Our May 2017 TCP editorial, "The Need For A National Guild in Psychology" generated a number of emails asking what are the advantages of having a national guild. Others inquired how would it work and others organizational and strategy aspects of forming a national guild. Now that The APA has embarked upon a strategy to accredit master degree programs in clinical psychology that will lead to independent practice for holders of this degree, the doctoral level is likely to lose its status as the entry into practice. Nothing positive will accrue to doctoral level practitioners as APA sees this a solution to their declining membership.
A national guild is like a union. Members of the guild pay a monthly or yearly fee and in return have access to specific benefits relating to practice. Like the current structure of labor unions, a psychology guild would represent practitioners in a collected bargaining arrangement as is typical in labor unions. A professional guild, however, would have a completely different structure and focus but would be aligned and affiliated with a national union as nurses and pharmacists now do. Following are some of the benefits and goals that a national psychology guild could encompass.
Dealing With Insurers on National Standards For Reimbursement
Presently, practitioners have no place at the table and none to little input on how insurers decide on reimbursement, panels, qualifications or utilization of psychological services. A national guild would have the clout to develop a quasi-bargaining structure with insurers, facility chains, and hospitals, through their national associations on many of these issues. With the help of allies in the affiliated labor union, the psychology guild would have the clout that we now lack. No state association or the APA is able to do this.
APA represents too diverse of a membership to focus their attention solely on practitioners. This is and has been our problem and is the main reason for the decline in practice. Practitioners need a single entity that is focused solely on practice, patients, and our interests. The biggest hurdle we face is acknowledging that we cannot do this alone and that being a professional does not mean we should remain alone and outside the broader labor market. Whether laborer or professional, what we all have in common is that we sell our labor. As such, we have every right to join together to have consistent and fair working conditions.
The American Medical Association Is A Guild
Why are physicians at the top of the practitioner food chain in the healthcare system? The sole reason is that they are structured and function as a national guild. They focus on issues that are common to all physicians without regard to where they practice. They also have policies that protect every one of their specialties. They do this by ensuring that any changes to the system will not benefit one specialty at the expense of another. In other words, they ensure and practice solidarity. They bargain with hospitals, insurers, and government yet they do not label themselves a union. They just function as one and it works. They have obtained license mobility for physicians. Psychologists have little license mobility and have difficulty in trying to get licensed in most states despite the fact that we, too, take and must pass a national exam and meet criteria that is almost identical in every state.
Physicians, because of the AMA, develop, control, and own practice reimbursement codes and set their relative value. Psychology input is relatively non-existent. Psychiatry owns the DSM and reimbursement rates depend on their input. The AMA has a strong lobbying presence. Psychology does not. APA has little clout because mental health is seen in state capitols and in Washington as the realm belonging to the ApA. The AMA and its state affiliates can stop and hinder any legislation that they see as negatively affecting their membership despite that fact that less about 50% of physicians belong to the AMA. Presently, if APA had 100% of psychologists as members, we still would be a no-nothing force in Washington. At the state level, being in the APA is of no consequence and state associations as APA affiliates means little. So, it is clear that the AMA is doing something, actually many things, that professional psychology is unable or unwilling to do.
A National Guild And State Boards of Psychology
Most state associations have little power with state BOPs. Contrast that with the power and influence that state medical associations have with their state boards. Things have gotten so bad for practitioners that it appears those entering the field might have to pass a third examination to get licensed. Why? Because practice is now being directed by the Association of State and Provincial Psychology Boards, a meta-entity that literally is taking control over the practice of psychology. Check out their website at http://www.asppb.net/ to see just how much they control practice. Clearly, this is the group that practitioners need to gain influence and we can do this with a national guild. APA and state associations have failed to gain any traction.
Help From Affiliates
Although unions are in decline with lower skilled workers, the one clout that remains is the aid, resources, and help that unions provide to each other. Professionals, on the other hand, have greatly gained from establishing a national guild and affiliating with a national union. Nurses, nurse practitioners and pharmacists, for example, are doing very well since forming their guilds. Nurses, for example, are becoming as powerful and influential as physicians. In some cases even more so. In fact, healthcare workers at all levels have been gaining through their affiliation with national unions. In many cases, these guilds are negotiating not with individual hospitals and facilities but with the owners of the hospital and facility chain.
As local hospitals and facilities increasingly are being consumed by large chains, these workers are able to negotiate both wages and working conditions with a single entity irrespective of geography. Clearly, the situation for psychology practitioners is different. Many of us are in solo practice. The benefit for us is with affiliation with other guilds that are rule bound to assist us. The ability to negotiate with insurers, where the market also is restructuring into control by just a few large companies, is analogous to negotiating with large hospital chains. Reimbursement, for example, should be based upon skill level, degree, time and service. Sixty dollars a session is not a living wage for professionals at our level. These insurers need to know that we are not alone.
One of the most significant benefits of having a national psychology guild is having the resources to get a remedy for unfair and the tortuous conduct of the entities that are related to our practice. These entities include state BOPs, insurers, facilities, and even other associations such as state medical associations, boards, and others who engage in restraint of trade against psychologists. State associations lack both the resources and motivation to do this. The APA prefers defending and settling lawsuits as opposed to bringing them. A national guild would have both the resources, help, motivation, and focus to use the courts to remedy the harms done to psychologists and patients. The use of legal strategies is perhaps the one way that psychology practitioners can achieve parity with physicians.
Presently, it is difficult and expensive for practitioners to obtain reasonable health insurance. A national guild can provide this insurance on its own or through affiliation with a larger union.
Access to a Wider Patient Population
A national psychology guild will give members access to a new and wider population of patients as we firmly establish doctoral level practice as the gold standard for treatment.
Now that APA has decided to abandon doctoral level practice by accrediting master level programs, it is important that doctoral level psychologists organize. There are many more benefits that psychologists and psychology would achieve through a strong national guild. Is a national guild a panacea for all of our problems? Of course it isn't. There are no panaceas. There may also be some disadvantages. Whatever they may be, however, we need to disrupt the way we do business.
APA and state associations are unable to cope in a 21st century healthcare environment. They are an outgrowth of academia. Their diversity of members means that they are unable to successfully focus on practice. Look at the APA motto: " APA: SERVING MEMBERS, STUDENTS, TEACHERS, POLICYMAKERS, AND THE PUBLIC." Despite the average annual budget that exceeds $115 million dollars, without counting real estate holdings and reserves, so little has been focused on practitioners. Subsequently, practice has declined for over two decades. Yes, APA had a practice organization but it was even more of a problem for practitioners. The PO was controlled by academics or former practitioners who prefer organizational bureaucracy to practice. No expectation of help there.
APA has now formed a
new organization that, they say, will advocate for all areas of psychology. They eliminated the Practice Directorate because clinical members
declined to pay the fraudulent mandatory assessment that APA had extracted over several decades. Practitioners may be diverse in many ways but we are singular in our needs - singular needs that revolve around maintaining and sustaining a practice and a profession that increasingly is being seen as irrelevant by others and sabotaged by APA. We cannot continue to do this with the present structures that abound in psychology. A national guild would go a long way in remedying our situation by bring a positive disruption to psychological practice.
Join NAPPP To Start The Guild
Numbers matter, and without those numbers, we all fail. Join NAPPP and become part of the change in professional psychology. With sufficient numbers we can become a guild worthy of respect and influence.