates in the 2004 election cycle (which included the presidential election) and $251.8 million in the 2006 cycle (which was just congressional). In both cycles, the health sector ranked sixth among the 13 sectors. Health sector contributions — $123.9 million in the 2004 cycle and $98.6 million in the 2006 cycle — accounted for about 7% of all donations. The majority of health sector contributions were from individuals; doctors and other health care professionals contributed the most. In the 2004 and 2006 cycles, more than 60% of the health sector funds went to Republicans. This contrasts with the beginning of the 2008 cycle, during which the fund-raising advantage went to the Democrats.

Like some other businesses, the health care industry spends substantially more money lobbying Congress and federal agencies than it does on elections. Organized psychology, represented by the APA, maintains an extensive public policy office within APA which vigorously lobbies Congress on issues of concern to the science, education and public interest constituencies within APA. The APA Practice Organization’s Government Relations Department lobbyists fight on Capitol Hill for issues affecting professional psychologists. The APA and the APA Practice Organization invest a substantial amount of financial resources in these lobbying operations which far exceed the amounts available in AAP’s psychology PAC, AAP/PLAN, not unlike the lobbying to campaign ratio of most other interest groups.

In 2006, the health sector spent $351.1 million to lobby the federal government — an amount that accounted for 13.8% of all spending on lobbying and nearly equaled similar spending by the financial sector, which ranked first. Within the health sector, manufacturers of drugs, medical devices, and other health care products spent the most; Pharmaceutical Research and Manufacturers of America (PhRMA) spent $18.1 million, Pfizer $11.8 million, and Amgen $10.2 million. The drug industry was followed by hospitals and nursing homes and then by organizations of health care professionals, such as the American Medical Association (AMA). Between 1998 and 2006, the AMA, the American Hospital Association, AARP (formerly the American Association of Retired Persons), and PhRMA spent, respectively, the second, fourth, sixth, and seventh most money on lobbying.

By contributing to political campaigns, individuals and PACs hope to influence both who gets elected and what they do when they are in office. Currently, there is broad support for making fundamental changes in or completely rebuilding the health care system. However, the details are complex, and as the discussion becomes specific, more people may prefer to maintain the status quo or to make incremental changes rather than start over. Contributions from the health sector to presidential and other federal candidates will likely increase in the months ahead. There are no assurances that the election of a new president will lead to major changes, although the potential for reform seems greater than it has for many years. Once again, it is incumbent upon psychology to amass the resources we need to insure our place at the table. Please be sure to renew your AAP membership NOW. Just as important, recruit a colleague to become an AAP member. If every psychologist contributed to AAP’s political advocacy program, psychology would be second among all health PACs in Washington. Currently, we are way down on the political giving totem pole. Please resolve to help us change that ranking today.

Fall 2007 Newsletter

It is no secret that a majority of psychologists lean toward the liberal end of the political spectrum. Despite this inclination, for the past 20 years, one of AAP/PLAN’s guiding principles has been to distribute its resources equitably to both Democratic and Republican candidates for federal office. In essence, it would be foolish for a political action committee to do otherwise. Legislators’ support from both political persuasions is needed to reach the critical mass needed to move psychology’s legislation. AAP’s bipartisan policy has proven to be most helpful in developing strong working relationships with Members of Congress from both parties. The bipartisan relationships we have developed have demonstrated time and again their value in promoting psychology’s legislative program on matters ranging from inclusion of psychologists in Medicare almost 20 years ago, to blocking passage of the recent HIMMA Bill, a detrimental measure that would have preempted highly favorable state mental health parity laws.

At this moment, you might say that the whole world is watching to see what if any changes will take place in the public policy arena since the Congressional regime change occurred last Fall at the polls. It has been more than a dozen years since both houses of Congress have been controlled by Democrats. During those 12 years, psychology’s legislative agenda encountered serious opposition from the party controlling Congress. While some legislative victories were won despite this opposition (the first Mental Health Parity bill, blocking HIMMA, etc.), other pressing matters of concern to psychology have languished in committee due to the restraints placed on them by the controlling party’s Leadership.

The Paul Wellstone Equitable Treatment Act is a case in point. Prior to January, the ruling party Leadership refused to allow a mental health parity bill to emerge from its Committee of jurisdiction for a floor vote, despite a majority of members supporting the measure. With Democrats in control of the Congressional agenda, it is expected that “mental health parity” legislation will not only be very likely to reach a vote, but stands a good chance of being enacted.

However, don’t assume for a minute that psychology’s advocacy program can now be placed on “cruise control”, or that we can simply sit back and reap the fruits of our long years of labor. The margins of control in both houses of Congress mitigate against such complacency because, for one, the margin of Democratic control is too narrow. This translates in a practical world to the following reality on Capitol Hill; reelection concerns always trump policy concerns.

Even so, there will be a significant amount of activity in Washington over the next 18 months. Democrats’ stunning electoral gains last November will certainly have major impact on health care and beyond. For starters, we will almost surely see a broadening of the economic agenda over and above President Bush’s focus on tax cuts to more populist debates over income inequality (such as the recently passed minimum wage increase), globalization, budget deficits and health care coverage, among other issues. Many of the Presidential candidates from both parties have already placed health care front and center in their campaigns.

The big question we are all waiting for answers to is whether Democratic control of the House and Senate will result in substantive change or merely political stalemate and posturing for the next presidential election. Many pundits believe the theme for the next year and a half will be showcasing for the ‘08 election. There is strong evidence to suggest that the post election weeks in November were only a temporary break from the seemingly never ending array of Presidential candidate appearances, news saturation about the candidates, and the candidates’ campaign ads.

On issues ranging from energy policy to a lobbying overhaul, Democrats acknowledge that they must show as soon as possible that they can govern.

Beginning in January, Democrats embarked upon an ambitious legislative agenda with their newly won control. At this juncture, not one of Speaker Pelosi’s major initiatives has as yet come to fruition. Just last week, in a triumph for the pharmaceutical industry, the Senate killed a drive to allow consumers to buy prescription drugs from abroad at a significant savings over domestic prices. On a 49-40 vote, the Senate required the administration to certify the safety and effectiveness of imported drugs before they can be imported, a requirement that officials have said they cannot meet. This defeat raises serious questions about whether the same fate may await Democrats’ promised legislation allowing the government to negotiate prices under the Medicare prescription-drug program. All this is to say, Democrats face a legislative traffic jam that threatens to leave the party without a single highprofile domestic victory heading into the Memorial Day recess.

Many Democrats see an immigration overhaul (S 1348) pending in the Senate as the party’s best hope for scoring a legislative victory. This week the Senate Judiciary Committee reached bipartisan agreement on an immigration bill which may ultimately be approved by a full Senate vote. The Senate is set to vote Wednesday (the last week in May) on whether to proceed on the immigration bill that enjoys the support of the White House, and some Senate Republicans and Democrats in both chambers. However, now many in the big business community have voiced their opposition to the bill due to what they believe will be a shortage in workers if it is enacted. If the bill is successful, the bipartisan breakthrough would give lawmakers an accomplishment to tout when they go home for the parades, picnics and commencements that put them face to face with so many constituents this time of year.

The fate of a similar bill in the House is a far more complicated undertaking, as is usually the case. Unlike their Senate colleagues, House members stand for election every two years and their electorates are far more homogeneous due to the highly political way in which the composition of Congressional districts is determined. This results in far more party polarization in the House which makes compromise all the more difficult there.

Many Democrats believe that they’ve been given a two-year test, and this period leading up to the next election is an opportunity.

Indeed, some Senate committee chairmen are coming under pressure to produce more domestic policy legislation in order to demonstrate clearly that Democrats can live up to their promises to be more productive than Republicans were when they controlled Congress.

But, they will clearly have their work cut out for them. Because Democrats don’t have a veto-proof majority in the House, or the 60 votes needed to limit Senate debate, some observers predict gridlock. Add to this the fact that the powerful business community sees an impasse in Congress as meaning less spending and this is generally bullish for the markets.

We have all heard the endless barrage of platitudes and niceties urging the two parties to work together to address economic issues. Democrats promised to reach out to Republicans, and Bush also vowed bipartisanship. These promises lasted all of about a millisecond. There’s still a chance to get some things done, but the window of opportunity is rapidly closing. The closer we get to the elections, the less likely it is that any meaningful policy will be moved in Congress. Of note for psychology, the odds are still high for the parity bill to be undertaken in this session of Congress.

Even if passing laws is difficult, Democrats still have plenty of power to shape the agenda. Democrats can, for instance, affect the economy by declining to schedule votes on pending trade deals or expiring Bush tax cuts. There are also must-pass measures to fund the government and the war in Iraq, where Bush has less flexibility. We have recently seen those bills being used as a vehicle for adding other Democratic priorities.

All of the above is to suggest to a situation that you may very well see come to pass over the next year. There is a good chance that what we will see in Washington for the next 18 months is what is commonly referred to as “gridlock”. I recently read an interesting article about gridlock which may seem on the surface like a real snoozer of a topic. Gridlock is not a modern legislative invention. Although the term is said to have entered the American political lexicon after the 1980 elections, Alexander Hamilton was complaining more than two centuries ago about the deadlock rooted in the design of the Continental Congress. In many ways, gridlock is endemic to our national politics, the natural consequence of separated institutions sharing and competing for power.

“…Democrats still have plenty of power to shape the agenda. Democrats can, for instance, affect the economy by declining to schedule votes on pending trade deals or expiring Bush tax cuts.”

If gridlock proves to be paralyzing to our agenda, there is a remedy with which all of us are most familiar. Elections, of course, are the ultimate recourse for voters dissatisfied by partisan polarization and the conduct of Congress. Nudging Congress back to the center by sending more centrist legislators to Washington would be one way to alleviate gridlock. Still, diagnosing the ills of a body politic is one thing; rousing the patient to seek treatment is another. This underscores the need for us to engage in an even more potent full court press in the area of political action. Not only must we provide the resources for psychology’s lobbyists to take our messages to Capitol Hill, we must also help to elect and reelect those legislators who support psychology’s legislative agenda.

Summer 2007 Newsletter

For many years in these pages, I have extolled the virtues of active involvement in the political campaign of candidates sympathetic to psychology’s concerns. Make no mistake; I continue to fervently believe in the value of political giving for psychology. This column, however, is devoted to what I view as the 2nd best way for psychologists to win friends and influence public policy makers at all levels of government.

Imagine a group of ten legislators and assorted staffers actively participating in a “therapy” group being facilitated by a psychologist. Assemblyman X waxes prolifically about a certain constituent whose daily demands to duplicate the same document over and over are driving her staffers to the limits of their tolerance. State Senator Y expounds about a constituent who, after an acrimonious divorce, expects the Senator to redress what he considers to be the outrageous inequities of the judicial system. Congresswoman Z submits that the stresses of weekly transcontinental jet travel and the demands of the job are taking a toll on her ability to manage his frustration adequately.

Sounds like a scene from a Hollywood film with Mel Brooks in the leading role, right? Wrong. This was a real situation which took place in San Diego almost 15 years ago. I am hopeful that this same scenario can be replicated across the country in order to promote the work of professional psychologists in the eyes of lawmakers at the local, state and national levels.

The scene described above came about due to a combination of serendipity and the vision of the San Diego Psychological Association’s (SDPA) leadership. The concept for a legislative workshop began with a phone call to the SDPA office from a state legislator’s staffer who requested permission to attend a closed training session for psychologist evaluators providing services in San Diego County‘s Juvenile Court system. It would have been inappropriate for a lay person to have attended such an event. But, the Chair of the Juvenile Court Committee of SDPA wisely recognized that a rare opportunity had been presented, even though it wasn’t in the area of the original request. It was, however, a chance to further explore an area of great importance to psychology, namely the legislative advocacy arena.

I suppose it was because I was the most vocal and the most persistent promoter for psychology’s need to become more involved in the political process, that the phone call from the state senator’s staffer was referred to me. After careful consideration of all the variables (taking a total of about 3 minutes) it was clear that we had stumbled upon what could become a golden opportunity if handled well. What could be better for psychology’s political advocacy agenda than to have a legislator’s office register their desire to participate in a psychology workshop? The fact that the specific workshop in which they had expressed interest was inappropriate did not prevent us from pursuing another kind of working relationship with that office.

To that end, a meeting was arranged with two staffers from the Senator’s office. The overarching goal of that initial meeting was to engage in a formal needsassessment of the staffers. The needsassessment approach was easy to apply in this specific situation because we were responding to a direct request made by a legislator’s office. Therefore, it was quite natural to explore the range and kind of on-the-job problems they regularly encounter. Needless to say, as in any meeting where psychologists interact with legislators, the guiding principle for such a meeting should be to demonstrate, in vivo, that we psychologists are competent professionals and that the services we provide have real value. The three psychologists who participated in that first meeting displayed psychology’s wares very effectively. The meeting soon developed into a small group experience facilitated by three professionals who functioned to help each participant to identify specific problems, ventilate emotionally about them, and offered some assistance in formulating a plan to resolve the most minor ones. We provided the staffers with a sample of our work product and they provided us with the seeds with which to develop an ongoing consulting relationship.

Following that meeting, it was apparent that we had an opportunity to design and implement a program for legislators which had the potential for greatly enhancing psychology’s advocacy activities. Traditionally, our advocacy efforts have revolved around developing and then nurturing personal relationships with legislators at all levels of government. We meet with them on a regular basis, keep them apprised of psychology’s political agenda, and when needed, ask them to support our position on a particular piece of pending legislation. On occasion, we ask a special friend in the legislature to carry an amendment to a particular piece of legislation. And on even rarer occasions, we ask a very special friend to author a bill.

It is almost exclusively through political giving activities that psychology turns the tables and actually offers elected officials something rather than asking for something. We have a lot of room for improvement in this area. As noted above, the emphasis of almost all other interactions is on psychologists approaching legislators with their hands outstretched, asking for something of the legislator (a favorable vote, authorship of a bill, support of an amendment, etc.) What a major shift it is to be able to interact with a legislator as a psychologist and offer him or her something of value rather than being in the more customary role of asking them for their help on some matter.

Based on the needs-assessment we thought a reasonable and an appealing theme on which to focus would the commonly experienced problem area in many legislative offices, dealing with difficult constituents who were challenging for legislators and their staffs to manage on a day to day basis. The actual format for the first workshop with legislators was designed to be both didactic and therapeutic. We aimed for a two hour program consisting of 45 minutes of didactic presentation given by a senior, polished psychologist, followed by small groups facilitated by other psychologists who were hand picked for their skills in working with small groups.

Anxiety ran a bit high for that first program. What if we had a party and no one showed up? We ended up with around 20 attendees at the workshop entitled “Dealing With Difficult Constituents.” We attempted to ensure that the legislator turnout would be high by employing efficient marketing techniques. Feedback from all the participants was most positive. As is often the case with group experiences like this, the participants seemed to relish the opportunity to share the various and sundry problems they had recently encountered in the workplace. The program worked like a charm, and all participants seemed to be pleased with the outcome and a follow-up session was agreed upon.

It is important to recognize the double impact which such an experience generates. First, displaying the services psychologists typically provide to patients to such an influential group like legislators/staffers is invaluable in promoting the recognition that psychological interventions result in both tangible and intangible benefits for consumers of such services. Few things could be more powerful in shaping opinions about any topic than to have had a personal experience with a particular intervention, regardless of what field or what discipline. Yes, there are certainly other ways to influence our legislators about the field of psychology, and we are constantly engaging in those pursuits by way of meetings, phone calls, the provision of information and fact sheets, etc. Even so, these methods pale by comparison to the type of in vivo experience which is provided by the workshop setting, except in rare instances when a legislator has had a beneficial personal psychotherapy experience with a psychologist. Second, psychologists are in the business of forming close therapeutic alliances or relationships. There is only one more powerful way to initiate a trusting relationship with policy, decision, or law makers than to do so in the context of teaching them interpersonal skills while functioning in the role of helping professional. The most powerful way, of course, remains contributing liberally to a legislator’s campaign fund. This always opens the door for expanded relational opportunities.

This model for working with legislators is a “no-brainer” for psychology. It can easily be duplicated or modified for use in every region of the country by teams of psychologists like those in San Diego. Meetings can be scheduled to take place on either a quarterly or monthly basis. Topics can range from, “Dealing With the Difficult Constituent” to “Developing an Effective Staff” to “Avoiding Burnout In the Public Sector,” etc. The specific topics you choose are only important insofar as they may be the inducement with which to initially attract your participants to attend the first meeting. In reality, after attending a workshop, there should be little problem in developing repeat customers. I know this is true because staffers are starving for opportunities to share the trials and tribulations of their daily work experience which is quite stressful. When we offer them a legitimate forum for voicing their concerns and hearing how colleagues may struggle with the same or similar issues, we can only be doing them a real service and they are appreciative of this.

Borrowing liberally from one of this country’s most notable leaders “Ask not what your Congressman can do for you, but rather what you can do for your Congressman.” Forgive me JFK. Please let me know if you are currently utilizing a similar program in your area or if you would like more information about the model I have described. I can be reached at (800.735.7305) or E-mail at smpfeiffer@ aapnet.org.

Spring 2007 Newsletter