PAGENO="0001" ~O / PSYCHOLOGY HEARINGS BEFORE SUBCOMMITTEE INO. 5 OF THE COMMITTEE ON THE DISTRICT OF COLUMBIA HOUSE OF REPRESENTATIVES NINETIETH CONGRESS SECOND SESSION ON H.R. 10407 and S. 1864 TO DEFINE AND REGULATE THE PRACTICE OF PSYCHOLOGY IN THE DISTRICT OF COLUMBIA MAY 20, JUNE 3 AND 19, 1908 Printed for the use of the Committee on the District of Columbia )4~55 jJ~9 U.S. GOVERNMENT PRINTING OFFICE WASHINGTON : 1968 `Y'~ ~C;~ L ~ / PAGENO="0002" THOMAS G. ABERNETHY, Mississippi WILLIAM L. DAWSON, Illinois JOHN DOWDY, Texas BASIL L. WHITENER, North Carolina B. F. SISK, California CHARLES C. DIGGS. JR., Michigan G. ELLIOTT HAGAN, Georgia DON FUQDA, Florida DONALD M. FRASER, Minnesota BROOK ADAMS. Washington ANDREW JACOBS. JR.. Indiana E. S. JOHNNY WALKER, New Mexico PETER N. KYROS, Maine ANCHER NELSEN, Minnesota WILLIAM L. SPRINGER, Illinois ALVIN E. O'KONSKI, Wisconsin WILLIAM H. HARSHA, Ohio CHARLES McC. MATHIAS, Jn., Maryland FRANK HORTON, New York JOEL T. BROYHILL, Virginia LARRY WINN, JR., Kansas GILBERT GUDE, Maryland JOHN M. ZWACH, Minnesota SAM STEIGER, Arizona COMMITTEE ON THE DISTRICT OF COLUMBIA JOHN L. McMILLAN, South Carolina, Chairman JAMES T. CLARK, Clerk CLAYTON S. GASQUE, Staff Director HAYDEN S. GARBER, Counsel SuBcoM~iITTEE No. 5 B. F. SISK, California, Chairman BASIL L. WHITENER, North Carolina - WILLIAM H. HARSHA, Ohio G. ELLIOTT HAGAN, Georgia FRANK HORTON, New York ANDREW JACOBS, JR., Indiana GILBERT GIJDE. Maryland E. S. JOHNNY WALKER, New Mexico JOHN M. ZWACH, Minnesota (II) PAGENO="0003" CONTENTS Page H. R. 10407 (McMillan), a bill to define and regulate the practice of psy- chology in the District of Columbia 1 S. 1864 (i\'Iorse), a similar bill 6 S. Rept. 1092 on 5. 1864 10 STATEMENTS American Psychological Association, Dr. Arthur H. Brayfield, executive officer 39 Broyhill, Hon. Joel T., Representative in Congress from the State of Vir- ginia 74 District of Columbia Government: Moyer, Thomas F., Assistant Corporation Counsel 111 Schultz, Dr. John D., Associate Director Mental Health and Retarda- tion, Department of Public Health 106, 111 District of Columbia Psychological Association: Bayroff, Dr. A. G., president 13, 115 Chambers, Reed, counsel 115 Cummings, Dr. Jonathan W., chairman, legislative committee~ 13, 15, 115 Hildreth, Mrs. Jane, legislative consultant 115 Levy, Dr. Bernard J., president-elect 13, 17 Meltzer, 1)r. Malcolm J., past president 13, 19, 11.~ District of Columbia Medical Society, Dr. John Hughes, member of the executive board 78,83,85 Starr, Dr. Dorothy A 101 Washington Psychiatric Society: Meltzer, Dr. Milton, president 78 Stienbach, Dr. Richard, past president 78 Washington Psychoanalytic Society: Kuder, Armin U., counsel 115 Legault, Dr. Oscar, president 78, 115 Zimmerman, Dr. Isaiah M 64 MATERIAL SUBMITTED FOR THE RECORD Amendments Proposed: District of Columbia government 105 Model for State Legislation Affecting the Practice of Psychology in 1967, adopted by the American Psychological Association 54 Revised bill submitted by the D.C. i\'Iedical Society, The \`ledico- Chirurgical Society, D.C. and the Washington Psycho-Analytic Society 149 Response of D.C. Psychological Association to proposed amendments 154 Senate Amendments 12,23 A~IERICAN PSYCHOLOGIST: Reprint of "Ethical Standards of Psychologists", Vol. 18, No. 1, Jan. 1963 69 Reprint of "A Critical Look at Professional Education in the Mental Field", Vol. 22, No. 4, April, 1967 40 Central California Psychiatric Society, Dr. Edward Rudin, l)resident-elect, letter to Chairman Sisk, dated May 10, 1968 66 District of Columbia Government, Thomas W. Fletcher, Assistant to the Commissioner: Letter to Chairman i\'IcMillan, dated May 17, 1968, reporting on H~R. .10407 and.S. 1~64 105 Letter to Chairman Sisk, dated June 18, 1968, reporting on substitute draft of bill 113 (III) PAGENO="0004" IV Page District of Columbia Psychological Association, Dr. Malcolm L. Meltzer, president, letter dated February 24, 1965, to Dr. Leon Yochelson, president, Washington Psychiatric Society and his reply dated March 22, 1965 108 Harley, Dr. Al B., telegram to Chairman McMillan dated May 24, 1968 - 107 Medical College of South Carolina Department of Psychiatry, Dr. R. Layton ~v1cCurdy, Chairman, letter to Chairman McMilan dated May 31, 1968 107 Mental Health Ministry, Rev. Grover Boydston, psychologist, memoran- dum to Chairman Mc~1fflan dated May 17, 1968 67 South Carolina Psychological Association, Dr. M. Kershaw Walsh, Chair- man, Special Committee for licensing Legislation, letter to Chairman Mc~\'1i1an dated May 26, 1968 University of Vermont, Dr. Hans R. Huessy, acting chairman, department of psychiatry, letter dated May 27, 1968 to Hon. Robert Stafford, Representative in Congress from the State of Vermont APPENDIX Amendments, as revision of H.R. 10407, proposed by D.C. Medical Society, the Medico-Chisurgical Society, D.C., and the Washington Psycho- analytic Society 149 Comments of D.C. Psychological Association on proposed amendments~_ 154 Requirements for Psychologists: District of Columbia Psychological Association, Dr. Jonathan W. Cummings, Chairman, Legislative Committee, letter to Congressman Zwach dated May 29, 1968, outlining training program for psychol- ogists 139 George Washington University, Department of Psychology, program in clinical psychology 139 Requirements for Psychiatrists: Georgetown University, Department of Psychiatry, residency training program in psychiatry 142 St. Elizabeths Hospital, Washington, outline of training curriculum in psychiatry 147 Washington Psychiatric Society, Dr. Richard A. Steinbach, letter dated June 6, 1968 to Congressman Zwach outlining training pro- gram for psychiatrists 142 PAGENO="0005" PSYCHOLOGY MAY 20, 1968 HOUSE OF REPRESENTATIVES, SUBCOMi\II'rPEE No. 5 OF THE COMMITTEE ON THE DISTRICT OF COLUMBIA, Wa$hington, D.C. The Subcommittee met, pursuant to notice, at 10: 10 a.m., in Room 1310, Longworth House Office building, Honorable B. F. Sisk (Chair- man of the Subcommittee) presiding. Present: Representatives Sisk (presiding), Whitener, Jacobs, Walker, Gude, and Zwach. Also present: James T. Clark, Clerk; Sara Watson, Assistant Coun- sel; Donald Tubridy, Minority Clerk; and Leonard 0. Hilder, Investigator. Mr. Sisk (presiding). Subcommittee No. 5 will come to order. Subcommittee will hold hearings today on H.R. 10407, a bill intro- duced by the distinguished gentleman from South Corolina, the Chair- man of the Committee, to define and regulate the practice of psychology in the District of Colun~bia. The Chair understan'ds that the purpose of H.R. 10407 is to provide for the protection of the public from the unqualified practice of psychology, and from unprofessioria.l conduct of persons practicing psychology in the District of `Columbia, by requiring all persons who' offer psychological services to the public for a fee to obtain a license from the District of `Columbia Government. At the present time, psychologists may practice psychology in the District of Columbia without license or regulation. The Subcommittee also has before it S. 1864, which in its original form, I understand, was identical to H.R. 10407, although I believe it has `had some minor amendments to it since. We will also consider it and the amendments made to it by the other body. Without objection, a copy of H.R. 10407 will be made a copy of the record at this point-and also I think we will include in the record a copy of S. 1864 as passed by the Senate, together with the Senate Report No. 1092. (H.R. 10407 and 5. 1864 and the Senate Report No. 1092 follow:) [H.R. 10407, 90th Cong., 1st sess., by Mr. McMillan, on May 29, 1967] A BILL To define and regulate the practice of psychology in the District of Columbia Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, That this Act may be cited as the "Practice' of Ps~~chology Act". SEC. 2. The practice of' psychology in the District of `Columbia is hereby declared to affect the public health, safety, and welfare, and to be subject to (1) PAGENO="0006" 2 regulation and control in the public interest to protect the public from the unauthorized and unqualified practice of psychology, and from unprofessional conduct by persons licensed to practice psychology. Sue. 3. As used in this Act: (A) "Commissioners" means the Commissioners of the District of Columbia sitting as a board. or their authorized agent or agents. (B) "Person" includes an association, partnership, or corporation, as well as natural persons. (0) "Accredited college or university" means any college or university which, in the Commissioners' determination, offers either an acceptable full-time resi- dent graduate program of study in psychology leading to the doctoral degree, or a comparable program. In making their determination concerning domestic educational institutions, the Commissioners shall accredit those institutions included in the listings of approved academic institutions published by the Fnited States Office of Education; in determining what foreign educational institutions shall be accredited the Commissioners may take into account the published lists of accrediting agencies and of professional associations. (D) "The practice of psychology" is the rendering of or offering to render to the public for a fee, monetary or otherwise, any service involving the appli- cation of established methods and principles of the science and profession of psychology, except as provided in sections 5 and 20 of this Act. These principles and methods are concerned with understanding, predicting, and changing be- havior, and they include, but are not restricted to, the use of counseling and psychotherapy with groups or individuals having adjustment problems in the areas of work. family, school, and personal relationships; measuring, testing. and assessing aptitudes, skills, public opinion, attitudes, emotions, personality, and intelligence; teaching or lecturing in psychology and doing research on problems relating to human behavior. (B) Nothing in subsection (D) shall be construed as permitting either the administration or prescription of drugs or any infringement upon the practice of medicine as defined by the Healing Arts Practice Act of the District of Columbia, approved February 27, 1929 (45 Stat. 1326), as amended. Sue. 4. The psychologist who engages in practice is expected to assist his client in obtaining professional help for all relevant aspects of the client's prob- lem that fall outside of the boundaries of the psychologist's own competence: for example. provision should be made for the diagnosis and treatment of relevant physical problems by an appropriate, qualified medical practioner. ~uc. 5. It shall be unlawful for any person to practice or to offer to practice psychology, or to represent himself to be a psychologist, unless he shall first obtain a license or certificate pursuant to this Act, except as hereinafter provided. (A) Nothing in this Act shall be construed to limit the activities of and use of the title "psychologist" by a person in the employ of any governmental agency, academic institution, charitable agency, research laboratory, or business corpora- tion: Provided. That the services performed by such an employee are a part of his office or position and are provided only within the confines of the organization or are offered to like organizations. Persons providing services to the public through governmental organizations, such as clinics, who are compensated by their employer rather than their clients are also exempted under the Act, Per- sons coming under the exemptions established by this subsection may offer lecture services to the public for a fee but may not offer other psychological services to the public for a fee w-ithout having obtained a license. (B) Nothing in this Act shall be construed to limit the activities of a student intern, or resident in psychology, pursuing a course of study or research with an accredited college. university, or training center: Provided. That such activi- ties are supervised as part of his course of study. and he is designated by such title as "psychology intern." "psychology trainee." or other title clearly indicating traiiiee status. (C) Nothing in this Act shall prevent the employment by a person furnishing psychological services for remuneration, of an individual not licensed as a psy- chologist under the provisions of this Act to assist in the performance of psycho- logical and other services, if such individual works under the supervision of a licensed psychologist who assumes full responsibillty for his acts, and if such individual is not in any manner held out to the public as a psychologist. (D) Nothing in this Act shall be construed as restricting the use of the term "social psychologist" by any person who had (1) received a doctoral degree in sociology or social psychology from an institution whose credits in sociology PAGENO="0007" 3 or social psychology are accepted by an accedited college or university, and (2) who has passed comprehensive examinations in the field of social psychology as a part of the requirements for a doctoral degree, or has had equivalent special- ized training in social psychology, and (3) who has filed with the Commissioners a statement showing his intention to use the term "social psychologist" and demonstrating his compliance with this subsection. SEC. 6. (A) The Commissioners shall be responsible for reviewing the applica- tions of persons seeking licensure or certification f or practice of psychology `in the District, of Columbia, for the granting and renewal of such licenses and certifi- cates, for the preparation and administration of oral and written examinations, and for other matters related `to the purposes of this Act. (B) The Commissioners may appoint a Board of Psychologist Examiners to be selected from a list of psychologists submitted by the District of Columbia Psycho- logical Association. Each member shall be a citizen of the United States, licensed under the provisions of this Act, who shall either be a resident of the District of Columbia or have worked in the District of Columbia for at least two years preceding appointment to the Board. The initial appointees shall be psychologists eligible for licensure under provisions of this Act. (C) The Commissioners shall maintain: (1) a record of licenses and certifi- cates granted and refused and of licenses and certificates revoked or suspended wh'ic~ record shall be available to the public; and (2) a complete record of all hearings conducted pursuant to section 15(B) in connection with the denial, suspension, or revocation of a license. A transcript of an entry in a record of hearing, properly certified, shall be prima facie evidence of the facts therein stated. SEC. 7. The Commissioners shall grant a license to practice psychology to each applicant who submits satisfactory proof that- (A) `he is of good `moral character; (B) he `holds eith'er (1) a doctoral degree in psychology from an accredited college or university and has completed two years of postgraduate experience acceptable to the Commissioners, `such two years not to include term's of internship, or (2) a doctoral degree in a field related to psychology from an accredited college or university, plus two years of postgraduate experience: Provided, That his experience and training are considered by the Commis- sioners to be comparable to the `requirements set forth in (B) (1) of this subsection; (0) he `has passed an examination, written or oral or both, the scope and form `of which shall be `determined by the Commissioners: Provided, That `at any given examination session all examination's `shall be uniform; and (D) his application has been accompanied `by the necessary fees. SEC. 8. Within one year from and after the effective date of th'is Act, a license shall be issued without examination to any applicant who is of good moral char- acter, who either maintains a residence or office, or participates in psychological activities, as determined by the Commissioners, within the District of Columbia, who has submitted an application for license accompanied by the required fee, and who holds (A) a doctoral degree in psychology from an accredited college or univer- sity or other doctoral `degree acceptable to the Commissioners, a'nd has con~ pleted at least one year of postgraduate experience not including terms of internship; or (B) a master's degree in psychology from an accredited college or univer- sity, an'd ha's engaged in psychological practi'ce acceptable to the Commis- sioners for five years after the attainment of hi's highest degree. SEC. 9. The Commissioners may, in their discretion, grant a license without examination, on payment of the required fee, to any person who at the time of application is licensed or certified under the laws of a State or territory of the United `States, or of a foreign country or province whose standards, in the opinion of the Commissioners, were substantially equivalent at the date of such certifica- tion or licensiire, to the requirements of this Act. SEC. 10. A psychologist who is not licensed under the provisions of this Act, but (1) who is licensed `or certified under the laws of a State or territory of the United States or of a foreign country or province whose standards in the opinion of the Commissioners were substantially equivalent, at the date of this certifica- tion or licensure, to the requirements of this Act, or (2) who meets the require- ments `of subsections (A) and (B) of section 7 and resides in a State or territory of the United States, or in a foreign country or province which does not grant PAGENO="0008" 4 licenses or certificates to psychologists, may be employed or invited by a person who is a resident of or maintains a place of work in the District of Columbia to offer professional services in said District for a total of not more than sixty days in any calendar year without holding a license issued under this Act: Pro- vided. That such a psychologist shall report to the Commissioners upon his arrival in the District of Columbia the nature and duration of his professional activities in the District as well as the name of the person who has requested him to render services. A psychologist claiming exemption under the provisions of this section whO offers professional services in the District of Columbia for more than twenty days in any calendar year shall file with the Commissioners evidence of his right to such exemption. Upon proof of that right, to `the satisfaction of the Comniis- sioners, the Commissioners shall enter the name of the applicant in a register kept for that purpose and shall issue to the applicant a certificate in evidence of such registration. SEc. 11. The Commissioners may, in their discretion, waive all or part of the examination required under section 7(C) of this Act when the applicant has (1) achieved a position of eminence in the practice of psychology ah'd has demon- strated, over a number of years, competence in areas covered by the examination, or (2) has `been certified by a national examining `board: Provided, That the examination given by the national examining `board was as effective for the test- ing of professional competence as that required in the District of Columbia. SEC. 12. The Commissioners shall issue a certificate of registration, upOn payment of the required fee, to any association, partnership, or corporation which submits satisfa~ctory proof that (1) it is engaged in the practice of psychology as defined by this Act, and (2) at least one of its members or offices holds a valid license issued `by the Commissioners under this Act. Any such application and the certificate granted in reliance thereon shall list the name of each member or officer of the organization. and shall indicate which members or officers are licensed under this Act. For `any person to retain a certificate issued under this Act, at least one member or officer thereof shall hold at all times a valid license issued in his individual name. SEC. 13. Every person licensed or certified to practice psychology who desires to continue the practice of psychology shall annually pay the required fee for which there will be issued a renewal of licensure or certificate. An `association, partnership, or corporation seeking renewal of a certificate of registration shall provide evidence that at least one of its members continues to hold a valid license issued by the Commissioners under this Act. The Commissioners shall provide a written reminder of the renewal date to every person licensed or registered under this Act, which reminder shall be mailed at least One month in advance. A license or certificate not properly renewed as herein provided `shall l~pse. The Commissioners shall have the right to reinstate a lapsed license or certificate upon payment of the renewal fee plus a penalty fee. A psychologist who wishes to place his license upon an inactive status may do so by submitting notice thereof to the Commissioners. Such a psychologist may reactivate his `license `by payment of the renewal fee herein required unless his license has been inactive for a period exceeding five years, in which case he will be required to furnish the Com- missioners with evidence as to his competence to continue or resume the practice of psychology. SEC. 14. The Commissioners may refuse, revoke, or `suspend licensure or certification if the person applying or the person licensed or certified be: (A) convicted of a crime involving moral turpitude; (B) found to be using any drug or any alcoholic beverage to an extent or in a manner dangerous to himself, any other person, or the public, or to an extent that such use impairs his ability to perform the work of a psy- chologist with safety to the public; (C) convicted of a violation of any provision of this Act or of the regula- tions or rules promulgated pursuant thereto; (D) determined to be a mental incompetent by a court with proper jurisdiction; or (E) found guilty' of the unethical practice of psychology in violation of stthidards to be established by the Commissioners. SEC. 15. (A) Proceedings leading toward the suspension of revocation of a license or certificate shall `be begun by petition, setting forth good cause therefor, filed with the Commissioners and served on the respondent. PAGENO="0009" 5 The Commissioners may determine whether a license or certificate shall be suspended or revoked, and if it is' to be suspended the duration of such suspen- sion and the conditions under which such suspension `shall terminate. Revocation of a license shall not preclude the issuance after the passage of at least five years of a new license or registration to the offender, provided such person can show that he has complied with the provisions of this Act. (B) Before the Commissioners revoke or suspend or refuse to issue a license or certificate for any cause under the provisions of this Act, they shall give the person whose right to practice psychology is challenged an opportunity, to be heard in perSon or by attorney, and to produce witnesses on his behalf. After such hearing, should the Commissioners decide to refuse, revoke, or suspend licensure or certification, they shall set forth in writing their reasons for so doing, and shall include detailed findings of fact. (C) Any person who feels aggrieved by a decision of the Commissioners under subsection (B), of this section may, within thirty days after receiving notice thereof, seek review of said decision in the District of Columbia Court of Appeals. Such review shall be subject to appeal to the United States Court of Appeals for the District of Columbia. (D) In hearings conducted pursuant to subsection (B) of this section, the attendance and testimony of witnesses may `be compelled by subpena. Any person refusing to respond to such a subpena shall be guilty of contempt of court and may be punished as other persons `guilty of contempt of court are punished. `SEC. 16. Any person who shall practice psychology, a's defined `in this Act, without having a Valid, unexpired, un'revoked, and unsuspended license or cer- tificate of registration issued under this Act, shall be deemed guilty of a mis- demeanor and, upon conviction, shall `be fined not more than $500 or confined in jail for not more than six months, or both. SEC. 17. The unlawful practice of psychology as defined in this Act may ~e enjoined by the United States District Court fo'r the District of Colum'bia on petition by the Commissioners, upon a finding that the person sought `to be enjoined is guilty of a violation of the pi~ovi'sions of this Act. In any such proceeding it shall not be necessary to show that any person is individually injured by the actions complained of. If the respondent is found guilty of the unlawful practice of psychology, the court shall enjoin `him from so practicing unless and until he has been duly licensed. The remedy `by injunction her~by given is inaddition to `criminal prosecution and punishment based thereon, and not in lhu thereof. SEc. 18. It `shall be the `duty of the Commi'ssioners of the District of Columbia to enforce the provisions of this Act. SEC. 19. `In legal proceedings, no psychologist shall disclose `any information he has acquired from a `person consulting him in his professional capacity without the consent of `such person, except only (1) in aCtions', `civil or criminal in which a psychologist is suing or being sued by a former client or his legal representative, such as an action `against a psychologist for `malpractice, (2) upon an issue as to the validity `of a document, `such `a's `a will of a client, (3) in cases where the defendent to `a criminal action has i~aised the defen'se of mental in'capa:city. SEC. 20. (A) Nothing in this Act shall be construed as restricting `the use of tools, tests, instruments, or techniques usually denominated "psychological," provided that the user does not represent himself or itself in a manner pro'hibite'd by `this Act. (B) Nothing in this Act shall be construed to prevent qualified members of other profession's from doing `work `of a psychological nature consistent with their training and with the code of ethics of their respective professions: Provided, That they do no't hold themselves out to the public by any title o'r description incorporating the word's "psycho'logical," "psychologist," or "psychology," unless licensed und'er this Act, and excejit a's provided in section 5(D) o'f this Act. SEC. 21. Nothing in this Act shall be construed so as to `affect the authority vested in the Commissioners of `the District of Columbia by Reorganiza'tion Plan Numbered 5 of 1952 (66 Stat. 824). The performance of :any function vested by this Act in the Commissioners may be delegated by t'he `Commissioners in accord- ance with `section 3 of said plan. Szc. 22. There is hereby authorized `to `be appropriated out of the reven'ues of the District of Columbia such `sums as may be necessary to pay `the expe'nses o'f administering an'd carrying `out the purposes `of this A'ct. PAGENO="0010" 6 SEC. 23. SEVEuABU.ITY.-If any section of this Act. or any part thereof, shall be adjudged by any court of competent jurisdiction to be invalid, such judgment shall not affect, impair, or invalidate the remainder of any section or part thereof. SEC. 24. This Act shall become effective ninety days after the date of its enactment. [S. 1S64, 90th Cong., 1st sess., by Mr. Morse, on May 24, 1967] AN ACT To define and regulate the practice of psychology in the District of Columbia Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, That this Act may be cited as the "Practice of Psychology Act". SEC. 2. The practice of psychology in the District of Columbia is hereby declared to affect the public health. safety. and welfare, and to be subject to regulation and control in the public interest to protect the public from the unauthorized and unqualified practice of psychology, and from unprofessional conduct by persons licensed to practice psychology. SEC. 3. As used in this Act: (A) "Commissioner" means the Commissioner of the District of Columbia or his authorized agent or agents. (B) "Person" includes an association, partnership, or corporation, as well as natural persons. (C) "Accredited college or university" means any college or university which. in the Commissioner's determination, offers either an acceptable full-time resident graduate program of study in psychology leading to the doctoral degree or a comparable program. In making his determination concerning domestic educa- tional institutions, the Commissioner shall accredit those institutions included in the listings of approved academic institutions published by the linited States Office of Education: in determining what foreign educational institutions shall be accredited the Commissioner may take into account the published lists of accrediting agencies and of professional associations. (D) "The practice of psychology" is the rendering of or offering to render to the public for a fee, monetary or otherwise, any service involving the applica- tion of established methods and principles of the science and profession of psychology, except as provided in sections 5 and 20 of this Act. These principles and methods are concerned with understanding, predicting, and changing be- havior, and they include, but are not restricted to, the use of counseling and psychotherapy with groups or individuals having adjustment problems in the areas of work. family. school. and personal relationships; measuring, testing, and assessing aptitudes. skills, public opinion, attitudes, emotions, personality, and intelligence: teaching or lecturing in psychology and doing research on problems relating to human behavior. (E) Nothing in subsection (D) shall be construed as permitting either the administration or prescription of drugs or any infringement upon the practice of medicine as defined by the Healing Arts Practice Act of the District of Colum- bia. approved February 27. 1929 (45 Stat. 1326), as amended. SEC. 4. The psychologist who engages in practice is expected to assist his client in obtaining professional help for all revelant aspects of the client's problem that fall outside of the boundaries of the psychologist's own competence; for exam- ple, provision should be made for the diagnosis and treatment of relevant medical problems by an appropriate, qualified medical practitioner. SEC. 5. It shall be unlawful for any person to practice or to offer to practice psychology, or to represent himself to be a psychologist, unless he shall first obtain a license or certificate pursuant to this Act, except as hereinafter provided. (A) Nothing in this Act shall be construed to limit the activities of and use of the title "psychologist" by a person in the employ of any governmental agency, academic institution, charitable agency. research laboratory, or business corpora- tion: Provided. That the services performed by such an employee are a part of his office or position and are provided only within the confines of the organization or are offered to like organizations. Persons providing services to the public through governmental organizations, such as clinics, who are compensated by their employer rather than their clients are also exempted under the Act. Persons coming under the exemptions established by this subsection may offer lecture services to the public for a fee but may not offer other psychological services to the public for a fee without having obtained a license. PAGENO="0011" 7 (B) Nothing in this Act shall be construed to limit the activities of a student intern, or resident in psychology, pursuing a course of study or research with an accredited college, university, or training center: Provided, That such activi- ties are supervised as part of his course of study, and he is designated by such title as "psychology intern," "psychology trainee," or other title clearly indicating trainee status. (C) Nothing in this Act shall prevent the employment by a person furnishing psychological services for remuneration, of an individual not licensed as a psy- chologist under the provisions of this Act to assist in the performance of psychological and other services, if such individual works under the supervision of a licensed psychologist who assumes full responsibility for his acts, and if such individual is not in any manner held out to the public as a psychologist. SEC. 6. (A) The Commissioner shall be responsible for reviewing the applica- tions of persons seeking licensure or certification for the practice of psychology in the District of Columbia, for the granting and renewal of such licenses and certificates, for the preparation and administration of oral and written examina- tions. and for other matters related to the purposes of this Act. (B) The Commissioner may appoint a Board of Psychologist Examiners. Each member shall be a citizen of the United States, licensed under the provisions of this Act, who shall either be a resident of the District of Columbia or have worked in the District of Columbia for at least two years preceding appointment to the Board. The initial appointees shall be psychologists eligible for licensure under provisions of this Act. (C) The Commissioner shall maintain: (1) a record of licenses and certificates granted and refused and of licenses and certificates revoked or suspended which record shall be available to the public; and (2) a complete record of all hearings conducted pursuant to section 15 (B) in connection with the denial, suspension, or revocation of a license. A transcript of an entry in a record of hearing, properly certified, shall be prima facie evidence of the facts therein stated. SEC. 7. The Commissioner shall grant a license to practice psychology to each applicant w-ho submits satisfactory proof that- (A) he is of good moral character; (B) `he holds either (1) a doctoral degree in psychology from an accredited college or university and has completed two years of postgraduate experience acceptable to the Commissioner, such two years not to include terms of internship, or (2) a doctoral degree in a field related to psychology from an accredited college or university, plus two years of postgraduate experience: Provided, That his experience and training are considered by the Commis- .sioner to be comparable to the requirements set forth in (B) (1) of this sub- section; (C) he has passed an examination, written or oral or both, the scope and form of which shall be determined by the Commissioner: Provided, That at any given examination session all examinations shall be uniform; and (D) his application has been accompanied by the necessary fees. SEC. S. Wnithin one year from and after the effective date of this Act, a license shall be issued without examination to any applicant who is of good moral char- acter, who either maintains a residence or office, or participates in psycholog- ical activities, as determined by the Commissioner, within the Distrct of Columbia, who has submitted an application for license accompanied by the re- quired fee, and who holds- (A) a doctoral degree in psychology from an accredited college or univer- sity or other doctoral degree acceptable to the Commissioner, and has coin- pleted at least one year of postgraduate experience not including terms of internship; or (B) a master's degree in psychology from an accredited college or univer- sity, and has engaged in psychological practice acceptable to the Commis- sioner for five years after the attainment of his highest degree. SEC. 9. The Commissioner may, in his discretion, grant a license without ex- amination, on payment of the required fee, to any person who at the tinie of application is licensed or certified under the laws of a State or territory of the United States, or of a foreigii country or province whose standards, in the opinion of the Commissioner, were substantially equivalent at the date of such certification or licensure, to the requirements of this Act. SEC. 10. A psychologist who is not licensed under the provisions of this Act, but (1) who is licensed or certified under the laws of a State or territory of the United States or of a foreign country or province whose standards in the opinion PAGENO="0012" 8 of the Commissioner were substantially equivalent, at the date of his certifica- tion or licensure. to the requirements of this Act, or (2) who meets the require- ments of subsections (A) and (B) of section 7 and resides in a State or terri- tory of the United States. or in a foreign country or province which does not grant licenses or certificates to psychologists. may be employed or invited by a person w-ho is a resident of or maintains a place of work in the District of Colmnbia to offer professional services in said District for a total of not more than sixty days in any calendar year w-ithout holding a license issued under this Act. Upon arrival in the District of Columbia. such a psychologist shall re- port to the Commissioner with respect to the nature and duration of his profes- sional activities in the District as well as the name of the person who has requested him to render services. A psychologist claiming exemption under the provisions of this section who offers professional services in the District of Columbia for more than twenty days in any calendar year shall file with the Commissioner evidence of his right to such exemption. Upon proof of that right, to the satisfaction of the Com- missioner, the Commissioner shall enter the name of the applicant in a register kept for that purpose and shah issue to the applicant a certificate in evidence of such registration. SEC. 11. The Commissioner may, in his discretion. w-aive all or part of the examination required under section 7(C) of this Act u-hen the applicant has (1) achieved a position of eminence in the practice of psychology and has demon- strated, over a number of years. competence in areas covered by the examination. or (2) has been certified by a national examining board: Provided. That the examination given by the national examining board was as effective for the testing of professional competence as that required in the District of Columbia. SEC. 12. The District of Columbia Council is authorized to make regulations to carry out the purposes of this Act, and, after public hearings, to fix, increase, or decrease fees to be charged for services performed by the District govern- ment pursuant to the provisions of this Act in such amounts as may, in the judgment of the Council. be reasonably necessary to defray the approximate cost of administering this Act. SEC. 13. Every person licensed or certified to practice psychology w-ho desires to continue the practice of psychology shall annually pay the required fee for which there will be issued a renewal of licensure or certificate. The Commissioner shall provide a written reminder of the renewal date to every person licensed or registered under this Act. which remainder shall be mailed at least one month in advance. A license or certificate not properly renewed as herein provided shall lapse. The Commissioner shall have the right to reinstate a lapsed license or certificate upon payment of the renewal fee plus a penalty fee. A psychologist who wishes to place his license upon an inactive status may do so by submitting notice thereof to the Commissioner. Such a psychologist may reactivate his license by payment of the renewal fee herein required unless his license has been inactive for a period exceeding five years, in which case he u-ill be required to furnish the Commissioner evidence of his competence to continue or resume the practice of psychology. Suc. 14. The Commissioner may refuse. revoke, or suspend licensure or certifi- cation if the person applying or the person licensed or certified be: (A) convicted of a crime involving moral turpitude; (B) found to be using any drug or any alcoholic beverage to an extent or in a manner dangerous to himself, any other person, or the public, or to an extent that such use impairs his ability to perform the work of a psy- chologist with safety to the public; (C) convicted of a violation of any provision of this Act or of the regula- tions or rules promulgated pursuant thereto: (D) determined to be a mental incompetent by a court w-ith proper juris- diction; or (E) found guilty of the unethical practice of psychology in violation of standards to be established by the Commissioner. SEC. 15. (A) Proceedings leading toward the suspension or revocation of a license or certificate shall be begun by petition. setting forth good cause therefor. filed with the Commissioner and served on the respondent. The Commissioner may determine whether a license or certificate shall be suspended or revoked, and if it is to be suspended the duration of such sus- pension and the conditions under which such suspension shall terminate. Revoca- PAGENO="0013" 9 tion of a license shall not preclude the issuance after the passage of at least five years of a new license or registration to the Offender, provided such person can show that he has complied with the provisions of this Act. (B) Before the revoking, suspending, or refusing to issue a license or certifi- cate for any cause under the provisions of this Act, the Commissioner shall give the person whose right to practice psychology is challenged an opportunity to be heard in person or by attorney, and to produce witnesses on his behalf. After such hearing, should the Commissioner decide to refuse; revoke, or suspend licensure or certification, he shall set forth in writing his reasons for so doing, and shall include detailed findings of fact. (C) Any person who feels aggrieved by a decision of the Conunissioner under subsection (B) of this section may, within thirty days after receiving notice thereof, seek review of said decision in the District of Columbia Court of Ap- peals. Such review shall be subject to appeal to the TJnited States Court of Appeals for the District of Columbia Circuit. (D) In hearings conducted pursuant to subsection (B) of this section, the attendance and testimony of witnesses may be compelled by subpena. Any per- son refusing to respond to such a subpena shall be guilty of contempt of court and may be punished as other persons guilty of contempt of court are punished. SEC. 10. Any person w-ho shall practice psychology, as defined in this Act, without having a valid, unexpired, unrevoked, and unsuspended license or certifi- cate of registration issued under this Act, shall be deemed guilty of a inisde- meanor and, upon conviction, shall be fined not more than $500 or confined in jail for not more than six months, or both. SEC. Ii. The unlawful practice of psychology as defined in this Act may be enjoined by the United States District Court for the District of Columbia on petition by the Commissioner, upon a finding that the person sought to be en- joined is guilty of a violation of the provisions of this Act. In any such proceeding it shall not be necessary to show that any person is individually injured by the actions complained of. If the respondent is found guilty of the unlawful practice. of psychology, the court shall enjoin him from so practicing unless and until he has been duly licensed. The remedy by injunction hereby given is in addition to criminal prosecution and punishment based thereon, and not in lieu thereof. SEC. 18. It shall be the duty of the Commissioner of the District of Columbia to enforce the provisions of this Act. SEC. 19. In legal proceedings, no psychologist shall disclose any information he has acquired from a person consulting him in his professional capacity with- out the consent of such person, except only (1) in actions, civil or criminal in which a psychologist is suing or being sued by a former client or his legal repre- sentative, such as an action against a psychologist for malpractice, (2) upon an issue as to the validity of a document, such as a will of a client, (3) in case where the defendant to a criminal action has raised the defense of mental incapacity. SEC. 20. (A) Nothing in this Act shall be construed as restricting the use of tools, tests, instruments, or techniques usually denominated "psychological," provided that the user does not represent himself or itself in a manner prohibited by this Act. (B) Nothing in this Act shall be construed to prevent qualified members of other professions from doing work of a psychological nature consistent with their training and with the code of ethics of their respective professions: Pro- vided, That they do not hold themselves out to the public by any title or descrip- tion incorporating the words "psychological," "psychologist," or "psychology," unless licensed under this Act, and except as provided in section 5(D) of this Act. SEC. 21. There is hereby authorized to be appropriated out of the revenues of the District of Columbia such sums as may be necessary to pay the expenses of administering and carrying out the purposes of this Act. SEC. 22. If any section of this Act, or any part thereof, shall be adjudge by any court of competent jurisdiction to be invalid, such judgment shall not affect, impair, or invalidate the remainder of any section or part thereof. SEC. 23. This Act shall become effective ninety days after the date of its enactment. Passed the Senate April 24, 1968. Attest: FRANCIS R. VALEO, Secretary. PAGENO="0014" 10 [S. Rept. 1092, 90th Cong., second sess.] DEFINING AND REGULATING THE PRACTICE OF PSYCHOLOGY IN THE DISTRICT OF COLUMBIA The Committee on the District of Columbia, to which was referred the bill (S. 1864), to define and regulate the practice of psychology in the District of Columbia, having considered the same, reports favorably thereon with an amend- ment and recommends that the bill (as amended) do pass. The amendment, as indicated in the bill, as reported, by linetype and italic, is as follows: Strike out all after the enacting clause and insert new language as a substitute. PURPOSE OF THE BILL The purpose of the bill is to provide for the protection of the public from the unqualified practice of psychology and from unprofessional conduct of persons practicing psychology in the District of Columbia by requiring all persons who offer psychological services to the public for a fee to obtain a license from the District of Columbia government. NEED FOR THE LEGISLATION At the present time, psychologists may practice psychology in the District of Columbia without license or regulation. Your committee has been advised that there have been incidents in which the lives and well-being of residents in the Nation's Capital have been adversely affected by fraudulent persons representing themselves as psychologists. This is happening at a time when the profession of psychology is clearly expanding and is more and more in demand by citizens of this city and elsewhere in the country. Therefore, your committee believes that the bill incorporates the appropriate and necessary steps which must be taken promptly to regulate the quality of psychological services by regulating the prac- rice of psychology as exLsting law already requires the regulation of other professions within the city. HEARING The Subcommittee on Public Health, Education, Welfare, and Safety held a hearing on S. 1~4 on August 28, 1967. The bill received the support of the District of Columbia government, the District of Columbia Psychological Association, and the American Psychological Association. PROVISIONS OF THE BILL The first section of the bill cites the act as the "Practice of Psychology Act." Section 2 declares the practice of psychology to affect the public health, safety, and welfare, and to be subject to regulation and control in the public interest. Section 3 defines terms used in the bill and provides that "the practice of psychology," as defined in the bill, shall not be construed as permitted the admin- istration or prescription of drugs or any infringement upon the practice of medi- cine as defined by the Healing Arts Practice Act of the District of Columbia, as amended. * Section 4 state that psychologists are expected to assist their clients in obtain- ing professional help for aspects of the client's problems that fall outside the area of the psychologists' own competence; for example, that provision should be made for the diagnosis and treatment of relevant medical problems by an appropriate, qualified medical practitioner. Section 5 requires the licensing of persons who practice psychology for a fee; exempting psychologists employed by Government agencies, academic institu- tions, charitable agencies, research laboratories, and business corporations. Also exempted are psychology interns and residents, and persons employed by licensed psychologists as defined in the bill. Section 6 provides that the Commissioner shall be responsible for the issuance and renewal of licenses, authorizes him to provide for the preparation and administration of oral and written examinations, to appoint a Board of Psy- chologist Examiners to examine applicants for licenses, and requires the mainte- nance of public records respecting the granting, refusal, suspension, and* revocation of licenses. PAGENO="0015" 11 Section 7 sets forth the requirements for obtaining a license: Good moral character; doctoral degree in psychology or a related field; plus 2 years of postgraduate experience other than internship; and satisfactory performance in an examination. Section 8 provides for licensing within 1 year without examination of psy- chologists who either maintain a residence or office, or participate in psy- chological activities in the District and who have a doctoral degree and 1 year of postgraduate experience or a master's degree in psychology and five years of practice acceptable to the Commissioner. Section 9 authorizes the Commissioner to grant a license without examination to any person who has received a license from a State or foreign country whose standards are substantially equivalent to those of the District of Columbia. Section 10 provides that qualified psychologists from outside the District of Columbia may offer professional services in the District for not more than 60 days a year without obtaining a license on request of a person who resides or works `in the District. A psychologist claiming `this exemption and who offers his professional service within the District for more than 20 days in any calendar year must file with the Comniissioner evidence of his right thereto, have his name entered in a register kept by the Commissioner for that purpose, and be issued a certificate evidencing such registration. Section 11 empowers the Commissioner to waive the licensure examination when the applicant has achieved a position of eminence as a practicing psy- chologist or has been certified by a national examining board, whose examination was as effective for testing professional competence as that required in the District of Columbia. Section 12 authorizes th'e District of Columbia Council to make regulations to carry `out `the purposes of the act and to fix fees at levels to defray the expense of administering the act. Section 13 provides for the annual payment of the required fee for renew2l of licenses or certificates iss'ued under the act and contains provisions respecting the reinstatement of lapsed licells'es. Section 14 authorizes the Commissioner to refuse, revoke, or suspend licensure or certification if the applicant, licensee, or certificate holder be (a) convicted of a crime involving moral turpitude, (b) found to use d'rugs or alcoholic beverages so as to endanger himself or others or so as to impair his ability to `safely perform psychological services, (c) convicted of violating the `act or any regulation thereunder, (d) adjudicated mentally incompetent, and (e) found guilty of unethical practice of psychology in violation of standards set by the Commissioner. Section 15 sets forth the procedures to be followed by the Commissioner in suspending or revoking a license or certificate. Before a license is revoked. suspended, or refused to be issued by the Commissioner for any cause, the person whose right to practice psychology is challenged shall be entitled to a hearing and to produce witnesses on his `behalf. Decisions of the Commissioner refusing, revoking, or suspending licensure or certification must be in writing and must include detailed finding of fact. Any person feeling aggrieved by a decision of the Commissioner may seek a review of the Commissioner's decision in the District of Columbia Court of Appeals, which court's decision shall be subject to appeal to the U.S. Court of Appeals District of Columbia. Section 16 provides that any persons practicing psychology w-ithout a license or registration certificate shall be guilty of a misdemeanor, and upon convic- tion be fined not more than $500 or confined in jail for not more th'an 6 months, or both. Section 17 permits injunction actions in the U.S. disti~ict court to prevent persons found guilty of violating the act from continuing to practice psychology. Section 18 directs the Commissioner to enforce the provisions of the act. Section 19 provides that i:n legal proceedings, no psychologist shall disclose any information he has acquired from a person consulting him in his professional capacity without the consent of such person, except (1) in actions, civil or criminal, in ~hi'ch a psychologist is sui'ng or being sued by a former client or his legal representative, such as an action against a psychologist for malpractice, (2) upon an issue as to the validity of a document, such as will of a ellent, and (3) in cases where the defendant in a criminal action has raised the defense of mental incapacity. Section 20 provides that so long as a user does not represent himself or itself in a manner prohibited by the act, nothing in the act shall be construed as PAGENO="0016" 12 restricting the use of tools, tests, instruments, or techniques usually denominated "psychological," and that the act shall not be construed to prevent qualified members of other professions from doing work of a psychological nature con- sistent with their training and the codes of ethics of their professions, so long as they do not hold themselves out to the public as psychologists unless licensed or certified in accordance with the act. Section 21 authorizes appropriations necessary to pay the expenses of admin- istering and carrying out the purposes of the act. Section 22 provides a standard severability clause. Section 23 provides that the act shall be effective 90 days following its enactment. COMMITTEE AMENDMENTS Your committee struck out the term "physical" on page 3, line 18, and inserted in lieu thereof "medical." The purpose of the amendment is to emphasize the nonmedical character of the psychology profession and make clear the com- mittee's intent that a person with organic `disease complications to behavioral problems should be referred by the psychologist to a medical doctor. The amendment was requested by the District of Columbia government. Your committee deleted section 5, subsection (D), establishing different licensing requirements for social psychologists than for other psychologists. This action w-as taken because the committee sees no justification for treating social psychologists differently from other psychologists in the matter of licensing. Your committee deleted the language in section 6(B) requiring the Commis- sioner to name members of the Board of Psychology Examiners from a list submitted by the District of Columbia Psychology Association. The committee believes that the Commissioner should be permitted to name any qualified psychologist to the Board and not be restricted to any list of names submitted by the above-mentioned professional association. Your committee deleted the language in section 12 permitting the Commissioner to give a certificate of registration to an association, partnership, or corporation. The committee sees no justification for permitting the group practice of psy- chology when only one member of the group has a license issued in his individual name since the practice of psychology should, as with other disciplines, be licensed on a personal basis. There is ample provision elsewhere in the bill permitting a psychologist to have a trainee or other unlicensed person assist him providing the psychologist is entirely responsible for the,actions of such a person working `under the licensed psychologist. In lieu of the language which has been deleted from section 12, the committee amendment authorizes the District of Columbia Council to make regulations to carry out the purposes of the act, and, after public hearings, fix fees to be charged for services performed by the District government pursuant to the provisions of the act. Section 21 has been deleted by the committee, as no longer applicable in view of Reorganization Plan No. 3 of 196T. Mr. SI5K. The Chair finds that. we have had a number of requests to testify. I think we will proceed this morning by hearing primarily the proponents of the legislation. We have listed here several doctors from the D.C. Psychological Association Dr. Bayroff, Dr. Meltzer, Dr. Levy, and Dr. Cummings. If you gentlemen are all here and would like to come to the witness stand together, why, we will be ha.ppy to have you do so. I might say that the American Psychological Association also has asked to appear, being represented by Dr. Bra.yfield. Is he here? Dr. MELTZER. He is on his way. Mr. SI5K. Does he prefer to testify separately or with you? Dr. MELTZER. Separately. Mr. SISK. The rest of you, then, may come forward. I believe, Dr. Bayroff, you are the President of the D.C. Psycho- logical Association? Dr. BAYROFF. Yes, sir. PAGENO="0017" 13 Mr. SIsK. All right. Dr. Bayroff, do you wish to lead off, and then any of the other gentlemen there with you who have statements, why, we will be glad to hear them in whatever order you prefer to have them heard. I might say that I believe that we have copies of their statements. You may read your statement or you may summarize it, and your entire statement will be placed in full in the record-whichever way you prefer to do so. You are recognized. STATEMENT OP DR. A. J. BAYRO'PP, PRESIDENT, DISTRICT OP CO- LUMBIA PSYCHOLOGICAL ASSOCIATION, ACCOMPANIED BY DR. MALCOLM L. MELTZER, PAST PRESIDENT; DR. BERNARD I. LEVY, PRESIDENT-ELECT, AND DR. JONATHAN W. CUMMINGS, CHAIRMAN, LEGISLATIVE COMMITTEE Dr. BAYROFF. Thank you, Mr. Chairman. Dr. Meltzer, our immedi- ate past president, will read our principal statement. Mr. SIsK. All right, Dr. Meltzer. Dr. MELTZER. Mr. Chairman, my name is Malcolm L. Meltzer. I am immediate past president of the District of Columbia Psychological Association. I reside in the District and I am Associate Professor of Psychology and Director of Clinical Psychology Training at The George Washington University. I hold `a Ph.D. in clinical psychology from the Catholic University of America. V\Tith me are Dr. A. G. Bayroff, who is currently the President of the District of Columbia Psychological Association. Also with me are Dr. Jonathan W. Cummings and Dr. Bernard I. Levy both of whom are presenting written testimony for the record. Dr. Cummings is Chairman of the Legislative Committee of the District of Columbia Psychological Association and is employed as Chief of the Psychology Service at the Washington, D.C. Veterans Administration Hospital. His testimony touches on the scope of psychological activity, the efforts of psychologists to regulate their own `field, and the need for the legal protection for our citizens that H.R. 10407 would provide. Dr. Levy is Professor of Psychology and Chairman of the Department of Psychology at The George Washington University. He `is repre- senting his colleagues in psychology departments in the other uni- versities in the District, and his testimony touches on the `support of the universities and the community for the legislation before this Subcommittee. I am speaking today on behalf of H.R. 10407 as a representative of the 650 members of the District of Columbia Psychological Associa- tion. DCPA is the major scientific and professional organization for psychologists in the Washington area, and it is `affiliated with the 26,000-member national organization, the American Psychological Association. Founded `in 1935, DCPA is the oldest of the affiliated state psychological associations. The membership of DCPA has gone on record as being overwhelm- ingly in favor of legislation to define and regulate the practice of psychology in the District of Columbia. 94-755---GS-------2 PAGENO="0018" 14 ~EED FOR LEGISLATION The reasons for this support are simple and straightforward. At present, in the District of Columbia, anyone, no matter what his back- ground or traming or qualifications, is permitted to call himself a psychologist and to offer psychological services to the public. There is no law regulating the practice of psychology in this jurisdiction. However, there are laws defining aiid regulating psychology in thir- ty-seven of our States, including our immediate neighbors, Maryland and Virginia. There is a present and increasing danger to our citi- zens as this situation continues. The District of Columbia is becoming one of the few places in the nation where charlatans and unqualified practitioners may come when they are driven out of other states. There have been incidents of charlatanism and unqualified practice in the District of Columbia. A fairly recent incident. in which a totally unqualified person called himself a psychologist aiid offered psycho- logical services led officials of the District of Columbia Government to inquire about the need for regulation of psychology in this city. at present, classified advertisements in newspapers contain fan- tastic offers and promises of psycholgical help aiicl unclerstanclmg for every type of human unhappiness. In the Yellow Pages of the telephone book, the listing of psychologists is a mixed bag of the qualified and the unqualified. Since psychology deals with the hu- man personality and human behavior, unqualified and unprofessional practice can have a most detrimental effect upon the wellbeing and happiness of our children and adults. Identification of those properly trained and control of those who are iiot is necessary to insure the safety and welfare of the public. SCOPE OF Bu~i4 H.R. 10407 would allow for the identification of the qualified psy- chologist and would prevent the untrained person from offering psychological services. It would protect the full range of psychological services, including clinical, counseling, industrial, educational, and so on. It would not restrict other bona. fide professionals from doing work of a psychological nature which is in keeping with their profes- sional training, standards, and ethics. The law would not interfere with the activities of Government agencies or universities, because it would cover only those psychological activities which are offered directly to the public for a fee, outside of any recognized agency or institution of our society. Such a law would not only protect the public by excluding the out- and-out quack, but it also helps by establishing standards that would exclude the marginally trained psychologist who has been refused licensure in his own state. It insures that a. psychologist is well trained and experienced before he offers services to the public for a fee. In addition, the public would have some legal recourse in those cases where there may be unprofessional or unethical behavior on the part of a psychologist licensed under the law. Also, some benefit would accrue to the profession of psychology itself, in that its reputation would be protected from the unqualified and shoddy practices of those who currently masquerade as psychologist.. PAGENO="0019" 15 The legislation authorizes no new activities nor grants any new privileges to psychologists. I think that is important. It establishes no new pattern nor does it change the status of the relationships among any of the professions. It merely specifies who may call himself a psychologist or offer psychological services. H.R. 10407 is similar in many respects to the laws in the tlurty- seven states with regulations. It follows the guidelines established by the American Psychological Association, and it has the endorsement of that organization. I also call to your attention the great amount of effort and con- sultation that went into the preparation of this proposed legislation. Work began on it in February, 1965, at the encouragement of the city government, and the bill evolved from consultation with a large and varied number of professionals and community service organiza- tions. It was carefully scrutinized by the city government, especially -the public health, medical, legal, and licensing branches. We were very pleased to accept the amendments they suggested and we appre- ciate their endorsement of this bill. Their thoughtful suggestions have made it a much stronger bill. Ii~ partic~ilar, Dr. Grant pointed out that with the amendments the bill adequately delineates the practice of medicine and the prac- tice of psychology and insures that the psychologist must defer to his medical colleague when there is a question of a medical problem. In supporting this legislation, the District of Columbia Psychologi- cal Association is acting in accord with the Ethical Standards of Psychologists. Principle 2-A of those standards calls upon psycliolo- gists to "discourage the practice of psychology by unqualified persons and to assist the public in identifying psychologists competent to give dependable professional service." In 1963, the DCPA began a program of voluntary certification of its members, and it publishes a list of psychologists who have presented their credentials and passed the examination. It is a non-statutory program, and while it has some educational value for the public, it cannot protect our citizens against the unscrupulous and the unprincipled person who misrepresents him- self and his abilities. H.R. 10407 would provide this protection, and it is for this reason that the District of Columbia Psychological Asso- ciation strongly supports it and urges its enactment. Thank you for the opportunity to present our views. Mr. SI5K. Let us see, I think that Dr. Cummings has a statement that he would like to make. I might say that before the witnesses are questioned, we will get all the statements first and question all of you then. You may proceed, Dr. Cummings. Dr. CUMMINGS. Mr. Chairman, in the interest Qf time, I will give you just the main thrust of my testimony. Mr. SI5K. All right. Then, without objection, the entire statement of Dr. Cummings will be made a part of the record at this point, or an appropriate point in the record. If you wish to summarize it, fine. Dr. CUMMINGS. Mr. Chairman, I might say, by way of reinforcing some of the things that Dr. Meltzer has said, that the professional psychologist or professional psychology has burgeoned out so much PAGENO="0020" 16 in re~nt years that it includes all of the kinds of activities that you see on page 2 of my testimony, a list of the various ways in which psychologists have played important roles in serving community needs.. Whenever this is the case I think the door is wide open for folks who are not well trained and not of the high standa.rds who might seek this opportunity to line their own pockets, and I would propose that H.R.. 10407 is first and foremost a. measure to protect the public of the Dis- trict of Columbia from such unethical and unqualified people. It. does not do anything either monetarily or in any other kind of gain for psychology. It is to protect. the public of the District, of Columbia. Thank you very much, Mr. Chairman. (The prepared statement submitted by Dr. Cummings reads in full as follows:) STATEMENT HEARINGS OF SUBCOMMITTEE NO. 5, HOUsE DISTRICT COMMITTEE, ON HOUSE BILL 1040T: To DEFINE AND REGULATE THE PRACTICE OF PSYCHOLOGY IN THE DISTRICT OF COLUMBIA, MAY 20, 1968, BY DR. JONATHAN W. CUMMINGS, CHIEF PSYCHOL- OGIST, VETERANS ADMINISTRATION HOSPITAL, 50 IRVING STREET, X.W., WASH- INGTON, D.C. 20422 Mr. Chairman, my name is Dr. Jonathan Cummings. I serve as Chief psychol- ogist at the Washington, D.C., Veterans Administration Hospital. In the following remarks I should like to draw a picture of what psychology is and how it is used by our society. Psychology is both a science and a pro~ fession. As a science it involves the study of all aspects of human behavior: how people think, learn, feel, and act in all the areas of human endeavor. These scientific activities of the psychologist tend to be associated primarily with teaching and experimentation in the university setting. However, governmental agencies, business and industry utilize the experimental skills of psychological scientists, too. For example, over half the research grants provided by the National Institute of Mental Health go to support studies in which a psychol- ogist is the principal investigator, and other federal, state and local agencies employ many psychologists in capacities where the main emphasis is on scientifie exploration. Years ago, the great majority of psychologists were to be found in such teach- ing and experimental situations as those just described. But in the past two decades, there has emerged a new set of functions for psychologists. I refer to the increasing utilization of psychologists in service settings, where the skills and knowledge accumulated in scientific study have been applied to the intensely felt needs of individuals, groups and organizations in the community. An idea of the extent and variety of these areas of application may be gained from the following chart, in which the titles and brief definitions of several types of psychological specialization are presented: Counseling psychologists-counseling with young people and adults on vocational and educational plans~ Clinical psychologists-helping individuals understand and solve their peraonal and emotional problems. Industrial psychologists-developing methods and programs for selecting, classifying, and training employees, and improving employee morale. Social psychologists-surveying public opinion and studying group processes. Experimental psychologists-laboratory experimentation and research on all aspects of human behavior. Measurement psychologists-developing, administering, and interpreting psychological tests of intelligence, aptitude, interest, personality and motivation. Educational psychologists-studying Improved methods for the education of young people in schools, and helping them with learning and study' difficulties. Rehabilitation psychologists-helping handicapped and disabled persons to readjust to vocational and social life. One of the most interesting features of this listing is the degree to which it reflects how wide has been the felt need for, and use of, psychologists by society: PAGENO="0021" 17 education, vocational matters, industry, rehabilitation, mental health, and so on. It might be well to take a more detailed look at the ways that psychology contributes in one of these several areas. Let us consider the mental health field, *since this is an area which is receiving so much attention generally at present. Federal agencies employ well over a thousand clinical psychologists, not to men- tion those others who receive their `support from state, local and private sources. The Veterans Administration alone employs 800 staff psychologists in its treat- ment program; in addition, it provides training for 750 psychology graduate students and utilizes the services of a `like number of consultants. It has been estimated that about 85% of all psychotherapy performed in the VA program is done by psychologists. Approximately 450 psychologists serve as consultants to the Social Security Agency, as vocational and clinical experts in the field of evaluating the employability of claimants seeking compensation under disability laws. Psychologists serve on the National Advisory Mental Health Council, the Council of the `National Institute of Child Health and Human Development, and on the training and research grant :pa'nels of the National Institute of Mental Health. And Congress itself has recognized the contributions which psychology makes in the health and rehabilitation fields by including psychological services in the provisions of such important legislative acts a's the Mental Retardation Facilities and Community Mental Health Centers Construction Act Amendments of 1965, PL 89-105. The training of a psychologist typically involves the earning of a Ph. P. degree. This degree is at the same level as that earned by other scientists, such as physicists and biologists, in their particular specialties. It requires about five years of study beyond college graduation and includes training in basic psy- chology as a science, development of professional skills, and supervised practice in the field of specialization. rfllrough the American Psychological Association, the 26,000-member national organization of psychologists, educational and pro- fessional standards have been established. These include formal accreditation of doctoral programs in clinical and counseling psychology in the graduate schools of universities, and internship programs in practicumn agencies. The American Psychological Association is responsible for the establishment, main- tenance, and extension of high professional standards in psychology. These standards have been formally incorporated into a code of ethics by which all psy- chologists are expected to govern themselves in their professional activities. Psychology has a strong commitment to the principle that the public welfare and the patient's and client's welfare take precedence in all professional psychological matters. The American Board of Examiners in Professional Psychology (ABEPP) was established in 1047 to grant diplomate status, through examination, to those psychologists who have qualified themselves as advanced specialists in clinical, counseling or industrial psychology. The services being provided by psychologists apply to vitally important seg- ments of community life. Because of the importance of these matters, psychology has sought continuously to establish standards, controls and self-regulation through its national and lcoal professional organizations. However, these standards and controls are limited to members of the professional organization and have no consequence to those individuals who either stay outside of, or are ineligible for membership in, the organizations. It is to make these standards applicable to all who function as psychologists, and thereby to protect the mem- hers of the community from substandard, unethical practice, that I urge the passage of this licensing bill. Thank you for the opportunity to spe'ak in behalf of HR 10407. Mr. SIsK. Thank you, Dr. Cummings. Do you have a statement Dr. Levy ~ If so, you may proceed. Dr. LEVY. Mr. Chairman and members of the Subcommittee. My name is Bernard J. Levy. I would like to briefly summarize the comments which I submitted earlier to the committee. Mr. SI5K. Without objection, Dr. Levy's statement will be made a part of the record at this point, or following his oral presentation. Dr. LEVY. Mr. Chairman and members of `the Subcommittee. PAGENO="0022" 18 I am Professor of Psychology and Chairman of the Department of Psychology at the George Washington University. There are other people that I speak for, those from Catholic University, Georgetown University, Howard University, and George Washington Univer- sity. They recognize the fact that there is a profound need evident in the District to control the practice of psychology and, in addition, they are pleased to know that the bill contains some standards which provide a basis for the continued training of the graduate students who will, eventually, become either academic or professional psy- chologists. There is no feeling that the bill has any impact upon the training and educational ftrnctions. Academic freedom is preserved, since each department has its own option to train or to emphasize professional training as opposed to scientific or research training. Thank you. Mr. SIsK. Thank you, Dr. Levy. (The prepared statement submitted by Dr. Levy reads in full as follows:) STATEMENT HEARINGS OF SUBCOMMITTEE No 5. HOUSE DISTRICT COMMITTEE, ON HOUSE Bu~r. 10407: To DEFINE AND REGULATE THE PRACTICE OF PSYCHOLOGY IN THE DISTRICT OF COLUMBIA. MAY 20, 1968. BY DR. BERNARD I. LEVY, PROFESSOR AND CHAIR- MAN, DEPARTMENT OF PSYCHOLOGY, THE GEORGE WASHINGTON UNIVERSITY Mr. Chairman, my name is Bernard Levy, I am a Professor of Psychology anct Chairman of the Department of Psychology of the George Washington LTn1- versity. I speak for myself as well as executive officers of other Departments of Psychology ii~ the District of Columbia: Dr. Hans Fnrth who is Chairman of the Department of Psychology and Psychiatry of The Catholic University of America. Dr. John O'Hare who is Chairman of the Department of Psychology of Georgetown University, Dr. Leslie Hicks who is Chairman of the Department of Psychology at Howard University, and Dr. Fred Nothman who is Chair- man of the Department of Psychology of American University. We all strongly support the principle of legislation whose purpose is the appropriate and reason- able control of psychologists offering professional service. Thus we endorse HR 10407 as a proper vehicle to define and regulate the practice of phychology in the District of Columbia. Above all else, we wish to offer our support to any move on behalf of the public. Legislative control of the practice of psychology can strengthen our profession's interest in making available to the public only the most competent practitioners. In this primary goal we are in accord with such organizations as the Middle Atlantic Division of the American Association of Marriage Counselors, the American Personnel and Guidance Association. the Legal Aid Agency for the District of Columbia, Big Brothers, The Rabbinical Assembly of tl1e Greater Washington Area, the Public Schools of the District of Columbia. the Florence Crittenton Home and Hospital, the District of Columbia Society for Crippled Children. Inc., the Archdiocese of Washington, the Department of Vocational Rehabilitation of the District of Columbia, and the B'Nai Brith Vocational Serv- ice, all of whom share our concern for the public's welfare and our desire for the best and most up-to-date practice of psychology to be made available in the District of Columbia. As educators our interest goes beyond the restricted concern for psychologists as mental health practitioners. We have responsibility for conveying to our stu- dents the importance of the study of behavior within the spectrum of the liberal arts. That responsibility is most crucial for undergraduate education. However. as we train graduate students, we necessarily become involved in profession~ii issues since specialization and technology become a focus for gradTEte training. Thus we train industrial psychologists. experimental psychologists, counseling psychologists, specialists in the construction and use of measurement instruments. clinical psychologists and educational psychologists-all of whom might offer their unique and hard won expertise to the public. As you have sensed, we educate for the academy and for the market place. PAGENO="0023" 19 We have a difficult problem. Whereas professional schools such as those in medicine, law, social work and education provide technical training with implicit vocational goals underlying their programs, departments of psychology provide both liberal arts and professional training. A consequence of this split function is that we can not be certain which of our graduates will offer service to the public. Hence we try to provide opportunities, by both seminar and precept, for acquiring sound scholarly, scientific and professional values. I am making this point for other than academic reasons. Legislation which will provide a legal basis for the practice of psychology will inevitably contain defini- tions and standards which, in time, will affect the education of psychologists. The guidelines for training implicit in legal definitions and standards will not abridge academic freedom. A department of psychology need not provide profes- sional training if its faculty and students wish to concentrate upon scholarly and scientific activities. However, for those departments wishing to provide profes- sional in addition to academic training, the implicit model for psychologists pro- vided by legislation can offer strong hints for curriculum development and super- vised experience. Thus the proposed legislation can be helpful on more than one score. Thank you for the opportunity to present these ideas to the committee today. Mr. SIsK. Doctor, do you have any statement in addition that you desire to make? Dr. BAYROFF. No. PSYCHOLOGY DEFINED Mr. SISK. I will direct this to you, Dr. Meltzer, and then if anyone else can comment on it, who would desire to do so, they may, but, cer- tainly, for my own edification and I hope for the record, I would ap- preciate it if you would define "psychology" and the "practice of psy- chology" in connection with the situation with which are concerned and are discussing here today, where psychologists are available for a fee to practice their profession in the District of `Columbia, to define- and I suppose this could go on indefinitely, but as briefly as possible,. give us a definition of the practice of psychology, as it compares with the practice of psychiatry, and, keeping that in mind, would you make comments on that, and to what extent there may be overlapping or no overlapping in these fields. Dr. MELTZER. May I take some time to do that? Mr. SISK. Yes, sir. I appreciate that this is a $64 question, but, as I say, for the benefit of the record and, in view of the fact, that I am sure that we are going to have further testimony, I understand, and I might say that I have received from my own state of California letters in connection with this bill raising certain questions, and I think it would be well if we could lay out for the record right now the area and the guidelines of the practice of psychology vis-a-vis the practice of' psychiatry and other healing arts or arts that fall within that category' dealing with mental health and the wellbeing of people. I think that is- about as well as a layman can put the question. Dr. MELTZER. I should like, since I know the field of psychology the best of all, to start from that standpoint. In general, a psychologist is a person who specializes in the under- standing, prediction, and the changing of human behavior. That is the n'iost general statement that one can make. Now, going from that one could say that there are two basic types, and then there are many other kinds of differentiations that I will give in a moment, but one type of psychologist is the basic scientist~ psychologist who is interested in the general law of human behavior,. who is interested in understanding, knowing about how people learn~, PAGENO="0024" 20 how personalities develop, what. the. aspec.ts of personality are, how personality can be changed, how group behavior can act towards one another. That is one of the basic interactions. This is the basic scientist- psychologist, and this is concerned with knowing all people, knowing people in general, laying down the basic laws for human behavior. These types of psychologists mostly work in universities, in research laboratories, and institutes, and their concern is not in knowing an individual nor necessarily with the change in an individual. They are concerned with the science of human behavior. That is one type. Another type is the type that is interested in applying these sciences, often in the understanding and helping of an individual or a group of individuals. These a.re the more or less applied psychologists, and they are often concerned with problems of individual adjustment, develop- ing ways of unclersancling, particularly in the individual, of applying psychological principles, say, to employee selection or to the problems of learning, vocation adjustment, to the problems of attitudes, a.nd so forth. And these applied psychologists often work in clinics or hospitals, in industry, in private offices, and private research firms, et cetera. In all of each two major types which I have described the training has many similarities. There is the typical degree of doctor of philoso- phy, the Ph.D., the highest degree awarded by the great universities of the country. The typical program is one of four, five years of graduate-training following college work. There are many other types that have to do with the content, whether for example a person is interested in children or in adults or in indus- trial problems or in adjusting the problems of individuals or social practices with a group at national or international levels, but all of them get the basic sciences, and then, also, application in their specialty. And, as I say, the typical program is four or five years of graduate training after graduation from college. Now, the clinical psychologist is the one who perhaps comes the closest to the psychiatrist. The psychiatrist shares t.liings with the clin- ical psychologist, and it is wit.h this subtype that there may be some confusion. PsYcHoLoGIsTs AND PSYCHIATRISTS DISTINGHISHED The psychiatrist, generally, has much less to do with the vast re- mainder of the field of psychology. The clinical psychologist perhaps represents-and this is an esti- mate from some figures-about 50 per cent throughout the country of the psychologists who are clinical psychologists. Now, the clinical psychologist is trained, specifically, in understand- ing and adapting pat.ricular individuals and groups of individuals from the standpoint of intelligence, personality, behavior, adjustment, et cetera. All universities train psychologists in how to influence that be- havior, how to help that behavior. Pa.rticularly, the terms of this activity is psychotherapy. Now, tile psychiatrist, on the other hand, is not trained in psychol- ogy. He is trained in psychoinedicine instead. He receives an M.D. PAGENO="0025" 21 degree, and after this, after he has finished medical school, then the major part of his training in psychiatry takes place. Obviously, the psychiatrist is interested in the abnormal, in mental illness, but also he deals with the problems of adjustment just as the psychologist does. And here is where there is a fair amount of overlap. And it depends upon which psychiatrist and which clinical psychologist one is talking about. There are clinical psychologists and psychiatrists who are al- most indistinguishable in terms of what they do. There are clinical psychologists and psychiatrists who look like they come from different worlds who share not any activity with one another. The place that they probably come the closest is when both the clinical psychologist and the psychiatrist set up some sort of practice in which they deal with problems of adjustment and see people who are sent to them, helping to change their behavior, and when they re- strict their activities to these kinds of things. Obviously, some psychiatrists do a lot more than this. They use all kinds of physical and medical kinds of procedures, including the use of drugs, the physical treatment such as shock, and so forth. Many of them, of course, work in institutions and are concerned with people who have also physical ailments. Obviously this type of psychiatrist would be doing things that a clinical psychologist would not. Many clinical psychologists are less interested in changing people than in understandiii,g them and in doing research in understanding them. Psychiatrists are a. little less likely to be involved in that kind of activity. So, in a way, what we are talking about is really one kind of psychol- ogist, the clinical psychologist, comparing him to the psychiatrist, and, in addition, we have to make all kinds of qualifications, depend- ing on which psychiatrist and which psychologist we are talking about. I could go into more detail to describe the training of the clinical psychologist; whatever your wish is. Mr. SIsK. I appreciate very much the comments you have made, Dr. Meltzer. I recognize that my question was quite comprehensive. But, as I understand it, there are certain areas where the clinical psychologist and the psychiatrist get, let us say, very close together in connection with the types of people that they may be dealing with and the types of problems that they are concerned about. That was the reason that caused some questions being raised in the mail that I received, and I wanted to get your understanding. Let me ask you this further question, because, to some extent, it is along the same general line: As patients or as individuals which call a licensed psychologist here in the city, assuming that we would pass this legislation, for an ap- pointment, at what point or by what measurement. would he possibly be referred to a medical practitioner-if I can use that term in its broadest sense as meaning a psychiatrist or a medical doctor? Do psychologists have, as I assume you are dealing with this, cer- tainly, they have many cases-At what point, under what set of circumstances and under what requirements generally would a. psy- chologist refer a patient or an individual with whom they are coun- seling to a medical practitioner? Could you comment on that, because generally in these areas what are sometimes referred to as peripheral PAGENO="0026" 22 medicine-and I suppose that, is a term that I came up with that may not be a good term, but I happen to have been involved for several years in trying to rewrite the laws of optometry, and I have run into all kinds of problems with my friends, the ophthalmologists, where ~n optometrist, ceases to have jurisdiction, if you will permit me to use a legal term, and where the ophthalmologist takes over. Compare the psychoho~ist, vis-a-vis the psychiatrist, what do you feel to be your obligation and responsibility of referral under that set. of `circumstances? Dr. MELTZER. Let me go into some detail, but not quite as much as ~before. I think it is important to understand that this bill would improve the situation with regard to the working relationship between the psychologist and the psychiatrist.. It would help to insure that re- ferral. The way that worics i~ that a psychologist nii.i~t not practice. outside of the' bounds of his competen~y: `he `must refer; when~ever there is a medical problem, the problem to an efficient medical prac- titioner. This will be written into the code of ethics that will be incorporated into the bill. At this point, the only thing that could happen to a. psychologist who did not refer, who did not consult, is that we could throw him out of the D.C. Psychological Association and the Medical Psychological Association. There would be no way, of stopping t:he psychologist from continuing to go his own merry way. `With this bill it now becomes possible to take this fellow's license away from him; it becomes possible to stop him from doing this, :a.nd this is certainly necessary. The majority of psychologists who see patients publicly and who *see patients privately often ask for a. referral, and the reason for this is clear: a consultation would be important because medical-legal aspects very often are involved. The problem is how careful could this be spelled out when you have such imprecise terms as "mental illness" now. There is no agreement, even amongst psychologists or amongst psychiatrists what exactly is a "mental illness." As I pointed out, there is a very large gray area in which there is `a great deal of disagreement. There probably is someagreement at the extreme. For example, most people would recognize schizophrenia or dementia psychosis. defrustrative suicidal tendencies, a clear-cut mental illness kind of problem. The same way with problems in which there is some type of disturbance on the basis of brain disfunction. People would, generally, agree that this is the kind of problem that must be seen by a medical person. In addition, if the person complains of physical symptoms, ob- viously, his responsibility is to encourage and make sure that he sees a -physician. This, incidentally, is no more than a lawyer working with `a legal client about problems that happened in his life, or a minister `working with his parishioners and counseling them. He encourages his client to get other kinds of help from other types of people. So there is this area which is a large gray area. And then there is another area that has to do with problems of ad- justment. Most people will agree this is a strictly psychological kind of issue. PAGENO="0027" 23 I think that this bill would insure that the psychologist would refer to a physician if there was `a question of medical need. All I can do is to repeat what Dr. Murray Grant said, that they looked this over very carefully, as did the Corporation Counsel's Office and the Department of Occupations, and Dr. Grant pointed out that this bill as amended by the Senate very clearly delineates the practice of medicine and the practice of psychology. He also said that it makes clear that the psychologist must refer to a physician in case of medical difficulty. I should like to add one other thing: It is a two-way street, too. A lot of the patients that I see in my `office are sent to me by psycholo- gists, and their question to me is: "How stupid is this person? Does he have a mental illness? Is he psychotic? Is this person's brain dam- uged? Does he have organic difficulty? Does he have a central nervous system problem? He is well trained in his techniques, and it is very difficult for a psychologist to consult with a psychologist about mental illness, and this will insure this being done. Mr. SIsK. Thank you, Dr. Meltzer. I think that you have done a very able job of outlining the situation. Let me just add one `or two other questions that I think will be of concern to the Committee that has to do with the changes in the Senate bill. It is my understanding that these two bills were identical at the time that they were introduced. To what extent were there amendments? Could you briefly summarize the amendments that were offered in the Senate bill? I have not had an opportunity to compare the two bills. SENATE AMENDMENTS Dr. MELTZER. In Section 4, the word "physical" on line 18, page 3, should be stricken, and the word "medical" put in. This makes it all the more clear about the need for referral. Section 5(D) is dropped entirely. Mr. SIsK. That is page - what? Dr. MELTzER. That is page 5. Dr. CuMMINGS. That is on page 5. Mr. SIsK. Section 5(D), that has been dropped? Dr. MELTZER. Yes, that has been dropped. These are all amendments that have been suggested. The ne~tt one comes in Section 6(B), and the words "to `be selected from a list of psychologists"- Mr. SI5K. Wait a minute. The first one was Section 5(D) was stricken? Dr. MELTZER. Right. Mr. SIsK. And now the second one is-what? Dr. MELTZER. 6(B), but not the whole sentence. It starts, to say, "to be selected from a list". Mr. SIsK. Yes, sir. Dr. MELTZER. Strike that, "to be selected from a list of psychologists `submitted by the District of Columbia Psychological Association"; that phrase is dropped. PAGENO="0028" 24 Mr. SI5K. That is to be stricken. That simply does away to limiting it to a group selected by the local people? Dr. MELTZER. Yes. Section 12, lines 5 to 17, are amended: We could read to you the new wording. He is a little bit lengthy. Mr. SIsK. I have the new wording. I see there has been a change there. I am just trying to get, primarily, the main area in which there has been a change. Dr. MELTZER. This gives the Commissioner a free hand in changing regulations, to make them more-to change the fees and to make regulations. Mr. SIsK. Yes. Dr. MELTZER. And the next is Section 13. The second sentence is stricken, starting with: "An associa.tion, partnership, or corporation seeking renewal of a certificate of registration"- Mr. SI5K. That has been stricken? Dr. MELTZER. Yes, sir~ Then there is a section added someplace that has to do with the trans- fer of functions from the Coimnissioners to the Commissioner and the Council. Mr. SIsK. I recognize, of course, that we will have to bring the bill up to date. We will have to up-date the bill. Dr. CUMMINGS. Has that been done in the copy that is before you? Mr. SIsK. That has not been done. The copy that I have before me does not have it. It may have been done in a. later copy. I am talking again, from the House bill. Of course, that will have to be changed. I assume that the Senate bill does have that. Dr. MELTZER. Yes, sir. Dr. CUMMINGS. We could make available to you the four pages of those changes. Maybe they change the plural of "Commissioners" to "Commissioner". They do not change the substance of the bill. We have it all under one roof. Mr. SIsK. Does the gentleman from Indiana desire to ask any questions? Mr. JACOBS. Thank you, Mr. Chairman, yes. MENTAL DIsEAsE The term "mental disease", Doctor, does tha.t include only organic disorders, or would it go beyond that? Dr. MELTZER. Generally, it does include other problems besides or- ganic disturbances. Mr. JAcOBS. I infer from what little I have heard and from what little I understand about this area of public service that it is very difficult to define the term "mental disease"; is that correct? Dr. MELTZER. Yes, sir. There are some psychiatrists and some psy- chologists who would like to see the words not used at all. They do not believe they are definite. We have problems with this. Mr. JACOBS. Well, assuming-and I suspect at the moment that it does-assuming that it does have meaning as a term, is it your view that the psychologist should be licensed to treat any kind of mental disease? PAGENO="0029" 25 Dr. MELTZER. No, this license does not allow the psychologist to treat mental disease. If he works with a person who has a medical disease, he would have to be in consultatidn with a psychiatrist. Mr. JACOBS. You are sure that the language of this proposed legis- lation will accomplish the purpose that you have just stated? Dr. MELTZER. I think so, yes, sir, and I base it on the fact that there are 37 states that have the same kind of laws that work. It is better than what we have now. Mr. JACOBS. I do know, but would there be evidence presented concerning that question, about how this kind of law is functioning in other states? Dr. MELTZER. Dr. Brayfield of the American Psychological As- sociation will testify. Mr. JACOBS. He has statistical material and opinion evidence on the part of officials in those states? Dr. MELTZER. I am not sure of that. Mr. JACOBS. What you have just said, in law it is called a conclu- sion. I assume that there will be forthcoming evidence on that question. As I have tried to speedily read through this bill, I do not really see any reference to the term "mental disease". Have I missed it, or is it mentioned? Dr. MELTZER. It is not in this bill. Mr. JACOBS. Would you have any objection to the inclusion of that term, in order to accomplish the purpose that you have described just now; namely, that those who are medically trained treat mental disease and those who are not medically trained should not do so? Dr. MELTZER. In Section 4, that is covered. That is in Section 4. Mr. JACOBS. I do not see the word "disease". I see "medical", and you said that word supplanted the word "physical" which suggests organic to me. I just wondered if "medical" and "physical" really, in so far as you have described the term "disease" means disease? Dr. MELTZER. Well, if "mental disease" is a medical problem, then this would include "mental illness" as well as physical illness. Mr. JACOBS. You are talking about "metal disease"? Dr. MELTZER. "Mental disease," yes, sir. Certainly, mental disease is construed as a medical problem. Mr. JACOBS. You would have no objection then to the use of the word "disease" in this bill? Dr. MELTZER. I would object to psychologists having anything to do with disease. Mr. JACOBS. Then, you would have no objection to this bill spelling out the fact that they should not? Dr. MELTZER. No. Mr. JACOTS. You have no objection to a reference to the words "metal disease", so long as that is in the lexicon of your disciplines at present? Dr. MELTZER. I do not understand that. Mr. JACOBS. You have no objection to the use of the term "mental cbsease" appropriately in this proposed legislation in order to make clear that "mental disease" is to be treated only by psychiatrists- do you? PAGENO="0030" 26 Dr. MELTZER. No, the word "medical" is a much more powerful word. Mr. JACOBS. You do not rule it out, thought, categorically? Dr. MELTZER. No, I would like to see it in there. Mr. JACOBS. If the Chairman doe.s not object. Mr. SI5K. I might state to the gentleman from Indiana that all four of these gentlemen here are members of the local psychological association. They all came up here together to testify. And so we were questioning them en masse. Dr. CUMMIXG5. Dr. CnMMINGS. My name is Dr. Jonathan W. Cummings. I think I would object to the use of the word "disease", to protect all parties to this, in the object that we are trying to achieve. The word "disease" is probably very much in the gray area that the Chairman mentioned before, and I think, although I do not know a lot, about writing legisla- t.ion, I would imagine, wherever possible you would try to write legis- lation which will not have to be gone over every once in a while. I think that to achieve that, you would try to get the wording which is the more general rather than the more specific. I think that Dr. Meltzer has said that the use of the term "medical" covers very adequately all of those aspects of "psychological" and "psychology" whichever might come up for issue. The important point is in terms of protection for the public. The bill as presently written allows for the delicensing or the punishing of anyone who is found guilty of not referring to others for appropriate kinds of help whenever they have gone beyond the bounds of their competence. And because of this, then, I would certainly most highly recommend that we retain the word "medical", because it encompasses the whole thing, and having encompassed then, then we do not tie ourselves to this, because there are large groups of psychologists and psychiatrists who believe this term is quite meaningful, and I do not believe they worry about this. It is a very difficult one to define legislatively, aiicl the like. Mr. JAcoBs. I might say that there are two schools of thought on the question of specificity in the draftsmanship of public law and public discipline. I think it was Huxley who wrote in the "Brave New World Revisited" that it is "the soul of wit may become the body of untruth," and I happen to subscribe to that view. It does not hurt to try to be as accurate as possible and, therefore, as specific as possible, particularly when you are dealing with a technical discipline for public service. I may be a little off in my philology, but "medical" suggests an organic matter to me, and the good doctor has just testi- fied that "mental disease" is not restricted to the organic. Therefore,, I renew my question as to whether the term "medical" is sufficient to cover the concept of "mental disease" which should be, as I under- stand it, the exclusive province of a psychiatrist. What would your response be to that? Dr. Cu~r~nNGs. It would be that I think that I would restate what I said, that the very fact that there is so much uncertainty that exists in the definition of the term "mental disease", I think that we woulft not be gaining actually by including it in the legislation. This is just my personal opinion. PAGENO="0031" 27 Mr. JACOBS. Would you agree that the word "medical" indicates the treatment of organic disorders? Dr. CUMMINGS. Yes, it certainly includes that, but it, of course,. goes without saying that the psychiatrist is a bona fide member of the medical profession. Mr. J±~coI3s. I do not think anything goes without saying. Having practiced law for a good many years, I can say that judges do not agree that it goes without saying when it comes to a written law. Dr. CUMMINGS. I think- Mr. JACOBS. That is our problem. Dr. CUMMINGS. I say that psychiatrists are members of the medical profession, and, therefore, the term "medical" does, indeed, refer to all of those areas of medicine which are in medicine. Mr. JACOBS. You see, we lawyers seldom admit this, but the fact of the matter is that there isn't anything just terribly magic about the law. It deals with the same English language, in the case of the United States, that everybody else speaks, and we would like to think that by throwing in a few a fortiori's and res ipso loquitur's that we are sounding important and mysterious, but we must, in the end, if we want to write statutes, speak the human language to govern human problems. That is the reason I am very concerned that we pick our terms carefully, so that some judge somewhere along the line will understand, again to use the parlance of the clay, that it is told as it is. PSYCnOTIIERAPY The term "psychotherapy", which is, in this bill, applied to defining the practice of psychology gives me a little trouble. I take it that psychotherapy means a treatment of some illness or disease. Does that. give any of you gentlemen any problem? Could you enlighten me a little bit about the use of the word "therapy"? Dr. MELTZER. It is diagnosing, not practicing medicine; when he diagnoses Mr. JACOBS. Is he being therapeutic? Dr. MELTZER. I am just trying to suggest a word, as you pointed out. I do not think there is too bi~ of an issue in the sense that the psychiatrist says that the psychologist uses psychotherapy. It would be very hard to find disagreement about that fact. Of course, it is backed up by the fact that the United States Government spendsa great deal of money training psychologists to do psychotherapy through the Public Health Service, NIH, and so on. The question is: What is psychotherapy? Mr. JACOBS. We want to have something in the record. Dr. MELTZER. May I read a definition from Random House's Defi- nitions of the English Language? Psychotherapy is described as a method of curing psychological ab- normalities by psychological techniques. I think this is the basic kind of notion that this is a generic term that involves: How do you handle psychological problems in a psychological manner? How do you change a person where there are no psychological problems no longer mani- festM ? This iswhat is involyed. Psychotherapy does involve a relationship between two people, one of whom is the expert in human behavior, and the other is a person PAGENO="0032" 28 who comes to him with some problem, some serious difficulty, some type of unhappiness, some type of behavior that he wishes changed to relinquish, some type of suffering that he no longer wants that he wishes to relinquish. The approach then is one of trying to help the person, every often through talk, to understand himself, to under- stand the causes and the purposes of his behavior and helping him then to see other words of acting, of behavior of relinquishing that way of behavior. A very psychological procedure. Mr. JACOBS. If I retained properly the definition that you read, you included the phrase "the curing of psychological disorders." The curing of psychological disorder could clearly include the treat- ment of organic disorder which manifested itself in a psychological disorder, could it not? Dr. MELTZER. Would you repeat that? Mr. JAcoBs. Please read back the question. (The question was read by the reporter.) Dr. MELTZER. I do not think I can answer that, in that manner. Mr. JACOBS. I will rephrase the question, then. I am simply saying that when a psychiatrist treats an organic disease or an organic dis- order which manifests itself as a psychological disorder, it could be accurately said that that he is attempting to cure a psychological dis- order; is that not correct? Dr. MELTZER. Yes, sir. Mr. JACOBS. Therefore, I am asking whether the term "psycho- therapy" perhaps does not include at least the psychiatrist discipline as well as the psychologist discipline? Dr. MELTZER. Are you asking as to the psychiatrist in pyscho- therapy? Mr. JACOBS. I am asking if the term is not broader than the specific discipline of a psychologist, t.ha.t is, the term "psychotherapy"? Dr. MELTZER. Yes, and that is why we are not attempting to restrict it in this bill. We recognize that a large number of other things exist. Mr. JACOBS. That is fine. Then you are saying that the practice of psychology includes psychotherapy without then qualifying the term "psychotherapy" as applied to the practice of psychology, and, per- haps you overshoot the runway. Dr. MELTZER. If we have, I think we have helped the situation later in the bill when we point out that there is no intention to restrict the activities of other professions. Mr. JACOBS. Then, you would have no objection to helping the situ- ation immediately following the word "psychotherapy" if, indeed, it is included to restrict its meaning to the sphere of competence or the sphere of attempted competence of the psychologist? Dr. MELTzER. The bill states that very clearly. It already says that. Mr. JACOBS. Just as I read the definition? Dr. MBLTZER. It is not exactly in that part, but it has to do with the practice of psychology that he must practice within his competency or he will lose his liéense if he does not. Mr. JACOBS. When you go to the definition section, you will agree with me then that the term "psychotherapy" could imply more than you are advocating that the psychologist be licensed to perform? Dr. MELTZER. That was the intent. Mr. JACOBS. Well, sir, I am not referring to your proviso. PAGENO="0033" 29 Dr. MELTZER. It is in the context of it. One would not know where, if you said "psychotherapy," but if one takes it in the context- Mr. JACOBS. But in the definition section, you do not have any defi- nition to that point. Dr. MELTZER. I would like to have it. Mr. JACOBS. If you have objection to striking "psychotherapy," do you recognize a need for further wording? Dr. MELTZER. Frankly, I do not. I think that the context qualifies the meaning of that term tremendously. The context points out that people have their problems of adjustment, that it is not to be the practice of medicine. I think the word is qualified within the context. Mr. JACOBS. And you have some objection to qualifying it within the context of the definition section of the bill; do you? T)r. MELTZER. No, you ask me now-~- Mr. JACOBS. You said you would object to seeing it? Dr. MELTZER. You did not ask me that. You asked me if I felt it needed to be. Mr. JACOBS. Then, you would not object? Dr. MELTZER. I do not feel it needs to be. Mr. JACOBS. You do not object? Dr. MELTZER. I would be happy~ to see the word in there. Mr. JACOBS. O.K. Dr. CUMMINGS. I think that you raised one definition, and I think that is very clearly covered. I hope that this will straighten this up. Three different times in the past decade the question that you have asked us this morning has come up in the legislative or legal kiiid of question. In California, in Michigan, and in one other state where they have passed upon it. In each case, it went to the state attorney gen- eral's office for a decision. And in each of the three decisions by the state attorney general, in the states of New York, Michigan, and California, the ruling was that psychotherapy is ~ot limited to medical practice. Psychotherapy as they studied the definition of their various acts is a form of activity which is just as much engaged in by others as by physicians. I have the full text here. Mr. JACOBS. I think I understand it. I think that belongs in the record at this point. However, I call your attention to the fact that the matter, about which we are talking, is a definition of the practice of psychology, because the term "psychotherapy" is not restricted only to the practice of psychology, but I believe it needs further definition, further clarification within the definition of the practice of psychol- ogy, because if it is left naked as a term within a series, then there is some ambiguity that the practice of psychology could possibly include the treatment of organic disorder relating to mental disorder. That is my point. I do not know if anybody cares to comment upon that further, or not. Dr. MELTZEB. I would disagree. Mr. JACOBS. Excuse me. You are saying that you disagree that the term "psychotherapy" includes more than the practice of psychology? Dr. MELTZER. Pyschotherapy is a technique, and it is not restricted to any particular discipline. Mr. JACOBS. You have not answered. If it is not restricted to your discipline, it can hardly be an unqualified term to describe your discipline. 94-755-----GS----3 PAGENO="0034" 30 Dr. MELTZER. The problem is not with the. technique. It is by whom the technique is employed. This is what differentiates the psychologist from the psychiatrist. Mr. JAcoBs. I shall not belabour the pomt, but I think the record is amply clear for our consideration in executive session. I want to ask one further question which is with reference to the bill that is before us, S. 1864. Mr. SIsK. I might say that we have two bills. The House bill is H.H. 10407. and S. 1864 which is identical-or was at the time it was origi- nallv introduced-is the Senate bill. It has had some amendments as has been pointed out earlier. Mr. JACOBS. I am talking about Section 6(B). What. did you say, as in Beethoven? Dr. MEIJFZER. In Beethoven. yes. Mr. JAcoBs. I see in the bill that it is permissive. I am just. wonder- ing whether it should be permissive to appoint a Board of Psychologist Examiners if they have specific duties to l)erfOrln? Why would it. be a permissive provision? Dr. MELTZER. Would you expl am what you mean by that? Mr. JACOBS. It. says that. the Commissioner may appoint, a board of psychologist examiners. and, then, as I understand it., the bill goes ahead and requires specific performances from that board which may or may not e.xist. Can you enlighten me as to why it was "may" and not "shall" as to its appontment? Dr. MELTZER. I believe that when we discussed this with the city government., we were told that we could not tell the Commissioners that. they had to do so; that one "allowed" them to do so. Now, whether or not that is correct, I do not. know. Mr. JACOBS. I think I have something to learn. Just one final question. This is purely a. matter of first impression with me. I have had very little `correspondence about it, and very little information about it, although questions have been raised to me. Has there been cooperation between the Association of Psychiatrists and the psychologists in this jurisdiction in the preparation of this legislation? Dr. MELTZER. I am sorry t.o have to talk to this point. We began work on this in January 1965, trying to decide whether or not to have a bill. In Februa.ry 1965, we wrote to the Washington Psychiatric Asso- ciation and asked if they would join with us in writing such a bill. We got an aswer saying "No, we are aga.inst suc.h legislation." Mr. JACOBS. Can you submit that for the record? Dr. MELTZER. Yes, sir, I can. (The correspondence referred to appears at p. 108.) BACKGROUND OF LEGISLATION Mr. MELTZER. For two yea.rs we ha.ve attempted to have some type of communication, and it was not until last May, one year ago or over two years a.fter our first contact wit.h them, that we started to have discussions. This came at the time when the bill was submitted to the Senate. They wanted to modify the bill in some way. The suggestions that were made by the psychiatrists made it totally unacceptable. They PAGENO="0035" 31 had it where psychotherapy would be defined as the practice of medi- cine. They would have added a section which would have said that a psychologist may do psychotherapy only as an exception to the inedi- cal practice arts. As Dr. Cummings has pointed out, three states have ruled on this question-ruled that it was not an exclusive medical practice, but their suggestion was to give us an exception to the act so that we could do so. They would have, in effect, asked this Congress to act, as no state has ever acted, to define "psychotherapy" as medicine. Secondly, they suggested that the Board of the Examiners of Psy- chologists contain several psychiatrists. Well, this is totally impossi- ble. First of all, psychology is a much broader field than psychiatry. As they themselves point out, only a fraction of the psychologists do psychotherapy. They have familiarity as to the competency of the broad field to sit in judgment on psychology. C~rtainly, psychologists clearly say that they are not psychiatrists. I wish that the~ psychiatrists would admit that they are not psychologists. But could not have been determining the fate of a.n independent profession. Finally, one of the other major suggestions had to do with the prac- tice of psychology, the practice of counseling and psychotherapy. Now, there is a lot to this. It has all kinds of implications. Mr. JACOBS. May I ask at this point: Did you say at one point that the Psychiatry Association wanted to rule out the concept of psycho- therapy altogether and at this point that they suggested that there be a separate license for psychologists? Dr. MELTZER. Yes, sir. Now, in the separate licenses, these are the problems that are involved. First of all, the psychiatrist~s point out that the reason they suggested that we have an omnibus bill that in- cluded all fields and that this would strengthen it, I think they are talking about their own field'. There is nothing that contains more di- verse activity than the healing arts practice act. There is nothing more diverse than surgery and psychotherapy. The conflicts of techniques and learnings are totally different. What would happen if they got out to do this? Incidentally, none of the 37 states have a separate licensing of this nature. It specifies that. It would be the first time that. that would be. First `of all, I think it would bring to a halt much of counseling work that is done in this city by the legal profession, by ministers, by so- cial workers, because what they said then is that this counseling and psychotherapy is a medical practice, that no one is allowed to do this except a physician. And those psychologists would have a license and it would be disastrous. In addition, this room today would be overwhelming with social workers, ministers, and lawyers. It has tremendous other ramifications. Mr. JACOBS. I think that responds fully to my question. Thank you very much, Mr. Chairman. Mr. Sisic. The gentleman from Maryland, Mr. Gude. TRAINING Mr. G-UDE. Thank you, Mr. Sisk. In section 7(B), on page 6, it would appear to me that it includes any type of training, for example, (B) (1). PAGENO="0036" 32 Dr. MELTZER. That is a very specific reference. You refer to the in- ternship-that refers to the psychological internship which the grad- *uate student might take while he is a graduate student. What the sec- tion does, it says that the psychologist cannot count that experience towards the two years postgraduate experience that he must have before he can apply for a license. Mr. GLDE. Section 3(D) speaks of the use of counseling and psy- chotherapy with individuals having problems in the area of work, et cetera. Is it not necessary for a person working in this area to have some knowledge of medicine, for example, for a person to have some knowledge of physical or organic change? Dr. MELTZER. You are talking as to the training of the clinical psychologists? Mr. Gu~E. Yes, sir. Dr. MELTZER. This is the pattern of training, to have the psycholo- gist in training work closely in various medical fields. For example, in the five or six years, two and one-half years in the Veterans Ad- ministration working in the hospitals, in the out-patient clinics such as here in Baltimore and in Washington. This is one of the reasons, too, that we say to the psychologists, "You cannot offer yourselves to the public for a fee until three years after your degree, because you have to work in a setting which will prepare you for what you are trained to do under the supervision of other disciplines," and so forth. In the training of a psychologist, he must do an internship. And these internships, invariably, are in medical institutions, in clinics, or in hospitals. Many of the courses are related to the same types. And for two years after the degree, the psychologist would not be able to practice independently. If this were the law, he would have to work under supervision. Mr. GvDE. Do you think that this educational program, carried forward in a medical environment, is a guarantee under the terms of this requirement to have a degree in psychology? Dr. MELTZER. I am talking about the specific parts of it, that is, the practical training, in addition to the work in the universities. Other types of psychologists, counseling psychologists, industrial psy- chologists very rarely see the medical part. The clinic psychologists, yes. Mr. GUDE. Would this bill provide for the licensing of industrial psychologists? Dr. MELTZER. Yes, it would. Mr. Gv~E. He would be able to engage in psychotherapy? Dr. MELTZER. No, tha.t is the situation. Right now at this moment, an industrial psychologist could practive psychotherapy in this city. He is not in violation of the law. He can be thrown out of the D.C. Psychological Society and be sued for malpractice, but he cannot be stopped. What this bill would do is to say that a psychological must practice within the purview of this authority, within the confines of the training in the areas of his competence, a.nd if he steps over that line then we would remove his license and we could stop him. This makes sure that the industrial psychologist would not do so. He would be thrown out of the organization, which is all we can do now. And he is going to be unprincipled. If he is that will not n~ater. Mr. GtmE. Where would this guarantee be? PAGENO="0037" 33 Dr. MELTZER. Those are two sections. One is in Section 4 where it states that the psychologist who engages in practice is required to assist his client in obtaining professional help for his client's problems that fall outside of the boundaries of the psychologist's own competence. Then, again, it comes up in terms of the reason for the revocation of the licensure on page 12 of the Senate bill. it is in Section 14(E), "found guilty of the unethical practice of psychology in violation of standards to be established by the Commissioner." Now, this is the reason for that. The ethical standards of the psy- chological association makes it clear that the psychologist must not offer services in a specialty that he was not trained in. The other states incorporate those in the code of ethics. It will serve to be the cause of the loss of license. It is in two places. Mr. GUDE. On page 3, Section 4 reads: The psychologist who engages in practice is expected to assist his client in obtaining professional help for all relevant aspects of the client's problem that fall outside of the boundaries `of the psychologist's own competeuce. I thought I heard you say that before he engaged in the practice that he must assist his client- Dr. MELTZER. It is in the section. Mr. GUDE. That seems to me as broad language. Dr. MELTZER. He will lose his license if he does it. Mr. Sisic. Mr. Whitener? STANDARDS Mr. WHITENER. Referring to 5. 1864, in subsection E, of section 14, at page 11, it says "found guilty of the unethical practice of psy- chology in violation of standards to be established by the Commissioner." I am wondering where in the bill is there any authority for the Commissioner to establish standards. I have not seen anything of that import in the bill. The Senate bill (5. 1864), as I read it, gives to the existing District `of Columbia City Council the right to establish regulations, `but in the bill itself it says "standards to be promulgated by the Commissioner." It seems to me that subsection E of section 14 is meaningless, unless there i's something in the bill that I have not read. Dr. MELTZER. I understood that it was included among the regula- tions that the Commissioner would set up. Mr. WHITENER. As I read the bill, there are no regulations to be set up `by the Commissioner. Dr. MELTZER. This is piartly an amendment t:hiat was added to it. Mr. WHITENER. It does not do what you say it does. It is meaning~lcss. Dr. MELTZER. It would be the amendment. Mr. WHITENER. I was wondering what one woni'd find from reading the bill. Do you find anywhere where the Commissioner is given that authority? Mr. GtTDE. No, I do not. Are you `aware of where the section is that the Coimnissioner is given the authority? PAGENO="0038" 34 Dr. MELTZER. One part, as i understand it, is the section that deals with-Section 12. It. can be amended at. anytime. Mr. \VHITE~;ER. That does not. do what you say it. does. Dr. MELTZER. The Commission is authorized to make regulations for the purpose of- Mr. ~\mTExER. It does not say that-it. is the District of Columbia Council. Mr. GvDE. That. is Section 12, on page 9. Dr. MELTzER. It. has to be amended. Mr. WHITENER. That is the same way it. came over here. It. is the Senate bill. Dr. MELTZEE. It sa.ys that the Commissioners shall do so. Mr. WHITENER. You said that Section 12 covers that, where it. gives the authority to fix standards. If you will refer to that-that it will do this-then, Subsection E might do what you say it will do. I have never see~~ this bill until just a. few minutes ago. I have never reacT it before. But you testified in response to a. question from Mr. G-ude that. by reason of Subsection (E) of Section 14 which appears on page 11, lines 3 through 5 of the Sena.te. bill, S. 1864, that a. person could lose his license as the result of being found guilty of unethical practice of psychology in violation of standards to be established "by the Commissioner." My question to you is: Where in the Senate bill is there any author- ity given to the Commissioner t.o "establish standards" ? Dr. MELTZER. I assume I had it. in that section that I pointed out t.o von where apparently the Commissioners will do so. Mr. SIsK. If you will yield, I think the basis of the authority given the Commissioner is in Section 6. I am not. saying that it goes to the subject raised by Mr. Whitener, but I think that Section 6, basically, is the authority-the basic authority-given to the Conunissioner with reference to his power to appoint a. board and to carry out the licens- ing, aild so on. So, what authority this bill gives to the Commissioner is found in Section 6. Mr. WHITENER. If the gentleman will yield further. As I read it, Section 6 does not give to the Commissioner any authority to set stand- ards. Section 6 just gives him the authority to review applications and to appoint a. boa.rd and t.o maintain the record. So, I say this unethical subsection appears to me to be absolutely meaningless. I do not mean to take up your time, Mr. Gudie. You may disagree with the proposi- tion, I do not know. Mr. GuDE. This is another point. Regarding Sect.ion 6(B), there is another question raised in my mmd. It says in Section 6(B), that the Commissioner may appoint a boa.rd of psychologists, et c.etera. Dr. MELTZER. Mr. Jacobs pointed that out, also. The reason it. is worded that way, apparently, is that they said they wanted it worded that way. Mr. GEDE. You stated t.hat there a.re different categories of psychol- ogist.s set up under the terms of this bill; audi that the Commissioner in framing the regulations, for example, would provide that. industrial psychologists couldi not practice psychotherapy, on the other hand, there would be certain other categories of psychologists who c.ouldi pract.ice psychotherapy. What I was woiidermg is: To what extent would psychologists have to have some medical training to the point PAGENO="0039" 35 where they would be able to diagnose various types of organic dis- ease which would require medical treatment by a doctor of medicine? Dr. MELTZER. The typical pattern of the work today in the sense that the colleges are trained to some extent, and then they are required to make sure that they consult. As I pointed out before, colleges in particular and many, many physicians refer to psychologists to get these various similar kinds of questions answered. I weekly see people in my office who come from physicians or psychiatrists, and the question there is: Does this person have a psychological or organic disturbance? How sick is this person? Does he have a mental illness? Is he psychotic? I refer patients to them, and they refer them to me, too. This is the kind of working closely together that goes on. This bill assures that the practice will continue. If the psychologist goes merely on his way, he is liable to lose his license, if he does that. Mr. GUDE. I am more concerned about the patient. Moving in an- other direction, the patient comes to the psychologist and thinks that he is in the hands of a person who would take care of his particular problem. My concern would be whether the psychologist would have the necessary professional training. There might be some disease which would indicate that the patient must go to a medical doctor. I think this is my concern, because this would make the psychologist more of a professional person, in raising the standards. Dr. MELTZER. It would protect against the psychologist who does not have the sort of training required. This would provide that kind of protection that does not exist now. Mr. GLTDE. I was looking in the Yellow Pages of the Washington telephone directory. Would he be entitled to advertise in here if this legislation were enacted? I see the name of a doctor listed under "Psychologists", who prac- tices in D.C. He has a Ph.D and a P.S.D. in psychology. He says he specializes in Metaphysics, Epistemology, Hypnosis, Emotional Prob- lems, Insomnia, Tension Release, Homosexual Problems, Memory and concentration Improvement and Post and Self-Hypnotic Therapy. Dr. MELTZER. He would not be able to advertise. Mr. GUDE. Thank you. Mr. Sisic. Are there any further questions? My good friend has been here since we started this morning. Mr. Walker. Mr. WALKER. I notice from our agenda that we have some other witnesses. I have been very interested in the colloquy between the members and the witnesses. I find it very interesting, as a matter of fact. They have already raised some questions that I am concerned with. However, so far as I am concerned, I would like, before I go ask any questions, to have an opportunity to listen to some of the other witnesses. There are other areas that I am a little concerned with. Mr. SIsK. Thank you. As the list indicates, we will hear from representatives of the Na- tional Association. We also have a group of psychiatrists here who will be testifying. Mr. Zwach? PAGENO="0040" 36 TRAINING Mr. ZWAOH. Just one question, Mr. Chairman. I notice that you gentlemen all have the title of doctor. Is this a Ph.D. in psychology? Dr. MELTZER. Yes, sir. Mr. ZWAOH. Will you present to the Subcommittee the curricula of studies that you have pursued? I would be very much interested in the course of studies that you have pursued to earn this doctorate. Dr. CUMMINGS. Most definitely, we can supply `that. (The information requested appears in the appendix at p. 109.) Mr. ZWACH. Are there in the District of Columbia people uslng the same title of doctor without having earned the degree? And are they hanging out their shingle calling themselves "Dr. So and So"? Dr. MELTZER. That is correct. Mr. ZWAOH. That is all, Mr. Chairman. Mr. SIsK. Mr. Whitener. Mir. WHITENER. I would like to ask this question, gentlemen: Do you know who prepared the bill. the original bill? Did your lawyers do it, or somebody here on Capitol Hill? Dr. Cu~I~nNGs. We did it; I think with the help of the lawyers and with the help of tile folks who have assisted in writing s~miI ar legislation. Dr. MELTZER. And the amended bill, too. Mr. WHITENER. My question will not relate to the merit or the de- merit of your proposal as much as to the draftsmanship of the bill. On page 1 of the Senate bill, lines 8 and 9, you say `~to protect the public from the unauthorized and unqualified practice of psychology". To me "unqualified practice" might have many meanings. What you mean t.ilere i.s the practice of psychology by unqualified persons, do you not? Is that what you are getting at ~ Dr. Cn~r~rixos. Yes, sir, I think that is it., sir. Mir. WHITENER. I understand tilat you have never atteilded law school. Dr. CUMMINGS. That is correct, sir. Mr. WHITENER. I think it could have all entirely different, meaning from what I lmderstand your intent to be, and I would think that you would want to amend that language to say "practice by unqualified persons", because the words "mlautllorized to practice" means that person is not autllorized. It may not even need the word "unqualified", if you are setting up an authorization system and saying `anyone who did not meet the requirements of that authority would not be eligible to practice, and if they do so they would `be violating the law. Appar- ently, you are dealing in confusing surplusages of language. Now, on page 3. lines 5 and 6, your definition of the practice of psychology includes "teacll~llg or lecturing ill pSycilology aild doing research on problems relating to human behavior." "Teaching or lecturing" later on in the bill, as I read it, is permitted if it is certain educational institutions, but I am wondering if you are not getting into dangerous ground when you try to proscribe the teaching `and lecturing in pSycllology, whether it be by qualified or unqualified people-or is it unauthorized persons? PAGENO="0041" 37 Dr. MELTZER. rri~ reason that is in there is that somebody could say "I am not practicing", or "I am not trying to change somebody-I am just teaching," instead of calling it what it should be, "counseling." Let us say he says, "I am teaching-I am teaching psychology." So the intent is to make sure somebody cannot get away with that. `That is the main purpose of that. Mr. WnITENER. We do want to get to it. Your Section 4 is the most unusual language I have ever seen in a bill submitted to the Congress, because it is not law; it is just a lecture. It says this: "The Psychologist who engages in practice is expected to assist his client in obtaining professional help for all relevant aspects of the client's problem that fall outside of the boundaries of the psychologist's own competence; for example, provision shall be made for the diag- nosis `and treatment of relevant medical problems by an appropriate qualified medical practitioner." What would that language add to the body of the law other than just a lecture in the procedures and practices that you hope people in the future will indulge in? Dr. MELTZER. I think you have got `a good point there. I do not think it is necessary in there. It was put in `there to show that we mean business. Mr. WHITENER. That is one o'f my arguments. You want a bill that means business. If you did so, you would revise it this `way, that the psychologist who is engaged in practices shall assist his clients in ob- taining professional help for all relevant apects of the client's problem that fall outside of the boundaries `of the psychologists own compe- tence. He shall make a provision for the diagnosis and treatment of relevant medical problems by an appropriate, qualified medical prac- titioner. If you had that language, you would have it. Dr. IMIELTZER. That is the language that will be in the code of ethics. Mr. WHITENER. We are not talking about the code of ethics. We are talking about the language of the bill. Dr. MELTZER. Each bill has a code that determines how the psychol- ogist must function to get or to keep his license. Mr. WHITENER. You are talking about some other document that might now or hereinafter be in existence. Dr. MELTZER. It is in there. Mr. WHITENER. We are talking about the language of the bill before us. Dr. MELTZER. It gives a cause for the revocation of the license in this bill. Mr. WHITENER. That is irrelevant to my question. My question is: Are you recommending that the Congress engage in writing of lectures as to what people in my profession or in some other profession is ex- pected to do? Dr. MELTZER. No, sir. REolPEocITE Mr. WI-IITRNER. Now, under your Section 5, there is no provisi'on for comity, but in a later provision there is authority to license one duly licensed in another state, or if he is from a state that does license, they PAGENO="0042" 38 may license him if they are satisfied as to his qualifications. But, as I understand it, there are very few- states that. now have a. licensing pro- cedure for psychologists. Is that correct? My state has one. The last legislature passed one. Many other states do not.. Dr. CU3IMINGS. Did you say "certified", Mr. Whitener? Mr. WHITENER. Who have an examining board. Dr. cTTMMINGS. 31 states and six Canadian provinces. Mr. WHITENER. And when we get over to page 9, section 11, you state: "The Commissioner may, in his discretion, waive all or part of the examination required under section (C) of this Act when the appli- cant has (1) achievecl a position of eminence in the practice of psychology." Wlia.t sort of guideline do on have in determining that you or I or some other professional man has "achieved a position of eminence"? Dr. CUMMINGS. I think that the Board of Psychologist Examiners would have to talk with the Commissioner in setting up standards or criteria for that. It is not a large number. Our conservative estimate is that it would be used in no more than four or five cases in a decade to take care of t.hose folks of national prominence. Mr. WHITENER. We are talking about. the practical side of this legis- lation. You set up a procedure in this legislation whereby an appl~- cant is authorized to take a certain appeal if he feels that he has not. been dealt with properly. Suppose that t.he applicant seeks his license on the groimcl that he has adiieved a position of eminence, where is there anything in this bill that would give to the courts any sort of legal guideline for determining whether or not you are au eminent. psychologist or a non-eminent, psychologist? Dr. CUMMINGS. It would be reasonable to expect this to he written into the regulations to accompany this if this Act were to be passed. Mr. WHITENER. I do not know that these regulations can be written in conflict with the words of the statute. So that. the regulations would not necessary be binding on the courts if they were not consonant. with the language of t.he statute. I point this out. to you to show that I think somebody has clone some rather unusual draftsmanship. The Senate has amended the legislation as introduced, originally. I understand that the Senate bill originally, before the amendments, was the same as the House bill, H.R.. 10401. The Senate says that the Distric.t. of Columbia council shall make the regulations. That is agree- able with you, gentlemen, is it not? I notice that you keep saying that the Commissioner can make the regulations, but the bill as passed by the Senate does not give the Com- missioner that authority. It gives it to the Colmcil. Is this in keeping with your wishes? Dr. CUMMINGS. Yes, sir. Mr. WHITENER. Thank you. That. is all. Mr. SISK. Thank you. Well, gentlemen, we appreciate very much your statements. I t;hink that at. this time we will go along and see if we can hear from Dr. Bray- field if he has arrived. Dr. GUMMINGS. Thank you. Dr. MELTZER. Thank you. PAGENO="0043" 39 Mr. Sisic It does not look like we will be able to extend these hear- ings this morning, and apparently we are not going to finish the hear- ings, but we will simply go along as far as we can, and then we will see where we go from there. Thank you, all of you, doctors, very much for your testimony. Now, Dr. Brayfield, of the American Psychological Association is our next witness. We will be glad to hear from you. Mr. SIsK. Is your office in Washington? Where is your headquarters? Dr. BRAYFIELD. 1200 17th Street. Mr. SisK. By the way, do you have a prepared statement? Di. BRAYFIELD. Yes, I do. Mr. Sisic All right. Without objection your entire statement will 1)0 made a part of the record. You can read the statement in its entirety if you desire, or you can speak extemporaneously, whichever you care to do. STATEMENT OF DR. ARTHUR H. BRAYFIELD, EXECUTIVE OFFICER, LMERICAN PSYCHOLOGICAL ASSOCIATION Dr. BRAYFIELD. Mr. Chairman, I ani accompanied by Mrs. Jane D. Hildreth who is our consultant on legislative matters. If you have questions to direct to me she may be of assistance to me in responding. I am here representing, as Executive Officer, the American Psycho- logical Association. Its membership includes most of the psychologists in the country. There are, approximately, 27,000 members. The mem- bers cover all possessions and territories and the commonwealths of the United States and has affiliated state associations in all states ex- cept Alaska where, unfortunately, there are few psychologists. My main purpose in appearing here is, at the invitation of the Sub- committee, to express the strong support of the National Association for the aims and content of H.R. 10407. The Association in 1955 adopted a series of policy guidelines for state associations to use should they wish to develop legislation de- fining and regulating the practice of psychology. An up-dated policy statement, based upon experience with the laws in the intervening years, was adopted by our Council of Representatives in September, 1967. The Association does not enter into legislation of this sort directly. It provides suggestions. I do want to re-emphasize that there are now laws in 37 states and six Canadian provinces, the most recent one being the licensing act in the state of South Carolina in March of this year. Finally, I should like to comment concerning questions that have been raised about the proposed legislation by the local associations of psychiatrists and psychoanalysts, questions concerned primarily with safeguards for the client requiring services outside the psychologist's area of competence. I would point out for the record that these are raised by local associations and not by the national body. PAGENO="0044" 40 It is a question of concern primarily with safeguards for supplying services outside of the psychologist's area of competence. For the Committee's information, and for the record, I should like to point out that the proposed legislation contains a specific provisiofl, Section 4, on this matter, and that it is in accord with the official policy adopted by the American Psychiatric Association in 1964, a policy agreeing with similar action by the American Medical Association in 1960. Further, Section 4 is consistent with recommendations made jointly by what we call the "relations" committees of the two national associations, the American Psychological Association and the Ameri- can Psychiatric Association. I should like to expand for just a moment beyond my written testi- mony, in the light of the questioning that has gone on this morning. First, I would like permission, Mr. Chairman, to submit for the record a lengthy article entitled "A Critical Look at Professional Education in The Mental Health Field," by Allen S. Mariner, who is in the private practice of psychiatry in New York State. I think that article will be most helpful in answering some of the questions that have arisen this morning with respect to the medical basis of psycholog~ca.l practice. Mr. SIsK. What length is that article? How long is it? Dr. BRAYFIELD. It is about five pages. Mr. SIsK. Without objection, I think that we will make the full text of that article a pa.rt of the record, it seems it might be of some value to the Committee. (The article referred to follows:) A CRITICAL LOOK AT PROFESSIONAL EDUCATION IN THE MENTAL FIELD Allen S. Mariner [Reprinted from American Psychologist, Vol. 22, No. 4, April, 1967] Ontario County Mental Health Center, Canandaigua, New York `~~rarious writers in the "mental health" field-that is, that area of human endeavor devoted to helping persons with emotional or psychological problems- have considered the problem of educational preparation for the field. Looming large in their considerations have been questions concerning the relevance of medical education and training to the actual practice of those working in the field. This questioning began almost as soon as the field was first defined in meaningful intellectual terms, and it was begun by the man who was most instru- mental in defining the field as we know it today-Freud himself, in his well- known essay on "The Question of Lay Analysis" (1947, orig. pubL 1926). Since the appearance of this essay, others have added their arguments to Freud's original contribution; among contemporary writers Kubie (1954, 1957, 1964), Szasz (1959, 1961), Gardner (1960, 1962), Eissler (1965), and Schofield (1964) have addressed themselves to this problem. Discussion of the issues involved has been severely hampered by intense interprofessional rivalries and by problems of definition. Among "medically oriented" psychiatrists, the problem is "solved" by forcing the professionally ob- served and manipulated phenomena into what has seemed to many a Pro- crustean bed of quasi-medical terminology; by defining deviant behavior and feeling in terms of "illness" or "disease," these psychiatrists place such phenom- ena firmly within the domain of medicine. The defenders of this position have been vigorously challenged by militant clinical psychologists with the able back- ing of dissident psychiatrists. Psychiatric caseworkers and lay analysts have remained largely aloof from this argument, at least in print. Caseworkers have been beset with the most acute problems of professional identity: With rare exceptions, they lack the magic degree which enables one to be called "Doctor"; PAGENO="0045" 41 they fre~uent1y approach the issue with an air of diffidence and conciliation and become involved in apologetic and largely unsuccessful attempts to differentiate their practice of office "casework" from "psychotherapy" so that no one will be angry with them (Grinker et al., 1961; Hollis, 1964; Josselyn, 1948; Kaplan, 1963). Lay analysts consider themselves strictly "psychoanalysts"; they stem directly from a European tradition and, because of the official position of the American Psychoanalytic Association, see themselves as a dying breed for whom there is no longer any point in fighting. They constitute a small group, but included among them are such illustrious and respected figures that they cannot be omitted. I have thus introduced the four professional groups who supply most of the professional psychotherapeutic help given in this country at this time. (There are, `of course, others who supply such help-some clergymen, nurses, and even aides in certain psychiatric hospitals, Warme, 1965-but the present discussion will be limited to the four more officially recognized groups.) Two questions immediately arise with reference to the work `of these professionals: 1. To what extent can their work be identified with their professional origins? 2. Do the psychiatrists (including medical psychoanalysts) have a significant advantage over the others in the conduct of their day-to-day professional work? If they do have an advantage, from what does' it stem? Is it specifically related to their medical training, and, if so, in what way? To approach the first of these questions, let us imagine an experiment to which random samples `of the work of experienced professionals from these four groups are observed by an experimenter who does not know the professional origins of the subjects. It will be immediately apparent that certain professional activities would identify the subject `at once: If he were prescribing drugs or giving electro- shock therapy, he would have to he a psychiatrist; if he were giving psychometric tests, he would almost undoubtedly be a psychologist; if he were using hypnosis, he would be either a psychiatrist or a psychologist; if he were making a home visit, he would in all likelihood be either a social worker `or a psychiatrist; if he were engaged in an interview in which the patient w-as on a couch, lie w-ould be either a psychiatrist or a lay analyst. If, however, the experimenter were con- fronted with samples of professional behavior limited to "interview material" in the usual sense-individual, family, or group-~he w-ould find it extremely diffi- cult, if not impossible, to deduce the subject's professional origins in terms of the so-called "disciplines." Instead, he would probably find himself identifying Freudian analysts, Jungians, Rogerians, psychoanalytically oriented therapists, rational-emotive therapists, existential-experiential therapists, and other breeds. In other words, he would be able to make deductions about the theoretical bias of the therapist, about the teachers Who had left their imprint on his work, and about the books he had read far more easily than he would whether the subject h'ad ever gone to medical school or held a doctorate in clinical psychology. While he might well be able to identify a psychoanalytic interview `as such, he would undoubtedly not be able to tell whether the analyst had had medical training. Further, if he could observe the course of an entire therapy, he would still not be able to identify with any certainty the professional "discipline" of the therapist as long `as the therapeutic contact included none of the "parametric" be'haviors mentioned above and as long as the therapist's verbalizations did not include any jargon which is identified with one particular discipline (e.g., if a therapist spoke of "sharing information," he could probably be identified as `a social worker on the basis of this verbal clue). It is assumed that the above a'ssertions will not appear strange or `untenable to most sophisticated `workers in t'he psycho- therapeutic professions. Those who wish corroboration `are referred to the work of Hans Strupp (1960) and to the excellent discussion in Schofield's Psycho- therapy: The Purchase of Friendship (1964, Oh. 6). `It `has been foun'd that even the observable differences among therapeuti'c schools ten'd to `diminish with in- creasing `age and `experience `of therapists. It may be concluded, then, that the work of professionals in this field can be i'dentified as to discipline of origin only w'hen certain specific `behaviors are em- ployed; even then, there are very few such `behaviors `which could firmly identify a `subject in our imagined experiment as having had `medical training (assuming that he is n'ot "wearing two h'ats" `and fu'nctioning `also as a general `physician) performing physical examinations, prescribing or administering drugs, and giving electroshock treatment. (He might also be identified by certain administrative behaviors such as giving or withholding wa'rd privileges in a hospital, signing PAGENO="0046" 42 commitment papers, or testifying in court as to legal sanity; these activities will be discussed later.) With this fact in mind, we may proceed to the second of the two questions posed above: Do psychiatrists have a significant advantage over other therapists in the conduct of their day-to-day professional work? The preceding discussion makes it clear that this question must be subdivided into two questions: (a) Do psychiatrists have a significant advantage when functioning purely as "psycho- therapists" in the usual sense-that is. without employing physical methods? (b) To what extent does the possibility of employing the physical methods men- tioned above constitute an advantage for the psychiatrist? Two main arguments have been advanced to sustain the claim that medical training confers an advantage on the psychotherapist: these might be termed the argument from knowledge and the argument from attitude and charisma. The proponents of the former maintain that the physician's knowledge of physical symptoms and disease constitutes an important part of the armamentarium of the psychotherapist and/or that this knowledge is essential because the therapist must assume what Is termed "medical responsibility" for the patient. The assertiol1 that knowledge of physical medicine is important to the psycho- therapist appears patently false when one considers the obvious fact that large numbers of nonmedical therapists function quite effectively w-ithout this know-l- edge. Therapists of every background. medical and otherwise. routinely make a practice of depending on general physicians, internists, and other medical men for opinions and recommendations regarding organic problems in their patients; and the suspecting of organic disease is most assuredly not limited to psychia- trists. Two situations known to the author are relevant in this connection: "A psychologically sophisticated patient dismissed certain abdominal symp- toms as being obviously "psychosomatic" because they appeared to be related to material with which she was dealing in therapy. Her therapist, how-ever, insisted that she consult a physician. Examination revealed a twisted ovarian cyst. The therapist w-as a lay analyst. A w-cman was seen in psychotherapy over a prolonged period because of persistent abdominal symptoms for which extensive physical investigations had revealed no cause. The therapist was convinced that the symptoms were somatic expressions of feelings related to the patient's intensely conifictual marriage; numerous connections between various symptomatic manifestations and the vicis- situdes of the marital situation were observed in the course of the therapy. The treatment ended precipitously when the patient consulted a surgeon whom she had never seen before; this surgeon performed a laparotomy and found the patient's peritoneal cavity to be extensively invaded by a malignant tumor. The therapist in this case: a psychiatrist. Further examples may be found in Eissler's (1905) ][edical Orthodoxy and the Future of Psychoanalysis. The term "medical responsibility" is often used but seldom defined. Opera- tionally. one assumes responsibility w-hen one agrees to perform a certain function (professional or otherwise). What, exactly. does one who assumes medical respon- sibility take upon himself? The answer. obviously, is that the responsibility varies according to the field in which the professional is w-orking. The ophthalmologist assumes responsibility for diagnosing and treating eye conditions; he does not assume either diagnostic or therapeutic responsibility for other conditions. If a patient mistakenly visits his office with intestinal complaints, he does not assume any reponsibility for the patient other than to refer him to an appropriate source of help. If he has a patient in the hospital for an eye operation, he asks a general physician to do the routine physical examination. If the patient develops post- operative pneumonia he w-ill assume the responsibility for calling in an internist to treat the pneumonia; he will not take the responsibility for diagnosing and treating it himself because he (quite correctly) considers it outside his realm of competence. Thus even within the field of organic medicine, medical responsibility is not a global responsibility; institutional rhetoric and operational reality are two different things. In the psychiatric field, the confusion is particularly important because an issue is made of the medical responsibility concept. The ophthalmologist is not criticized because he does not assume the responsibilities of the general physician or the internist, but the psychiatrist is admonished-albeit with no clarity of thought-to "assume medical responsibility for the patient.." This injunction may be view-ed from both sides-the psychiatrist's and the patient's. From the psy- chiatrist's side, one immediately sees a strange contradiction: The psychiatrist PAGENO="0047" 43 is told to assume medical responsibility but is also repeatedly-and correctly- reminded that he cannot or should not assume it, both because he no longer has the competence and because of the difficulties invoLved in trying to play both medical and psychotherapeutic roles (Colby, 1951; Kubie, 1954). From the patient's side, as Szasz (1959) has pointed out, it would appear quite unwar- ranted to transfer responsibility for physical health matters from the patient and his physician to the psychiatrist. The assertion that the psychiatrist should assume medical responsibility is frequently coupled with the idea, usually expressed covertly, that physical disease is an ever-present possibility in the psychotherapy patient. Kubie, for example, in his long and valuable paper on "The Pros and Cons of a New Profes- sion: A Doctorate in Medical Psychology" (1954), advises that patients in psychotherapy be subjected periodically to "meticulous organic scrutiny" lest sonic physical abnormality be overlooked. There would appear to be only two possible rational reasons for such physical investigation of the patient who is undergoing psychotherapy for, let us say, exhibitionism or agoraphobia: (a) the exhibitionism or agoraphobia (and I must stress that these are randomly chosen examples) is suspected of being basically organic in orgin-a most un- likely suspicion; or, (b) exhibi;tionis'ts and agroaphobics are more prone to physical disease than other people and should therefore have regular physical examinations more frequently. There is a striking paradox inherent in this position-namely, that if a patient deemed it necessary to subject himself to repeated physical examinations in the absence of any signs or symptoms of physical disease, his behavior would almost undoubtedly be adjudged indicative of hypochondriacal anxiety or unwillingneSs to give up the defensive idea that "it's really physical." Thus, it is as if the very behavior which would be deemed neurotic on the part of the patient were to be instutionalized as desirable or even essential on the part of the therapist. Actual practice, of course, is more realistic: psychotherapy patients are not subjected to periodic physical exami- nation, whether their therapists are medical or nonmedical; like everyone else, they consult medical men when some indication for such consultation arises. There is no rational basis for the assumption that a person involved in psy- chotherapy is, for that reason alone, any more apt to develop organic disease than anyone else. (Kubie, in the above-mentioned paper, introduces another-and even stranger-"argument from knowledge" when he suggests that only physicians can recognize psychosis. The reaction of any seasoned clinical psychologist to this suggestion need not be described.) A widespread misunderstanding exists with regard to the medically trained therapist-namely, that his behavior as a therapist reflects his medical knowl- edge. Operationally, this is simply not true. Unless he is functioning also as a general physician, the psychiatrist-therapist does not actually do anything about physical symptoms or physical illness `in his patients which is in any way different from what the nonmedical therapist does. He deals with these phe- nomena as aspects of the patients' psychological world; he may be concerned about their meaning to the patient's ways of dealing with them, but be will not undertake to deal with them himself at the physical level. Thus, a therapist may focus a patient's attention on his reluctance to seek medical help for sus- pected or obvious physical disease, but he will not attempt to diagnoSe or treat the physical disease himself. These statements are just as true in cases involving the so-called "phychosomatic" diseases as they are in such cases as that of the patient who breaks his leg in a skiing accident in the course of psychotherapy. The psychiatrist does not prescribe a diet for-or perform a gastric resection on -the patient with a peptic ulcer, nor does he set the fracture of his skiing patient. In summary, the mental health professional assumes responsibility for the mental health task; the extent to, which this task is "medical"-and hence requires a medical education-is the basic question to which this paper is addressed. To pursue this question at a very practical level, I decided to list all the courses' of my own premedical and medical education for the purpose of assess- ing their relevance to' my own functioning as a psychotherapist. I knew that I would find more in the "irrelevant" column than in the "relevant" column, but I was somewhat surprised at the enormous' imbalance. Being as realistic and honest as possible, I had to conclude that virtually all of my internship PAGENO="0048" 44 and medical school experience, with the single exception of the specifically psychiatric courses and clerkships, was irrelevant. The required premedical courses in biology, chemistry, physics, and mathematics were also, of course, grossly irrelevant. Courses in English composition and literature fared some- what better, the former as* training in the organization and presentation of thought and the latter as an exposure to some of the vagaries of human behavior. Two elective college courses in philosophy and ethics seemed to have more di- rect relevance to the kinds of problems with which I deal than did all the endless hours of chemistry, zoology, pathology, surgery, and the like. (I do not, of course, mean to imply that all of these "irrelevant" courses were totally worthless in terms of general educational background; I am concerned here only with the question of more or less direct relevance to a particular profes- sional task.) What, then, did prepare me to be a psychotherapist? Very simply, residency training in therapy, reading, and experience (including experience as a patient, both in analysis and in analytically oriented psychotherapy). For none of these was my medical background necessary or even significantly helpful. Figure 1 is an attempt to present the interrelationships among the various elements in my professional background. The other argument in favor of medical training for the psychotherapist is the argument from attitude and charisma. It is sometimes held that "only the doctor" (i.e.. the physician) can assume the proper therapeutic attitude toward the patient and command the supposedly necessary degree of reverence from him (Zilboorg, 1943). The patently institutional assertion that physicians have a monopoly on therapeutic attitudes is one w-hich seems too manifestly false to warrant detailed refutation. Anyone who has open-mindedly worked with phy- sicians and with nonmedical psychotherapists knows that attitudes toward patients and modes of relating to them vary with the personalities and theoretical orientations of the professionals and cannot be related to academic background in any direct way. Further, it has been repeatedly and clearly pointed out that the nature of the relationship between psychotherapist and patient is distinctly different from that between physician and patient (Sobel, 1964; Wheelis. 1958). Specifically, ik is worth noting that physicians habitually speak of "taking care of" their patients; the psychotherapist is frequently actively concerned with getting the patient to "take care of" himself and speaks of "seeing" or "working with" a patient. Thus one might well question the desirability of a traditional "medical attitude" in dealing with the psychotherapy patient. One particularly subtle way in which psychiatric writers sometimes imply that nonmedical therapists are "inferior" is exemplified by the familiar state- ment that the threat of suicide represents a inectical emergency; one w-riter (Lesse, 1965) has compared it directly with threatened coronary occlusion. The hidden implication in this statement is that conditions or situations which are "serious" are ipso lacto "medical" and that only physicians "can" or "should" deal with them. That the threat of suicide is a serious problem very few would deny, but conditions which are serious are not necessarily medical; the threat of suicide might more appropriately be termed a "humanistic emergency." a "psychological emergency," perhaps even an "existential emergency." There is no logical reason for placing a problem in the domain of medicine simply because of its importance or seriousness; the substantive content of the problem should be the determining factor. Similarly, there is no reason to assume that the ability t~ behave in a responsible manner, both in a general human sense and within the framework of a professional role, is inextricably linked with medical experience. It may be granted that for some patients the charisma of the physician is an important determinant of attitudes and behavior (Frank, 1961). For rea- sons of status, because of misinformation regarding professional functioning, or for manipulative reasons, certain patients insist on having medical therapists. This sort of behavior on the part of a patient, however, is clearly irrational; and for psychiatrists to capitalize on it as a justification for asserting a them. peutic monopoly is strangely ironic. They frequentiy do, however; and non~ medical therapists often fall into the trap, defining themselves into a state of "inferiority"-and hence of lessened therapeutic efficacy-as a result of ex- posure to the medical "party line." * It seems clear, then. that whatever advantage accrues to the psychiatrist functioning as a psychotherapist stems not from his medical knowledge but from irrational attitudes on the part of his patients, his colleagues, and him- self (or, of course, from nonmedical training experiences). PAGENO="0049" PU0FE5SIONAL EDUCATION 275 ID -~1 HIGH SCHOOL COLLEGE 1U~ICAL SCHOOL INTERNSHIP RESIDENCY PRACTICE SOTANEEMBRYOL. I III~T" AND SELF-EDUCATION BIOtOGY< ZOOLOGY~CONPAR ANATOMY~PATHOLOGY 0~ ~ ~EUHOANAT~EUROPATH °~ SURGERY HISTOLOGY~ ~CLINICAL PEDIATRICS. CHEMISTRY INORG ORGANIC- ~BIOCHE~~~ PATH.~ OB-GYN - CHEM.~ CHEM. ~. \V~ACTERIOL QUANTIT. I A PARASITOL.~ UROLOGY - PHYSIOL .-~ PHARMACOL. ENT, EYE PHYSICS- PHYdICS ETC. - ANAL. 4' ~/ `I,~ \~NEUROLOGY ALGEBRA-~ ~ GEONETRY~ ~GEOM. STATISTICS--.....~ PUBLIC HEALTH TRIGONOM. INPATIENT INPATIENT PSYCHOL.* PSYCNIATflY~PSYCHIATRY~PS~IATRY- PSYCHIATRY ~PSYqH.~ ~ PSYCH. INTHODUC. E.S.T. AND - >DRUGS EXPERIENCE ENGLISH ENGLISH r--i LATIN GERMAN OUTPATIENT o PSYCH; - ~ `., I -~ SSj FRENCH PHILOSOPHY~ *1 HISTORY ETHICS I EXPERIENCE o.eas I ~e ______ 0 fl ~ERSONAL 4~j `~` I ARROWS INDICATE CONNECTIONS BETWEEN COURSES THERAPY L_J * A COURSE WHICH COULD HAVE LED TO MORE MEANINGFUL MATERIAL RUT DID NOT Fio. 1. Diagrammatic representation of the author's professional education. PAGENO="0050" 46 We may now ask whether the availability of physical techniques as ad- juncts or alternatives to purely psychotherapeutic methods constitutes a signifi- cant advantage for the psychiatrist in contrast to other therapists. There are. as noted above, three such techniques to be considered, one diagnostic and two therapeutic. The diagnostic techniques is, of course, the physical examination. The most obvious fact relevant to this technique is that the psyche-the object of study of psychiatry and psyclology-is not a physical object and hence can- not be examined physically; its disorders cannot be diagnosed by physical meth- ods. It is hardly surprising, therefore, that most psychiatrists do not perform physical examinations except on hospitalized patients, and then frequently only as a matter of routine compliance with hospital rules. I am sure that I am by no means atypical in reporting that I have not done a single physical examina- tion in 8 years of private office practice and 4 years of clinic practice. I am sure also that I am not typical in stating that I would not trust my own ability as a physical diagnositican in any but the most obvious situations. In the kinds of cases in which the interpretation of physical findings is diagnostically impor- tant-cases involving cardiac symptoms, suspected hyperthyroidism, questionable neurological manifestations, and the like-sound practice demands the sort of reliable and expert opinion which can be provided by the internist or the neurol- ogist. not the opinion of one whose expertise lies in quite a different field. For really serious purposes, then, the physical examination is not a functioning part of the average psychiatrist's armamentarium. To maintain sufficient expertise in physical diagnostic observation to offer definitive judgments in cases such as those mentioned above, the psychiatrist would have to continue to perform numer- ous physical examinations; such use of psychiatric time would appear mani- festly unw-arranted in view of the availability of specialists in the appropriate medical fields. It is a fascinating irony that many psychiatrists who hold the view that physical medicine is an appropriate basis for mental health practice and who would object strenuously to any questioning of the relevance of physical exam- ination techniques to that practice make no secret of their ignorance of the only psych odiagnostic tools we have other than the interview (or pure observation)- i.e.. psychological tests. Whatever may be their usefulness, they constitute the only method we have which even roughly approaches the diagnostic tests of physical medicine; it would seem only reasonable, therefore, for all workers in the field to be at least somewhat conversant with them. The prescribing of drugs has become a far more important part of psychiatric practice since the advent of the "psychotropic" drugs; and while there are some psychiatrists who avoid all use of drugs, there can be no doubt that for many, the ataractics, antidrepressants, sedatives, and stimulants constitute a useful set of pharmacological tools (Bahn. Conwell. & Hurley, 1965). Even those psy- chiatrists who use these drugs infrequently would presumably agree that they do contribute significantly in the task of helping certain emotionally disturbed people, particularly the psychotic and the severely depressed. The actual administering of drugs by psychiatrists is usually limited to hospital situations. There are a few psychiatrists who occasionally use intra- venous pentothal for office interviews, but this practice is apparently extremely rare, and most psychiatrists' offices are not equipped for this sort of medical procedure-a fact which in itself indicates that most psychiatrists do not re- gard it as a significantly helpful technique. It is safe to say that the over- whelming majority of drugs employed by psychiatrists are prescribed, not di- rectly administered by the psychiatrist himself. The use of electroshock has, of course, decreased markedly since the beginning of the "drug era." There remains, however, a group of patients for u-horn it is unquestionably extremely useful, if not irreplaceable; these are the patients with severe endogenous depressions who do not respond to antidepressant drugs and with whom psychotherapy is a practical impossibility. It is of crucial im- portance to note, however, that many, if not most, psychiatrists do not actually give electroshock therapy themselves. It is, for this large group a specialized procedure for which they refer patients to practitioners who employ it frequently and who are thoroughly familiar with its use and with the complications which may ensue. These practitioners are equipped, either in hospitals or-less often- in their offices, with the apparatus and additional staff needed to administer the treatment; they are also covered with the substantially larger amounts of in- surance required. Since the number of patients for whom electroshock is defi- mtely "indicated" baa alirunk ao drastically with the advent of the psychotropic PAGENO="0051" 47 drugs, this specialization appears inevitable and appropriate. The relevant con- clusion in terms of the larger question being considered here is that awareness of indications for electroshock and its availability are importa;nt for most psy- chiatrists while the actual giving of the treatment is frequently left to those who make a specialty of it. Of the three distinctly medical techniques under discussion, then, only one- the prescribing of drugs-is commonly employed by large numbers of psychia- trists. It is important to note that the list of drugs used by psychiatrists is a very short one in comparison to the entire pharmacopoeia, being limited, with most practitioners, to tranquilizers, antidepressants, sedatives, and energizers, The implications of this observation w-ill be developed further later in the dis- cussion; a question may be posed at once, however, as to whether it may be realistically claimed that 4 years of medical education is an operationally necessary prerequisite for the prescribing of four very limited classes of drugs. There are, as noted earlier, certain administrative behaviors which are al- most invariably performed by psychiatrists and hence could serve to identify the subject in our imagined experiment; such behaviors would include hospitali- zing patients, giving and withholding privileges on psychiatric wards in hos- pitals, signing commitment papers, testifying as to legal sanity, and the like. When the suggestion is made that such activities could just as effectively be car- ried out by-for example-clinical psychologists, the outrage of the psychiatrist frequently finds expression in some such question as: "Would you want anyone but a doctor to make decisions like these ?" it is asserted that only the physician can "take the responsibility.' This sort of assertion indicates not only "status paine" but also a complete confusion of operational and institutional considera- tions. When the psychologist states that he "cannot"-for example-sign com- niitmnent papers, he is saying simply that institutional regulations do not permit him to sign them; he is not saying that he lacks the knowledge or judgment to do so. If one is careful to avoid the institutional trap, it appears dbvious that medi- cal training is not in any way operationally necessary for the performance of the administrative behaviors being considered here. What is necessary is the observa- tional skill and judgment which comes only from experience with disturbed people-experience which is common to psychiatrists and other mental health Professionals but not, frequently, to general physicians, who, because of the in- stitutional rules, "can" make various: administrative decisions about people who come under this scrutiny (e.g., sign commitment papers). One type of professional behavior which is sometimes mentioned as inherently "medical" is the applying of diagnostic labels. Here again one encounters confu- sion between institutional rules and operational realities. As an example, in Florence Hollis's recent book entitled Caseworh: A Psychosocial Therapy (1964)-which is, as one reviewer pointed out, a treatise on psychotherapy as practiced by caseworkers-the author makes this statement (p. 195) : "An opinion about the nature of a mental disturbance becomes a medical diagnosis only when it is expressed by a physician." If a social worker labels a client "schizophrenic," this is "a casework diagnosis . . . designed for casework treat- mnent." Presumably, then, a similar diagnosis made by a psychologist would be a "psychological diagnosis' `-something different from a "casework diagnosis" and different also from a "psychiatric diagnosis." In reality, all three professionals are saying the same thing, performing the same professional act, when they state that a patient (or "client") is schizophrenic, provided only that they agree on the meaning of tIme term. If disagreements arise among professionals of differ- emit disciplines about matters of diagnosis, they are true disagreements, not artifacts resulting from differences in professional origin. I have defined the "mental health" field as "that area of human endeavor devoted to helping persons with emotional or psychological problems"; it is, to be somewhat more expansive, the field of man's anxieties, depressions, irrational doubts and fears, irresponsibilities, disturbed social relations, maladaptive behavior, disturbed thinking-the field of the psychic problems of man as man, a social, symbolizing being, not man as a biological machine, It is altogether appropriate to ask, from an operational viewpoint unhampered by any prexisting institutional rules, what we need to know about man in order to help him with these kinds of problems (and-if need be-to make decisions about him when lie becomes socially incompetent in the course of trying to deal with them). This sort of question may be approached from a theoretical base or from the practical, purely operational surface, with subsequent inquiry into the relevant underpinnings of operational knowledge. From a theoretical point of view, to an PAGENO="0052" 48 observer unhampered by institutional concerns, it would seem apparent that a knowledge of human behavior, thought, and emotion would be the logical and necessary foundation on which a professional practice dealing with disturbance of behavior, thought, and emotion would have to rest. Thus psychology-or, more generally, "behavioral science"-would seem, unquestionably, to be the basic academic discipline of choice. (That this should be considered a heretical state- ment when made by a psychiatrist is evidence of the almost incredible irration- ality of the medical profession in this area; "a psychological background for dealing with psychological problems" would seem as obvious a choice as "a biological background for dealing with biological problems.") The relevance of personality theory, learning theory, communication theory, and the study of group interactions seems too obvious to need emphasis. Also relevant to the professional task would be some knowledge of sociology, to provide a broader perspective and to place the individual and the family in a social framework, and some knowledge of human biology, of the body in and through which man per- ceives his environment and expresses himself. A broad humanistic education and education in scientific method should be included to guard against what the French so aptly term deformation profession cue. To approach the question from the other direction, the earlier discussion of the operational surface of the mental health professions may here be briefly recapitulated: The work of the mental health professional consists mainly of formulating, within some psychological theoretical framework and in psycho- logical (or sociopsychological) terms, the problems presented to him by those who seek (or are brought into) his professional influence, and attempting to ameliorate these problems. The methods used in the formulating (or "diag- nostic") aspect of the professional task are interviews of various sorts and, sometimes, psychological testing. The methods used in the therapeutic aspect of the taks are-again-interviews of various sorts (individual, family, group. etc.). environmental structuring (e.g., hospitalization), the prescribing of a limited number of "psychoactive" drugs, and (in a decreasing number of cases) electro- shock therapy or referral for such therapy. What are we to make of the fact-and I take it to be a fact-that good "diag- nosticians" and therapists come from backgrounds which include nothing in common beyond training and experience in formulating and working with human problems by means of interviews? What are we to make of the dis- comforting fact that Margaret Rioch can train intelligent housewives to perform quite competently as therapists without the benefit of specific backgrounds in any of the usual "disciplines" (Pines, 1962)? What of the fact that psychiatrists w-ith no training whatever in psychology other than psychoanalytic theory can be excellent therapists? The clear implication of these facts is that psychotherapy is still largely without true scientific underpinnings-is still, to use a cliché, as much art as science (perhaps, alas, more art than science). Just as surely as this is the case today, however, the academic field to w-hich we must look for elucidation of what we are already doing in diagnostic and therapeutic interviewing-and for scientific instruction in how w-e might do better-is psychology-whether it be the study of the intrapersonal psyche, the study of interpersonal behavior, or the study of the effects of hospital ward environments. If the practice in which we spend most of our time-namely, the psychological aspect of mental health work-has any scientific validity what- ever, then our common basic discipline is psychology. If the important "answers" are really to be found in some other area-for example, neurophysiology or biochemistry-then we have been wrong all along-just as wrong as one would be in trying to treat a uremic delirium by psychotherapy. If, for example, cer- tain cases of what we call "schizophrenia" were found to be caused by a chemical deficiency, those cases would at that point pass out of the realm of the mental health professional and into the realm of organic medicine (like delirium tremens, general paresis, and psychoses associated with brain tumors). The particular manifestations and emotional reverberations of the chemical aberration might be investigated psychologically, but the basic problem would be a medical one. It may be objected that although the disturbances with w-hich we deal are "psychological," physical methods can be-and are being-found to take the place of that cumbersome and time-consuming activity known as psychotherapy. In this view, pragmatic therapeutic "answers" may come from such fields as bio- chemistry and neurophysiology even if the theory explaining the disturbances remains psychological. To the extent to which this view proves valid, the mental PAGENO="0053" 49 health field as an area of phychological therapeutic effort will cease to exist. If it were learned, for example, that anxiety could be effectively and easily dealt with by inserting a needle into a specific area of the thalamus, then the relevant training would be that of the neurosurgeon. (We may leave aside the Orwellian questions raised by such an idea.) This sort of therapeutic activity could be labeled "psychiatry" only by a change in the meaning of the term. It is con- ceivable that a new medical specialty may evolve, based on neurosurgical, neuro- chemical, and neurophysiological methods; such a specialty, however, would be far removed from what we know today as "psychiatry," and the specialty train- ing which today's psychiatrists receive would be almost as irrelevant to its practice as medical education is to most of the activities of today's psychiatrists. Among the pragmatic physical therapeutic modalities now in use, the "psy- choactive" drugs, as indicated earlier, are by far the most widely used. For the practicing psychiatrist, the use of these drugs is an empirical activity based on knowledge of their psychic effects and not on knowledge of their chemistry or their loci of operation within the nervous system. Put in bald, practical terms, this means that the psychiatrist knows that 4 milligrams of a chemical known as Stelazine, for example, may-if taken two or three times a day- modify psychotic behavior in certain presumably desirable ways. He does not know-nor does he need to know-the chemistry of this drug; he does need to know what may happen if too much of It is ingested, what side effects it may produce, and that people with damaged livers should not take it. I would venture to say-again heretically-that all the factual material relevant for the effective and practical use of the psychoactive drugs `could be learned in 2 weeks by the average intelligent student in the mental health field. Anyone who is inclined to dismiss this statement as absurd might well reflect on the fact that many practicing psychiatrists went through their entire training before the tranquilizers and antidepressants had even `been heard of. These psy- chiatrists spent `their weeks and months in pharmacology courses learning facts nbout drugs which, except for the sedatives and a small number of amphetamine prepara'tions, they have never used and never will use in their work as psychia- trists. Phus, their knowledge of-and experience with-the newer drugs stems entirely from their own informal self-educative activities, while their formal `training in pharmacology was largely devoted to material having no relevance to their later practice. It is not implied here that formal training in pharma- cology is unnecessary, but simply `that a `brief, concentrated `course in what has been termed "psychopharmacology" w-ould be far `more to the point `than months spent in learning the intricacies of various digitalis preparations, antibiotics, and dozens of other drugs which are of vital importance to the work of the physician dealing with physical illnesses `but of no importance to the work of the mental health specialist. Operationally, one certainly does not `have to be able to prescribe all drugs in order `to prescribe some drugs; institutional rules have already encompassed this fact in regulating the prescribing done by p0- diatrists, for example. The important questions confronting `any professional field serve as good indicators of the underpinnings of knowledge relevant to the field. In the mental health field, `there are such questions as these: 1. Is anxiety generated and maintained in a purely reflex fashion (as the behavior `therapist would say), as a result of cognitive processes (as .the rational- emotive therapist would say), or as a result of conflict between instinctual drives and intrapsychic repressive forces (as the psychoanalyst would say), or `by different mechanisms in different situations? 2. To what extent is behavior unalterably de'termined by infantile and early childhood experiences? How "free.' in the existential sense, is man? 3. How much of what we observe in human behavior is attributable to intra- psychic forces and how much `to interpersonal influences? What is the interre- lationship `between the intrapsychic and the interpersonal? 4. What really happens in `the various forms of psychotherapy? 5. What is the role of values in the practice of psychotherapy? The questions raised by the coexistence of such diverse practitioners as existential-experiential `therapists on the one hand and behavior therapists on the other lead swiftly `to questions about the very nature of man. Signifi- cantly. however, `these-like the questions listed above-are all questions for `the psychologist or `the philosopher, not for the anatomist or the physiologist. Even the most reductionistic of `the therapeutic approaches, behavior therapy, comes straight from `the laboratory of the experimental psychologist. Of the PAGENO="0054" 50 really important questions confronting the mental health field today, only three are not basically questions in psychology. sociology, or ethics: 1. Are there biochemical and/or genetic abnormalities which play a causative role in schizophrenia? 2. Are endogenous depressions really manifestations of physiological malfunction? 3. To what extent does "subclinical" cerebral dysfunction play a part in childhood behavior disorders? The investigation of these questions is properly in the hands of the biochemists. the geneticists, and other researchers; it is beyond the professional scope of' the psychiatrist as we usually know him, despite his medical training. And. to repeat. if these conditions should be found to be. let us say, "metabolic diseases." they would cease to be primarily `mental health problems" in the same way that "psychosomatic headaches" cease to be a "mental health prob- lem' when they are discovered to be caused by a brain tumor. The mental health professional, then, is really working in the field of applied psychology in the best sense of that much-misused term-psychology applied to the task of alleviating psychological suffering-with some excursions into the realm of applied psychopharmacology. This is his true operational field no matter what is professional background has been. That jurisdiction over this field should `be claimed by a profession whose basic education usually includes not a single course in psychology is, when viewed dispassionately, little short of fantastic. My purpose in this paper is not to propose the details of a curriculum for future mental health professionals, but rather to evaluate the present education of the most influential of these professionals-the psychiatrists-and to suggest a direction for change. Such change must be in a psychological direction if our education is to make sense in terms of the realities of our professional w-ork. When is some enterprising university going to formulate a curriculum for a School of Mental Health, based on the existing curriculum in clinical psychology and including appropriate additions from other fields (medicine, sociology, social work). and produce graduates whose w-ork can then he compared with that of their more traditionally trained colleagues? It is a dream w-orth considering. REFERENCES BAHN, A. K.. C0NwERL. 54.. & HURLEY. P. Survey of private psychiatric practice. Arc/i ives of General Psychiatry. 1905. 12. 295-302. COLBY, K. 54. A pi'uner for psychotherapists. New- York: Ronald Press. 1951. ErssrEn, K. R. Medical orthodoay and the future of psychoanalysis. New York: International Universities Press. 1965. FRANK. J. D. Persuasion and healing. Baltimore: Johns Hopkins Press, 1961. FREUD. S. The question. of lay analysis. (1926) London: Imago. 1947. (1st English ed.) GARDINER, 54. A note on accreditation. Bulletin of the Philadelphia Association for Psychoanalysis. 1960, 10, 56-5S. GARDIXER. 54. The seven years of dearth. Bulletin, of the Philadelphia Association for Psych oa.nalysis, 1962, 12. 168-170. GRIXKER. R. R., SR.. et al. Psychiatric social work: A transactional case book. New- York: Basic Books. 1961. HOLLIS, F. Casework: A psychosocial therapy. New York: Random House. 1964. JO5SELYX. I. 54. The caseworker as therapist. Journal of Social Casework. 1948. 29, 351-355. KAPLAN. A. H. Social w-ork therapy and psychiatric psychotherapy. Arch fees of General Psychiatry. 1963. 9. 497-503. KL-BIE. L. S. The pros and cons of a new profession: A doctorate in medical psychology. Teceas Reports on Biology and Medicine. 1954. 12. 692-737. KUBTE, L. `S. Need for a new subdiscipline in the medical profession. Arch ices of Xenrology and Psychiatry. 1957. 78. 2S3-293. KITBIE. L. S. A school of psychological medicine within the framew-ork of a medical school and university. Journal of Medical Education. 1964. 39. 476-480. LESSE. S. The psychotherapist and apparent remissions in depressed suicidal patients. American Journal of Psychotherapy. 1965. `19. 436-444. PINES, 54. Training housew-ives as psychotherapists. Harper's Magazine. 1962. 224, 37-42. PAGENO="0055" 51 `SCHOFIELD, MT. Psychotherapy: The purchase of friendship. Englewood Cliffs, Prentice-Hall, 1964. SOBEL, R. Role conflict or resistance. American Journal of Psychotherapy, 1964, 18, 25-34. STRUPP, H. H. Psychotherapists in action. New York: Grune & Stratton, 1960. SZASZ, T. IS. Psychiatry, psychotherapy, and psychology. Archives of General Psychiatry, 1959, 1, 45'5-4fi3. `SzAsz, T. S. The myth of mental illness. New York: Hoeber-Harper, 1961. WARME, G. E. Consulting with aide-therapists. Archives of General Psychiatry, 1965, 13, 432-438. WHEELIS, A. The quest for identity. New York: Norton, 1958. ZILBOORG, G. Mind, medicine, man. New York: Harcourt. Brace. 1943. Mr. SIsK. We will also make your statement a part of the record at this point. (The prepared statement submitted by Dr. Brayfield reads in full as follows:) STATEMENT BY DR. ARTHUR H. BRAYFIELD, EXECUTIVE OFFICER, AMERICAN PSYCHOLOGICAL ASSOCIATION Mr. Chairman, my name is Arthur H. Brayfleld. I serve as Executive Officer of the American Psychological Association, which has its headquarters here in Washington at 1200 Seventeenth Street, NW. The Association, with over 27,000 members, includes most of the qualified psychologists in the country. Affiliated with the Association are psychological associations in the District of Columbia, the Commonwealth of Puerto Rico, the Province of Ontario, and in all States except Alaska. Under our Bylaws, the territories and commonwealths of the United States, as well as the Provinces of Canada, are considered to be the equivalent of States. In this statement, prepared at the invitation of this Subcommittee, the Ameri- can Psychological Association wishes strongly to support the aims and content of House Bill 10407. We gave similar support to its companion bill, Senate Bill 1864, in hearings before the Senate District Committee's Subcommittee on Public Health, Education, Welfare and Safety, on August 28, 1967. The amendments made to Senate Bill 1864 are entirely in accord with the Association's national policies with respect to regulatory legislation for psychologists. As you know, Senate Bill 1864 was passed unanimously by the Senate. In 1955, the Association adopted a series of policy guidelines for state associa- tions to use should they wish to develop legislation `defining and regulating the practice of psychology. An up-dated policy statement, based upon experience with the laws in the intervening years, was adopted by our Council of Representatives in September 1967. Let me summarize, if I may, what our policy statement suggests as basic provisions to be covered in a law regulating the practice of psychology. First, the qualifications of the `psychologist should be set at a realistic level, high enough to assure competence, but not so high as to limit severely the number of eligible psychologists available. Our recommendation is the doctoral degree in psychology and two years of supervised experience. Second, the law should not restrict qualified members of other professional groups from doing work of a psychological nature consistent with their training and codes of ethics, nor should it place undue restrictions on the work of psychologists' in institutional settings. Third, a code of ethics should be a part of the law or of its regulations. Fourth, adequate provision should be made for the licensing of psychologists already certified or licensed in other jurisdictions with standards no lower; this is fre- quently called reciprocal endorsement. Fifth, a provision should be included to protect the privileged nature of the psychologist-client relationship. House Bill 10407 meets all these criteria. There are now laws in 37 States and six Canadian Provinces. The newest law- is a licensing act approved in the State of South Carolina in March of this year. It is our earnest hope that Congress will act favorably on the bill before it. thereby giving public protection for the citizens of the District, and, in addition. providing a model for those states still without proper controls. The public has a right to expect help in locating competent psychologist services whenever they are needed; a legal definition of who may offer such services is a major contribu- tion in providing necessary safeguards. PAGENO="0056" 52 Finally, I should like to comment concerning questions that have been raised about the proposed legislatioll by the local associations of psychiatrists and psychoanalysts, questions concerned primarily with safeguards for the client requiring services outside the psychologist's area of competence. For the Com- mittee's information, and for the record, I should like to point out that the proposed legislation contains a specific provision (Section 4) on this matter, and that it is in accord with the official policy adopted by the American Psychiat- ric Association in 1964, a policy agreeing with similar action by the American Medical Association in 1960. Further, Secton 4 is consistent with recommenda- tions made jointly by what we call the "relations" committees of the two national associations-the American Psychological Association and the American Psychiatric Association. Thank you for the opportunity to appear before you today. Mr. SIsK. if you want to comment on something in the article, you go right ahead, but we will make the entire contents a part of the record. Dr. BRA1'rEi~1~. I think that I also would like to comment on some comments that you made., Mr. Chairman, with reference t.o the state of California.. I share with you a former residence in that state. I am familiar with many of the legislative practices. including the practice that the state of California. has had which we. in the national office, consider as one of the strongest and most helpful pieces of legislation governing the practice of psychology as it exists in the state of California. I wish also to comment, as one of the early witnesses did, that the Attorney General of the St.ate of California ha.s ruled recently with respect to the pract.ice of psychotherapy in which he has ruled that it is not a medical pra.ctice nor limited to medical practitioners. I would also like to comment as being relevant t.o earlier question- ing that psychologists for perhaps the last 20 years have in many instances carried malpractice insurance, as do many other professions. I would point out for the record that in the history of the coverage of clinical psychologists by malpractice insurance there has never been a court awa.rd under the terms of malpractice insurance. I think this is an interesting bit of evidence, as the way in which psycholo- gists have conducted their practices. I do want to comment., but only very briefly, on the question of mental disease and mental illness. I will call to your attention that the most recent and leading text in psychiatry, authored by the Dean of the Medical School at Harvard University and by the Chairman of the Department of Psychiat.ry at Chicago, does not use the concept "mental disease," does not use the concept "mental illness," but use entirely in the 800 or 900 pages "misbehavior disorder." I think this is evidence of the shifting nature of the conceptualization of what is included in this field. I believe it is relevant to the earlier lineup questioning. Thank you very much for the opportunity to appear here.. STANDARDS Mr. SIsK. Thank you, Dr. Bra.yfield. You have heard the questions asked by my colleague from North Carolina, Mr. Whitener, with reference to Section 4. In view of the comments contained in your prepared statement, would you objec.t to a rewriting of that section which spelled out that these things shall be a responsibility and shall be carried out., rather than it is now almost PAGENO="0057" 53 in the form as he indicated of a lecture or a suggestion, because, after all, we are dealing in law. That is what we have to do. Otherwise, there would be no real point in doing it. I would like to know whether you have any comments on the suggestions from the gentleman from North Carolina. Dr. BRAYFIELD. My experience with the Congress and with the states is such that we have considerable confidence in the legislative skill with which they write provisions. We would be guided by `that. In our own ethic codes-this goes to this same point-~ve use what may be considered stronger language-"shalL" I think that is in accordance with that. Mr. SIsK. Thank you. I might say, Dr. Brayfield, you mentioned California. I was in- terested in some comparison of the California law with the proposed programs for `the District of Columbia. I have a letter `of re~cent date, May 10, 1968, from Dr. Edward Rubin, President-Elect of the Central California Psychiatric Society, on the subject, and specifically re- ferring to this bill, in which he indicates that he is pleased `that an effort is being made to protect the public as to professional help in this bill-it seems `to indicate that there is a substantial support for a licensing bill which would improve the situation, and it winds up with five specifics which I am going to very briefly read to you for your comment as to whether or not you would agree or disagree. "Thus, the legislation should: "(1) Protect the public from unethical, inadequately trained practitioners. "(2) Define the scope of `services which can be rendered l)y psy- chologists, consistent with the training and ethics defined. "(3) Recognize that psychotherapy may be used appropriately by other professions (i.e.-p'hysicians) than psychology. "(4) Assure tha't the ethics and confidential relationship impera- tive in providing psychotherapy are adhered to and guarded when- ever any qualified person provides psychotherapy. "(5) Require that a non-medical psychotherapist avail himself of medical consultation and direction whenever the assessment of the person in distress suggests serious mental or emotional illness." You may or may not agree wi'th all five of those, as being the guide- lines along wh'ich we thought we should work. Dr. BRAYFIELD. I did not quite catch who submitted that to you, but I would say that I could not tell whether it was written by a psychologist or a psychiatrist, because in the state of California they enjoy mutually good relationships. Mr. SiSK. That is my understanding. The two professions do co- operate very closely and have a very good relationship. This was a letter written by the President-Elect of the Central California Psychiatric Society. The gentleman from Indiana. Mr. JAOOBS. I just want to compliment the Doctor on his testimony. I appreciate very much your testimony and the testim'ony of the previous witnesses also. I think `that, generally, it has been very helpful. 1 think that the record should reflect, however, one clarifica- tion in referring to `the action taken by attorneys general in the various states. I think that the record should make clear that my under- PAGENO="0058" 54 standing is that these are opinions which do not have the force of law but are advisory in nature for the conduct of public affairs, on the part of public officials. I commend you, Doctor, for saying in no uncertain terms that such a. bill should have the force of law, rather than be advisory. I want to thank you very much for your testimony. Dr. BRATFIELD. Thank you very much. Mr. SIsK. Mr. Gude? Mr. G-vDE. Thank you for a very fine statement, doctor. Dr. BRATFIELD. Thank you very much. Mr. SIsK. Mr. Walker? Mr. WALKER. No quest.ions. Mr. SIsK. Before you leave the witness stand, Dr. Bra.yfield, I would like to ask, if it could be done without substantial inconvenience, that you furnish to me-and I am not going to, a.t this time, request that it be made a part of t.he record, but that you furnish to the Clerk of our Committee for our consideration, copies of some of these principal acts that are now in effect in some of the states, particularly the one in Cali- fornia.. I believe there are 37 states that have laws regulating the prac- tice of psychology. Dr. BRATFIELD. That is correct. Mr. SIsK. Could you furnish, without undue difficulty, some com- pilation of these to the Committee and make it available to the clerk of the Committee, Mr. Clark, and, then, in the future, it might be possible that we will put. same into the rec.orcl. Could that be clone? Dr. BRATFIELD. We will pleased t.o do that, a.nd we will supplement it with our most recent statement of guidelines on that legislation. Mr. SIsK. I would appreciate that. I think it. would be very helpful to the Committee. (Subsequently, excerpts from the laws of the various States were furnished for the Committee files. A. model for State legislation, also submitted, is reprinted herewith:) A MODEL FOR STATE LEGISLATION AFFECTING THE PRACTICE OF PSYCHOLOGY 1967 REPORT OF APA COMMITTEE ON LEGISLATION {Reprinted from AMERICAN PSYCHOLOGIST, Vol. 22, No. 12, December, 1967] The Committee on Legislation, in the following report, attempts to bring to- gether viable existing policies, beginning with the basic ones adopted in 1955,1 to look historically at the legislative experience of the intervening 12 years, and to propose new policies in the light of that history. The Committee has been par- ticularly interested in reviewing and reexamining policies because of the increas- ingly important professional role of the psychologist and the implications of that role for psychology as a whole. The newer policies recommended here reflect primarily current concerns of the research-oriented psychologist. Of particular relevance are Recommendations S. 9, 15, and 19. `Adopted as official APA policy by the Council of Representatives at its September 1967 meeting in washington. D.C. Developed over a period of 3 years, the report is the work of the following members of the Committee on Legislation 1965-67; Harold A. Edgerton (Chairman, 1967), Thomas Gordon. Harry I. Kalish. Harry Levinson (Chair- `nan. 1966), Thomas Magoon, Elton B. McNeil, Melvin P. Reid, L. Joseph `Stone, and Elizabeth B. wolf (Chairman. 1965). The numerical data are based on figures available as of July 1. 1967. Entitled "a model" by action of the Council. the intent of the report is to provide policy guidelines for those provisions in psychology laws covering areas where national consensus is to be desired. 2 Joint Report of the APA and CSPA (Conference of State Psychological Associations) Committee on Legislation. November 1955 issue of the American Psychologist. PAGENO="0059" 55 In these 12 years, 32 more laws have been added to the 9 in existence when the 1955 report was adopted.3 No laws have been repealed. Our attempts to measure the impact of legislation on the states which have obtained it indicate general satisfaction. Antagonism from other professions, notably medicine and specifically psychiatry, seems actually to have decreased as the diversity of applications of psychology as a behavioral science has con- tinued to develop. A decade ago most of the psychological services rendered to the public were in the specialty of clinical psychology; now there are increasing demands for other skills, such as experimental approaches to the design of equip- ment, survey methods, selection and training methods, systems research, inotiva- tional research, programmed instruction, etc. It has also become increasingly evident that while legislation has developed as the preferred means of protection for the public, as well as for the science and profession of psychology, we have not always been able to present a united front in our legislative efforts. There have been those who have resented, if not actively resisted, the idea of statutory control of their activities. Each state undertaking legislative effort has had to wrestle with the problem of whether legislation should be written to cover all psychologists, or only those engaged in the applica- tion of psychological science, as opposed to teaching land/or research. This prob- lem has been resolved in the individual case by the psychologists in a particular state, but since the problem arises again and again, we must face up to it and recognize that our solutions are in reality compromises. Prompted by an action of the New York State Department of Education in 1962, some of our members became aware of a possible threat to academic free- doimi, related to legislation. The Department requested that universities register their curricula with New York, so that their graduates wishing to apply for certification would be spared from course-by-course scrutiny to see if the training met the requirements of the New York Certification Act. It turned out that such registration is a common provision in New York for the various occupations and professions and was designed to facilitate the application process. It is not required. But the action served to point up our fears of external control and of loss of freedom, and we found ourselves reevaluating the implications of legisla- tion and facing a whole series of problems that conceivably might come up in reaction to legislation. Another development has been formalized in the Eastern Psychological Associa- tion's resolution in 1964 opposing state licensing or certification of research psychologists. This resolution was directed toward improving basic safeguards as they pertain to research freedom. Further, the ad hoc Committee on Scientific and Professional Aims of Psychology, in its deliberations on some of the issues involved in the increasing diversification of psychology, suggested in its Septem- her 1964 report that the Committee on Legislation attempt to formulate such policies as would not interfere with the free and diverse development of profes- sional practice or with the activities of psychologists whose primary concern is with teaching and research. The Committee on Legislation is in agreement with the ad hoc Committee in principle, but the solutions and implementations are not easily reached. As a result of 2 days' discussion at our December 1964 meeting, and 2 days' delibera- tion at our March 1965 meeting, including a discussion of proposed solutions at a morning session with Kenneth E. Clark and Bernard F. Riess of the ad hoc Committee, we undertook the formulation of a new policy statement, taking into account the various present and future developments within psychology. Subse- (luent meetings of the Committee, together wit.h comments arising from a con- sideration by divisions, state associations, and state examining boards of a draft version, have led to a consolidation of the views expressed in the present document. Our Committee is in basic agreement with the following statements in the September 1964 report of the SPAP Committee: "An appreciable advance in any part of psychology must surely deepen under- standing of the nature of man. It is the nature of man that is the subject of 3Alahama (63), Alaska (67). Alberta (60), Arizona (65), California (57), Colorado (61), Delaware (62), Florida (61), Hawaii (67), Idaho (63), Illinois (63), Kansas (67), Louisiana (64), Manitoba (66), Maryland (57), Michigan (59), Mississippi (66), Nebraska (67), Nevada (63), New Hampshire (57), New Jersey (66), New Mexico (63), New York (56), North Carolina (67), North Dakota (67), Oklahoma (65), Ontario (00), Oregon (63), Quebec (62), Saskatchewan (62), Utah (59), Wyoming (65). In 1955 there were laws in Arkansas (55), Connecticut (45), Georgia (51), Kentucky (48), Maine (53), Minnesota (51) Tennessee (53), Virginia (46), and Washington (55). PAGENO="0060" 56 psychology. In this wider sense, psychology is a unitary enterprise and the education and practice of psychologists, whatever their specialty, should reflect that unity. `Legislation exists as a means to protect the public and not as a procedure to strengthen any profession as such. However, we feel that our legislative policies should be carefully stated and implemented so as not to interfere with the free and diverse development of professional practice. or with the activities of psychologists whose primary concern is with teaching and research." Our Committee also strongly embraces the point of view that legislative problems can and should be worked out to permit both scientific and professional psychologists to perform their respective functions, yet remain unified within a single association, nationally and at the state level. Consequently. we felt it would be a serious setback if either of these groups of psychologists (assuming there are two different groups) splintered off from the present unitary association. We recognize that the APA Committee on Legislation has a limited function in its relationship to the states. We maintain a consultative role to the state associations which are affiliated with APA. We have served as a clearinghouse for legislative experiences in the various states. the kinds of problems which need to be provided for, and the most satisfactory methods for their resolution-or compromise. In our actions we have been governed by APA policies contained in the following published reports: "Psychology and Its Relations with the Other Professions," adopted by Council in 1953 and published by APA as a separate in 1954. Joint Report of the APA and CSPA Committees on Legislation. adopted by Council in 1955 and published in the American Psychologist, November 1955, Vol. 10, pages 727-756. Annual report of Committee on Relations with Psychiatry, adopted by council in 1958 and published in theAmerican Psychologist. December 1958, Vol. 13, pages 761-763. When consulted by those drafting legislation that would license or certify psychologists, we have offered recommendations that the proponents include provisions covering certain critical matters such as reciprocity with other states. privileged communication, consulting by psychologists temporarily visiting the state, lectures, special measures for psychologists trained in related disciplines such as sociology, and injunction authority. Our specific charge by the Council of Representatives is to "study the effect of current legislation on the scientific and professional activities of psychologists and formulate policies relative to proposed legislation to insure the wise use of psychology in the public interest. The Committee shall inform state associa- tions of what have been found to be workable provisions of existing laws, or unwise or restrictive proposals, and of minimum standards for new laws. It shall encourage mutual help among state associations in legislative and legal activities." During these 12 years the APA Legislative Committee has served as a consultative resource for states seeking legislation, reviewing with the states their projected laws in the light of official APA policy. It is not the function. nor has it ever been the practice, of this Committee to promote or initiate legislation. It is the Committee's function to collect and transmit to states that request it the experience of the respective states which have adopted legislation, and to make the states aware of any interprofessional agreements on a national level, such as that between the APA and the American Sociological Association. It is also the Committee's function to call to the attention of states seeking legislation projected prorisions in state laws which might set unfortunate prece- dents for psychology as a whole, or unduly restrict or subordinate the professional activities of psychologists, or of other legitimate professions. In defining the problems which may properly be resolved in legislation, it is important to remember the voluntary nature of each state association's affiliation, the sovereignty of each state, the different approaches to statutory control pre- ferred by the various legislatures. as well as the individual requirements of their existing codes. It has never been possible to prepare a "model bill." but the Committee has attempted to assist each state that has asked for help to find an optimal way of handling its unique problems within the legal framework and tradition of its legislature, and at the same time adhere to APA policies. It is recognized that no current law contains all of the provisions recommended here, and that the likelihood of large-scale amendments endeavor is small. Never- theless, it is reasonable to expect that state associations planning new legislation. or considering amendments, will find these recommendations helpful. PAGENO="0061" 57 RECOMMENDATION S In this section, the Committee makes a number of specific recommendations for adoption as APA policy. Some of them are reaffirmations of policies already adopted, in 1955, 1958, 1959, and 1963; others are new, representing suggestions made by the ad hoc Committee on Scientific and Professional Aims in Psy- chology, by state boards and associations, and policies growing out of dis- cussions within the Committee on Legislation. The goal is to get into one docu- ment, for the guidance of all, what is official APA policy with respect to state legislation in 1967. This present report, however, does not include the extended written discussion that led to the various 1955 recommendations that are re- affirmed here. The interested reader who compares the 1955 statement with the 1967 one will find differences in vocabulary and a less permissive tone to the 1967 recommendations. In 1955 there were only 9 laws; now there are 41, and more experience data are available. A. Type of Legislation The 1955 Joint Report of the APA and CSPA Committees on Legislation elab- orated on a variety of forms which regulatory laws might take. The primary distinction among the forms lay in the degree of restriction and control exercised over psychological work. The extreme degree of restriction would define a voca- tion solely in terms of its functions. As the 1955 statement indicated "anyone doing these things is ipso facto practicing psychology no matter what he calls himself and comes under the purview of the law." We are opposed to such re- strictions on the grounds that many psychological methods, practices and activi- ties are engaged in by large numbers of individuals and groups who are not psychologists. No current law is this restrictive. The descriptive terms used in the 1955 report for the various kinds of legisla- tion did not prove viable, and it is now the custom merely to speak of licensing and certification laws. A licensing law defines the practice of psychology and restricts the function to qualified persons, who may be psychologists, or who many be members of other professions using psychological techniques. A certifi- cation law, on the other hand, limits the use of the title "psychologist" to quali- fied persons; it may or may not have a definition of practice. Put more simply, a licensing law covers the practice of psychology no matter what the person calls himself, a certification law covers the practice of psychology only when the person wishes to call himself a psychologist. The actual words used in the laws do not necessarily indicate the nature of the law; several of the "licensing" laws are really certification laws, in that the use of the title is the controlled factor. The Committee regards the following three issues as critical ones: Preemption. Just as psychologists were concerned in past years about the possibility of other vocational legislation preempting their rights to certain practices, so now we should be exceedingly careful to ensure that our regulatory efforts do not have a preemptive effect upon other recognized professional groups, not identified as psychologists, but who use psychological techniques and methods in their work. This principal appeared originally as Principle 5.1 in "Psychology and Its Relation with Other Professions," adopted in September 1953: "The professional services rendered by psychologists vary greatly in their distinctiveness. Some are rarely carried out by nonpsychologists; others are shared with several other professional groups. Public welfare is advanced by the competent performance of socially useful services by a number of professions. Psychology believes it undesirable to attempt to control the practice of all psycho- logical functions by restricting them to members of any single profession encept insofar as it can be clearly demonstrated that 5UC/b restriction is necessary for the protection of the public. Psychology, therefore, does not favor narrowly restrictive legislation, which provides that only psychologists (or teachers, or physicians, etc.) may engage in certain applications of psychological knowledge and techniques." Innovation. The more restrictive are our regulatory laws, the more potential there is for the inhibition of innovative developments in psychological techniques and practices. Psychologists have a responsibility to ensure that provisions and interpretations of regulatory laws do net impede the evolution of psychological practices. Legal definition of vocations. In the use of exclusions of various vocations in the regulatory laws a predictable problem will emerge. While a number of voca- tions may come to mind as logical ones to exclude from psychology laws, in some states it may be impossible to cite vocations that are not legally defined in state PAGENO="0062" 58 law. It is incumbent upon psychologists to bend every effort to avoid any action which may have discriminatory effects as a function of the presence or absence of legal definition of recognized vocational groups within a state. Rules and regulations of the examining boards may be written to ensure what may be impossible in law. Because of the interprofessional climate at the time, and the assumed difficulty in writing a definition of the practice of psychology, the 1955 statement recom- mended that legislation take the form of certification, although the development of licensing legislation was encouraged. Now, how-ever, the interprofessional situation is no longer a factor, and the states have one after the other developed definitions that seem to be working. Of the state laws passed since 1955, 28 con- tain definitions of the practice of psychology. There does not seem to be any argument regarding which type of regulatory legislation is better for the public. Licensing provides greater protection for the public. It can control quackery if properly enforced whereas certification per se cannot. In a licensing law which provides for title and/or function, the nonlicensed cannot use the title and/or cannot perform the functions. The Committee on Legislation therefore recommends that APA policy w-ith respect to type of legislation be as follows: "1. States seeking legislation regulating the practice of psychology should attempt to develop laws falling in the caegory of licensing legislation." Integral to a licensing act is a definition of the practice of psychology. The Committee has hesitated in the past to recommend a specific definition, but now- that there are over 20 of them on the books, it seems reasonable to suggest one. There are several principles involved. First the use of the title should be covered as well as the function defined. Second, the definitions should be as broad as possible, in order to cover all activities of psychologists as psychologists; other provisions in the law take care of employment settings that may be exempted, or of persons in related fields whose activities may include some of a psychological nature. Third, there should be a definition of psychotherapy, if possible. The Committee feels, however, that the inclusion of such a definition, or even the use of the word `psychotherapy" (as opposed to "behavior modification," for example), should not be considered critical if there is support from the medical profession for all other aspects of the proposed legislation. With these principles in mind, the Committee recommends the following series of definitions: "2. A person represents himself to be a psychologist when he holds himself out to the public by any title or description of services incorporating the words "psychology," "psychological," "psychologist," and/or offers to render or renders services as defined below to individuals, groups, organizations, or the public for a fee, monetary or otherwise. "The practice of psychology within the meaning of this act is defined as ren- dering to individuals, groups. organizations. or the public any psychological service involving the application of principles, methods and procedures of understanding, predicting. and influencing behavior, such as the principles per- taining to learning, perception, motivation, thinking, emotions, and interpersonal relationships; the methods and procedures of interviewing, counseling, and psychotherapy; of constructing, administering, and interpreting tests of mental abilities; aptitudes, interests, attitudes, personality characteristics, emotion. and motivation; and of assessing public opinion." "The application of said principles and methods includes. but is not restricted to: diagnosis, prevention, and emelioration of adjustment problems and emo- tional and mental disorders of individuals and groups; hypnosis; educational and vocational counseling; personnel selection and management; the evaluation and planning for effective work and learning situations; advertising and market research; and the resolution of interpersonal and social conflicts. "Psychotherapy within the meaning of this act means the use of learning, conditioning methods, and emotional reactions, in a professional relationship. to assist a person or persons to modify feelings, attitudes, and behavior w-hich are intellectually, socially, or emotionally maladjustive or ineffectual. "The practice of psychology shall be as defined above, any existing statute in the state of to the contrary notwithstanding." Upon the advice of legal counsel, the Committee recommends that the wording of the provision covering exemption of members of other professions be as follow's: PAGENO="0063" 59 "3. Nothing in this act shall be construed to prevent qualified members of other professional groups such as , , or from doing work of a psychological nature consistent with their training and consistent with any code of ethics of their respective professions, provided, however, they do not hold themselves out to the public by any title or description incorporating the words `psychological,' `psychologist,' or `psychology.'" Medical disclaimer clause. The 1955 policy statement recommended that laws regulating the practice of psychology should include a disclaimer clause stating that certification or licensing under the act does not confer the right to practice medicine. In one form or another, all of the state laws passed to date do contain such a provision. It is the Committee's judgment, however, that since psycholo- gists do not represent themselves as other than psychologists, to disclaim the right to practice other professions is inappropriate. Here again, however, the Committee does not feel that inclusion or exclusion of such a provision should be be made a crucial issue. B. Level of Certification or Iiicensure The 1955 policy statement made three recommendations with respect to levels. Although a preference was expressed for a one-level law, the recommendations were relatively permissive. Experience with laws leads the Committee in 1967 to recommend that: "4. Legislation regulating the practice of psychology should be restricted to one level, requiring the doctoral degree from an accredited university or college in a program that is priniarily psychological, and no less than 2 years of super- vised experience, one of which is subsequent to the granting of the doctoral degree. This level should be designated by the title of "psychologist." Psychology should depend on the profession itself for higher level certification or licensure (of which AJ3EPP is an example) However, in some states It has been necessary to certify or license at more than one level. When this occurs, the legislation should reflect the following recommnendations: "5. If a state desires legislation below the psychologist level, this level should be designated by a title which includes the adjective "psychological" followed by a noun such as "examiner," "assistant," "technician," etc. It should require a defined program of at least 1 year of graduate training in an accredited university or college, plus experience leading to qualifications in the practice of certain defined psychological functions, under the supervision of a psy- chologist. In addition, the law should contain a provision prohibiting inde- pendent practice by such individuals. "6. If a state desires legislation beyond the psychologist level, this level should be designated by the title of "consulting psychologist." It should require competence and experience equivalent to that of the ABEPP diploma." That the 1955 recommendations have had an effect is shown by the fact tha.t out of 41 laws now in existence, 32 certify or license at one level, 1 (Michigan) certifies at three levels, with 8 providing for two levels. In 2 (Kentucky and Washington) of these 8, provisions for the nondoctoral person is via a cer- tificate of qualification for specified functions, rather than a specific title. The Committee on Legislation feels that this provision is in accord with Recommen- dation 5 above. C. Specialty As to specialty legislation, in its 1955 report, the Committee did not favor legislation which permits differentiation of specialties within psychology, re- gardless of whether these specialties are defined `by the functions carried out or by the locale where the work is done. These matters are best dealt with by intraprofessional controls. None of the current laws is specialty legislation. We reaffirm the 1955 policy statement against specialty legislation, and recommend that: "7. Legislation regulating the practice of psychology at the "psychologist" or "consulting psychologist" level should not `attempt to differentiate psychologi- cal specialties either by function or by locale." This policy still permits, in those states having certification laws, any person who has been trained as a psychologist to call himself by any o'ther name without being certified. In those states with licensing laws, titles nre not relevant. PAGENO="0064" 60 D. EacH? pt io as for Psych ologists Should legislation be written to include exemptions for psychologists who are salaried employees of certain organizations, such as state and Federal agencies, research laboratories, or academic institutions? By wording and by implication, present laws cover only the applied activities of psychologists rather than their teaching and research activities. To require the nonpracticing, salaried psychologist of the above named organizations to be certified or licensed is contrary to the generally stated purposes for legislation, since there may be little need to protect the public from the activities of teaching and research within such institutions. Furthermore, requiring such psychologists to obtain a certificate or license places upon them an unwarranted financial burden from which they derive no apparent direct benefit. On the other band, it is becoming increasingly common for psychologists employed for a salary by various institutions also to provide direct services of an applied nature to the public, often for a fee. Being a practitioner is not limited to any single field of psychology nor to any one setting. So the question becomes whether some guarantee should be given the public that such psy- chologists are qualified under the laws governing the practice of psychology in that state. The argument is given that the competence of such a psychologist is assessed by his institution before he is hired, that his activities are con- stantly evaluated while he is employed, and that the institution itself will assume responsibiliy for his activities. In practice, however, this is not always the case. Institutions do not always assess psychologists with respect to the skills and techniques they utilize in their outside applied activities, and it is questionable w-hether such institutions in fact would assume responsibility for the consulting activities engaged in by salaried employees outside of the normal duties for which they were hirect Furthermore, it may not be a valid assumption that Federal. state. or private institutions are qualified to judge the competence of those they hire, especially in areas of their consulting activities. Does the issue, then, revolve around whether the salaried psychologist renders his services for a fee? Is this the only point where there i-s a need for control by legislation of the qualifications for practice? While our Committee answers these questions affirmatively, we also are aware of the difficulty of defining "fee." Is a contract to do survey research, with a later feedback of the findings for the purpose of facilitating change in an organization, to be considered under the definition of "providing services for a fee"? Does the salaried university psychol- ogist who consults for a Federal agency provide psychological services for a fee? In their September 1964 interim report the ad hoc Committee on the Scientific and Professional Aims of Psychology proposed that: "All law-s should exempt salaried employees of academic institutions, state and Federal -agencies~ research laboratories, and business corporations while per- forming their duties for such organizations. Such exemptions, however, should not exclude the business or corporation per se from certification where they sell psychological services to the public." Although implementation of such exemptions may leave loopholes, our Com- mittee agrees in principle with the SPAP Committee and offers the following guidelines and recommendations with respect to this complex issue: "8. Persons employed as psychologists by accredited academic institutions, governmental agencies, research laboratories, and business corporations should be exempted, provided such employees are performing those duties for which they are employed by such organizations, and within the confines of such organizations." This does not mean that psychologists should stop their continuing efforts to improve the quality of psychological services offered within the confines of such employment settings. "9. Persons employed as psychologists by accredited academic institutions, governmental agencies, research laboratories, and business corporations con- sulting or offering their research findings or providing scientific information to like organ izatioiz-s for a fee should be exempted. "10. Persons employed as psychologists who offer or provide psychological services to -the public for a fee, over and above the salary that they receive for the performance of their regular duties should not be exempted. "11. Persons employed as psychologists by organizations that sell psychological services to the public should not be exempted." RecommendationS 8 through 11 cover the activities of psychologists. It is also necessary, in licensing legislation, to authorize activities of a psychological PAGENO="0065" 61 nature on the part of salaried employees in exempted settings who are not psychologists. The persons involved may be clerical personnel under the direct supervision of a psychologist, or they may be unsupervised personnel with responsibilities for selection `and placement, for example, that include the use of tests. The Committee recommends, therefore, that: "12. Nothing in the licensing `act shall restrict or prevent activities of a psy- chological nature on the part of persons who are salaried employees of accredited academic institutions, governmental agencies, research laboratories, and business corporations, provided such employees are performing those duties for which they are employed `by such organizations, and within the confines of such organization: provided, however, that they do not hold themselves out to the public by any title or description of activities incorporating the words `psychology,' `psycho- logical,' or `psychologist.'" Other exemptions recommended are: "13. Consideration should be given students of psychology, psychological in- terns, and other persons preparing for the profession of psychology under quali- fied supervision in recognized training institutions or facilities. These should be exempted provided they are designated by such titles as `psychological intern,' `psychological trainee,' or others, clearly indicating such training status. "14. The exemption of the sociologically trained social psychologist is recom- mended in accordance with the policy adopted in 1959 as agreed upon by the American Psychological Association and the American Sociological Association. A suggested wording for such a provision is: "`Nothing in this act is to be construed as restricting the use of the term `social psychologist' by any person (a) who has been graduated with a doctoral degree in sociology or social psychology from an institution whose credits in sociology or social psychology are acceptable by a recognized education insti- tution, and (b) who has passed comprehensive examinations in the field of social psychology as part of the requirement for the doctoral degree or has had equiva- lent specialized training in social psychology, and (C) who has filed with the board a statement of the facts demonstrating his compliance with Conditions ~ and b of this subsection.' "15. It is recommended that state laws should allow the psychologist who is exempted from certification or licensing by virtue of his employment setting, to offer lecture services for a fee." Lecturer provisions sometimes deal with the non-resident psychologist from another state or territory. Here the issue is one of the single or relatively few lectures provided within a relatively short span of time, and often to diverse groups. The exemption status of the organization supporting the lecture is a partial answer to this issue, but a more general answer lies in including in leg- islation, or in examining board regulations, some means of recognizing and deal- ing with the atypical event through discretionary powers given to the board of examiners. E. Offer for aPee This phrasing is a common one in regulatory laws. The laws are primarily intended for protection of the public. The expected misuse of title or function by an unqualified practioner is presumed to occur most frequently where the client (individual, group, or organization) is to make payment for services rendered. Payment for services rendered my take a wide variety of forms in- cluding but not limited to diagnostic fees and consultant fees. With the advice of legal counsel, the Committee recommends that: "16. When referring to the psychologist's services offered to the public, the phrasing be "for a fee, monetary or otherwise." F. Code of Ethics The Committee reaffirms the 1955 policy that: "17. Legislation governing the practice of psychology should be so written that the official code of ethics of the APA be adopted, as such or in substance, as the code of ethics for individuals covered by the law." The means of doing this will vary, for in some states reference to an outside organization (the APA) is not permitted in law. Rules and procedures of the board of examiners, however, may include wording identical with the APA Code. 94-755-68-----5 PAGENO="0066" 62 Seventeen of the current laws refer specifically to the APA Code of Ethics in the legislation itself. G. Accreditation It is recommended that: "18. All laws should limit eligibility for certification or licensing to individuals holding degrees from accredited (or recognized foreign) institutions." The practices of different states in professional legislation vary. Some permit explicit mention of APA or national and regional accrediting bodies, others do not. Rules of the board of examiners should designate the acceptable accrediting bodies. In September 1963, the Council of Representatives voted that it was the sense of that meeting that APA "disapproves of state procedures involving the regis- tration of graduate training programs in psychology in connection with certifi- cation or licensing of psychologists." The Committee therefore recommends that: "19. Nothing in the law or in the administration of the law should require the registration of departments of psychology or doctoral programs in psychology." H. Bwami~ing Boards It is recommended that: "20. Examining boards consist of psychologists representing the various fields of psychology. They should include psychologists responsible for the education and training of doctoral students as well as those involved with the public appli- cation of psychology. All of the members of the board should be certified or licensed, or in the case of the first board, eligible for certification or licensure. Where state precendent will permit, nominations should be provided by the state psychological association." I. Eaaminations Although written and oral examinations are customarily required under all but one of the laws, once the grandfather period is over, provisions should be made when possible for waiving examinations in special circumstances. It is recommended that: "21. Wherever possible, laws contain a provision that at the discretion of the examining board, written and/or oral examinations may be waived, either in whole or in part. when in the board's judgment the applicant has already dem- onstrated competence in areas covered by the examinations." Some existing boards are authorized to waive examinations when "in the public interest." It seems best. however, to specify the conditions. It is ~iso recommended that: "22. Where possible, the laws or the regulations of the examining boards should permit waiving the examination for diplomates of the American Board of Examiners in Professional Psychology." J. Reciprocity It is recommended that: "23. Each state law should contain a provision which enables the certifying or licensing board to grant a certificate or a license, without examination, to a psychologist who is licensed or certified in another state when the requirements for licensure or certification of that State are no lower than those in the present state." While the evaluation of "no lower than" may be seen as a barrier, that possi- bility is greatly reduced by the efforts of the American Association of State Psychology Boards and the consultative efforts of the Committee on Legislation of the APA. In addition, it is always possible for a psychologist to obtain lega.l redress if a state examining board is alleged to have acted capriciously or arbi- trarily. In this respect, each state law should serve the public interest by im- plementing stated APA policy and the scientific and professional traditions of psychology by facilitating rather than hindering the mobility of psychologists. K. The oiet-ol-State consultant Related to the need for adequate reciprocity provisions is the need to provide for the psychologist coming into a state for a brief period of time, as a consultant, but whose employer is in another state. Such activity is common for psycholo- gists working for an industrial consulting firm. It would seem inappropriate to PAGENO="0067" 63 require that such a consultant obtain a certificate or license. The degree of freedom granted to any state will depend upon a number of factors, but it is the Committee's recommendation that: "24. Provision be made in psychology laws for the visiting psychological con- sultant offering psychological services on a short-term basis." The following example from the Illinois law is' presented as a reasonable guide: "A psychologist who is not a resident of this State and offers professional services in this State for not more than 5 days in any calendar year is exempt from the provisions of this Act. "A psychologist who is not a resident of the State, but (1) is licensed or certified by a similar board of another State, or territory of the United States, or of a foreign country or province whose standards, in the opinion of the De- partment, are equivalent to or higher than, at the date of his certification or licensure, the requirements of this Act, or (2) meets the requirements of para- graphs (a), (b), (c), (d), (e), of Section 10 (basic requirements except for ex- amination) and resides in another State, or territory of the United States, or in a foreign country or province which does not grant certification or licenses to psychologists may offer professional services in this State for a total of not more than 60 days in any calendar year without holding a certificate issued under this Act; provided that such persons shall report to the Department the nature and extent of their practice in this State if it exceeds 20 days within any cal- endar year." L. Privileged connnunicat:ion provisions In `the policy statement adopted in 1955, the following appears, not as a formal recommendation, but as a general guideline: "Should the legislation give legal protection to the confidentiality of rela- tions between the psychologist and his clieiit? "In Ethical Standards of Psychologists the psychological profession has ac- cepted `the obligation to protect the confidentiality of psychologist-client relation- ships. It is consistent with this to seek provisions to make `the protection of confidentially legally feasible. "There is general agreement that a clause in the legislation to achieve this purpose might read as follows: `For the purpose of this Chapter (or Act) the confidential relations and communications between licensed applied psychologist (or certified clinical psychologist or licensed psychologist or psychological ex- aminer) and client are placed upon the same `basis as those provided by law between attorney and client, and nothing in this Chapter (or Act) shall be construed to require any such privileged communication to be disclosed.'" Recognizing the importance of the need to provide as much protection as possi- ble to the public which uses a psychologist, it is the Committee's position that the 1955 policy is probably a good guide for a state association that wants to in- clude a provision in a certification or licensing bill, but~ that the inclusion or exclusion should not be made a point of contention. It is also a'dvisa'ble to check to see what relationships are and are not privileged in a given state by statute, in assessing whether or not such a provision would prove injuriously contro- versial. It is reco'mmended that: "25. Wherever possible, a clause protecting the privileged nature of the psychologist-client relationship be included." Thirty-two of the 41 laws now on the books in the United States and Canada grant the privilege to the psychologist-client relationship, usually with the attorney-client relationship as the model. Up until a few years ago, there was little controversy about such provisions, either within psychology or without. Then questions arose in several state associations, and the Committee on Legislation itself began to wonder if the rather simple statement in the 1955 policy document was still appropriate. The Committee has spent a good bit of time at its meetings these past few years discussing privileged communication and related issues and has prepared a background paper on the matter of privilege. Since it is basic to our legal tradition that the privilege belongs to the client, not to the professional person, it has become increasingly evident that it should be accorded any person irrespec- tive of the professional designation or training of the helper whom he chooses. The Committee has come to take a broader view of privilege in light of its study and recommends that: "26. When appropriate, psychologists assist in obtaining general `across the board' legislation for such privileged communications." PAGENO="0068" 64 M. In-jv)wtion Avt1~ority Experience with laws has indicated that authority to enjoin the activities of a psychologist or other person who is in violation of the law can be an important factor in protecting the public. Fortunately, it is not an authority that needs to be used often, but it is good to have it in the law. The Committee recom- mends, therefore, that: "27. Psychology laws contain injunction authority." An example of such a provision, taken from the proposed licensing act for the District of Columbia and drafted by APA's legal counsel, is as follows: "Sec. 19. The unlawful practice of psychology as defined in this Act may be enjoined by the United States District Court for the District of Columbia on petition by the Board or by the Commissioners of the District of Columbia. In any such proceeding it shall not be necessary to show that any person is individually injured by the actions complained of. If the respondent is found guilty of the unlawful practice of psychology, the court shall enjoin him from so practicing unless and until he has been duly licensed. Procedure in such cases shall be the same as in any other injunction suit. The remedy by injunction hereby given is in addition to criminal prosecution and punishment." N. Review of Proposed Legiskttion. The Committee's last recommendation makes a matter of o~cial policy what -was "strongly urged" in 1958: "28. Because all psychologists have an interest in the public image of ~psychology, and because state legislation which may define the practice and ~qualifications of psychologists inevitably shapes this public image, state associa- -tions contemplating new legislation or revisions of existing legislation should consult with the national committee concerned with legislative principles, to -the end that the impact and effect of alternative forms and provisions in state ~1aws may be clearly understood at the state level." - Mr. SISK. The Committee now will be glad to hear from Dr. Zimmerman. ~\Te would appreciate it if you will please identify yourself and give your complete and correct address for the benefit of the Committee? You may proceed to read yoiu~ statement or to summarize it; but, in any event, your entire statement will be made a part of the record at the appropriate place. STATEMENT OP DR. ISAIAH M. ZIMMERMAN, WASHINGTON, D.C. Dr. ZumrER~rAN. Mr. Chairman and members of the Subcommittee. I am Dr. Isaiah M. Zimmerman, and I live at 5323 Potomac Avenue, Washington, D.C. I would just like to comment rather than read the statement which I have. I would like to say, in my own career I have had occasion to train and supervise both psychologists, social workers, and psychologists in the areas of group and individual psychotherapy, and that the rela- tions between them, in my experience, has been very creative, produc- tive, and that the comments that have been made, if one were to look in a one-way mirror, which is often used in training, and observed the treatments going on using psychotherapy without identifying the participants, it would be very hard to tell whether a social worker, a psychiatrist, or a psychologist was conducting the treatment. I also feel that the field is moving quite rapidly to the employment of a dialogue between two people or a group of people to promote the individual personality change, to promote community change, and as this trend proceeds, we will find it more and more difficult to PAGENO="0069" 65 tie down the dialogue psychotherapy. I think this legislation should. reflect this growing trend. And, finally, I would like to say that the need for such legislation in this jurisdiction where I practice and live is considerable and. would help in both private care and in the official institutional use of the professional psychologists. As I mentioned, in matters of law, in matters of administration, and in matters of security. Thank you. Mr. SI5K. Thank you, Dr. Zimmerman, for your statement. (The prepared statement submitted by Dr. Zimmerman reads in full as follows:) Mr. Chairman, I am Dr. Isaiah M. Zimmerman. I live here, and am also in the private practice of psychology here in the District of Columbia. My professional training was also received locally, at the Catholic University of America, and included an internship in the Psychology Department of D.C. General Hospital. I divide my time between practice and teaching. As Dean of the Group Psychotherapy Training Program tat the Washington School of Psychiatry, I am involved in teaching group psychotherapy to professionals in the mental health fields. As consultant to the Air Force Ho~pital at Andrews, to the Veteran's Administration Hospital in D.C., and to a number of other agencies, I am closely involved witJ~ training psychologists to do marital and family counseling, and child guidance. Due to this experience I would like to offer an ~pinion as to whether the practice of psychology can be defined, to carry out one practical pui~pose of this bill. On the other question, the need to regulate the practice of ~5~- chology, I too have an opinion to respectfully offer. It is based u4pon considerable "insider's" experience in my practice. I have occasionally needed to refer a client to a colleague; I frequently get calls from schools, lawyers, physicians, and clergy requesting the name of a qual- ified psychologist in their area. How does one decide? In a large city such as Washington one cannot hope to know and be known, in a close working sense, within most of one's own professional group. Even though I know that graduate training in psychology is exacting and highly regulated, it is still no guarantee against obsolescence of skills, or inappropriate or insufficient e~perience in someone who offers his services to the public. As more and more states enact laws covering psychologists, I do not want the District of Columbia to possibly be- come a refuge for the not-elsewhere-qualified practitioner. I have studied H.R. 14007 and offer these opinions to you: In regard to definition, it covers the field very well, and in terms that a regulatory board could practically apply. In regard to the need to regulate the practice of psychology, it does exist. Further, the high incidence of administrative, legal and security matters which characterize a Wash- ington psychology practice makes it crucial that both citizens and officials know who they can turn to for specialized consultation of care. I believe that this bill, if enacted into law, will provide a sound basis for the information and protection of the public in the District of Columbia in regard to psychological services. Mr. SIsK. The gentleman from Indiana. PAGENO="0070" 66 Mr. JACOBS. I have no questions. Mr. SIsK. The gentleman from Maryland. Mr. GuDE. I have no further questions. Mr. SI5K. Thank you very much, Mr. Zimmerman. As I understand it, you are in full si~pport of this legislation, and you feel that it would be beneficial to the community? Dr. ZIMMERMAN. les, sir. Mr. SIsK. In view of the time, we are not going to be able to finish the hearings today. The next witnesses are from the Washington Psychiatric Society and the Washington Psychoanalytic Societ.y, and also we have the District government officials. We are simp'y going to have to hear this testimony at another time. The Chair wishes to assure you that you will be heard. Unfortunately, we have run out of time. The House is in session. At this time, without objection, I would like to have the following letters made a part of the record at this point: A letter to me from the California Psychiatric Society dated May 10, 1968: and two letters to Chairman McMillan, namely, a. letter from the Mental Health Ministry dated May 17, 1968, and a letter from Dr. M. Kershaw Walsh with attachment. (The documents referred to follow:) CENTRAL CALIFORNIA PSYCHIATRIC SOCIETY, AMERICAN PSYCHIATRIC ASSOCIATION, Sacramento, Calif., May 10, 1968. B. F. SI5K. U.S. Congressman, Raybvrn House Office B i( ilding, Washington, D.C. DEAR CONGRESSMAN SISK: It has come to the attention of the Central California Psychiatric Society, a branch of the American Psychiatric Association covering the area including your constituency, that there is before your Subcommittee #5 of the House District ~ommittee, a bill to license psychologists. We have not seen the bill and would appreciate an opportunity to study it. However, we are pleased that an effort is being made to protect the public in its quest for pro- fessional help in coping with the multitude of emotional stresses and symptoms of which all of us are increasingly aware. We are aware that your committee and the Congress will be trying to protect the public while allowing as much manpower as possible to be available to help persons in mental and emotional distress. Since we in California have had similar concerns and have engaged in relevant deliberations we should like to throw what light we can on the subject. We concur with the need to define the qualifications of persons entitled to call themselves psychologists, to insure the adequacy of education, training, exper- ience, and discipline. We also believe it important to define the scope of responsibilities appropriate to persons with the stated qualifications. However, it should not be assumed or implied that only persons with the st.ated qualifications can offer the services set forth in a licensing bill. Although qualified psychologists should have the ethical discipline `and supervised training to permit them to provide psychother- apy. others, such as psychiatrists, also have such discipline and training. The law must not limit `the license to provide psychotherapy to one profession; it must recognize that psychotherapy is a procedure appropriate to other trained and disciplined professions. Indeed, psychotherapy is a significant modality of medical practice and must be continued to be subsumed under Medical Practice Acts. Indeed. this leads to a third consideration. Because psychotherapy is a treat- ment technique employed with seriously mentally ill persons, it seems important that a 11011-medical psychotherapist be required, in the interest of the protection PAGENO="0071" 67 of the emotionally ill, to consult with a medical person trained and experienced in the diagnosis and treatment of mental illness whenever there are indications that the distress may signify serious mental or emotional illness. Thus legis- lation should: (1) Protect the public from unethical, inadequately trained practitioners. (2) Define the scope of services which can be rendered by psychologists, con- sistent with the training and ethics defined. (3) Recognize that psychotherapy may be used appropriately by other pro- fessions (i.e.-physicians) than psychology. (4) Assure that the ethics and confidential relationship imperative in pro- viding psychotherapy are adhered to and guarded whenever any quali- fied person provides psychotherapy. (5) Require that a non-medical psychotherapist avail himself of medical con5ultation and direction whenever the assessment of the person in distress suggests serious mental or emotional illness. There are two psychiatrists, members of `the Central California Psychiatric Society, from your constituency and ~vell informed on these issues. We hope you will feel free to call upon them for information. They are James Peal, M.D., and Mark Ziefert, M.D. You may already have heard from or about one or both. Thank you for your interest in this increasingly complex and important area. Sincerely yours, EDWARD RTJDIN, M.D., Presideat-clect, C.C.P.$. MENTAL HEALTH MINISTRY, Washington~, D.C., May 17, 1968. To: Chairman John L. McMillan, Committee on the District of Columbia, U.S. House of Representatives, Washington, D.C.; News Media; Whom it May Concern. Re bill passed by the Senate and pending in the House of Representatives having to do with "regulating the practice of Psychology in the District of Columbia." I and many other people object strenuously to the stringent, unreasonable restrictions on the practice of psychology in the District of Columbia proposed by the Senate Bill and the one penthng in the House of Representatives. Some of our objections are: 1. There are not enough psychiatrists and psychologists now to fill the need for treatment of the mentally ill and this pending Bill proposes to limit the number of psychologists even more by. requiring the Ph. D. degree after the first year from the date of passage of the Bill. 2. Master's degree holders will not be eligible for licensing after the first year from the date of passage of the Bill. 3. Master's degree or equivalent in training and practice people can and do practice psychology most effectively in many States and some foreign countries. 4. The Ph. D. is not necessary for the effective practice of psychology. Master's degTee people do a great bulk of the work that is needed and to eliminate them will be disastrous. 5. Many jobs that require psychologists are not demanding enough for the Ph. D. and Ph. D. holders would not take them. If Master's holders are not per- mitted to practice psychology these jobs will go begging and the gap in psycho- logically trained people and the need for them will widen. 6. The legislation should allow licensing of Master's degree or equivalent in training and practice people who are engaged in the practice of psychology be- cause of the great need for people and the fact that this training is sufficient for the work they are doing. The Ph. D. holder will be free to accept more demanding work and higher pay as is the case at present. The Master's degree or equivalent people are the great bulk of workers; the Ph. D. holders are the heads and administrators of departments, etc. 7. A Grandfather Clause should be included in the Bill to cover those with Master's degrees or equivalent now in practice in the District of Columbia. Rev. GROVER BOYDSTON, Psych ologist. PAGENO="0072" 68 Columbia, S.C., May 26, 1967. HoN. JOHN L. McMu~x. Con gressni an, Fifth District Son th Carolina, House Office Building, Washington, D.C. DEAR Mn. i\IOMILLAN: I am writing in support of a proposed bill for the licens- ing of psychologists in the District of Columbia. My reason for this support does not stem from any special interest in the District, but is based on the fact that I am chairman of a special committee writing similar legislation in the State of South Carolina, initiated by the South Carolina Psychological Association. A bill to license psychologists was recommended by the Governor's Advisory Group for Mental Health, and our present bill is being personally sponsored by Senator Earl Morris of Pickens. It has been introduced in both houses and is being considered by their appropriate committees. As I have been working for a number of years in South Carolina and in close cooperation with the American Psychological Association and other state associations, I feel some degree of re- sponsibility for offering my support in the present situation. As I know that you are vitally concerned with the Welfare of the District of Columbia and of its residents, I felt that you would not consider my action in writing you offensive. While I am quite sure that you are well acquainted with the general need for licensing professional persons serving the general public, for your convenience I am taking the liberty of calling to your attention a few points relating to the proposed bifi. 1. An indication of a general recognition of the need for such legislation may be seen in the fact that a substantial majority of the states have already enacted similar laws, while others are rapidly moving in this same direction. 2. The demand for psychological services is very great and rapidly increasing. This situation is ideal for the multiplication of unqualified practitioners, who are exploiting the opportunity to sell their dubious services to the public. This will become a serious problem in large urban centers, of which the District of Columbia is a prime example. 3. Specialists such as clinical psychologists, school psychologists, and industrial psychologists quite frequently are employed by hospitals, clinics, school systems and consulting firms, where it is a relatively easy matter to determine training and competence. But when individuals offer their services to the general public, competence is not so readily verified unless governments assume some responsi- bility for the control of private practice. Where the happiness and well-being of individuals and families are involved, it becomes vital that practitioners are not only competent but regulated by well-defined ethical principles. This can be insured only where legal safeguards are established and maintained. 4. Most states having laws for the licensing of psychologists require a Ph. D. degree and an examination to determine areas of professional competence. As a rule, persons with graduate training below the doctoral level either are not licensed, or, if they are licensed, have limitations placed on their areas of prac- tice. Typically, the person at the MA. level is allowed to perform certain functions under supervision but does not assume full case responsibility. 5. Where no laws exist, anyone can hang out his shingle and advertise that he will help families with their psychological problems. Many such persons are outright quacks with no professional credentials. But regardless of the prac- titioner's education, it is important to be able to prevent unethical practices. The American Psychological Association has developed and published a Code of Ethics for Psychologists, which has become the guide for all psychologists and is always emphasized in the control of private practice by licensing boards. I am enclosing a copy of the Ethical Standards of Psychologists as reprinted from the American Psychologist in order to give you a better understanding of some of the issues involved in protecting the public from unethical practice. If I can be of any service to you in any way in ~btainthg information, do not hesitate to call on me. With best wishes. Cordially, M. KER5HAW WALSH, PH. D., Professor of Psychology, University of South Carolina, and Chairman~ Special Committee for Licensing Legislation, South Carolina Psycho- logical Association. PAGENO="0073" 69 [Reprint from AMERICAN PsYcrioLonisT, Jan. 1963, vol. 18, No. 1~ ETHICAL STANDARDS OF PSYCHOLOGISTS The psychologist believes in the dignity and worth of the individual human being. He is committed to increasing man's understanding of himself and others. While pursuing this endeavor, he protects the welfare of any person who may seek his service or of any subject, human or animal, that may be the object of his study. He does not use his professional position or relationships, nor does he knowingly permit his own services to be used by others, for purposes inconsistent with these values. While demanding for himself freedom of inquiry and commun- ication, he accepts the responsibility this freedom confers: for competence where he claims it, for objectivity in the report of his findings, and for consideration of the best interests of his colleagues and of society. SPECIFIC PRINCIPLES Principle 1. Responsibility. The psychologist,' committed to increasing man's understanding `of man, places high value on objectivity and integrity, and main- taii~s the highest standards in the services he offers. a. As a scientist, the psychologist believes that society will be best served when he investigates where his judgment indicates investigation is needed; he plans his research in such `a way as to minimize the possibility that his findings will be `misleading; and he publishes full reports of `his work, never discarding without explanation data which may modify the interpretation of results. b. As `a teacher, the psychologist recognizes his primary obligation to help others `acquire knowledge and skill, and to maintain high standards of scholarship. c. As `a `practitioner, the psychologist knows that he bears a heavy social responsibility because his work may touch intimately the lives of others. Principle 2. Competence. The maintenance of high standards of professional competence is a responsibility shared by all psychologists, in the interest of the public and of the profession as `a whole. a. Psychologists discourage the practice of psychology by unqualified per- sons and assist the public in identifying psychologists competent to give dependable profe~siona1 service. When a psychologist or a person identifying himself as a psychologist violates ethical standards, psychologists who know firsthand of such activities attempt to rectify the situation. When such a situ- ation cannot be dealt with informally, it is called to the attention of the appropriate local, state, or national committee on professional ethics, stand- ards, and `practices. *b. The psychologist recognizes the boundaries of his competence and the limitations of his techniques and does not offer services or use techniques that fail to meet professional standards established in particular fields. The psychologist who engages in practice assists his client in obtaining profes- `sion'al help for all important aspects of his problem that fall outside the boundaries `of his own competence. This principle requires, for example, that provision be made for the diagnosis and treatment of relevant medical problems and for referral to or consultation with other specialists. c. The psychologist in clinical work recognizes that his effectiveness de- pends in good part upon hi's ability to maintain sound interpersonal relations, that temporary or more enduring aberrations in his own personality may interfere with this ability or distort his appraisals of others. There he re- frains from undertaking any activity in which his personal problems are likely to result in inferior professional services or harm to a client; or, if he is already engaged in such an activity when he becomes aware of his personal problem's, he `seeks competent professional assistance to determine whether he should cont'inue or terminate his services to his client. Principle 3. Moral and Legal Standards. The psychologist in the practice of his profession shows sensible regard for the social codes and moral expectations of ~ A student of psychology who assumes the role of psychologist shall be considered a psychologist for the purpose of this code of ethics. PAGENO="0074" 70 the community in which he works, recognizing that violations of accepted moral and legal standards on his part may involve his clients, students, or colleagues in damaging personal conflicts, and impugn his own name and the reputation of his profession. Principle 4. Misrepresentation. The psychologist avoids misrepresentation of his own professional qualifications, affiliations, and purposes, and those of the institutions and organizations with which he is associated. a. A psychologist does not claim either directly or by implication profes- sional qualifications that differ from his actual qualifications, nor does he misrepresent his affiliation with any institution, organization, or individual, nor lead others to assume he has affiliations that he does not have. The psy- chologist is responsible for correcting others who misrepresent his profes- sional qualifications or `affiliations. b. The psychologist does not misrepresent an institution or organization with which he is affiliated by ascribing to it characteristics that it does not have. c. A psychologist does not use his affiliation with the American Psycho- logical Association or its Divisions for purposes that are not consonant with the stated purposes of the Association. d. A psychologist does not associate himself with or permit his name to be used in connection with any services or products in such a way as to mis- represent them, the degree of his responsibility for them, or the nature of his `affiliation. Principle 5, Public Statements, Modesty, scientific caution, and due regard for the limits of present knowledge characterize all statements of psychologists who supply information to the public, either directly or indirectly. a. Psychologists who interpret the science of psychology or the services of psychologists to clients or to the general public have an obligation to report fairly and accurately. Exaggeration, sensationalism, superficially, and other kinds of misrepresentation are avoided. b. When information about psychological procedures and techniques is given, care is taken to indicate that they should be used only by persons adequately trained in their use. c. A psychologist `who engages in radio or television activities does not par- ticipate in commercial announcements recommending purchase or use of a product. Principle 6. Confidentiality. Safeguarding information about an individual that has been obtained by the psychologist in the course of his teaching, practice, or investigation is a primary obligation of the psychologist. Such information is not communicated to others unless certain important conditions are met. a. Information received in confidence is revealed only `after most careful `deliberation and when there is clear `and imminent danger to an individual or to society, and then only to appropriate professional workers or public authorities. b. Information obtained in clinical or consulting relationships, or evalua- tive data concerning children, students, employees, and others are discussed only for professional purposes `and only with persons clearly concerned w-ith the case. Written `and oral reports `should present only data germane to the purposes of the evaluation ;` every effort should be made to avoid undue inva- sion of privacy. c. Clinical and other case materials are used in classroom teaching and writing only when the identity of the persons involved is adequately disguised. d. The confidentiality of professional communications about individuals is maintained. Only when the originator and other persons involved give their express permission is a confidential professional communication shown to the individual concerned. The psychologist is responsible for informing the client of the limits of the confidentiality. e. Only after explicit permission has been granted is the identity of research subjects published. When data have been published without per- mission for identification, the pychologist assumes responsibility for ade- quately disguising their sources. f. The psychologist makes provision for the m'aintenance of confidentiality in the preservation and ultimate disposition of confidential records. Principle 7. Client Welfare. The psychologist respects the integrity and protects the welfare of the person or group with whom he is working. PAGENO="0075" 71 a. The psychologist in industry, education and other situations in which conflicts of interest may arise among various parties, as between manage- ment and labor, or between the client and employer of the psychologist,. defines for himself the nature and direction of his loyalties and responsi- bilities and keeps all parties concerned informed of these commitments. b. When there is a conflict among professional workers, the psychologist is concerned primarily with the welfare of any client involved and only sec- ondarily with the interest of his own professional group. c. The psychologist attempts to terminate a clinical or consulting relation- ship when it is reasonably clear to the psychologist that the client is not benefiting from it. d. The psychologists who asks that an individual reveal personal informa- tion in the course of interviewing, testing, or evaluation, or who allows such information to be divulged to him, does so only after making certain that the responsible person is fully aware of the purposes of the interview, testing, or evaluation and of the ways in which the information may used. e. In cases involving referral, the responsibility of the psychologist for the welfare of the client continues until this responsibility is assumed by the professional person to whom the client is referred or until relationship with the psychologist making the referral has been terminated by mutual agree- ment. In situations where referral, consultation, or other changes in the conditions of the treatment are indicated and the client refuses referral, the psychologist carefully weighs the possible harm to the client, to himself, and to his profession that might ensue from continuing the relationship. f. The psychologist who requires the taking of psychological tests for didactic, classification, or research purposes protects the examiners by insur- ing that the tests and test results are used in a professional manner. g. When potentially disturbing subject matter is presented to students, it is discussed objectively, and efforts are made to handle constructively any difficulties that arise. h. Care must be taken to insure an appropriate setting for clinical work to protect both client and psychologist from actual or imputed harm and the profession from censure. Principle 8. Client Relationship. The psychologist informs his prospective client of the important aspects of the potential relatonship that might affect the client's decision to enter the relationship. a. Aspects of the relationship likely to affect the client's decision include the recording of an interview, the use of interview material for training purposes, and observation of an interview by other persons. b. When the client is not competent to evaluate the situation (as in the case of a child), the person responsible for the client is informed of the cir- cumstances which may influence the relationship. c. The psychologist does not normally enter into a professional relation- ship with members of his own family, intimate friends, close associates, or others whose welfare might be jeopardized by such a dual relationship. Principle 9. Impersonal Services. Psychological services for the purposes of diagnosis, treatment, or personalized advice are provided only in the context of a professional relationship, and are not given by means of public lectures or demonstrations, newspaper or magazine articles, radio or television programs, mail, or similar media. a. The preparation of personnel reports and recommendations based on test data secured solely by mail is unethical unless such appraisals are an integral part of a continuing client relationship with a company, as a result of which the consulting psychologist has intimate knowledge of the client's personnel situation and can be assured thereby that his written appraisals will be adequate to the purpose and will be properly interpreted by the client. These reports must not be embellished with such detailed analyses of the subject's personality traits as would be appropriate only after intensive interviews with the subject. The reports must not make specific recommendations as to employment or placement of the subject which go beyond the psychologist's knowledge of the job requirements of the company. The reports must not purport to eliminate the company's need to carry on such other regular employment or personnel practices as appraisal of the work history, checking of references, past performance in the company. PAGENO="0076" 72 Principle 10. Announcement of Services. A psychologist adheres to professional :rather than commercial standards in making known his availability for :professional services. a. A psychologist does not directly solicit clients for individual diagnosis or therapy. d. A psychologist or agency announcing nonclinical professional services may use brochures that are descriptive of services rendered but not evalu- may also include identification in a few words of the psychologist's major areas of practice; for example, child therapy, personnel selection, industrial psychology. Agency listings are equally modest. c. Announcements of individual private practice are limited to a simple statement of the name, highest relevant degree, certification or diplomate status, address, telephone number, office hours, and a brief explanation of the types of services rendered. Announcements of agencies may list names of staff' members with their qualifications. They conform in other particulars with the same standards as individual announcements, making certain that the true nature of the organization is apparent. d. A psychologist or agency announcing nonclinical professional services may use brochures that are descriptive of services rendered but not evalu- ative. They may be sent to professional persons, schools, business firms, government agencies, and other similar organizations. e. The use in a brochure of "testimonials from satisfied users" is unaccept- able. The offer of a free trial of services is unacceptable if it operates to misrepresent in any way the nature of the efficacy of the services rendered by the psychologist. Claim that a psychologist has unique skills or unique devices not available to others in the profession are made only if the special efficacy of these unique skills or devices has been demonstrated by scientifi- cally acceptable evidence. f. The psychologist must not encourage (nor, within his power, even allow) a client to have exaggerated ideas as to the efficacy of services rendered. Claims made to clients about the efficacy of his services must not go beyond those which the psychologist would be willing to subject to professional scrutiny through publishing his results and his claim in a prefessional journaL Principle 11. Interprofessional Relation. A psychologist acts with integrity in regard to colleagues in psychology and in other professions. a. A psychologist does not normally offer professional services to a person receiving psychological assistance from another professional worker except by agreement with the other worker or after the termination of the client's relationship with the other professional worker. b. The welfare of clients and colleagues requires that psychologists in joint practice or corporate activities make an orderly and explicit arrangement regarding the conditions of their association and its possible termination. Psychologists who serve as employers of other psychologists have an obliga- tion to make similar appropriate arrangements. Principle 12. Remuneration. Financial arrangements in professional practice are in accord with professional standards that safeguard the best interest of the client and the profession. a. In establishing rates for professional services, the psychologist considers carefully both the ability of the client to meet the financial burden and the charges made by other professional persons engaged in comparable work. He is willing to contribute a portion of his services to work for which he receives little or no financial return. b. No commission or rebate or any other form of remuneration is given or received for referral of clients for professional services. c. The psychologist in clinical or counseling practice does not use his rela- tionships with clients to promote, for personal gain or the profit of an agency, commercial enterprise of any kind. d. A psychologist does not accept a private fee or any other form of remun- eration for professional work with a person who is entitled to his services through an institution or agency. The policies of a particular agency may make explicit provision for private work with its clients by members of its staff, and in such instances the client must be fully apprised of all policies affecting him. Principle 13. Test Security. Psychological tests and other assessment devices, the value of which depends in part on the naivete of the subject, are not repro- PAGENO="0077" 73 duced or described in popular publications in ways that might invalidate the techinques. Access to such devices is limited to persons with professional interests who will safeguard their use. a. Sample items made up to resemble those of tests being discussed may be reproduced in popular articles and elsewhere, but scorable tests and actual test items are not reproduced except in professional publications. b. The psychologist is responsible for the control of psychological tests and other devices and procedures used for instruction when their value might be damaged by revealing to the general public their specific contents or underlying principles. Principle 14. Test Interpretation. Test scores, like test materials, are released only to persons who are qualified to interpret and use them properly. a. Materials for reporting test scores to parents, or which are designed for self-appraisal purposes in schools, social agencies, or industry are closely supervised by qualified psychologists or counselors with provisions for re- ferring and counseling individuals when needed. b. Test results or other assessment data used for evaluation or classification are communicated to employers, relatives, or other appropriate persons in such a manner as to guard against misinterpretation or misuse. In the usual case, an interpretation of the test result rather than the score is communicated. c. When test results are communicated directly to parents and students, they are accompanied by adequate interpretive aids or advice. Principle 15. Test Publication. Psychological tests are offered for commercial publication only to publishers who present their tests in a professional way and distribute them only to qualified users. a. A test manual, technical handbook, or other suitable report on the test is provided which describes the method of constructing and standardizing the test, and summarizes the validation research. b. The populations for which the test has been developed and the purposes for which it is recommended are stated in the manual. Limitations upon the test's dependability, and aspects of its validity on which research is lacking or incomplete, are clearly stated. In particular, the manual contains a warn- ing regarding interpretations likely to be made which have not yet been sub- stantiated by research. c. The catalog and manual indicate the training or professional qualifica- tions required for sound interpretation of the test. d. The `test manual and supporting documents take into account the prin- ciples enunciated in the Technical Recommendations br Psychological Tests and Diagnostic Techniques. e. Test advertisements are factual and descriptive rather than emotional and persuasive. Principle 16. Rese~rc'h Precautions. The psychologist assumes obligations for the welfare of his research subjects, both animal and human. a. Only when a problem is of scientific significance and it is not practicable to investigate it in `any other way is the psychologist justified in exposing re- search subjects, whether children or adults, to physical or emotional stress as part of `an investigation. b. When `a reasonable possibility of injurious aftereffects exists, research is conducted only when the subjects or their responsible `agents are fully in- formed of this possibility and agree to participate nevertheless. c. The psychologist seriously considers the possibility of harmful after- effects and avoids them, or removes them as soon as permitted by the design of the experiment. d. A psychologist using animals in research adheres to the provisions of the Rules Regarding Animals, drawn up by the Committee on Precautions and Standards in Animal Experimentation and adopted by the American Psychological Association. Principle 17. Publication Credit. Credit is assigned to those who have con- tributed to a publication, in proportion to their contribution, and only to these. a. Major contributions of a professional character, made by several per- sons to a cokmmon project, are recognized by joint authorship. The experi- mentor or author who has made the principal contribution to a publication is identified as the first listed. PAGENO="0078" 74 b. Minor contributions of a professional eharaeter, catensive clerical or similar nonprofessional assistance, and other minor contributions are ac- knowledged in footnotes or in an introductory statement. c. Acknowledgment through specific citations is made for unpublished as well as published material that has directly influenced the research or writing. .d. A psychologist who compiles and edits for publication the contributions of others publishes the symposium or report under the title of the committee or symposium, with his own name appearing as chairman or editor among those of the other contributors or committee members. Principle 18. Responsibility toward Organization. A psychologist respects the rights and reputation of the institute or organization with which he is associated. a. Materials prepared by a psychologist as a part of his regular work under specific direction of his organization are the property of that organ- ization. Such materials are released for use or publication by a psychol- ogist in accordance with policies of authorization, assignment of credit, and related matters w-hich have been established by his organization. b. Other material resulting incidentally from activity supported by any agency, and for which the psychologist rightly assumes individual responsi- bility, is published with disclaimer for any responsibility on the pai-t of the supporting agency. Principle 19. Promotional Activities. The psychologist associated with the development or promotion of psychological devices, books, or other products offered for commercial sale is responsible for ensuring that such devices, books, ~or products are presented in a professional and factual way. a. Claims regarding performance, benefits, or results are supported by scientifically acceptable evidence. b. The psychologist does not use professional journals for the commercial exploitation c~f psychological products, and the psychologist-editor guards ngainst such inisilao. c. The psychologist with a financial interest in the sale or use of a psy- thological product is sensitive to possible conflict of interest in his promotion (i~ 5'u~h products and avoids compromise of his professional responsibilities and objectives. Mr. SIsK. Also, we will insert at this point a statement. by our colleage, Mr. Broyhill. STATEMENT OP HON. JOEL T. BROYHILL, A REPRESENTATIVE IN CONGRESS PROM THE STATE OP VIRGINIA Mr. Chairman and members of the subcommittee, by these. brief re- marks I wish to record my opposit.ion to H.R. 10407, in its present form. Let me emphasize that I favor regulation of the practice of psychology as expressed in the preamble of the bill. The public needs protection against unqualified practice. Unfortunately, it appears to me that this bill eliminates existing protection against unqualified medical practice and offers inadequate safeguards in return. The present Healing Arts Practice Act has set high standards ~of medical competence for persons who treat the citizens of the. District of Colmnbia. H.IR. 10407 states that it does not mean to affect. the. Healing Arts Practice Act, `but in fact it specifically authorizes per- sons without medical training to offer psychotherapy alid similar forms of medical treatment to any persons who seek help for mental problems. Phychologists ought to be licensed to do what they are competent to do, but because of the obvious inclusion of this area of `psychology in the medical picture and because the individual seeking help does not necessarily know the non-medical limits of the psychologist's training, it is important that this bill be harmonized with the Healing Arts Practice Act to insure appropriate medical PAGENO="0079" 75 consultation and supervision in those cases in which the psychologist may be dealing with mental illness and treatment. Furthermore, it is necessary to be clear that even with consultation only a properly qualified psychologist, and no other non-medical persons, can engage in this area of practice so interrelated with medicine. H.R. 10407 fails co~npletely to do this. it is my understanding that representatives of the national psy- chiatric and psychological organizations, as well as the local braiTches, are aware of these problems and have discussed them. I am confident that given an expression of interest from Congress, these professionals can resolve the questions on the professional level where they belong and present a bill which all can agree will adequately protect the pi~blic. Thank you for permitting me to present these views. Mr. SIsK. The Si~thcommittee will stand in adjourrnnent, until fur- ther call of the Chair. (Whereupon, at 12:10 p.m., an adjournment was taken, subject to the call of the Chair.) PAGENO="0080" PAGENO="0081" PSYCHOLOGY MONDAY, JUNE 3, 1968 HOUSE OF REPRESENTATIVES, SUB00MMn'riE No. 5 OF THE COMMITTEE ON THE DIsmI0T OF COLUMBIA, Washington, D.C. The subcommittee met, pursuant to recess at 10.00 a.m., in Room 1310 Longworth House Office Building, lion. B. F. Sisk (chairman of the subcommittee) presiding. Present: Representatives Sisk, Whitener, Jacobs, Walker, Horton, Gude, and Zwach. Also Present: James T. Clark, Clerk; Sara Watson, Assistant Counsel; Donald Tubridy, Minority Clerk, Leonard 0. Hilder, Investigator. Mr. SISK. Subcommittee No. 5 will come to order. We have before us this morning a continuation of the hearings on H.R. 10407, by the Chairman of our committee, and S. 1864 which has passed the other body. It is a bill to regulate the practice of psychology. At the conclusion of our hearings some two weeks ago, we had heard from a group of psychologists and several other people with reference to the need for this legislation or for some kind of legislation to regu- late the practice of psychology. This morning the committee will be glad to heard from witnesses from the Washington Psychiatry Society and others interested in this legislation. First, the Chair would be happy to call to the witness stand members of the Washington Psychiatric Society, Dr. Milton Meltzer and Dr. Richard Stienbach. These are the two names that I have. Is there anyone else that you gentlemen wish to bring with you? If you prefer to make an appear- ance in a group, the committee would be very happy to have you do so. Dr. LEGAIJLT. We would like to appear as a group. Mr. SIsK. I might say, If you will, Doctor, please identify each one of the gentlemen seated at the table. I might further state that the committee would be glad to make a part of the record any statements that any of you gentlemen have. You may read those statements or you may simply make an extem- poraneous statement briefing the material. That is strictly up to you. Now you may proceed, Dr. Legault. (77) 94-755-68------6 PAGENO="0082" 78 STATEMENTS OP DR. MILTON MELTZER, PRESIDENT; DR. RICHARD STILNBACH, PAST PRESIDENT, REPRESENTING WASHINGTON PSYCHIATRIC SOCIETY; DR. OSCAR LEGAULT, PRESIDENT, WASHINGTON PSYCHOANALYTIC SOCIETY; AND DR. JOHN HUGHES, T~EMBER OP THE EXECUTIVE BOARD OP THE DISTRICT OP COLUMBIA MEDICAL SOCIETY Dr. LEGAtTLT. Mr. Chairman and members of the Subcommittee, I am Dr. Oscar Legault and I represent the Washington Psychoanalytic Society, an organization of psychoanalysts in Washington, D.C., rep- resenting over 100 physicians. We are all psychiatric specialists a.nd have had subsequent specialty training in a particular branch of psy- chiatry known as psychoanalysis. To my right is Dr. John Hughes, a member of the District of Co- lumbia Medical Society; and Dr. Milton Meltzer to my immediate right, President of the Washington Psychiatric Society; and Dr. Rich- ard Stienbach on my left, who is the immediate Past President of the Washington Phychiatric Society. In addition there was to appear with us this morning a representa- tive of the Medico-Chirurgical Society of the District of Columbia. They apparently are delayed. I am authorized by the President of that Society to join their endorsement of this statement that I am about to make. Mr. SIsK. You may proceed. Dr. LEGAULT. The District of Columbia Medical Society, which Dr. Hughes represents, is the local constituent body of the American Med- ican Association. Its 2300 members constitute the overwhelming ma- jority of medica.l practitioners in the District of Columbia. The Med- ico-Chirurgical Society of the District of Columbia represents the Negro physicians of the District of Columbia and its environs and is a constituent body of the National Medical Association. The Washington Phychiatric Society consists of over 400 phychia- trists practicing in this area. It is the loca.l constituent body of the American Psychiatric Association, as the Washington Psychoanalytic Society is the local constituent society of the American Psychoana- lytic Association, these being the two principal professional organiza- tions of medical psychiatrists. OB,rEcrloNs TO BILL Our memberships favor regulation of thep ractice of psychology in the District of Columbia. Unfortunately, H.R. 10407 does not regu- late the practice of psychology. To the contrary, with respect to those activities of psychologists in dealing with the mentally ill, this bill would eliminate the existing regulation of practice under the Healing Arts Practice Act of the District of Columbia~. We understand that there are many provisions of this bill which do not enter into the sphere of our concern, which is treatment of the mentally ill by psychologists. But to the great extent that the bill does affect the treatment of mentally ill members of the public in the District of Co- lumbia, we must oppose it in its present form. PAGENO="0083" 79 Our position that this bill would eliminate existing regulatory provisions of the Healing Arts Practice Act is not mere surmise. California had a statute quite similar in scope to the one being presented to this Subcommittee. The Attorney General of that state was forced to conclude in a written opinion that that law, by impli- cation, abrogated protections of the medical licensing law applicable to the practice of psychotherapy. The California Legislature acted promptly to amend its laws, and today licensing of psychologists in California is done ultimately by the Board of Medical Examiners, and I am advised that psychology is recognized as being controlled by the same body of law which has clevlopecl with respect to the practice of medicine. I would now like to depart from my prepared statement to enlarge somewhat on this focal point of California's experience. The difficulties in the California Act derived from the presence in it of a clause similar to Section 20(B) of H.R. 10407 which reads: ~otliing in this Act shall be construed to prevent qualified members of other professions from doing work of a psychological nature consistent with their training and with the code of ethics of their respective professions: Provided, that they do not hold themselves out to the public by any title or description incorporating the words "psychological," "psychologists," or "psychology," unless licensed under this Act . . . * * * I submit that by this wording H.R. 10407 would authorize any group of people whatsoever forthwith to found a. new profession and to proceed to practice psychotherapy with the mentally ill. Dr. Malcolm Meltzer in his testimony before this committee the other day said that the bill does not prevent the members of "bona fide professions" from "doing work of a. psychological nature." I see nothing in the bill that specifies in any way what is meant `by the phrase "qualified members of other professions." Possibly again this is an instance of the loose wording that is characteristic of this bill and is meant to mean members of other qualified professions, but then, of course, one would have to define what the qualified professions are which nowhere `appears in the bill. To illustrate the difficulties that such wording might cause, may I recount that t~ few years ago in the District of Columbia an individual whose sole professional qualifications consisted of his having been a science fiction writer decided that his fertile imagination would be better occupied in treating the mentally ill. He called the pseudo- science he established by a fancy title `and its practitioners whom he recruited by a fancier one. The case is well known to most professional persons in this room. Our pseudo-scientist would have been gratified by Section 20(B) of this act for he could hasten to claim that doing psychotherapy with the mentally ill would be certainly "doing work of a psychological nature" as defined in this act., would be certainly within the "code of ~thics" and "consistent with the training" of his new "profession" and who could gainsay since he and his group had thus defined it. He would, of course, be careful not to use the title "psychologist" or any other term proscribed in this act, thus easily evading the pro- visions the psychologists have claimed would protect the public against charlatans. PAGENO="0084" 80 In addition to the havoc of its permissiveness, Section 20(B) would simultaneously destroy the possibility of prosecuting charlatans of this sort under the Healing Arts Practice Act, which presently says that no unlicensed person shall treat anyone with any mental disorder (in my knowledge of the language this includes the term psycho- therapy). It does not provide exceptions to the Act merely on the grounds of belonging to a group that thinks psychotherapy of the mentally ill is within its code of ethics and sphere of professional competence. Section 20(B) of this Act, on the other hand, places the code of ethics in judgment of any such so-called professional group above existing law. At the present time. the Healing Arts Practice Act prevents indi- viduals from diagnosing a.nd treating bodily and mental disorders and diseases unless they have the proper medical training and a medi- cal license. But trained psychologists do treat mental diseases and disorders. At the present time, it is clear that this must be done sub- ject to medical responsibility. This vital aspect of the practice of psychology is regulated at present. The proposed bill does not. distinguish between these medical ac- tivities of psychologists, and those which involve psychological experi- mentation and testing with animals, public opinion polls, testing, job counselling, and the myriad other functions performed by psycholo- gists. The Congress must be concerned with this homogenizing of the various activities of psychologists in one licensing act which poses the threat tha.t the medical responsibility which the public expects for its protection will be lost. In this statement, we shall deal with the problem of t.he psychologist in this medical arena. The reason we must be concerned with the role of the psychologist in clinical practice is that they are not physicians and their training and background is rarely sufficient for dealing with the mentally ill. Recently I read an article in the Journal of the American Psycho- logical Association. it.self, by Saul Rosenzweig, Professor of Medical Psychology ot Washington University (although himself a psycholo- gist, not a physician) in which Professor Rosenzweig makes the point that psychologists "lack adequate practical or clinical experience" and that their "scientific and research preparation [is] inadequate." May I add we are prepared to furnish copies of this speech to the subcoimnittee. Although most psychologists in clinical practice are highly trained for their particular specialty, extremely competent, and highly ethical, I and my colleagues have seen sufficient evidence in our practices of persons who have been misdiagnosed, medically, by themselves or by non-medical counsellors and therapists, to be absolutely certain that non-medica.l specialists should not be allowed to legislate for them- selves the status to diagnose and treat mental disorders which they are not competent to do. It simply is not warranted by their training, which frequently is in installations such as student counselling serv- ices in universities and similar clinics, at which the clients suffer generally from relatively mild disorders or personality adjustments. I venture to say that if every psychologist appearing today were to be asked by this Subcommittee whether he ever had full responsibility for patient care during the course of his training, lie would be forced to admit that lie had not. PAGENO="0085" 81 For it is a fact that even the psychologist who does avail himself of in-hospital training which gives experience with the more seriously maladjusted, always functions under the supervision of psychiatric medical personnel and his training always is restricted to the psycho- therapeutic aspects of treatment and never, since he is not a physician, can he or does he assume overall responsibility for any other aspects of the case. As a result, the fully trained psychologist, the well-trained one, cannot often without medical assistance ascertain which pros- pective clients for psychotherapy, the psychologist's method of treat- ment, are in need of other medical measures such as drug or physical treatment or in-hospital care. Since these very measures are often life-saving in many instances, the public should not be exposed to sit- nations where they cannot be knowledgeably considered. BACKGROUND OF LEGISLATION The method by which H.IR. 10407 and its companion bill in the Senate, 5. 1864, have been presented to the Congress is indicative that the public interest is not the chief concern of the bills' proponents. When hearings were held in the Senate on S. 1864, our concerns and differences with the psychologists' organizations were laid upon the table. It was agreed by all concerned that the psychologists' and psychiatrists' organizations could and should explore and resolve these differences in the interests of appropriate public protection. The view was expressed by us, and we thought at the time adopted by all con- cerned, that as professional specialists we could present a bill together with appropriate safeguards for the public. As a result, our repre- sentatives and representatives of the psychologists' associations began discussing precise language and amendments to the bill which is 10407. Then, in the middle of these conferences, in which the public in- terest and concern was our pole star, we received a telephone call from a representative of the D. C. Psychological Association which advised us that they had been informed that appropriate maneuver- ing could bring their bill to a vote and they no longer wished to confer with us. Still later, when these non-professional efforts bogged down, there was another telephone call to start treating the problem at a professional level again. And once again, there was a telephone call to terminate these efforts, not on any ground that the public inter- est would be promoted by such termination, but because it was felt that the bill could be enacted in a hurry without further scrutiny. SPECIFIC OBJECTIONS If this were not sufficient evidence as to the true nature of this bill, we can turn to its provisions themselves. Section 5(0) permits any psychologists to hire as many nonpsychologists as he wishes and so long as they are employed by him they can practice psychology with- out a license. I submit that a doctor would be deprived of his license almost instantly if he attempted to treat people in this fashion. Sec- tion 12 of the bill permits a corporation to make a psychologist an officer and then, with all its corporate anonymity, corporate limita- tion of liability, and no personal responsibility, to treat people with PAGENO="0086" 82 problems and disorders. It is fantastic to call this a bill to "regulate." It is to eliminate any meaningful regulation. Another equally blatant provision is the "grandfather clause" of this bill which should be renamed a "youth clause." Instead of requir- ing greater clinical experience, of one who will be exempted from an examination to determine his competence, this bill requires less experi- ence for those licensed immediately than for those who also have to ta.ke the examination to be licensed in future years. This is an obvious self-serving provisioli for existing members of the proponent groups, and not an attempt to protect the public from inexperienced practi- tioners. Even the part of the bill which seems to regulate psychologists by referring to their role when clients' problems fall outside of the boundaries of their own competence (Section 4), is an attempt to mislead the Congress. The Code of Ethics of the American Psycho- logical Association requires that "provision be made for the diagnosis and treatment of relevant medical problems and for referral to or consultation with other specialists." In the bill which this Subcom- mittee is being asked to approve, the mandatory language of the Code of Ethics has been reduced to an expression of hope: "The psy- chologist who engages in practice is expected to assist his client in obtaining professional help" and he "should" (not must) refer to medical practitioners. Then, too, the definition of medical problems as being beyond the scope of the psychologists' competence is delib- erately changed in this bill to physical problems. In our understand- ing, the words "medical problen~s" in this context, including as they do "psychiatric problems" is much superior to the text now before the Congress, though it falls short of what we would recommend as a solution to the considerations we are raising. Our purpose is to make certain that the usychologists' own Code of Ethics prevail over this watered-down bill, and to insure tha.t the standards of medical Practice present.fv exist.in~ in the. District, of Columbia are not. lost t.o the public. The Code of Ethics says that there must `be medical supervision of psychologists when dealing with medi- cal, including psychiatric, illnesses. Our Healing Arts Practice Act insures that thetrained physician has this clinical responsibility. The medical profession has long dealt with ns'vchologists on a professional level and ire welcome licensing of this growing and important. pro- fession. But in enacting a bill which is apnlicable. equally to psychol- ogists clea.lin~ with individual disorders and others who never have clinical functions, this Congress should not eliminate. tho medical supervision and responsibility which members of the public rely on when they are sick and seeking help. It is interesting to note that the Healing Arts Practice Act, itself, recognizes that. persons with skills other than ,in medicine a.nd surgery may work with diseased and disordered individuals. Title 2, section 111 of t.he D.C. Code provides for any group, such as the psychologists. practicing a healing art. without drugs, to apply for licensure under the Healing Arts Pract.ice Act.' So far as we know, the psychologists have never attempted to invoke this authority. 1 45 Stat. 1327, approved Feb. 27, 1929. PAGENO="0087" 83 Since the psychologists have expressed to us their desire to regulate' clinical psychology in the same fashion as industrial psychology, school counselling, and other nonmedical functions, and since they have re- fused to write distinction's into their bill, we can only ask th'at H.R.. 10407 not be enacted into law, or if it is to get such consideration, that it be amended so as not to repeal or vitiate the safeguards of the Heal- ing Arts Practice Act. To this end, `we have prepared a draft bill which follows as closely as possible H.R. 10407 and S. 1864 in those areas which do not concern the medical profession, but this draft contains the minimal safeguards which we feel are necessary to eliminate unregulated and unsupervised. public practice. We request `the permission of this Stibconirnittee to present this draft for inclusion in the record after the `close of `these hearings. During the prior hearings on this bill, while the representatives of the psychologists' organizations were testifying, a number of searching questions were asked by the Subcommittee and elicited responses about which we should comment. Rather than try to anti'cipate the further questions of the Subcommittee, however, I will reserve such comment. The other representatives with me would like the opportunity to make brief statements, after which we all would be most happy to try and answer the question of the Subcommittee. I believe Dr. Hughes wished to make a brief statement. Mr. SIsK. Th'ank you, Dr. Legault. Dr. Hughes, do you want to make a statement now? Dr. HUGHES. Yes. Mr. `Cha:irman and members of the subcommittee, my name is Dr. John Hughes. I am a member of the Executive Board of the Medical Society of the District of Columbia. The Medical Society strongly supports the statement by Dr. Legault concerning H.R. 10407. `The Medical Society commends the desire of the psychological profession to regulate their practice. We must, however, express our concern th'at the proposed legislation does not specifically require `medical consultation for `those patients suffering from physical and/or mental disease. Training in psychology, no matter how excellent, does not lead to clinical competence in diagnosis and treatment of patients with physi- cal and/or mental disease. These activities are sharply distinct from psychological services in counseling, testing or group evaluation. Many physical diseases, metabolic `abnormalities and toxic states may first manifest `themselves by mental aberration. These circum- stances require diagnosis and evaluation by a trained and licensed physician. T'o `allow otherwise would subject our citizens to medical treatment `by persons lacking proper medical training and without medical licensure. `The Medical Society of the District of Colun~bia earnestly requests that H.R. 10407 be amended to insure continuance of adequate safe- guards in the treatment of the physically and/or mentally ill. I am grateful for the opportunity to express the Medical Society's concern. Thank you. Mr. SIsK. Thank you, Dr. Hughes. Dr. Meltzer? PAGENO="0088" 84 Dr. LEGAuLT. The remaining members would prefer that we simply respond to questions. We hope that unless questions are specifically directed to one of us, that we can feel free to contribute our answers as indicated. Mr. SIsK. Dr. Meltzer, or Dr. Stienbach, do either of you have a statement for the record? If so, we would like to have them for the record. Thank you, Dr. Legault, for a rather comprehensive statement as to the position of the Psychiatric Society as well as, as I understand it, the Psychoanalytical Society and the D.C. Medico-Chirurgical Society. This is more or less of a combination of the three societies? Dr. LEGAULT. The Medico-Chirurgical Society, that represents all the medical organizations of any significant size in the District of Columbia. Mr. SISK. As I imderstand, Dr. I~gault, in your statement, you recognize and agree that there is a. need for and your membership does favor regulation of the practice of psychology in the District of Columbia? Dr. LEGAULT. Very definitely. PROPOSED AMENDMENTS Mr. SIsK. Do I understand that you have prepared, or the D.C. Medical Society has prepared, a substitute bill for this, or amendments, which you are prepared to submit to the committee? Dr. LEGAULT. We are in the process of preparing that. We have a sort of a draft bill which we will submit shortly after the end of the meetings, or we can submit it now. We would like to polish it a little bit. Mr. SI5K. Without objection, I would like to have it made a part of the record, if you will have that within a reasonable period of time. Dr. LEGAULT. Yes, sir. Mr. SIsK. I might say the Chair hopes to conclude these hearings this morning and it would be assumed we would keep the record open for a. week or 10 days. Dr. LEGAtILT. Certainly within a week. Mr. SIsK. Without objection, submit that and we will include it in the record. (For draft, see p. 149.) Mr. SI5K. In your reference to the Healing Arts Act in the District of Columbia, which was referred to, and I know we have gone over this in previous hearings on other legislation, let me ask you this: Do you feel that that as to act, in view of the fact it is now some forty years old, with some minor amendments, do you feel there is any need to rewrite that law and update it? Has the Medical Society-and I might ask this of Dr. Hughes or any of you making a comment-has consideration and study been given to a complete rewrite of the Healing Arts Act here in the District of Columbia? I ask this question because in so many instances various groups raised questions about it over the period of the last several years. I would just like to discuss briefly with you what your feelings are with reference to that law. PAGENO="0089" 85 Dr. LEGAULT. We have not considered that, Mr. Chairman. I could oniy answer from my personal feelings about it, without representing any particular feelings on the part of my organization, and maybe' the other members of the group here have some feelings about it. `I was struck, myself, in reading the Act, with the specific reference to how it might apply to the practice of psychiatry, that the wording could be altered. It has a certain antique flavor. Mr. SI5K. Very antiquish, I might say, in many aspects of it. It is a pretty old law. Dr. HUGHES. Mr. Chairman ~ Mr. SIsK. Yes. Dr. HUGHES. The Medical Society of the District of Columbia has been actively seeking initially to amend and ultimately we hope to engender or stimulate a complete rewriting of this 1929 law with its many subsequent amendments. I have been on the committee that has worked on this and is con- tinning to work on it quite actively in the Medical Society. Our concern with the changes proposed in this li'censure law, Healing Arts Practice Act, involve the difficulty primarily in licensure of physicians from other jurisdictions and other countries, which is a major problem with so many foreign-trained and foreign-born physicians in the country; also, with problems in allowing some sort of temporary licensure for medical residents since the modus operandi of the practice of medicine in hospitals today is so much different from what it waS ii~ 1929. The medical residents are six years in training and they need some licensure to allow them to function because, indeed, in many respects they are functioning beyond the stage of the ordinary trainee in the later years they are training. The Medical Society in its consideration of the Healing Arts Prac- tice Act has never had any quarrel with nor would we think it would be desirable to eliminate safeguards regarding adequate training, ade- quate background, adequate examination in the selection of candidates for licensure. The Medical Society's concern would be somewhat antiquated li- censure statutes. I don't believe from the standpoint of the Medical Society it would be applicable to this question of psychologists, which was something totally foreign to the law itself. Mr. SIsK. The thing that I was curious about, as you know, is that there are a number of groups which we might call for lack of a better term "peripheral groups" in the field of health care of one kind or' another. I am trying to choose my words carefully because you may disagree. I recognize that in any profession of medicine there are many aspects in the business of specialization where everyone seems to be specializing in a particular field. Do you feel that by fragmen- tation-by that I mean a separate Department under the Healing Arts Act for psychologists dealing with licensing procedures, and so on, the' same thing for groups dealing in psychiatry, and one which we have' had be-fore us now for several years, practice of optometry in the District as differentiated from an ophthalmologists-do you feel frag- mentation into individual acts dealing with licensing and practice is better than an overall rewrite of the 1929 Act, or should we continue an overall law by which all people dealing with the care of our citi- PAGENO="0090" 86 zenry in every aspect of their health care, actually disease of the body, physical disease, et cetera, should be guided? Would you make some comment on that, Dr. Hughes? This does go to the heart of some concerns by members of this committee and others who have some concern with what is going on in the District of Columbia. Dr. HUGHES. I believe that the Medical Society would feel that the optimum situation would be if the entire Healing Arts Practice Act were rewritten, updated, modernized, and ideally that would include all professions, all endeavors that are involved in health care. It. has been our understanding, perhaps erroneously, that it is a somewhat monumental task and might take a grea.t deal of time. That is why the Medical Society in other connections has addressed itself to an amendment or two to try to meet a current problem. The ultimate optimal situation would be to rewrite the entire thing from scratch, elhninating things anachronistic and bringing it up to date. If it could include everyone that deals with sick people in any way, I think this would be ideal. I believe the Medical Society would feel that way unquestionably. Mr. SIsK. I appreciate your statement, Dr. Hughes. I realize the question was all-comprehensive and all-inclusive. The reason that I ask the question is that there is pending now in Congress a. variety of bills dealing with licensing procedures, practices, all in the periph- eral area of care of people a.nd of their needs from t.he standpoint of physical needs. For example, there is a bill dealing with the practice of podiatry here in the District. We have this one on psychology. There is another one on optometry. I remember there a.re also two or three more dealing with specific licensing procedures for specific groups. That is the reason why it seems to me maybe at some point there should be a comprehensive study and analysis made on how best to proceed in this field. It is evident there is some need to rewrite a.nd update old, outmoded laws. I believe we all recognize that. Dr. LEGAULT. May I add to something I sa.id before? Mr. SISK. Yes. Dr. LEGAULT. Although our psychiatric and psychoanalytical soci- eties have not considered t.he actual mechanics of the problem of writ- ing laws for what. we would call the ancillary professions, t.hose pro- fessions that serve in a helping mode. the central profession of medicine, though we ha.ve not considered how the regulation of such professionals should be written into the law in the District, we have been concerned certainly with a particular point which I think all medical organiza- tions agree on; that. is, t.hat in the. writing of separate laws for either separate or comprehensive laws for the regulating of such ancillary professions there not. be lost sight. of the fact that medicine is orga- nized in a rather hierarchal fashion and that this organization of medicine in writing such separate laws must not. be interfered with. It must provide for central responsibility of the physician at the core of all licensing acts~ provisions for necessary consultation with i~im whenever it is required. Mr. SISK. Thank vou~ Dr. Le~ault.. PAGENO="0091" 87 I don't wish to take more time. We have a good turnout of the committee here this morning and I am sure the members have ques- tions. I would like to quickly explore one further thought with you. As I understand it, this bill has passed the Senate. What was the date of the passage in the other body? Do you recall? Dr. LEGAULT. I don't recall. It was the 25th, I believe. Mr. SI5K. April 24, 1968. At that time, I understand that your Society did make a presentation to the other body? Dr. LEGAULT. We did. Mr. SIsK. Let me hasten to say what the other body does would not govern what this body does or what the committee may do. I am a little bit concerned. This bill did pass the Senate unanimously, is that correct? Dr. LEGAtTLT. Yes, sir. Mr. SI5K. Yet you presented basically the same testimony there you presented here? Dr. LEGAtTLT. Basically, yes. Mr. SIsK. The Chairman of our committee, Mr. McMillan, intro- duced this bill on May 29, 1967. That has been slightly over a year ago. In view of that, I was curious; have you been interested in this throughout this time? Have you made your feelings known or dis- cussed them with interested people? Dr. LEGAULT. We have discussed our approach of our organizations at the time the psychologists were planning to introduce the bill. We knew of their intention to gain a licensing bill before the bill was intro- duced. Our organizations have been in contact with the psychologist tip to the time that they broke off negotiations with us concerning the wording of their bill. WTe have met many times with the representatives of their organizations and during the time that we were involved in discussing the proposed legislation with the psychologists we made no attempt to present our views which we felt were in the process of formation rather than fixed views to any member of the Senate. As a consequence, no representative of any of our organizations has per- sonally contacted any Senator at any time. The only representations we ever made to the Senate were at our formal hearings. As a conse- quence, we feel that our views were really not very adequately pre- sented to the Senate. Mr. SISK. Apparently after it passed the Senate, as I recall, you were somewhat more active in letting your views be known. Dr. LEGAULT. We have been considerably more active, Mr. Chairman. Mr. SI5K. Thank you, Doctor, and gentleman, for your appearance this morning. The gentleman from North Carolina, Mr. Whitener. Mr. Wmri~NER. Doctor, the only thing that I would ask about is Section 4 in H.R. 10407, the House bill. As I understand it, it is iden- tical to Section 4 in S. 1864, the Senate bill. In view of this language about a psychologist engaged in practice expected to assist his client in obtaining professional help outside of the known area of compe- tence, for example, provision should be made for the diagnosis and treatment of relevant physical problems by an appropriate qualified medical practitioner. PAGENO="0092" 88 The staff has provided me with a copy of the North Carolina Act which was passed by the North Carolina Legislature in 1967.' I note that Section 3 reads as follows: PRACTICE OF MEDICINE AND OPTOMETRY NOT PERMITTED Nothing in this Article shall be construed as permitting licensed practicing psychologists or psychological examiners to engage in any manner in all or any of the parts of the practice of medicine or optometry licensed under Articles 1 and 6 of Chapter 00 of the General Statute, including, among others, the diag- nosis and correction of visual and mr~scular anomalities of the human eyes and visual apparatus, eye exercises, or orthoptics, vision training, visual training and developmental vision. A licensed practicing phychologist or psychological ex- aminer shall assist his client in obtaining professional help for all aspects of his problems that fall outside the boundaries of his ow-n competence, including provision for the diagnosis and treatment of relevant medical or optometric problems. In rendering psychotherapy in any form, the licenses practicing psy- chologist or psychological examiner shall develop liaison, communication, and meaningful collarobation with a physician, duly licensed to practice medicine in North Carolina, designated by the client. That language is much more specific than the language proposed here. I am wondering what you gentlemen feel about using the North Carolina language in lieu of the language of Section 4 in the proposed House bill. Dr. LEGAuLT. I think that I can speak for all of my colleagues here. We would be very much in favor of it, not only the language of the North Carolina statute but similar language in licensing laws through- out the United States, but. of similar precise legal language deftning the relationship between the professioi~als; in this case the phrase "effective collaboration," that. is a phrase used in other licensing acts which say that really spells it out, what the requirements of the law are. \Ve would be very much in favor of that. Mr. WHITENER. If that language or similar language were placed in this legislation, that would remove most of the objection you gen- tlemen have to the legislation, would it not? Dr. LEGAULT. It would remove some of the objections. I don't, think most of them, Mr. Congressman. Because of the fact that there are other things in this legislatiorl, Pal'ticulallY Section 20(B) which I commented on in my prepared statement, which really offer very, very large loopholes as to permission to charlatans to practice in the District of Columbia. Then there are provisions on corporate practice and which I also commented ~n with which we are very much in disagree- ment. Mr. WTHITENER. This language, "members of other professions~" that may mean what? Dr. LEGAULT. That can mean anyone. Mr. WHITENER. It could mean a lawyer. Mr. SIsK. The gentleman from New York, Mr. Horton. Mr. HORTON. Dr. I~gault, your prepared statement refers to a draft bill which your organization has been preparing. Has that been sub- mitted? Dr. LEGAULT. It has not been submitted. Mr. SIsK. If my colleague would yield, we had a discussion toward the end on that. They have prepared it, but they want to polish it a North Carolina Laws, Ch. 910, Laws 1967, Senate Bill No. 578. Ratified 22 June 1967 PAGENO="0093" 89 little bit. I already agreed to have it inserted in the record shortly after the termination of these hearings. Mr. HORTON. That, I would assume, would point out also your con- cern with H.R. 10407? Dr. LEGAtTLT. Yes, sir. Mr. HORTON. I don't have any questions. Mr. SI5K. The gentleman from Indiana? PSYCHOTHERAPY Mr. JACOBS. I only have a brief inquiry to make, Dr. Legault. I want to thank all of you doctors for appearing this morning. With reference to your prepared text on page 5, where you say that the training of psychologists is always restricted to the psychothera- peutic aspects of the treatment, I had some trouble with the term "psychotherapeutic" when the psychologists were testifying. I thought perhaps it was a rather broad term and included activity beyond the admitted sphere of competent activity by psychologists. Is my alarm well founded? Your statement indicates that psychotherapy perhaps is the exclu- sive province of psycholo~ists? Dr. LEGAULT. No; if it indicated that, Mr. Congressman, I rnisspoke. What I meant by that was that the training of the psychologists in an in-hospital situation in the performance of psychotherapy, he is not trained in anything else in the hospital, with the exception of certain specific psychological things, such as testing and so forth. So far as his quasimedical activities are concerned, his training is restricted to psychotherapy. It is understood that a doctor is trained to do many other things besides this. Mr. JACOBS. Doctor, aren't some of the things that an M.D. alone is competent to perform properly classified as psychotherapy? Dr. LEGAULT. Yes; that is what I was coming to. Also, there are certain forms of psychotherapy and certain psycho- therapeutic measures, and particularly psychotherapy with certain types of patients that are not the province of psychologists. In a hos- pital setting, a psychologist is never permitted to do psychotherapy with any patient apart from being supervised actively by a physician. Certain types of patients a psychologist will never treat, or rarely treat, but I wouldn't want to say that they never treat. That is an exaggeration. I personally have supervised the psychologists in treating a schizo- phrenic, which is a very serious form of mental illness. This is a rarity. Generally speaking we do not train psychologists to perform those functions. Mr. JACOBS. What did this Jack-of-all-trades psychologist call his profession? Dr. LEGAULT. The reason I didn't want to say his name is I didn't want to be sued. Mr. JACOBS. Not his name. Dr. LEGAULT. He called his activity dynaphetics. Mr. JACOBS. Dynaphetics. Mr. HORTON. Mr. Chairman? Mr. SIsK. Yes. PAGENO="0094" 90 ~EW YORK LAW Mr. HowroN. Doctor, I have a. letter from the New York State Psychological Association. They refer to the fact that New York State has had a statute in effect similar to tue BI.R.. 10407 for over ten years. This statute requires a person representing himself as a psychologist in this state be a member with a level of competence based on a doctoral degree, have two years of supervised experience a.nd completion of the state examination. Are you familiar with the New York statute? I am not familiar with it and I wondered whether it is comparable to the bill before us? Dr. LEGAULT. I am not personally familiar with that. Is anybody familiar with that? If you don't mind, I will consult with our attorney here, who is more expert.. Mr. HORTON. You might not be prepared to answer that.. That is perfectly all right. I thought you might have some knowledge of that. The association in New York State is urging my support for the bill. They have indicated that New York has a law similar to this bill in existence for over ten years and it worked well. Dr. LEGAULT. Mr. Cooter, our attorney, informs me New York State does not have a licensing law but a certification law. Mr. HORTON. Perhaps you might for the record get something for us on that. Dr. LEGKULT. We would be very pleased to. Mr. HORTON. That would be helpful. Mr. SIsK. If the gentleman would yield, we have copies of all state laws here. Mr. Clark has them available. The committee will take a look at some of them. You may want to make a study of the California law. We have, as I understand it, a. law that is working quite well. In fact, I put in the record in the last hearing a copy of a letter from California representing the group of psychiatrists basically in s'ip- port of a general regulatory law for psychologists. The feeling is the California law is working very well. I have not had an opportunity to compare it. wifli other State laws. Is the gentleman from New York finished? Mr. HORTON. Yes. Mr. SIsK. The gentleman from Maryland? MARYLAND LAW Mr. GUDE. Thank you, Mr. Sisk. I wonder if anyone would be able to comment on the Maryland laws that affect psychology as compared to what. is proposed in this bill. Dr. LEGAULT. So far as I am aware, Maryland law again is not a licensing law; it is a certification law. Do I have to go into the dif- ference in this case? The certification law, one of t.he essential differ- ences in the licensure laws, as I understand it, is that they spell out activities of a particular profession, whereas certification laws write out. permitted act.ivties but do not specify them as closely as a licensure law. The general position of the American Psychiatric Association since 1951, I believe, has been in favor of certification laws for psychol- ogists. This protects the public by registering the title, psychologist, which is all that this bill does, to protect the public. PAGENO="0095" 91 Mr. GUDE. Does the Maryland law give a psychologist the legal authority to carry on psychotherapy? Dr. LEGAtTLT. I am not sure of the exact wording. It does not specifically mention that. Mr. GUDE. You propose to submit to us an amended version of this legislation which you are going to draft. On this legislation as amended, would you urge its adoption or would this merely be some- thing that you could live with, so to speak? Dr. LAGAULT. No. We would urge its adoption. Mr. GtTDE. You do urge its adoption and feel there should be some type of registration or certification? Dr. LEGAULT. Very definitely so. Mr. GUDE. Thank you. Mr. SIsK. The gentleman from New Mexico. Mr. WALKER. Thank you, Mr. Chairman. Over the weekend I did a little research on this bill and the hearings we have had up to now and with the remarks and questions made by my colleagues from this committee. This has enlightened me somewhat. As a matter of fact, Dr. Legault this morning further enlightened me. For the record and my own curiosity, I would like to ask a few questions I have worked up here. I take it, number one, from Dr. Brayfield of the American Psycho- logical Association, from his remarks the other day the psychology profession nationwide is in accord, also that the psychiatrists nation- wide are not opposing this bill. What is your interpretation of this, Dr. Legault? Did I make the question clear? `Dr. LEGATJLT. I think so. I think if I understood it. correctly, you are referring to Dr. Brayfield's comment that he saw no national or- ganizations of psychiatrists represented here and that lie implied by this omission that since he represented the National Organization of Psychologists, our local organizations did not have the support of our own national organizations. Mr. WALKER. That is the point. Dr. LEGAULT. This is of course untrue. The American Psychiatric Association and the American Psychological Association have long had a standing committee on the matter of regulation of psychologists. Our position with respect to the legislation which is being proposed is in accordance with the stand of our national organization, which has always at all times emphasized that the practice of psychotherapy should in some way be correlated with some sort of effective medical collaboration. Now, the position that Dr. Brayfield took, that our national organi- zations are not in support of our position is really interesting, because of May 13 at the recent American Psychiatric Association meeting in Boston a representative of our very organization in the assembly of our national organization moved, after presenting what the situation was here~ m the District, that the American Psychiatric Association reaffirm its stand with respect to the fact that when psychologists undertake to practice psychotherapy they should avail themselves of medical consultation, and that was passed not more than a few weeks ago by the American Psychiatric Association. PAGENO="0096" 92 Furthermore, as I am sure some members of the subcommittee know, other state psychiatric associations have expressed their interest in this bill and we certainly are not isolated from our colleagues in the point of view we are presenting to this subcommittee by any means. Dr. MELTZER. If I may add, I have a position statement by the Council of the American Psychiatric Association, February 1964, basic positions of the American Medical Association and the American Psychiatric Association, and this is related to principles underlying interdisciplinary relations between the professions of psychiatry and psychology. May I read this excerpt: It must be fully realized that physicians have the ultimate responsibility for patient care and that they and they alone are trained to assume this responsibility. It goes on further in another section to note that in connection with legislation: Such statutes relating to services which involve the diagnosis or treatment of nervous, mental or physical illnesses or disorders of individual patients, should require such services to be performed under the direct supervision of or in genuine collaboration with a qualified physician. Mr. WALKER. That is the point right there that concerns me, Doctor. Mr. Chairman, the other day when we had the first meeting of this subcommittee-and I might add here that I for one am impressed by the point t.hat my colleague, Congressman Whitener, here brought out as far as the North Carolina law is concerned. That would go quite a ways as far as I am concerned personally in helping make this a better bill. But with that remark that was made in clarifying my first question, as far as I am concerned at least the bill before us now- and also my colleague Mr. Jacobs brought out in the discussion and colloquy with the witnesses here the other day, and along with the statement that has just been made by Dr. Legault, what worries me is the infringement upon the practice of medicine as defined by the "Healing Art Practice Act", a.nd then Dr. Malcolm Meltzer made the point several times, as I recall, in response to the questions at our last hearing, that the psychologists do not treat mental diseases. This is the thing that has me disturbed. With that, I have a three-part question here, Mr. Chairman, if you will allow me to pursue this. MENTAL ILLNESS First, I would like to ask one of the witnesses, is it true that psychologists never treat persons with mental diseases or illness in their private practice or in hospitals? Dr. L~Aui~T. I think I would like to answer that question. I think that the stand that the psychologists are making that they never treat people with mental diseases in the hospital or in private practice cannot possibly be substantiated. I will take Dr. Brayfield's testimony here the other day in which he pointed out that Dr. Redlake, who is Dean of the Yale Medical School and a psychiatrist, had written a textbook of psychiatry in which the term "mental illness" was not used at all. There was no mention of that term. All of the PAGENO="0097" (`I') mental aberrations and disorders are described as behavioral disorders in this text. In other words, all of the major mental illnesses are described in the language that the psychologists have included in their bill such as behavioral adaptations or adaptive maladjustments of behavior. It is all used in those terms and therefore the psychologist would be licensed under their bill to treat mental illness though they call it by a different name. The fact that they are using different terms to describe a different mental illness does not mean that they are not practicing it. As a matter of fact, in hospitals they do in fact treat mental ill- ness though they do so under supervision. That is the first point I would make about their treating mental illness. The second thing I would like to point out is that if in fact psy- chologists do not wish to treat mental illness, it would be very simple to simply put a clause to that effect in the law-psychologists are not hereby empowered to treat mental illness. That would certainly take care of a great deal of the difficulty. But we would not favor such a clause because that would be ridiculous and would be restricting our psychological colleagues in the practice of something we feel they really ought to do, but they ought to do it under proper circumstances. So far as the treatment of mental illness, again, I would like to point out Dr. Brayfield's response to the reading of the letter from Dr. Rudden. `When the Chairman read the letter from Dr. Rudden of the California Society, Dr. Brayfield said lie was in complete agreement with that letter. That letter says in point No. 5 which Dr. Rudden recommended to the committee that the psychologist, when- ever he is treating serious mental diseases, should consult with a phy- sician. That is the essence of the communication from Dr. Rudden. It seems to me that Dr. Brayfield would have said at that point we are not in agreement with Dr. Rudden's position because psychologists never treat mental disease of any sort. He did not say that. What he said was, he was in total agreement with it, which implies what in fact is his real position, that is that the psychologists intend to treat mental diseases of a minor nature, that is not the serious types of mental diseases. But his agreement with that position is a clear indication of what his feeling is. The other publications of the psychologists very clearly state what they do. For instance, in this pamphlet which is put out by the Ameri- can Psychological Association, entitled "The Psychologist and Vol- untary Health Insurance," this pamphlet is a document which is addressed to insurance companies, stating that psychologists do in fact engage in the practice of psychotherapy and should be reim- bursed for this on medical insurance claims. When they are arguing to the insurance companies, they state as follows: Question. Who provides diagnostic and psychotherapeutic services? Answer. The clinical psychologist is a psychological specialist and the psy- chiatrist is a medical specialist, both of whom are concerned with the diagnosis and treatment of mental and emotional disorders. Mr. WALKER. Doctor, I assume from your testimony and the way you answered the question that the medical community we might say, also from what Dr. Hughes' short statement said, that they are certainly opposed to this legislation as it is written now. Is that a fair statement? Dr. LEGAULT. That is a correct statement, Congressman. O4-75~-GS----7 PAGENO="0098" 94 Mr. WALKER. Mr. Chairman, you brought this out somewhat a minute ago and I would like to clarify it for the record. It is my recollection that Dr. Meltzer again stated in response to a question concerning the effort of your various organizations to get together on the bill, in fact you also brought this up to quite an extent this morning yourself, Dr. Legault, in this discussion, that at first they opposed the psychologists doing psychotherapy and only later changed their opinion. You have already hit on this so we will not belabor it, but I got the impression that you started these negotiations and discussions and then this legislation was introduced, and then all of a sudden the negotiations and the talks, or whatever you want to call them, were dispensed with. Am I right in my assumption here? Dr. LEGAULT. That is correct, Mr. Congressman. We did engage, we started our discussions with the psychologists concerning the wording of the bill and the aims of the bill early last spring, and we continued our discussions throughout the year after having had extensive discussions in our own society as to what our feelings were about the psychologists, our psychological colleagues. We continued to discuss the bill with them right up to the time that the hearings were held in the Senate and after the hearings were held in the Senate. We continued to discuss matters with the psy- cologists until last March. The discussion at this point had come to a point where the professional representatives of both organizations had agreed that the matters that we were considering were legal mat- ters and that we should have attorneys representing both organiza- tions meet and recommend back to the individual organizations how they might agree. On March 8 I received a letter from Dr. Ba.yroth, the President of the P. C. Psychological Association, which read a.s follows: DEAR DR. LEGATJLT: I am concerned that a recent flurry of events interrupted the talks which our groups and lawyers were conducting concerning the bill to license psychologists in the District of Columbia. I am writing now to express our genuine interest in continuing our discussions. He then summarizes his position. He then says: Recently we received word that if our bill were to receive full hearings and action in the 90th Congress. we must step up our pace and make only thOSe modifications required by the change in the District Government. We agreed to do so in the knowledge that we were backing a very safe piece of legislation. Accordingly. we instructed our attorneys to discontinue further discussion with your attorney. And we were so informed. This letter is asking us to resume nego- tiations, which we did. \~Te then instructed our attorney to proceed with the negotiations. And then after we had proceeded to do that we again received notifi- cation that the negotiations were broken off and that was, as you see, in March. \~Te would have had ample time probably to come to an agreement if the attorneys had continued their negotiations at the time. Mr. WALKER. Doctor, being a practical politician, I would have to say if I were negotiating with someone and if I thought I could get some legislat.~on through, I would not see much pomt in negotiating with you further either. So much for that. PAGENO="0099" 95 PSYCHOLOGISTS AND PSYCHIATRISTS Mr. Chairman, I do not want to take too much time here. I would like to close by clarifying another point. At the present time, do psychologists and psychiatrists confer and in general what is their working relationship? Dr. MELTZER. I would like to attempt to answer that question. At the present time psychologists and psychiatrists do confer and I would distinguish two different kinds of conferring. In the first instance, the psychiatrists will refer a patient that he has seen and who has been given a medical and psychiatric work-up, he will refer such a patient to a psychologist for clinical testing. And the testing, along with every kind of available information, is made part of the psychiatrist's ultimate determination of diagnosis, prog- nosis and treatment plan. In that sense the psychiatrist is using the psychologist's services somewhat in the form of the way other medical practitioners make use of other kinds of investigations, X-rays and laboratory tests and the psychologist's examination is by no means the sole determinant of the psychiatrist's responsible decision in terms of diagnosis and treatment. This is a very useful service that the psychologists provide and is one that is made use of extensively. In the second kind of conferring, and this is after the traditional model of the hospital and mental hygiene clinics, where psychologists who have been exposed to psychotherapy have received the training that has introduced them to this. The traditional model is that the physician in the hospital or mental hygiene clinic sees the patient, examines the tests, makes the diagnosis, correlates the medical and physical data and then, in selected instances that have to do with minor mental illnesses which are within the competence of the psy- chologist, refers and delegates psychotherapy to the psychologist for him to do under the continuing supervision of the psychiatrist. In fact, this works out in clinics and hospitals. For instance, a psy- chologist may see the patient who has been referred to him two or three times a week and will have one supervisory session a week. So there is a very close and intense planning regulation and overseeing. This kind of thing also goes on but not nearly so frequently, as Dr. Legault suggested, in areas of practice outside of clinics and institutions. There is the custom wherein a psychiatrist who has seen a patient, who was worked him up, has made the diagnosis and evaluation, has assessed the hazards in treatment and so on, will refer such a private patient in a noninstitutional setting to a psychologist for such treat- ment, and these are usually people who know each other very well, who have worked together extensively and who have a useful collabo- ration and liaison with each other. There, too, it is after the model of supervised delegated treatment. Dr. Malcolm Meltzer referred to I think, or implied, another kind of relationship in which the patient is first seen by the psychologist. In such a setting, if the patient is first seen by the psychologist, the psychologist does not have available through his own skills the opportunity for the full medical evaluation, the evaluation of psycho- somatic factors and I cannot comprehend, by the way, how a psychoso- PAGENO="0100" 96 matic illness, which may take the form of high blood pressure for instance, or many others can be construed as a behavior disorder. Nonetheless, it is an important and serious physical and psychiatric illness. If the psychologist sees such a person, it would be of course sensible for him to refer for consultation and evaluation, initiating the referral, to a psychiatrist a.nd to a medical practitioner. What I am trying to say is that the referrals go in both direct.ions. And these are the kinds of practice-related referring back and forth that do go on in the community. TRAINING Mr. WALKER. Mr. Chairman, the doctor has already practically answered my last question here. If you will allow me, I would line for the record, I think it is very important, for him to briefly sum up the training; what if any would be the difference in the training of a psychiatrist and a psychologist to equip them to deal with mentally ill persons. The reason I want this in the record, Mr. Chairman, is I think this is the whole crux of this thing. Dr. LEGAULT. Mr. Walker, I believe you would like to ask Dr. Steinbach this question because lie is the chairman of the depart- ment and Professor of Psychiatry of Georgetown TJniversit.y Medical School, and has very much in the forefront of his interest the training of psychiatrists and somewhat, I imagine, psychologists too. Dr. STEINBACH. There are of course many differences in the training of the two. One of the i~nportant differences would be in the periodT of time, in that the training of the psychiatrist is at least three years longer, if not more, than the training of the psychologist. The total training period for the psychiatrist after finishing college is at least eight years, as many of on may know, and starts out with the first two years of medical school which emphasizes the basic sciences of medi- cine, physiology, pharmacology, other courses that relate to one's future work in medicine. The remaining six years. the training starting with the third year of medical school and the internship and the residency, this six-year per~odl is one that very nnich emphasizes clinical contact with patieiits and is geared very much toward a program of increasing responsi- bility in the care of pat~ents. This again is a significant difference in training because the psychologist training has really very limited clinical experience and not at all this process of developing more and more responsibility for patient care as you go along. I think it is important to point out also that in medical school clur- ing all four years there is not only the initial emphasis on the basic medical sciences and later clinical work in all fields of medicine, but also a large amount of curriculum time in all medical schools now is devoted to psychiatry as a program which runs through the entire four years of medlical school. Also, there is a trench in medical school education to allow students to spend more and more time in elective work. So that a student is able to speiicl a large amount of elective time in psychiatry, but while lie is working in medical school with medical and surgical and other PAGENO="0101" 97 kinds of patients this is very much integrated with psychiatric teach- ing. So that his experiences are those in which he is generally thinking about, not only the medical and surgical aspects of the case but also the psychological aspects. So even before beginning his internship or his three years of formal residency training in psychiatry, he has had extensive experience in general medicine as well as in psychiatry per Se. As I mentioned, the training of the clinical psychologist is really exclusively limited to psychology and courses which relate to psy- chology, whereas the psychiatrist learns psychology in addition to his work in the basic and clinical medical sciences. I think another important difference which Dr. Legault has spoken to briefly is the area of total responsibility and, as he has described, the training of the psychiatrist is very much geared toward assuming more and more responsibility so that when a psychiatrist flmshes his training and is ready to go into practice, he is able to assume total care for a patient. rjlhat means lie can assume responsibility in any medical area and obviously make all major decisions about the patient. There is really nowhere in the training of the psychologist that he has a total kind of responsibility for patient care. Dr. Meltzer pointed out in his comment a couple of weeks ago lie had spent one or two years in a veterans' hospital. I think we can be sure in such a setting a psychologist in training does not have the experience of really taking on responsibility for the person and deciding what orders should be written on the patient. It is only the physician writes orders deciding what kind of treatment the patient needs and making decisions as to when the patient would be well enough to leave the hospital and things of this sort. So the work of the psychologist trainee is always under the direction of psychiatrists or other medical personnel. Perhaps the last major difference is that the psychiatrist in training does have extensive experience with all kinds of mental illnesses and psychiatric training is geared so that the trainee spends a large amount of time with hospitalized, very sick patients, he spends time with patients who have combined medical psychiatric problems, and lie spends time with patients who have minor psychiatric illnesses, but his experience in diagnosis and treatment does run the gamut of all psychiatric, psychological, medical kinds of illnesses. And again a psychologist in his training program is usually very limited. He may be assigned for his psychology internship to a stu- dent health clinic where lie would not have the opportunity to severe sick patient or usually the internship he would have would be in one setting which obviously does not provide the diversity of experience. So I think these are some of the major differences. Mr. WALKER. Thank you, Doctor. Thank you, Mr. Chairman. Dr. LEGAULT. May I add something to that? Mr. SI5K. Yes. Dr. LEGAULT. It is something I really feel must be commented on because it leaves a feeling every time I hear the term. We have to use it, I know it is necessary. We keep referring to the psychologist really treating minor mental illnesses, which in effect they do, but they are only minor from the point of view of the doctor considering the whole PAGENO="0102" 98 serious gamut of mental illnesses. There is no such thing as a mental illness, as I `am quite sure anybody will recognize. We are dealing with minor physical illnesses, but there are no minor mental ones, and to undertake to treat them, treat any mental illness is to be involved in effect in doing something equivalent to major surgery. The surgeon never knows what he is going to run into when he opens up a belly, for example. He has to be prepared to do what has to be done. That is the reason why psychologists in their training, although they are trained to treat minor mental illnesses, nevertheless do so under continuing medical supervision. Mr. SIsK. Thank you, Dr. Legault. The gentleman from Minnesota. Mr. ZWAOH. On the first day of our hearings I asked the psychology association to present to the subcommittee the exact course of study and curricula in a particular program on psychology. I would like to ask Dr. Steinbach to present to the committee the course of .study at Georgetown liTniversity for psychiatrists. Could you do that, Doctor? Dr. Smm~AoH. For psychiatrists? Mr. ZWAOH. Yes, so we may compare both the courses and try to get a clear picture. (The information requested appears in the appendix at p. 142.) Then I would like to go to page 6 of your testimony, that disturbs me very, very much. You are talking here about trying to work out an agreement for the public good between your groups, and it says: As a result, our representatives and representatives of the psychologists' as- sociations began discussing precise language and amendments to the bill, which is 10401. Then in the middle of these conferences, in which the public interest and con- cern was our pole star, we received a telephone call from a representative of the D.C. Psychological Association, which advised us that they had been informed that appropriate maneuvering could bring their bill to a vote and they no longer wished to confer with us. I do not know what implications and connotations there is in your statement, but then you go on: Still later, when these nonprofessional efforts bogged down, there was another telephone call to start treating the problem at a professional level again. Presumably rather than political. And once again, there was a telephone call to terminate these efforts, not on any ground that the public interest would be promoted by such termination, but because it was felt that the bill could be enacted in a hurry without further scrutiny. It has been my privilege to sit as a legislator for 34 years. I have never heard any testimony that comes anywhere close to this type of testimony. I want you to enlarge on that. I think, Mr. Chairman, that this subcommittee ought to enlarge on that testimony. This testimony has a lot of implications and connota- tions. Whether it is indicating somebody in the other group or whether it reflects on the Congress, I do not know. I am asking you, sir, to enlarge on that statement you made. Dr. LEGAtJLT. Yes, I would be very pleased to, Mr. Congressman. I think, first of all, I would like to say that the major difficulty in the situation as I look upon it now, and what occurred between us and PAGENO="0103" 99 the psychologists and in our dealings with the Senate subcommittee, the major- Mr. ZWACH. V%Tas this addressed specifically to the Senate, these statements here? Dr. LEGAULT. At the time the bill was before the Senate subcom- mittee. Mr. ZWACH. It was really speaking more to the other body? Dr. LEGAULT. Oh, yes. So far as our relationships with this subcoin- mittee are concerned, they have been most cordial. Mr. SIsK. If the gentleman will yield, I would like to say this has been made rather clear, I thought, that this had to do with the situa- tion that existed earlier in the year at that time. Had I felt this had any implications to this committee or this body I would have arisen in somewhat holy wrath, as my colleague has. I thank the gentleman for yielding. Mr. ZWACH. I really appreciate that statement because it is very important to me. I think he still can elaborate a little more on it be- cause I want to be sure that does not involve the House of IRepresenta- tives. Dr. LEGAULT. Certainly by no means do we feel this subcommittee or any of the representatives on this subcommittee have in any way attempted to treat us in any other fashion but to find out what the issues are in this bill, and we have been most pleased with our contacts with every one of the representatives that we have tried to get in con- tact with. So far as our statement about the situation in the Senate is con- cerned, we do not wish to make any sort of statement about unfair treatment on the part of the Senate. It was our own fault. We actually were commenting on our political naivete. As Mr. Walker pointed out, as a p'erfe~tly elementary fact of poli- tics, if a bill is up for legislation that one should take care to see the legislators involved in the matter and that these things take primary consideration. It is absolutely ridiculous that no representative from any of the professional organizations seated here at this table made any attempt to contact any senator concerned with the bill. It is absolutely preposterous. We were continuing our professional conversations with the psychol- ogists in the naive expectation that possibly our professional group could hold up on recommending legislation until we were in a position to come to an agreement on it, which we felt we could come to an agreement on because of the fact our position, the position our groups have taken, is the position that is written into laws concerning the regulation of psychology in practically all jurisdictions. In other words, we were not proposing to the psychologists anything which we expected that they would be terribly in objection to. Mr. ZWAOH. Would you say that this statement is perhaps a little indiscreet? Dr. LEGAULT. I readily admit to that. I accept that. Mr. ZWACH. Mr. Chairman, that answers my question. Mr. SIsK. I thank the gentleman from Minnesota. I was not going to pin it down quite that much, but I think the gentleman is exactly right. I think this went maybe a little bit beyond. PAGENO="0104" 100 Here again, maybe because the gentlemen are experts in their field and not too much so in the political field. No criticism is implied. The gentleman from North Carolina. Mr. WHITENER. Doctor, relating our thought for a moment to Sec.- t.ion 20(B) in the present House bill. I note that in the North Carolina statute, comparable language is as follows: Nothing in this Article shall be construed to limit or restrict physicians and surgeons or optometrists authorized to practice under the laws of North Carolina or to restrict qualified members of other professional groups in the practice of their respective professions, provided they do not hold themselves out to the public by any title or description stating or implying that they are practicing psychologists or psychological examiners, or are licensed to practice psychology.1 That seems to be rather specific language as compared to Section 20 (B) in the House bill. Dr. LEGAULT. I think so. I have not read the entire law. Mr. WHITEXER. This relates to the same subject matter as Section 20(B) where you are talking about other professionals. As I read the legislation now before us, the House bill at least, it does not restrict other professions to the degree that the North Carolina statute does, and I am wondering if this language, in lieu of Sect.ion 20(B), would not be helpful. Dr. LEGACLT. I think it would be better. I would have a. question though as to definition of "other professions". Somewhere in the bill it would have to. st.ate what another profession is. For instance, is a. dyneticist a professional ? Mr. WHITENER. I do not believe you would have any trouble because, after referring to other professional groups, it limits it to the practice of their respective professions. Dr. LEGAULT. That is right.. Mr. WHITENER. And the statute in North Carolina. at least with reference to the legal profession or medical profession or cosmetoloty profession or whatever it. might be would clearly define what the prac- tice is within "their respective professions". Dr. LEGAULT. I agree. Mr. WHITENER. If you look at. the North Carolina Act., subsection (ci). just above where I was referring to, tell us a little bit about. social psychologists and whether we. need language in the District of Colum - bia bill with reference to that. Dr. LEGAULT. As I understand it, that section was stricken from the Senate bill. Mr. WHITENER. We are starting over here. We are not too coii- ccrnecl, I believe, with what is stricken in the Senate bill. I am asKuig why was that language in the North Carolina Act and what is the significance of it. IVe are not experts in your field, and we need a. little instruction ourselves. Dr. LEGAULT. I can say something about it. Mr. WHITENER. If I may interrupt you, I gather from the language of this section in the North Carolina. Act, that you have social psychol- ogists and psychologists and a sociologist might. engage in social psy- chology or a psychologist might. engage in social psychology; is that right? 1 North Carolina Laws. supra. Section 4 (e). PAGENO="0105" 101 Dr. LEGAULT. That is close. I think that the language which is in H.R. 10407- Mr. WHITENER. Let's stick to the language in the North Carolina Act. Dr. LEGAULT. The North Carolina Act, the reason for including pro- visions about social psychologists is that the training of a social psy- chologist is somewhat different from the training of a psychologist generally, and they wanted to not be specifically delicensed by the bill. The psychologists recommended that there be a similar phrase in our own bill, similar legislation, similar clause in our own bill exempting social psychologists, and we somewhat demur about it but are not very munch opposed. Mr. WHITENER. In other words, you are not particularly fond of the North Carolina exception? Dr. LEGAULT. That is right. It is an exclusion and it is a loophole. Mr. WHITENER. Many of the other states apparently have similar or identical language. Dr. LEGAULT. We do not like exclusions in the bill, but we are not very much opposed to it. Mr. WHITENER. That is all, thank you. Mr. SI5K. Thank you, gentlemen, for appearing this morning and for the testimony that you have offered and for your willingness to answer questions. The committee appreciates it very much. Dr. LEGAULT. Thank you very much, Mr. Chairman. Mr. SI5K. I believe we have one further witness scheduled this morning which will conclude the hearings, as far as I know. Dr. Dorothy A. Starr. Dr. STARR. I have just briefed your statement. I notice you have some rather interesting comments. You may proceed. STATEMENT OF DR. DOROTHY A. STARR I am Dr. Dorothy Starr, a physician engaged in the private prac- tice of psychiatry in the District of Columbia since 1957. Since I represent no group or organization, I have outlined my credentials to speak to this subject. I am a former Naval Medical officer (1950- 54), a former Chief of the Adult Mental Health Division of the District of Columbia Department of Public Health, and a former Councillor of the Washington Psychiatric Society (1965-67). 1 am a Diplomate of the American Board in Psychiatry (1959) and wa~ elected to Fellowship in the American Psychiatric Association (1965). Currently, in addition to private practice, I am a Lecturer at the Catholic University, an Assistant Clinical Professor of Psychiatry at the Howard University School of Medicine, a member of the Board of Directors of the D.C. Mental Health Association and a Consultant at St. Elizabeths Hospital. For the past year, I have been Chairman of the Committee on Relations With Allied Professions of the Wash- ington Psychiatric Society. The public need for services in the mental health field is so great that maximal use must be made of the skills of all disciplines. Legis- lation is very much needed to serve the public interest by preventing untrained, unscrupulous and/or incompetent individuals offering PAGENO="0106" 102 t.h~mselves, on a private fee-for-service basis, under some title or other that implies training or expertise in the. field. A reference was made at the previous session of the hearings to the classified telephone listings, under psychologists. May I point out there is an equally mixed assortment under mar- riage and family counselors also in the classified section. STANDARDS The present legislation will set standards for psychologists but those who are not qualified a.s psychologists may continue "business as usual" by designating themselves as Family Counselors, Marriage Counselors, Counselor in Personal and Emotional Problems~ Therapist or Lay Analyst to name a few possibilities. Unfortunately, there is no clear or practicable line that can be drawn between counseling and psycho- therapy and there is no clear or practicable line that can be drawn between adjustment problems or behavior problems and mental or emo- tional illness. There are trained individuals of many backgrounds who are competent to administer this particular treatment modality in appropriate cases and altho psychotherapy is only one among many treatments in use, it is the most time consuming. Because of this, the public interest would be much better served by the licensnre of all therapists and counselors who offer themselves on cc ~r~va.te fee-for- service ba.sis as competent to understand, predict or alter personal, emotionaL behavioral, adjustment or family problems. I think that each of the many disciplines involved-social workers, nurses, mar- riage counselors and others-can, as the psychologists have, outline the educational a.nd experiential standards necessary for competence in the independent practitioner. I stress the therapist-counselor in private practice because public and private non-profit agencies have many built in safeguards of the clients interest in their own standards, their selection policies, their supervisory structure and the use and availability of medical consulta- tion. Of course, the counseling offered by a. clergyman in the pursuit of his usual pastoral duties is excluded unless he goes into the business of counseling on a fee-for-service basis, in which case, he too should meet standards as a. therapist-counselor. The statuatory standards for each group must be sufficiently high to eliminate the unqualified but obviously would vary. They should explicitly require that the individ- ual therapist-counselor be aware of and accept his own limitations in regard to the type of case he is qualified to work with `and the scope of treatment he can provide. There should be severe penalties, e.g. loss of licensure, fines, etc., for the therapist-counselor who presumes to offer or presents himself as offering other treatment modalities or evaluation beyond his competence. Further. the standards should re- quire that the therapist-counselor must seek proper consultation or make appropriate referral to a physician. a psychiatrist or a hospital when such might be indicated or beneficial. In my experience. com- petent non-medical therapists use discretion and judgment in declin- ing to treat individuals who need other therapies~ or hospital care or who are suicidal or potentially dangerous. The effect of such legisla- tion as I am suggesting would be to rid the Leld of the unscrupulous PAGENO="0107" ~C3 quack, regardless of how he labels himself whereas H.R: 10407 will simply make it illegal for him to call himself a psychologist. Thank you. Mr. SI5K. Thank you, Dr. Starr, for an interesting bit of testimony, because I think you do bring out some need here and some problems that certainly we will be faced with in attempting to protect the public from unscrupulous operators or from what amounts to actually pure quackery, as you indicate in your statement. As I would understand, you feel there is a need for licensing; how- ever, as I understand it, in your conclusion you say: The effect of such legislation as I am suggesting would be to rid the field of the uns~rnpu1ous quack, regardless of how he labels himself, whereas HR. 10407 will simply make it illegal for him to call himself a psychologist. In other words, you apparently feel there should be some broader control or some way to eliminate the pure quack in the field of coun- seling and so on. Is that basically what you are saying? Dr. STARR. Yes, sir. The untrained and incompetent person who offers himself on a pri- vale fee basis as a therapist or counselor. Mr. SIsK. I appreciate the statement. Are there any questions. Mr. JACOBS. I have one question, Doctor. On the last page of your prepared statement you mention the needed obligation on the part of nonmedical personnel to make appropriate referrals. You finish by saying "when such might be indicated or beneficial". I assume that that which was indicated in this area would be beneficial but that which was beneficial might not necessarily be indicated. Is that the nub of the problem, establishing some standards to make that determination? Or can we establish any standards? Dr. STARR. This is part of the problem. The nonmedical therapist is not qualified by his training to evaluate the use of therapy and treat- ments in which he has no experience or training. But if the burden is on him to refer those who might benefit by such treatment, I be- lieve the competent and ethical practitioner of these other disciplines will indeed seek medical consultation. Mr. JACOBS. He will not seek it in cases where it is beneficial and not indicated or indicative because of the lack of his understanding of the problem, will he? Dr. STARR. I am sorry, I am not sure I can answer. I think you are making a distinction that I am sure is necessary legally. Mr. JACOBS. I think it is necessary as a practical, social matter. I am wondering, the essence of my question, whether it is possible for us to erect legislatively standards by which these referrals can be made. Dr. STARR. No, sir; I do not think that the legislature can write standards. Mr. JACOBS. When you get right down to it, you are possibly placing the responsibility upon those who are not competent to make a judg- ment as to when the referral is necessary. How do we get `around that paradox? PAGENO="0108" 104 Dr. STARR. Without any wide understanding of how laws operate, it would seem to me that if the burden is put on the practitioner that he must know what at least he cannot know or does not know. This is the same burden under which medical practitioners `operate all the time. t*o know the limit.s of your competence, to not open an abdomen if you are not competent to deal with everything in it. Mr. JACOBS. We are really talking about a "knowingly" prohibition rather than a. malpractice. When we say that the psychologist is not. to treat a* medical problem, do we really mean lie is not to knowingly treat a medical problem, and if so, do we not. have evidentiary prob- lems that would delight the wildest Philadelphia lawyer? Dr. STARR. I think it is within the limits of his competence to make a. positive judgment. about what lie can manage, and what I am asking is that legislation put the burden on him to stop at what he knows lie can manage. Mr. JACOBS. That is a knowingly situation. Dr. STARR. You know what you can manage but. you are not al- ways able to evaluate what you cannot manage in terms of what the proper disposition would be. Mr. JACOBS. My experience has been that. some objective standards beyond the subject of knowing, a person doing right or wrong or proper or improper acts, is most desirable. Some objective standards. You might, in fact all of those interested in this legislation might consider that point, and I am sure the committee will consider it very beneficial to have views along those lines. I am not talking about the competent practice of politics or even of law now. This is a highly technical matter about which I know little and would like to know more. Dr. STARR. As Dr. Legault pointed out, what societies were trying to do in discussions with the psychologists was come up with some kind of standards in part. Mr. JACOBS. Thank you very much, Doctor. Mr. SIsK. Are there any other questions? Mr. Gude of Maryland. Mr. GUDE. I believe Dr. Starr has well pointed up what to me is a real concern. If a psychologist is licensed or certified in the District, the general public feels they are putting themselves into the hands of people who are able to deal with problems which actually might be beyond their competency as professionals. It is brought to my attention that by virtue of rfitle 47, Section 2344 of the D.C. Code the government of the District of Columbia is an- .thorized and empowered within its discretion to require a. license of other businesses not listed in the D.C. Code which in its judgment require supervision and regulation. Perhaps the D.C. Council might well hold hearings on some of these activities you mentioned regarding marriage counseling, family counseling, etc. Thank von. Mr. SIsK. Are there other questions? Thank von, Dr. Starr, very much. This concludes the witnesses except for the D.C. Government wit- i~esses, a.nd at this time, without objection, I am going to put in the record a. statement signed by Mr. Thomas W. Fletcher, Assistant to Commissioner Walter Washington. PAGENO="0109" 105 Also t~ statement from Dr. John D. Schultz, Associaite Director. These two gentlemen are both here in the room. (The statements follow:) GOVERNMENT OF THE DISTRICT OF COLUMBIA,~ Ecvecutive Office, Washington, May 17, 1968. The Honorable JOHN L. MO'MILLAN, Chairman, Committee on the District of Co'umbia, U.S. House of Representatives, TVashington, D.C. DEAR Mn. MeMILLAN: The Government of the District of Columbia has for report H.R. 10407 and S. 1864, bills "To define and regulate the practice of psychology in the District of Columbia." Both bills seek to protect the public welfare by requiring all persons who offer psychological services to the public for a fee to obtain a license from the District. The bills define the practice of `psychology and set forth the qualifications which an applicant must have. They also provide for examination and related admin- istrative considerations. Further, they each contain a provision allowing for the licensing by endorsement of psychologists moving to the District from jurisdic- tions where at least con~parable controls over the practice of psychology exist. Finally, the bills list those actions which would constitute violatiOns of the proposed Act, and the procedures for investigating and punishing those who violate its provisions. The District government is of the view that the public should be protected by the licensing Of psychologists, and believes that S. 1864 is the better bill for such purpose. While HR. 10407 is in large part identical with S. 1864, it has certain features which the District considers undesirable. We believe that legislation licensing psychologists should emphasize more strongly the non-medical character of the profession and `the necessity `that a `person with organic disease complica- tions to behavioral problems `must be `referred by the psychologist to a medical doctor. In addition, the District believes that social psychologists should not be trea'ted differently from other psychologists, that the Commissioner `should not be bound, in selecting members of `the Board of Psychologist Examiners, by lists submitted `by the Psychological Association, and that a certificate of regis- tratiOn should not be issued to an `association, partnership, or corporation, but only to an individual. The District also `believes that the District of Columbia Council should have authority to m'ake regulations to carry out the purposes of the `legislation and to fix fees for services rendered in licensing by the District. Since S. 1864 meets the foregoing requirements better than `does HR. 10407, the Distric't `prefers the former bill. If, however, the Committee `desires to report out HR. 10407, the District rec- oinmends that the bill be amended as follows: (1) Amend section 4 by striking out "physical" in line 18 of page 3 and inserting in lieu thereof "medical"; (2) S'trike section 5 (D) (3)~ Amend the first sentence of `section 6(b) by striking "to be selected from a list of psychologists submitted by the District of Columbia `P.sycliolog- ical Association" in line 25 on page 5 and lines 1 and 2 on page 6; (4) Amend section 12, lines 5 to 17 on page 10, to read as follows: "See. 12. The District of Columbia Council is authorized to make reg- ulations t'o carry :out the purposes of this Act, and, a'fter public hearings, to fix, increase, or decrease fees to be charged for services performed by the District government pursuant to the provisions of this Act in such amounts as may, in the judgment of the Council, he reasonably neces- sary to defray the approximate `cost of administering this act." (5) Amend section 13 `by `striking the second sentence. As I have indicated above, `the District favors the enactment of S. 1864, as being the preferable bill. However, if `the foregoing amendments be made in HR. 10407, the District would also favor `its enactment. Sincerely yours, (5) Thomas W. Fletcher, THOMAS W. FLETCHER, Assistant to the Commissioner. (For Walter E. Washington, Commissioner). PAGENO="0110" 106 STATEMENT OF DR. 3OHN B. SCHULTZ, ASSOCIATE DIRECTOR, MENTAL HEALTH AND RETARDATION, DEPARTMENT OF PUBLIC HEALTH, DISTRICT OF COLUMBIA Dr. SCHULTZ. Mr. Chairman, the l)~l1Tose of this Bill is to pro~nic1e for the protection of the public from the unauthorized and unqualified practice of psychology and from unprofessional conduct of persons practicing psychology in the District of Columbia. At the present time, psychologists may practice in the District of Columbia without license or regulation. The intent of this Bill is to regulate the practice of psy- chology as existing law already requires the regulation of other pro- fessions within this City. We believe that the practice of psychology as is the case with a nmnber of other disciplines, is closely akin to the practice of the healing art as currently defined by statute in the Dis- trict of Columbia. We believe, therefore, that it is in the public interest to have the practice of psychology defined and regulated and we fur- ther believe that it is reasonable. to expect that only licensed psycholo- gists should practice their specialty in this City. In our testimony before the Senate Hearings on this Bill, Mr. Chairman, we recommended certain amendments, which I need not repeat in detail here. These have been incorporated in the Bill, as reported by the Senate Committee, and are identified in Mr. Morse's report of April 23, 1968, on page four, under the heading "Amendments." I would, Mr. Chairman, like to point out that the amendment to Section 4, page 3, line 18, striking the word "physical" and inserting in lieu thereof the word "medical," has implications which may not be fully recognized. Psychotherapy is a method for the treatment of mental illness, which is a. disease of the mind. Hence, psychotherapy is a medical treatment and, therefore, the Bill as amended would require the psychologist who uses the psychotherapy to refer such patieimts to physicians for diagnosis, thus eliminating the danger of overlooking physical or mental disorders which might. affect the men- tal condition of the patient and mental states which cause physical or mental disabilities. There is danger in authorizing the psychologist to practice psychotherapy without medical referral. So that there may be no ambiguity in the amendment. suggested for Section 4, I would like to offer for consideration the following language: SEC. 4. The psychologist who engages in practice shall assist his his client in obtaining professional help for all relevant as- pects of the client's problem that fall outside of the boundaries of the psychologist's own competence; he shall make provision for the diagnosis and treatment of relevant medical problems by an appropriate, qualified medical practitioner before undertaking psychotherapy. Mr. SIsK. Mr. Moyer and Dr. Schultz, here is what the Chair would like to suggest. We would like to suggest that you gentlemen be furnished a copy of the proposed amendments or possible substitute bill which you heard discussed this morning. We would like to have your comments at that time. PAGENO="0111" 107 What Mis; Clark will doa~ that is made available to us, is to submit th~t to you and at a later. date, as early as possible, we would like to ask you geñtlelnen to come back and be prepared at that time, in addition to comments you have made in your statement now regard- ing certain amendments which you have suggested to the present pro- posed legislation, to comment on this proposal which we will submit to you. Do you follow me? Mr. MOYER. Yes. Mr. Sisic With that, then, the committee stands adjourned. (Whereupon, at 12:00 noon, the committee adjourned, subject to call of the Chair.) (Subsequently, the following letter to Chairman McMfflan, together with other documents, were submitted for the record:) MEDICAL COLLEGE OF SOUTH CAROLINA, DEPARTMENT OF PSYCHIATRY, May 31,1968. The Honorable JOHN L. MCMILLAN, U.s. Post Of/ice, Florence, ~South Carolina DEAR MR. MCMILLAN: This is pursuant to our recent telephone conversation. As I discussed with you, I have become interested in the current legislation before the District of Columbia Committee concerning the licensure of psy- chologists. In my opinion, the licensure of psychologists is a very desirable thing. One of the problems with this profession in the past has been the fact that without licensure the door is open to any individual who calls himself a clinical psychologist and who can practice without adequate training and ability. These people frequently exploit the public and often do a great deal of harm. Appro- priate licensure legislation will surely help correct many of these atrocious practices. I do not believe that the current legislaton under study by the Com- mittee will constitute sufficient control to eliminate this kind of practice by charlatans. I have discussed this with my good friend, Dr. Richard Steinbach, Chairman of the Department of Psychiatry at Georgetown University. I believe that the District of Columbia would be greatly served by your having the chance to talk with Dr. Steinbach and other representatives of the Washington Psy- chiatric Society. The vast scope of mental health problems in our own state as well as in our nation's capital is begininng to receive appropriate attention from our government. While I am greatly heartened by this enthusiasm and support I also feel that we must be cautious in studying these newer* approaches to treatment. I would like to wish you the best of luck in your forthcoming election. With kindest personal regards, I am Sincerely yours, R. LAYTON MCCURDY, M.D., Professor and Chairman. FLORENCE, S.C., May 24, 1968. Representative JOHN i~IcMILLAN, Member of Congress, Washington, D.C.: Strongly recommend amendments to H.R. 10407. Psychologist should not be allowed to form cooperation. Also, they definitely need consultation and/or supervision by psychiatrist. AL B. H~rEY, Jr., M.D. PAGENO="0112" 108 UNIvERsITY OF VERMONT, COLLEGE OF MEDICINE, BvrZington, Vt., May 27, 1968. Hon. ROBERT STAFFORD, Congressman for the State of Vermont, U.S. House of Representatives, Washington, D.C. DEAR CONGRESSMAN STAFFORD: I believe there is a bill S1864 before your com- mittee on the District of Columbia. This bill deals with the licensing of clinical psychologists for practice. I just would like to add my voice to that of many others. We have here in Vermont struggled with such a licensing bill. The crucial factor is that some provision be built in that "no patient may be dealt with by a psychologist who has not had a thorough evaluation from a medical point of view," as psychologists by training are not in a position to perform an adequate differential diagnosis on the basis of which they can decide whether the clients symptoms are due to organic disease or due to psychological disorder. Sincerely yours, HANS R. HuEssy, M.D., Acting Uk airman. (Correspondence between the District of Columbia Psychological Association and the Washington Psychiatric Society, referred to at page 30, follows:) DISTRICT OF COLUMBIA PSYCHOLOGICAL ASSOCIATION. Washington, D.C., February 24, 1965. LEON YOCHELSON, M.D. President, Washington Psychiatric Society, TVashingtcm, D.C. DEAR DR. YOCHELSON: As you are aware, various officials of the D.C. Government have expressed an interest in being able to identify and prosecute those persons who are holding themselves out to the public as psychologists. but who in fact lack education and training in the field of psychology. Twenty- five states have laws which specify who may call himself a psychologist or who may practice as a psychologist. The District of Columbia has no legisla- tion controlling the practice of psychology. The District of Columbia Psychological Association is presently review-ing this matter through its Legislative Committee. There is a possibility that the DCPA w-ill introduce some type of licensing legislation this year. Before we do this, we wish to solicit the views and Suggestions of interested community groups. Such legislation would probably cover all applied psychologists, includ- ing those in research and development, social, personal, counseling, industrial, clinical, etc. Obviously such legislation would have great importance in pro- tecting the public from unqualified people offering mental health services. For this reason, we recognize that the Washington Psychiatric Society would have an interest in such legislation, as well as some suggestions concerning it. We w-ould like to have your thinking and views on how such legislation might be written to best serve the community. If the membership of DCPA indicates a willingness to proceed with a legisla- tive proposal this year, we probably would need to have a Bill before Congress by late April. This is a bit of a rush. Would there be an opportunity to consult w-ith the Washington Psychiatric Society in the near future? How might this best be done? I understand that you also are Chairman of the D. C. Medical Society~s Committee on Mental Health. Would it be possible to talk with this group also? Any suggestions you have as to how our two organizations might confer would be appreciated. It is a shame that we did not already follow the advice of our two APA's and set up local joint committees. A vehicle for discussion would then be at hand. In any case, we would appreciate an opportunity to talk with you about such legislation. I can be contacted at D. C. General Hospital (LI 7-9200. xt 33i) during the day. My home phone is 387-7514. I am looking forward to talking with you further about this. Sincerely yours, MALCOLM L. MELTzER, PH. D.. Chairman, Legislative Committee. PAGENO="0113" 109 THE WASHINGTON PSYCHIATRIC SOCIETY, Washington, D.C., March 22, 1965. MALCOLM L. MELTZEB, Ph. D., Washington, D.C. DEAR DR. MELTZER: Thank you for your recent letter informing me of the activity of the American Psychological Association with regard to the desira- bility of legislation for the licensing of psychologists in the District of Columbia. This matter was presented again to the Council of this Society as well as to the Mental Health Committee of the District of Columbia Medical Society. These two organizations, after full discussion, arrived at identical conclusions, namely that they saw no reason at this time to change their policies regarding the licensure of psychologists. The suggestion as to some sort of liaison committee acting as a clearing house for information between our societies is currently under study and I will be happy to inform you when a decision has been reached. Thank you for your courtesy in briefing me on your present situation. Sincerely yours, LEON YOCHELSON, M.D., President. 94-755--GS-----S PAGENO="0114" PAGENO="0115" PSYCHOLOGY WEDNESDAY, JUNE 19, 1967 HOUSE OF REPRESENTATIVES, SImCOMMIrTEE No. 5 OF THE COMMITPEE ON THE DISTRICT OF COLUMBIA, Washington, D.C. The subcommittee met, pursuant to recess, at 10:30 a.m. in room 1310, Longworth House Office Building, Hon. B. F. Sisk (Chairman of the subcommittee) presiding. Members Present: Representatives Sisk (Chairman), Walker, Nel- sen, Horton, Marsha, and Gude. Also present: James T. Clark, clerk; Hayden S. Garber, counsel; Sara Watson, assistant counsel; Donald Tubridy, minority clerk, and Leonard 0. Hilder, investigator. Mr. WALKER (presiding). The committee will come to order. Mr. Sisk has had to go to another committee to testify, and will be back in just a very few minutes. In the meantime, we will conclude the hearings on H.R. 10407 and S. 1864, to regulate the practice of psychology. At the last hearing the Washington Psychiatric Society requested permission to present certain amendments which they have filed with us and which we would like to have them present, as well as receive any comments that the Psychological Association may have thereto. We requested the District of Columbia Government representatives, Mr. Moyer and Dr. Schultz, to review these prepared amendments ~iJso so that their views would be welcome. At this time if Dr. Schultz and Mr. Moyer will come forward, we would be glad to hear any remarks that you may have. STATEMENT OP THOMAS P. MOYER, ASSISTANT CORPORAflON COUNSEL; ACCOMPANIED BY DR. JOHN B. SCHULTZ, ASSOCIATE DIRECTOR, MENTAL HEALTH AND RETARDATION, DISTRICT OP COLUMBIA DEPARTMENT OP PUBLIC HEALTH-Resumed Mr. MOYER. My name is Thomas F. Moyer, assistant corporation counsel, presenting the views of the District on these bills and on the proposed substitute bill. Dr. Schultz of the District Department of Public Health also has a statement on the bill. I would like for Dr. Schultz to present his statement and then, if I may, briefly sum up what the District's position is as reflected in our various reports. Mr. WALKER. Dr. Schultz, you may proceed to either read your statement, comment on it or put it in the record, as you wish. (111) PAGENO="0116" 112 Dr. SCHULTZ. With your permission, I would like to read it. It is relatively brief and sums up, I think, our thinking. I express here my thinking on behalf of the Department of Public Health of the District. Mr. WALKER. Proceed. Dr. SCHULTZ. I am Dr. John D. Schultz, Associate Director of Mental Health and Retardation, Department of Public Health. Mr. Chairman, at the hearings on this proposed legislation June 3, 1968, I submitted a prepared statement which was entered in the rec- ord. This indicated our support of the intent of the Bill, which is designed to regulate the practice of psychology in the District of Co- lumbia. In the same statement I reaffirmed the need for clarification of some of the language, particularly with reference to Section 4. PROPOSED AMENDMENTS A draft of a proposed amended Bill submitted to the Subcommittee by the D.C. Medica.1 Society, the D.C. Medico-Chirurgical Society, the Washington Psychiatric Society and the Washington Psycho- analytic Society, has been referred to us for comment. This draft has been examined in this Department and, while generally acceptable and desirable in the changes that it makes, there are one or two areas where the Department has some doubt as to the desirability of the proposed changes. Section 3(E) of the proposed amendments does not seem to us to be particularly meaningful. It would read (see p. 150) as follows: (E) For purposes of this Act, references herein to "the practice of counseling and psychotherapy" mean the offering by an indi- vidual of services involving the application of the principles and techniques of counseling and psychotherapy, individually and in groups, to individuals with personal complaints and/or symptoms. I do not understand why this definition was added. It apparently is adde.d to make clear that counseling as used here is essentially synon- ymous with psychoterapy. They define the practice of counseling and psychotherapy. I would modify my statement to the extent that I think t~hat Section 3(E) does add something of significance and should be included. The changes in Section 4 are acceptable and appear to clarify with- out substantially changing the intent of this section. There are cer- tain minor changes in Section 5 which the Department thinks are not controversial and these are supported. There is an important change in Section 6(B) which provides for the Commissioner to appoint a Board of Psychology Examiners with- out the requirement that they be recommended by any specific group. The Department concurs in this change as it believes that the Com- missioner should not be limited in his selection of Board Members, if he determines they are qualified. Section 7(B) makes additional requirements of a licensee who in- tends to "practice consultation and psychotherapy," both in the exam- ination and training requirements. While this seems to be, at this time, a novel division of what has been generally considered the practice of psychology, the Department sees no reason to object. Neither is this enthusiastically supported as it would seem that all psychologists should be subject to the same requirements insofar as the examination given and the training required. PAGENO="0117" 113 Section 8(C) has been added and is necessary if the change in Sec- tion 7(B) is made. Section 12, as contained in the draft, is designed to meet a recom- mendation made previously by the Department with respect to H.R. 10407. rfte only change in Section 13 is to conform with the changes ~)reviOusly made in Section 7(B) and the additional 8(C). The remaining sections in the draft are without substantive changes insofar as we can see. It is recommended that the committee support the proposed changes indicated in the draft, except that I am mildly inclined to believe that the same standards of education should be required of all psychologists. In other words, Mr. Chairman, we support generally the changes that are recommended, with the very mild reservation that we are not quite clear that there is a need for the division of the examina- tion and licensing into two categories. Mr. WALKER. Thank you, Dr. Schultz. Mr. Moyer, would you like to summarize now? Mr. MoYER. Mr. Chairman, on May ith the District submitted a letter to Mr. McMillan commenting on these two bills, S. 1864 and H.R. 10407. This morning we submitted a letter addressed to Mr. Sisk, dated June 18, in which we commented on this proposed sub- stitute draft bill. In our letter of May 17 we recommended that the bill as passed by the Senate be considered by the committee because it had several desirable amendments, and in our letter to Mr. Sisk in commenting on the proposed substitute bill we have said that we had no objection to these provisions in the substitute bill. They appeared to clarify the relationship of psychologists to psychiatrists in the field of psycho- therapy. Therefore, we offer no objection to this substitute bill. Basically, the District's position is that which I have just enumerated. Mr. WALKER. At this point, for the record, (the letter to Congress- man Sisk from Mr. Fletcher will be made a part of the record. It is dated June 18th. (The letter follows:) GOVERNMENT OF THE DISTRICT OF COLUMBIA, EXECUTIVE OFFICE, Washington, June 18, 1968. Hon. B. F. SISK, Chairman, Subcommittee No. 5, Committee on the District of' Columbia, United States House of Representatives, TVashington, D.C. Dii~n MR. SisK: In connection with your hearings on HR. 10407 and S. 1864, bills "To define and regulate the practice of psychology in the District of Columbia", the Clerk of the Committee, James T. Clark, Esquire, furnished to District of Columbia representatives for comment a draft substitute bill pro- posed by the District of Columbia Medical Society, the Medico-Chirurgical Society of the District of Columbia, the Washington Psychiatric Society, and the Washington Psychoanalytic Society. The District Government has reviewed the proposed substitute bill. We note that while in large part it is similar to 11.11. 10407 and S. 1864, some of the sections of the substitute bill include language which clarifies the relationship of the psychologist to the psychiatrist in the medical field of psychotherapy. In the District's May 17, 1968 report on HR. 10407 and S. 1864, we supported the provisions of the bills requiring the psychologist to refer his client to a PAGENO="0118" 114 medical practitioner for treatment of medical aspects of the client's problem. We- therefore offer no objection to those provisions of the proposed substitute bill which clarify the responsibility of the psychologist to confer with, and be subject to the supervision of, a medical practitioner in the medical field of psychotherapy.~ Sincerely yours, /s/ Thomas W. Fletcher, THOMAS W. FLETCHER, Assistant to the Commissioner. (For Walter B. Washington, Commissioner). Mr. MOYER. Thank you. I would ask that our letter of May 17 to Congressman McMillan also be made part; of the record. Mr. WALKER. I think that has already been made part of the record. (Seep. 105.) Are there any questions from Members of the Committee? Mr. NELSEN. Are these amendments to an existing Act that we are talking about? Mr. MOYER. This proposal of the Psychiatric Association is a pro- posed substitute bill which is very similar to 5. 1864 and H.R. 10407. Mr. NELSEN. Are there standards for psychologists presently set up in the District? Mr. MOYER. There are no present licensing procedures of psychologists. Mr. NELSEN. Without question, then, there must be some feeling that there is a deftnite need for standa.rds, otherwise we would have a wide variety of qualifications of those practicing here. Is that true? Mr. MoYEAI. Yes. I would say this, and I want to mention this in summing up, that it appears that everyone who has testified, repre- sentatives of the Psychiatric Association, the Psychologists, and rep- resentatives of the District Government all agree that there should be licensing of psychologists a.nd there should be standards set up in order that a qualified practitioner could be licensed. Mr. NELSEN. In the policing or administration of a program of this kind, is there any estimate as to the added cost to the District Govern- ment? Will an increase in personnel be required? What is the estimate on that? Mr. MOYER. We do not have an estimate. There are provisions in the bill authorizing the District to cha.rge fees for licensing, whicit should cover the costs. Mr. NELSEN. Thank you. No more questions. Thank you. Mr. WALKER. Mr. Harsha? DEFINITION OF THE PRACTICE OF PSYCHOLOGY Mr. HARSHA. May I refer you to page 3 of S. 1864, the draft of the bill with the amendments in it, you apparently enumerate different phases of work covered by psychology. I think it is in the definitlon section, and defines "the practice of psychology." In `that definition, you refer to "public opinion." I am not sure what you mean by that. Do you mean that in order to conduct a poll, say a Gallup Poll, you have to have a license to practice psychology? Mr. MoYER. I will defer to Dr. Schultz on that. Mr. WALKER. If the gentleman would yield. Dr. Schultz, if neither you nor Mr. Moyer want to comment on this at this point it' might be helpful if we called for the representatives of both the other groups, the Psychiatrists as well as the Psychological group, to come up and have PAGENO="0119" 115 a round table discussion. It might be helpful if concerned would enter into this, and probably we could come nearer answering the questions. This is just a suggestion. Mr. HARSHA. I certainly have no objection. I don't care who an- swers it. Mr. WALKER. At this time, then, why don't the representatives of these two Associations come up to the table. I am not cutting you off from answering his question, Dr. Schultz. You may proceed, or yield to someone else if you wish. Dr. SCHULTz. I will be happy to try to answer the question. I am not sure that I understood Mr. Harsha's question. Mr. HARSHA. On page 2, under Section 3(D), it says (reading): "The practice of psychology" is the rendering of or offering to render to the public for a fee, monetary or otherwise, any service involving the application of established methods and principles of the science and profession of psychology, except as provided in sections 5 and 20 of this Act. These principles and methods are concerned with understanding, predicting, and changing be- havior, and they include, but are not restricted to, the use of counseling and psychotherapy with groups or individuals having adjustment problems in the areas of work, family, school, and per- sonal relationships; measuring, testing, and assessing aptitudes, skills, public opinion. * * * What does public opinion there mean? Why was it included in the definition? Dr. SCHULTZ. That language was in both the original Senate and House versions. I have not myself contributed to the language there~ in any sense. I think perhaps the psychologists could better explain the meaning of that than I could as a psychiatrist. This is a definition of what psychologists do. Mr. WALKER. Dr. Meltzer, would you like to contribute something? Before you do, will you identify yourself as you enter into the. discussion? STATEMENTS OF DR. A. J. BAYROFF, PRESIDENT; DR. MALCOLM L. MELTZER, PAST PRESIDENT; DR. ~ONATHAN W. CUMMINGS, CHAIRMAN, LEGISLATIVE COMMITTEE; MRS. JANE HILDRETR, LEGISLATIVE CONSULTANT; AND MR. REED CHAMBERS, DIS- TRICT OP COLUMBIA PSYCHOLOGICAL ASSOCIATION; AND DR.. OSCAR LEGAULT, PRESIDENT, AND MR. ARMIN U. KUDER,. WASHINGTON PSYCHOANALYTIC SOCIETY-Resumed Mr. MELTZER. I am Dr. Malcolm L. Meltzer of the D.C. Psychologi- cal Association. Public opinion polling is one activity of psychology, and that is why it is part of the definition of psychology. However, it is also an activity carried on by other professionals in addition. For example, we recog- nize that while we practice psychotherapy that other people practice psychotherapy, such as psychiatrists. In these terms it is put in the definition of psychology. But in Section 20(B) of the bill it is made clear that this is not restrictive legislation in the sense that other professionals, recognized professionals who have their own code of PAGENO="0120" 116 ethics may continue to do what they are doing. So there is no attempt to haniper Mr. Gallup, or anything of that kind. Mr. HARSHA. Is 5. 1864 with the amendments, which is before us, acceptable in all phases of practice in this field, to the psychologists and to the psychiatrists? Dr. MELTZER. It does not pertain to psychiatrists. They are covered by the Healing Arts Practices Act. This bill is related to one who may call himself a psychologist and what a psychologist may do. Mr. LEGAnLT. Mr. Harsha, I am Dr. Oscar Legault, and I repre- sent the psychiatrists. We have no objection to the definition of the practice of psychology in this bill. Mr. HARSHA. I have no other questions. Mr. WALKER. If there are no further questions at. this time from the committee, Dr. Legault, would you like to lead off and comment on your proposed amencimeilts which have been printed in full in the record. (See Appendix, p. 149.) PRoPosED AMENDMENTS Dr. LEGAULT. I really have nothing to add to the comments that I have already made about the amendments to the bill. `We have in- cluded our statements in our general presentation. We feel that the purposes of our amendments are really to write a bill which would allow the practice of psychology to be carried out under realistic reg- ulations. WTe do not aim to be restrictive, as we are accused of being, but we do feel that the frnction of a law is to regulate, which is what the law says it is going to do. In order to regulate, it has to say what things can be done and wha.t things cannot be done. Our changes have been in the direction of changing the loose wording, particularly the wording of Section 4 which was criticized by Members of the sub- committee generally as being a prayer rather than a law. `We have aimed to transform it into wording of law. Generally, the rest of our suggested amendments have been along that line. I do not think I have any further comments. I would welcome questions, however. Mr. WALKER. Mr. Nelsen. any questions? Mr. ~\ELSEN. No. Mr. WALKER. Mr. Harsha? Mr. HARSHA. Am I right that psychologists presently are not licensed in the District? Dr. LEGAtTLT. That is correct. Mr. HARSHA. What is a Ps. D. in psychology? Dr. LEGAULT. I don't know. Mr. HARSHA. I have here the yellow pages of the Washington tele- phone book. Someone here represents himself as a Ph. D. and then he has the capital P, again with a smaJl "s" between it and the capital D, in psychology. He practices metaphysics, epistemology, hypnosis, emo- tional problems. insonmia, tension release, and a few other things here. Will he come under the purview of this law now? Dr. LEGAULT. He would come under the purview of this law. He currently comes under the purview of the Healing Arts Practices Act so far as I understnad. Why he is there in that book, I would have PAGENO="0121" 117 to ask other people. But in any case, he certainly would come under the purview of this law and other laws. Mr. HARSHA. Here is another man who says he is psychologist certified by Maryland and D.C. Is there a D.C. Board that certifies psychologists? Dr. LEGAULT. Not to my knowledge. Mr. WALKER. Dr. Cummings. Would you identify yourself for the record, sir? Dr. CUMMINGS. I am Dr. Jonathan W. Cummings of the D.C. Psy- chological Association. We have attempted to police ourselves in a nonstatutory certification manner. This is nowhere near as complete as the type of Act that we are presenting here today because it is voluntary. It protects the title "psychologist", of anyone who wishes to have it protected. I think many of the gentlemen or persons who represent themselves in the yellow pages are not those who would seek this kind of nonstatutory certification because, for instance, the degree that you have named is generally believed to be obtainable from a diploma mill, that is, obtainable without any well worked-out course of study in the nature of behavioral problems, et cetera. I believe I am safe in saying that one of the main purposes of our actions here is to secure an Act or a law which would prevent this kind of potential charlatanism, potential bilking of the public. After all, our No. 1 aim as proponents of S. 1864 and H.IR. 10407 is to protect the public of t.lie District of Columbia. Mr. HARSHA. You say this certification is voluntary. Do you take an examination? Dr. CUMMINGS. Yes, there is an examination. Mr. HARSHA. Who conducts it? Dr. CUMMINGS. The D.C. Psychological Association; actually the Board of Examiners, which is a separately constituted group but sponsored by the D.C. Psychological Association. Mr. HARSHA. Thank you. Mr. WALKER. Thank you, Mr. Harsha. Would anyone at the table or anyone here care to contribute any- thing further at this particular time? Dr. Cummings, do any of your group have comments to make for the record respecting the proposed amendments, or otherwise? Dr. CUMMINGS. I would be happy to start talking. Dr. Legault., did you have the floor? Is it all right if I commence here, Doctor? Dr. LEGAULT. No, I do not believe I have the floor. I believe the sub- committee designates who has the floor. Dr. CUMMINGS. Very well. You were asked a question and I did not want to butt in, of course. I wonder if I might say, sir, at the outset that, unfortunately, mem- bers of my organization were not here on June 3rd when the Psychi- a.tric Society and the Psychoanalytical Society representatives were heard. Therefore, I would like to make just a comment or two about. their testimony which I have had the opportunity to read. Mr. WALKER. Go right ahead. GENERAL COMMENTS Dr. CUMMINGS. This will be very brief, and then we will get to the business at hand. I would like to express `the keen disappointment of PAGENO="0122" 118 my organization in some of the points which were raised on June 3rd. I just thought I would mention three or four of them because-by way of correcting the record. I think, for one thing, there was an inference there that psychologists are in high doubt as to the adequacy of their training. I believe the references made there in the testimony are really taken quite out of context. We are very happy that ours is a profession in which individuals can spea.k up and can make suggestions as to how to improve our training. I believe that this is what the particular phrases taken in that testimony were really referring to. I am very glad to belong to a profession that does in fact feel free to come forth with suggestions about how to improve our own training. A second point was a rather incredible intimation in the testimony that psychiatrists in any way train us clinical psychologists. We will, of course, look anywhere, to any corner, sociologists, anthropologists, physicians, as well as professors within our own field of psychology for training, but I don't believe in any specific sense we are trained professionally by psychiatrists. There was also a questionable attempt to assert that psychiatric training is more appropriate for dealing with psychological prob- lems than is our training in psychology, a.nd I would certainly reject that. One more point is, I believe there was a suggestion made that we in the D.C. Psychological Association have dealt duplicitously or at an infraprofessional level. I can only say most sincerely that we have not, that we wish to be open and free with everyone who has anything ~to say about this very important matter in front of us, and with that point I can move right into remarks more pertinent to this morning's ~liscussion. Those remarks would simply be that we come here in a spirit of doing everything possible to improve our bill. The Senate of the United States passed it unanimously in April. But I guess that it could be said that there is no such thing as a perfect piece of legis- lation. Sure, there are points at which any bill perhaps can be im- proved, and we are here to consider jointly with you folks this morn- ing how we can be of help in improving this bill. As I have said before, I think, as our behavior over the next few minutes will indicate, we are ready to consider any kind of improve- inents that may be indicated. We have received a copy of the amendments proposed which were submitted by the psychiatrists to you on June 3rd. I wonder if it is your wish that we move into that now. Mr. SIsK. (presiding). Dr. Cummings, I want to say first I apolo- ;gize for being delayed. I was here earlier but had to leave for an- other committee appearance. I am sorry that I did not hear all your statement and other statements which have been made. Basically, my first question to you is whether or not you and your Association of Psychologists have had an opportunity to look over and study or analyze the proposed amendments by the Psychiatrists' group. Dr. Cu~r~rINGs. We have, sir. Mr. SIsK. I would like to have any comments you wish to make on those proposed amendments. I think in view of the fact we have attempted here to put them in some order as they would apply to the PAGENO="0123" 119 Senate bill, S. 1864, using that bill as a vehicle, that we might consider them in the order in which they would go into the bill, followed by any comments that you have. I think it is of concern to the committee to see whether or not we may be able to reach some general agreements or some modification of the positions. Again, I am not necessarily setting myself up-and I am sure the committee is not-as a peace. maker between the psychiatrists and the psychologists, but frankly it is my understanding that every one agrees there is no need for iegislation in this field. To the extent that there is that need, this committee would like to be of service to the District of Columbia by bringing this about. Do you have any comments in sequence there so that we can discuss these amendments individually? If you want to make some general comments on the amendments please go ahead. Dr. CUMMINGs. Thank you every much. I am happy to be here and happy to hear you say what you said, because that is precisely how we approached the task of arriving at our opinions on the proposed changes to the bill. In other words, we took S. 1864, without judging it in any way, as the first model, then held the psychiatric proposals up against that and they were, in fact, written into that framework. Then we make our comments to both of these. So when I use the word "original" from time to time I will be referring to Senate Bill 1864. Mr. SIsK. That is the bill that we have before us for the sake of ~discussion right now, and the one we have attempted to use to try these various amendments on for size and have attached them thereto. Your prepared comments will be included in the record in the Appendix, following the amendments. (See p. 154.) SECTION 3. DEFINITIONS Mr. SISK. If you want to start out with their first proposed amend- ment, which we show on page 3, starting at line 7, as a new sub- section (E) of Section 3, and make such comments as you would, you may go right ahead. (E) For purposes of this Act, references herein to "the practice of counseling and psychotherapy" mean the offering by an indi- vidual of services involving the application of the principles and techniques of counseling and psychotherapy, individually and in groups, to individuals with personal complaints and/or symptoms. Dr. CUMMINGS. Thank you, sir. In Sections 1 and 2 there are no dif- ferences, and of course no comment. Section 3, as you have pointed out, is the first place at which there are potential differences of opinion. I think we do have a difference here. Let me say first what the Psychiatric proposal has done. They have replaced Section 3(E)-which in Senate 1864 was a medical disclaimer statement-they have replaced it with a definition of counseling and psychotherapy. I must make a statement here because this will recur throughout our observations on the proposed amendments, and therefore I think will PAGENO="0124" 120 be very appropriate right here. In our discussion of the next two sec- tions below and subsequent sections also, we will be expressing our dissatisfaction with, on the one hand, linking the two activities, psyco- therapy and counseling, together as a running pair and, secondly, sepa- rating them out from the rest of the tools and techniques which are in the armamentarium of a psychologist. Now, with respect to the definition of psychotherapy that the Psychiatric proposal substitute in place of 3(E), we are perfectly happy to comply with including a definition of psychotherapy. We would suggest what we consider a slightly better one, and that comes from the Licensing Act of the State of North Carolina 1 which is one of the more recent of the 17 or 18 licensing laws which have been passed across the country. Section 2(e) of that Act states: "Psychotheral~~" within the meaning of this Act means the use of learning or other psychological behavioral modification methods in a professional relationship to assist a person or persons to modify feelings, attitudes, and behavior which are intellectually, socially, or emotionally carried or ineffectual. Mr. HARSHA. Have you copies of your comments? Dr. CUMMINGS. Yes, I have some rough drafts. WTe have had very little time, of course to prepare. Would it be apporpriate to share with you these copies? Mr. SI5K. Yes. If you have rough drafts that you could pass around to the members, it. would give us the opportunity to examine them. We can look up the North Carolina Act. I think the suggestion of the gentleman from Ohio is a good one. I do not know how far we will get on this. As I say, this is a some- what. informal approach to the legislation. The idea is to try to see if there is a. happy medium here. Dr. CUMMINGS. May I say t.his is an incomplete working notes sort of thing? If I may have them back, we will take the responsibility of re- typing them and putting them in better form. This is merely a working paper. I have just read the North Carolina definition of psychotherapy which we would propose to put in as Section 3(E). I do not believe it is materially different from the one which has been suggested, although there may be a difference of opinion on that. COUNSELING AND PSYCHOTHERAPY Mr. SIsK. Could I ask you to repeat at least for my better under- standing? I believe you made some statement in the beginning in the discussion of this particular Section 3(E) that you found some prob- lem in connection with counseling and psychotherapy. Dr. CUMMINGS. That is correct, sir. Mr. SIsK. Would you explain a little more. fully what you mean by that. statement.? Dr. CUMMINGS. Certainly. Incidentally, there are large. sections of the notes you have in front of you which deal with this very issue. 1 North Carolina. Regular Session. Ch. 010, Laws 1067. Senate Bill No. 578, ratified 27 June 1067. PAGENO="0125" 121 Mr. SIsK. I might tell you here, parenthetically, that in discussion with the staff this morning, I had some problem with the `definition of counseling and psychotherapy. I was curious to have your definition or any comments you have on it. Dr. CUMMINGS. Might I say at the outset, it is probably a little diffi- cult to define psychotherapy and counseling. It might be possible to say that one of the sources of difficulty among various professions may be the very absence of a generally agreed upon definition. Let us leave psychotherapy at one side for the moment, because I- I think I speak for my Association-do subscribe to the definition of psychotherapy which I have just read and which is from the North Carolina statute, and which you will find in the notes there. Where counseling is concerned, I can only say that it is a murky problem. It is an activity which on the one hand people talk about confidently doing, and yet on the other hand they find it very difficult to define it or sometimes to differentiate it from some form of psycho- therapy. I think the most important observation we can make is that so many qualified, ethical professionals of a variety of professions do in fact use what they call counseling. We have marriage counselors, which in many States have regulatory authority and le~islation controlling them. We have vocational counselors, educational counselors. Without stretching the point too much, lawyers are often referred to as coun- selors. Ministers and priests and rabbis have as an important part of their activities the act of counseling. At one point here in what I have handed to you, at the bottom of page 3, we issue a heartfelt and friendly warning to our psychiatrist colleagues. I do not believe they really intended to bring the term "counseling" into the practice of medicine, because I would fear they would be bringing down a torrent of objections on their heads from so many other folks who are in fact doing what is called counseling with people who have one or another kind of difficulty. Mr. Sisic. I want to clarify a bit, if I may, what I mean, and then I will yield to the gentleman from Ohio. I appreciate what I understand to be your definition and explana- tion. WTithout making comment on the definition found in the North Carolina law, I do not want to get into a controversy between you gentlemen; as a matter of clarification and for the edification of the committee, Dr. Legault, your definition as contained in your first proposed amendment to Section 3(E), frankly, is what I am having a problem with, because you are defining a term with the same term. I am curious to know, first, do you find any fault with the definition in the North Carolina Act? Dr. LEGAULT. No, sir, we do riot. The problem concerning the lan- guage of the bill, particularly the utilization of the term "counseling", has to do with the fact that, as has been noted, the regulatory provisions of the Act have to be carefully spelled out. If one does not include the term "counseling", then the activity of counseling the mentally ill is thereby given a loophole, in the bill. WT0 are concerned with the problem of counseling those individuals who suffer from mental disease, and we wish to specify that this is a medical function. This is, therefore, the meaning of our attempting to debne the "practice of counseling and psychotherapy" in Section 3(E) PAGENO="0126" 122 is a. phrase which can be compared to the practice of medicine. We indicate that by subsequently introducing the term "complaints and/or symptoms", which is what we feel patients generally have. Mr. SIsK. I appreciate your comments. Your proposed Section 3(E) reads: For the purposes of this Act, the references herein to "the practice of counseling and psychotherapy" mean the offering by an individual of services involving the application of the prin- ciples and techniques of counseling and psychotherapy, individ- ually and in groups, to individuals with personal complaints and/or symptoms. Of course, that is really not a definition, because it uses the same terms to define terms. You are not really defining the meaning of counseling and psychotherapy. You are actually attempting to make a deffnition as it. applies in a particular medical case. Is that not what you are. saying? You cannot. in stating a definition of any given word use the same word to define it. Do you see what I mean? Mr. KUDER. Perhaps I can answer that, Mr. Chairman. I am Arrniii U. Kuder. I have been assisting the Psychoanalytic organization in the draftino~ of this language. I think &e purpose of this section is not so much to define psy- chotherapy-that is the reason that Dr. Legault can so readily adopt the language of the North Carolina bill-but to define the practice,. which is, (1) offering certain services to the public (individual counsel- ing and psychotherapy and group counseling and psychotherapy), and (2) identifying the individual who would be receiving it. This defines not so much the teclmique but the activity of the psychologist. If psychotherapy were being done in a. university setting for teaching- purposes or something like that, that would not constitute the "prac- tice" of counseling and psychothera.py. Mr. SIsK. Thank you. The gentleman from Ohio had a question. Mr. HARSHA. I just wondered if the North Carolina definition does not at least imply counseling. It says "to modify feelings, attitudes, and behavior which are intellectually, socially, or emotionally malad- justive or ineffectual." Are you not in fact counseling? Dr. Cn~DrIxGs. Certainly, when trying to define it, it is broader. I think possibly it might. be said that psychotherapy is one particular~~ form of counseling. I am not sure of myself here, but I think it is a possibility. Mr. HARSHA. Does the North Carolina definition meet your objec- tion? Dr. LEGAULT. I have no objection to that.. I generally felt the North Carolina Act is a very good Act all around, including the definition of psychotherapy. Mr. SIsK. I agree with that. Dr. CuMMINGS. I might say, parenthetically, it represents a couple or three other very good statutes which have actually used this defini- tion. We could have cited a couple of other States, too. North Carolina.. is one of them. Mr. SIsK. Go ahead, Doctor. PAGENO="0127" 123 MEDICAL DISCLAIMER Dr. CiTJMMINGS. Yo,u will remember in S. 1864, as passed by the Senate, there was in Section 3(E) what I have called the medical disclaimer statement. At the top of page 2 of the notes you have in front of you (see p. 154), we have indicated that it is so important to us and to our code of ethics that we cannot possibly leave it out. This idea must be represented in the bill. We have taken what is Section 3(E) of S. 1864 as passed by the Senate and have made it part of Section 4. At the bottom of page 2, then, extending on to page 3, you will see our suggested wording for Section 4, as follows: SEC. 4. (A) The psychologist who engages in practice shall assist his client in obtaining professional help for all aspects of the client's problem that fall outside of the boundaries of the psychologist's own competence, such as, for example, in medical or legal matters. In those instances when a medical problem is involved, there must be effective collaboration with an appro- priately qualified medical practitioner. (B) Nothing in this act shall be construed as permitting the administration of drugs, surgery, or any manual or mechanical treatment whatsoever, by any person not certified under the Heal- ing Arts Practice Act of the District of Columbia, approved Feb. 27, 1929 (45 Stat. 1326), as amended. I would like to make a few comments about this and invite other members of my group also to comment as they see fit, because I think, as has been suggested here, Section 4 is very important. The difference seems to distill itself down sooner or later `to difficul- ties in defining and clearly grabbing onto such terms as "mental ill- ness," "treatment," "counseling and psychotherapy," and what have you. I think that the point we have to make here is that we in psychol- ogy join eminent psychiatrists and many others in the mental health field in questioning whether the practice of psychotherapy, for instance, is co-extensive with or limited to the area of mental illness. I have a very weak-minded way of looking at this myself. If I could take a moment to spell it out, I can conceive of a square whch is mental illness, and another square which we can refer to as psychotherapy. If you picture those two squares overlapping to a certain extent in your mind's eye, this would be descriptive of how I see the relation- ship between psychotherapy and mental illness. It is true, as I have noted here in sections 4 and 5, talking generally about the whole area, psychotherapy is in fact applied-of course it is-to some of the most serious kinds of emotional disorders, those requiring hospitalization, those iiivolving si~iicidal potental, and what have you. But I think I state a pretty generally held feeling that the term psychotherapy is applied to a far greater range of problems than simply to people who could be described as having a mental disease or a mental illness. Let me give you an example. For instance, a person who is expe- riencing difficulty in living in general, a general dissatisfaction with h1s life. Certainly an individual like this typically would not be seen as being mentally ill, I do not believe. All of this is part of the matter as to what our relationship is to the medical profession on such issues, PAGENO="0128" 124 which is the section 4(B), both in the Society's proposal and in our comments here. Is it feasible, is it really necessary for a psychologist practicing within the boundaries of his competence and under his code of ethics, on a mandatory basis to have every client he sees examined by a physi- cian? This subcommittee on June 3 heard the testimony of a psychia- trist, not part of the official representation, and it seemed to me as I read her testimony she was saying, no, in her experience psychologists are very capable of making the decisions as to when it will be impor- tant for the psychologist to recognize that the client has problems, be they medical. legal or in any other area, which exceed his boundaries of competence. At that point, under our code of ethics, he must assist that client in obtaining the kind of help appropriate to the client's problems. Dr. Brayfielci, in the hearing on May 20, mentioned Dr. Allen S. Mariner, who is a nationally prominent psychiatrist who has written an article which bears on the point we are making here. Dr. Mariner, even though he is not a psychologist, would seem to be making the point very forcefully that as long as what I have just indicated here is the case-and he believes, incidentally. that psychologists are very capable of recognizing when there are symptoms which should be referred to an appropriate medical individual-whenever the psychologist realizes this, he is to refer the patient. Otherwise, the feeling of these peoile and so many others is that a psychologist can very effectively practice psychotherapy, counseling and diagnostic evaluation or psychological testing or consumer analysis or behavior or any one of the several kinds of psychological activity. These comments bear on both Sections 4 and 5. I am raising ques- tions here as to whether we need to be controlled as vigorously as the psychiatrists would appear to want to control us in their wording of both Sections 4 and 5. That is the question I am raising. Mr. SIsK. I appreciate your comments, Dr. Cummings. Apparently Sect.ions 4 and 5 represent to some extent the problem and the differ- ences in a.pproach by representatives of practicing psychiatry here as against the psychologists. I was interested in hearing your comments. As I understand, if I may interpret-I do not want to put words in your mouth-this new proposed (B) imcler Section 4, which is a proiosal, goes a good deal further than von feel is necessary. Is that, in essence, what you are saving ? Could I then ask this question: Do you feel it does irreparable harm to the legislation which we are attempting to develop, dealing with the regulation of the Practice of psychology in the District? Dr. Cu3r3nxGs. I feel a. little at a loss to evaluate, in your terms, whether irreparable harm would be done by any of the provisions of the statute- Mr. SIsK. Maybe I should not have used the term "irreparable." Do you have a feeling as to whether it would be helpful or hurtful? Dr. Cu~r~rIxGs. I believe Section 4(B) in its present form would definitely be hurtful, because it seems to me that it leads to control of the profession of psychology or one important aspect of the profession of psychology by psychiatry to a degree which would eventually hurt the using public of the District of Columbia. PAGENO="0129" 125 For one thing, it would very possibly reduce the number of available man-hours of professional help which are so desperately needed by the population throughout the country as a whole, and here in the District of Columbia, too, because it would lead to all kinds of prob- lems, a main one of which would be an excessive amount of direct contact, I presume, between the two professions, and an inability of the psychologist to function in a helpful way. He would always have to be checking back. As we read it, he would never take a patient on in psychotherapy, as we have defined it in North Carolina terms, without first having had the equivalent of an O.K. from a psychiatrist. Mr. SI5K. That is the point I wanted to discuss. In attempting to interpret the proposed amendment in Section 4(B); it seems to me it means that in every case you would first be required to have the patient examined by a physician, an M.D., after which the practice, help and assistance of the psychologist would be a part of the treat- ment handled to some extent under the direction of a physician. Is that your interpretation of it? Dr. CUMMINGS. I would agree with you, sir, that is my understand- ing of the proposed 4(B). Let me ask my colleagues, do they agree? (Pause). It goes further, one of my colleagues says, in terms of primary responsibility, which is a phrase used in the proposed Section 4(B). I think that bears on the point I was trying to make before. The psy- chologist is widely recognized by many reputable agencies of our culture, has the training and has available to him the ethical controls in our code of ethics, so he can and does function at a far more profes- sional level in those States where licensing does exist than is implied in Section 4(B). I think I would agree with you, sir. Mr. SIsK. This is not in terms of controversy, but I would like to ask, Dr. Legault, how do you interpret 4(B) as you have written it? I am asking this question basically because at some point the com- mittee must make a policy decision on these points. We are trying to determine as best we can how this will be interpreted in the medical community and the psychology community if an Act is finally passed to regulate the practice. Dr. LEGAULT. If I understand Dr. Cummings' statement, he has stated to you that the psychologists are not interested in treating disease; that pyschotherapy as used overlaps and treats other things besides disease with psychotherapy. We are in total agreement with that. That is exactly what we wanted our Section 4 to specify, namely, that at no time may a psychotherapist from any profession treat disease without being in effective contact with a physician. The proposed alteration of the bill by the psycholo- gists in Section 4(B) specifically eliminates reference to the fact that they would be treating disease. They have left out that phrase. Section 4(B) as they have written it simply specifies that they will not be utilizing physical methods of treatment, but any psychological method of treatment can be utilized by them even for the treatment of mental illness. Our contention is that if it is for the treatment of mental illness, the primary responsibility for this should fall in the hands of the physician. We do not take the position that psychologists should not 94-755-GS-----9 PAGENO="0130" 126 treat mental disease. We take the position that if they treat it, they should do so in consultation with a physician. That is the aim of our writing, and I think it is very clear. Dr. MELTZER. May I comment on this? I think there are very tough issues wrapped up in this. I think, first of all, to counter what Dr. Legault said, we are not saying in this bill that we treat disease. The medical disclaimer part of the bill states that very clearly. Second, in the Section 4(A) as we have it, we point out that when it is a medical problem it must be referred to a physician. This is taken care of. It is not an attempt to sneak in, in a.ny way, as he tried to suggest. One of the problems is the very compelling notion that when there is a disease, of course a. physician is involved. I think that is true. From this, what in the world is a disease? The thing that bothers us about this section is that it is quite probable for any psychiatrist to come along and say, "That is a disease you a.re treating." By his definition of disease, disease can include almost anything. It is a very vague term. For example, the Statistical and Diagnostic Manual of the American Psychiatric Association included as diseases such human proble.ms as stuttering, nail-biting, sexual deviation, chronic misbehavior, imma- turity, and criminality. All of these things can get a medical diagnosis andbe called a. disease. I think all of us are just as much concerned that people not be identified as mentally ill and mentally diseased when there is no real disease there. This has done irreparable harm to patients in hospitals when this happens. I think many times we are worried that psychiatrists are much too free in finding that a pe.rson has some deep mental illness or deep disease. One example of this, if I might, was that FACT magazine was able to get over 2~OOO psychiatrists to diagnose Barry Goldwater by mail and to claim he had some sort of mental illness. They came to the American Psychological Association, and the American Psychological Association refused to sell them names and addresses of psychologists and told them that any psychologist who tried to make a comment about this would be violating the ethical code of the American Psycho- logical Association. I think we have to be very careful that everything is not construed as a disease. I am afraid if this type of provision stays in here, any psychiatrist can say that. a. person who has misbehaved or is a criminal has some sort of medical disease. I think we have seen this in courts to an extreme extent, where every kind of behavior is claimed to be due to some sort of mental illness. This section would, I think, give control over every psychologist by every psychiatrist, no matter what his philosophy is. This is the harm of that section. Mr. SIsK. We appreciate all your comments. I recognize there is some little difference of opinion. I am sure you are aware sometimes here on the Hill we have a difference of opinion. I think we will move along. I shall recognize the gentleman from New Mexico or any of you gentlemen when you have questions on sect.ions as we discuss them. Let us try to analyze the proposed amend- PAGENO="0131" 127 ments and understand the different definitions we may have. At some point we will have to consider the inclusion of these amendments or their modification. Mr. HARSFIA. I have one question with respect to proposed sec- tion 4(B). Maybe this does violence to the whole section, I do not know. Is there any objection to the following language: Nothing in this Act shall be construed as permitting the ad- ministration or prescription of drugs, surgery, or any manual or mechanical treatment whatsoever, by any person not certified under the Healing Arts Practice Act, District of Columbia, 1928, as amended. Dr. CUMMINGS. This is in accordance with our code of ethics, sir. Dr. LEGAtJLT. No, I do not think that that would be complete enough. That is the suggested change of the psychologists. It follows very much the way they have wished to change their 4(B). We do not think that it is complete enough because it ducks the issue of under what circumstances the psychologist shall be permitted to treat mental disease without supervision. Some way or another, this limitation has to be specified in the Act, and the subcommittee will have to come to a conclusion as to how to do that. Whether it is agreeable or not, this is the issue. The psychologists are attempting to deal with the issue by saying everything can be called a mental disease and, therefore, their activities cannot be limited by referring to such a vague term. On the other hand, we know very well that there are such things as mental diseases and, therefore, we wish to specify that in these circumstances there be some wording in the law regulating its treatment. I wish to point out the differences in the attitude of our two groups here. Dr. Meltzer's statement is that the diagnostic and statistical manual of the psychiatrists called nail-biting, stuttering, mental dis- eases. This is not the case. There is no mental disease called stuttering or nail-biting in the diagnostic and statistical manual. There is in the back of that manual an enumeration of a great number of different symptoms which may or may not be evidences of mental disease, but that is an exaggeration as he stated it. His general statements are exaggerated. The psychiatrists did not testify anything whatsoever about Sena- tor Goldwater. It was established in court in New York that the en- tire matter was a fraud, and that the American Psychiatric Associa- tion was in no way involved and no reputable psychiatrist was ever involved in doing anything of the sort. I resent these implications being made about our profession. Mr. SISK. Gentlemen, we must keep this strictly on a gentlemanly basis. Sometimes we disagree, but we try to disagree agreeably. I appreciate your position, Dr. Legault, and also Dr. Meltzer's. MENTAL ILLNESS Mr. HARSHA. Can we define mental illness in the bill? Mr. SIsK. We have had some discussion on that. Do any of you want to make a brief comment? Definition seems to be difficult in the area of psychology and psychiatry. PAGENO="0132" 128 Mr. KUDER. As an attorney having dealt with this, perhaps I may suggest one answer, and that is, you do have the District's Healing Arts Practice Act, which refers to disease and to which we have con- sistently tied this language. We also have a large body of law not tied to the problem of psychol- ogists or psychiatrists, as to what is mental ilhiess in the criminal area. It was our thought in developing this that the line between personal problems and mental illness would be drawn in this area just as it is by the courts in many other areas, both in negligence and malpractice law and criminal law, and that it did not make a great deal of sense to try to write an elaborate definition of something which was changing regularly and was subject to great professional scrutiny, and which was being defined for the edification of all quite regularly in the courts. That is why we did it this way in drafting this language. Mr. HARSHA. I cannot speak for the rest of the committee, but one of our problems is that we know very little about either of your fields. We are in a foreign area, so to speak. We not only want a good law for the District of Columbia, but the cha.nces are this law will be a model for the rest of the country for States where there is not such a law. We have to be exceptionally careful, under the circumstances. Mr. KUDER. If the committee would look at the more recently en- acted laws, there is frequently reference to this kind of thing. If you are to be treating mental illness, then you must collaborate or con- sult with the doctor. Nebraska, North Carolina, South Carolina, and Kansas were the models that we used. The only thing which has been changed is where they say mental illness, because their medical act. refers to mental illness, we use "dis- ease" because our medical act uses "disease" and refers to the body of law which has been developed as to the meaning of that. I would agree with you, Mr. Harsha, it would be very difficult for nonprofessionals to define these terms for all time in this Act. That is why I think it makes more sense to refer to this body of law which is on the books and is available for everyone, and has been developed because there are psychiatrists and psychologists in court testifying at the particular time as to whether something is a mental illness or not. Dr. MELTZER. May I agree with Mr. Kuder about this. I think it would be very difficult to write a definition of mental illness. Our intention was to make it clear that a psychologist does not practice in the area of medicine under our Section 4. The medical problem-I assume that mental illness is a medical problem-is that the psychol- ogist must get consultation, must refer, must make provision. This wording is in there. That was our intention all along. I think that is very clear in the bill. Mr. SIsK. We are running short on time. We shall move along ra.the~ quickly. SEcTI0X 5. LIcENsING; Ex~rrTIoxs Dr. Cummings, in Section 5 as it is now written in 5. 1864, there is the recommendation on page 3, line 21, to strike the language, "un- less he shall first obtain a license or certificate pursuant to this Act, except as hereinafter provided", and to a.dd the new language which you have before you, which says: PAGENO="0133" 129 unless he shall have a valid, unexpired, unrevoked and unsus- pended license pursuant to this Act, and for any person to practice, or to offer to practice, or to represent himself to practice counsel- ing and psychotherapy unless he shall have an appropriate valid, unexpired, unrevoked and unsuspended license to do so, endorsed pursuant to section 7(B), except as hereinafter provided. Would you find that language objectionable? Dr. Cu~r~rINGs. My present memory is that we do not find that objectionable. Let me check my notes. Mr. SIsK. It is proposed in Section 5, at the bottom of page 3, line 21, to strike, starting after the comma, the words "unless he shall first obtain" and the rest of the clause, and to insert in lieu thereof the some- what more lengthy language I read, which seemingly is just clarifica- tion. I am not sure. Dr. MELTZER. That is the separation of counseling and psychother- apy. This is a continuing thing psychiatrists have done in their version, and I am not sure why, because the bill itself makes it very clear a psychologist cannot practice in an area for which he is not trained. If he is not a counseling or clinical psychologist, he does not do psychotherapy. I am not sure at all why this continual separating out of these two terms is necessary. It certainly is unprecedented in other situations as far as I know of. Does a lawyer get a separate or special license to do marriage counseling versus corporate law versus doing income taxes? Does a physician get one license to do surgery and another to do psychotherapy? No. Certainly nothing could be more different than psychotherapy and surgery, for example. But the place this is handled is in the regulation itself, which says a psychologist must do what he is trained to do, what he is qualified to do, what he has experience to do. If he does not, he loses his license. \~,Te have no control like this right now. There is no control like this. All you can do is throw him out of the local society of the American Psychological Association. This is included. Why separate it out? I do not think it is necessary. It is taken care of in the bill. Frankly, this is not the problem. If the psychiatrists are worried about who does psychotherapy, they should look at their own house. It is the physicians, not the psychiatrists, but medically trained physi- cians who are not psychiatrists, who are doing psychotherapy and counseling that they are not trained for. There is nobody stopping them. This is one of the great problems. There is no training in medical school in psychotherapy. They will tell you there might be a course or so, but a psychiatrist learns to do psychotherapy after medical school, in residency primarily. I think this is much more of a problem in medicine than it is in psychology. We have it taken care of in this bill. Mr. SIsK. As I understand what you are referring to here as objec- tionable is the "or to represent himself to practice counseling and psychotherapy" as separating it out. Do I understand correctly? Dr. MELTZER. That is correct. Mr. SIsK. I notice throughout the bill in the proposed amendments there is the term "counseling and psychotherapy." In other words, this is the rock on which the ship will break up. I would like to call on PAGENO="0134" 130 Dr. Lega.ult to make some comment on this. I am beginning to get the idea. maybe the nub of the question is the definition of these terms vis-a-vis the psychologists and psychiatrists. Would you comment on that, Dr. Legault, particularly as pertains to this particular language, or even in general, as I know you use it. in your proposed amendment. Mr. HARSHA. If we accept the North Carolina definition of psycho- therapy, then we delete the word "counseling" and just refer to "psychotherapy" as we have defined it in the bill. Dr. LEGAULT. I repeat the remark I made about counseling. In all of these instances I would like you to see where if one word is changed, what happens in the rest of the bill. It is very difficult for me to think about that as you are asking these questions. All the different State. laws accomplish their goals differently. For instance, North Carolina's, are very carefully worded bills. Where it seems to allow things in one section, it restricts them in other sections, so it comes out in the end that psychologists who attempt to treat mental illness cia have to consult with physicians. As a matter of fact, their regulation of this matter is far more carefully defined in the North Carolina bill than we are proposing in ours. However, you are correct, Mr. Chairman, in saying that the nub of the question has to do with the matter of counseling and psychother- apy. As a matter of fact, the psychiatrists have no interest whatsoever in the practice of psychologists, other than in their practice of that aspect. of psychology. All of our concern is with that particular activity. So far as the particular wording of Section 5 is concerned and why we wish to have the practice of counseling and psychotherapy specified and perhaps particular regulations concerning it in the licensing bill, let me say first of all, that it is not unprecedented. As a matter of fact, in the neighboring State of Virginia a psychologist who wishes to pract.ice psyc.hotherapy must obtain subsidia.ry licensure. After he has been licensed by the State Board of Psychology Examiners, he must obta.in subsidiary licensure from t.he Board of Medical Examiners. This is a special provision made for cilinical psychologists in Vir- ginia. Similar provisions are made throughout the different licensing Acts. Dr. CUMMINGS. That is not true. Dr. LEGAULT. Excuse me. I have the floor now. Mr. SIsK. Dr. Cummings, we will give you your chance in a moment. Dr. CUMMINGS. I am sorry. Dr. LEGAULT. It is difficult to speak when people are interrupting you. The matter of this specification of this activity we feel is very impor- ta.nt because the regulation of fraudulent practice in this regard is the main concern of our organizations. We have no quarrel whatsoever with Dr. Cummings and Dr. Meltzer when they point out the high ethical qualities of their profession and that they aim to regulate the practi- tioners in their profession. I am quite aware of the fact that that is perfectly true and I have no quarrel with that what.soever. They are also aware of the fact that it is perfectly true that I have similar regards with the regulation of practice in my profession. So that we have no quarrels whatsoever in this regard. PAGENO="0135" 131 The question, however, is writing the law `such that it will not allow evasion. The evasion that may take place in the law has to do with this particular activity, the practice of counselling and psychotherapy. Any loose wording with respect to this, any absence of making provisions which shall specify who shall do this particular thing with the mentally ill will provide great temptations to people to attempt to evade it. Mr. SIsK. Thank you, Dr. Legaui't. Now, Dr. Cummings, you may make a comment here. Then we are going to move on to the next amendment. I want to quickly try to review at least the high points of all the amendments. Dr. Cummings. Dr. CUMMINGS. First I want `to say that one thing Dr. Legault said about the State of Virginia is in fact true. It is, in fact, the only statute which does include that `provision. But it is not in accord with the APA code or the guidelines f'or shaping psychology legislation in the States. Mrs. Hi'ldreth, would you care to comment on that? Mrs. HILDRETI-I. I just affirm that. Virginia~ `is the only State that requires separate licensure of any kind of psychologists. It happens to be `the clinical psychologist. Mr. SIsK. In other word's, in the State of Virginia, as I understand it, a person can be licensed to practice psychology in its broadest terms; but if he is going to be a clinical psychologist and practice psycho- therapy, in the area that we are discussing now, he ha's to secure an additional license. Mrs. HILDRETH. Yes, sir. Mr. SIsK. Fine. I think we have gone far enough on th'at. I notice on page 4 again there is this term in which it is suggested as an amend- ment in line 6, they suggest "an'd are not the practice of counseling and psychotherapy." They again spell out th'e same thing at the bottom of the page, a similar insertion, "other than counseling `and psycho- therapy." We have pretty well covered the situ'ation where there is some difference of opinion by the two professions involved here. I think the committee, in its wisdom, with whatever information we can gather, as a policy matter is going to have to make the policy determi- nation on this. I am not saying we are more intelligent or better prepared to make it than you gentlemen are, but at some point we are going to have to be the referee. We will have to consider the best evidence `available on this. SECTIoN 7. QuALIFICATIoN To PRACTICE; EXAMINATION I would like to move over to page 6 where there are several amend- ments proposed. Dr. Cummings, would you briefly comment on the proposals on page 6? And if I have skipped over something which is of note, will you comment briefly on `that also? Dr. CUMMINGS. I do not have `any in `addition. You now have reference to Section 7? Mr. SIsK. Yes. ` Dr. CUMMINGS. Fine. The psychiatrists have suggested the addition of a subsection applying specifically to counseling and psychotherapy, where examinations are concerned. For reasons stated above we reject this subsection. We wOuld respectfully observe that Section 7(0) `allows for the tailoring of examinations to the various types of special- PAGENO="0136" 132 ties within the practice of psychology. So specific reference to counsel- ing and psychotherapy is not. required in the wording of our bill. Mr. SI5K. You are referring to this proposed additional language which they suggest. as section 7(B); is that correct? Dr. Cu~rMIxGs. That is right. Mr. SIsK. Dr. Legault, would you want to make a brief comment on that? Dr. LEGAULT. I think we have already covered that. Mr. SIsK. I notice there are some additional proposed changes in section 7, the use of the word "accredited" at two places. There is no objection to the use of "accredited", or does this again lead to a problem, educationally speaking? Dr. Cu1\n\nNGs. There is no problem there at all, sir. Mr. SIsK. What does "accredited" mean in this connection? Why was that particular term used? Is this in order to specify the institu- tions from which these degrees are to be obtained? Is there a problem in this area at all? Dr. LEGAULT. No, there is no problem. Mr. SIsK. All right. We will move on. Now, new language is proposed here on page 7, under-Section 7 rather, Dr. Legault., will you quickly make a comment as to the im- portance your group attaches to that in view of the comments by Dr. Cummings? Dr. LEGAULT. I think I have already made the comments. Addition- ally, Virginia is the only State that has this particular requirement; however, other States have similar requirements. South Carolina. for instance, has a requirement spelling out who shall practice psychology under what specific heading; that is, this shall be a published list. There are other legal means whereby the specification of a practice shall be enumerated. Also, California, the licensing of psychologists is entirely carried out by the State Board of Medical Examiners. That is, the Psychologist Examination Board goes through that body. and therefore offers the opportunity for that purpose. Mr. SIsK. Dr. Meltzer, I notice you shaking your head. Dr. MELTZER. I would like Mrs. Hildreth to make a comment. Mrs. HU~DRETH. I think we should not take the time of the sub- committee describing the California law. Briefly, the Psychology Ex- amining Committee is administratively under the California Medical Board. The California. Medical Board must, in both the old law and in the recent 1967 law, issue a license to a. person who has been found eligible by the psychology examining committee. If the subcommittee wishes, I can provide them with chapter and verse on the California law. It is true that technically the California Board of Medical Ex- aminers' name is on the license the person gets, that is true. Mr. SIsK. You agree with that Dr. Legault? Dr. LEGAULT. I agree. Mr. SIsK. Let's move along quickly. We now have a quorum call just starting. SECTION 8. LICENSING WrrHou!r ExAMINATION On page 7, Section 8, again we have some insertion of language on line 12. For example, in (B) it would read "a master's degree in psy- chology from an accredited college or university, or comparable train- PAGENO="0137" 133 ing as determined by the Commissioner"; does anyone. have any particular comment? Dr. CUMMINGS. Very briefly, we would reject the reference to coun- seling and psychotherapy for the reasons previously stated. However, we accept with thanks our psychiatric colleagues' observation that the experience requirements here may very well be changed and we agree with their amendment. In other words, they would increase the number from one year to two years in (A), and in Section (B) from five to seven years. We thank them for that observation. Mr. Sisic. They propose a new title: (C) The license shall state whether the licensee may practice counseling and psychotherapy if the training and experience of the applicant is in counseling and psychotherapy as determined by the Commissioner. I understand you object to that language. Dr. CUMMINGS. Yes, at the risk of being boring, again the same ob- servation we made before about separating out these two activities from the main body of psychological practice. Mr. SIsK. The staff calls to my attention, Mr. Clark, that I over- looked an amendment at the bottom of page 6, line 25, the first part of Section 8, where we again have an addition in language, so that it will read: SEC. 8. Within one year from and after the effective date of this Act, a license to practice psychology, and one endorsed with re- spect to counseling and psychotherapy, as appropriate, shall be issued without examination to any applicant. This goes to the same general discussion we have already had as to the additional licensing procedure for clinical psychologists. There again I would assume the positions in both cases would remain the same. There are some suggested changes on pages 8 and 9. Dr. Cummings, would you quickly comment on the proposed change there? One is on page 8, line 5, Section 10, of the S. 1864 where they insert "if he wishes to practice counseling and psychotherapy". Dr. CUMMINGS. We reject that for the same reasons. SECTION 11. WAIVER OF EXAMINATION Mr. SISK. They would also strike out certain language at the top of page 9, in Section 11. The language to be stricken is as follows: (1) achieved a position of eminence in the practice of psy- chology and has demonstrated over a number of years competence in areas covered by the examination, or (2) has. I couldn't guess why they would want to strike that. Section 11 would then read: SEC. 11. The Commissioner may, in his discretion, waive all or part of the examination required under sections 7(A) (3) or (B) (1) of this Act when the applicant has been certified by a national examing board: PROVIDED, That the examination given by the national examining board was as effective for the testing of professional competence as those required in the District of Columbia. PAGENO="0138" 134 Dr. CUMMINGS. Sir, we do not feel that that is as dangerous a pro- vision as perhaps they do, but we are perfectly willing (recognizing it is perhaps somewhat unusual) to strike that. SECTIoN 12. REGULATIONS, FEES, AND STANDARDS Mr. SIsK. All right. Now, referring to page 9, line 17, at the end of Section 12 it is proposed to add this language "and (B) to establish standards for the ethical practice of psychology" so that it will read: SEC. 12. The District of Columbia. Council is authorized to make regulations to carry out the purposes of this Act, includ- ing, after public hearing, (A) to fix, increase, or decrease fees to be charged for services performed by the District Government pursuant to the provisions of this Act in such amounts as may, in the judgment of the Council. be reasonably necessary to defray t.he approximate cost of administering this Act; and (B) to establish standards for the ethical practice of psychology. Dr. CUMMINGS. We thank the psychiatrists and also Mr. Whitener for pointing that out. ~\Te thank them for these. observations. Mr. SIsK. Fine. Next, I notice in Section 15, on page 11, line 19, they use the word "endorsement" instead of "certificate". Is there any problem with that? Dr. CUMMINGS. It is the same matter as the counseling and psy- chotherapy. Might I briefly point out two things we may have skipped? Mr. SISK. All right. Dr. Cu~I~rINGs. In Section 13, appears in the Senate bill on page 10, we would respectfully reject the last six words of that provision, again for the same reasons, as follows: SEC. 13. Every person licensed or certified to practice psychology who desires to continue the practice of psychology shall annually pay the required fee for which there will be issued a renewal of licensure or certificate. The Commissioner shall provide a writ- ten reminder of the renewal date to every person licensed or registered under this Act, which reminder shall be mailed at least one month in advance. A license or certificate not properly re- newed as herein provided shall lapse. The Commissioner shall have the right to reinstate a lapsed license, or certificate upon pay- ment of the rene*a.1 fee plus a Penalty fee. A psychologist who wishes to place his license upon an inactive status may do so by submitting notice thereof to the Commissioner. Such a psycholo- gist may reactivate his license by payment of the renewal fee herein required unless his license has been inactive for a period exceeding five years, in which case he will be required to furnish the Commissioner with evidence as to his competence to continue or resume the practice of psychology, and, if desired, counseling and psychotherapy. We would delete the last six words which read, "and, if desired, counseling and psychotherapy." SECTION 14. DENL~L, REvoCATIoN OR SUSPENSION OF LICENSES With respect to `Section 14, we would accept with many thanks your pointing out to us where the original draftsmanship was in error and PAGENO="0139" 135 we will bring it into balance with Section 12 by substituting the word "Council" for "Commissioner", on page 11, line 5. Mr. SI5K. Yes. That is at the top of page 11. Dr. CUMMINGS. Mr. Whitener was very right about that. We thank you for that change. SECTION 16. PENALTY PRovIsIoNs Mr. SISK. Now we move over to Section 16, where they do a rewrite, striking out existing language and putting in new language, to read as follows: SEC. 16. Any person who shall violate any of the provisions of this Act shall, upon conviction of such violation, be punished for the first offense by a fine of not more than $500 or by confinement in j au for not more than six months, or both; for the second offense, by a fine of not more than $1,000 or by imprison~nent for not more than one year, or both; and for the third and subse- quent offenses, by a fine of not more than $5,000 or imprisonment for not more than five years, or both. Will you comment quickly on that? Dr. CUMMINGS. Yes. For some reason I don't have that right here, but I think what the psychiatrists have done there is very helpful. I believe this is a further spelling out of the penalties involved ~n the Act. Mr. Sisic. It actually increases the penalties? Dr. CUMMINGS. Yes, it increases them. It is our opinion that we accept that, with thanks. Mr. SIsK. Fine. Of course, again I am sure in Section 17 the addi- tion of "counseling and psychotherapy" would meet with the same response. Dr. CUMMINGS. At two places: in the first sentence, and in the next to the last sentence of the psychiatrists' proposed amendment. Mr. SISK. You object to those on the same ground? Dr. CUMMINGS. Yes. SECTION 19. PRIVILEGED COMMUNICATIONS Mr. SISK. They do a rewrite of Section 19 and Section 20. SEC. 19. Title 14, D.C. Code, § 307 (77 Stat. 519) is amended by adding the words "or psychologist" after the word "surgeon" and before the word "may" in the first sentence thereof. Dr. CUMMINGS. As to Section 19, could I have Mr. Chambers re- spond to that? Mr. CHAMBERS. I am Reed Chambers, counsel to the D.C. Psycho- logical Association. Section 19 in the original bill was appropriate, we felt, for the psychologists, for two reasons that are not in Title 14, Section 307. First, the original Section 19 gives the psychologist an exemption from privilege. In other words, he can divulge confidential communications that his client made to him. If he is sued by his client for unethical practice or malpractice, that is. It is the same kind of protection available to lawyers, for example, and we think it is simply appropriate to psychologists. PAGENO="0140" 136 Second, he is also permitted to divulge communications when he is testifying as to the validity of a. document. such as the will of a client. We feel in the original Senate bill again that this is appropriate, that often mental competence of the deceased may be in issue and he should be allowed to go ahead and testify on that. Mr. SISK. Is there any quick comment on that, Dr. Lega.ult? Dr. LEGAULT. I have no comment. Mr. Kuder is here. Mr. I(u~n. As a lawyer, I felt it was appropriate that the privilege question be handled in that section of the D.C. Code which has been codified by Act of Congress so that the privilege of the psychologist would be in the same section as the privilege of the surgeon or the physician. That is why we did it the way we did. As for these other points raised, there is a great deal of law about patient privilege. What we have done here is really made it applicable to psychologists in the same as doctors. If amendments are required, in time they would apply to doctors and psychologists in the same way. It would seem appro- priate that they follow each other. Mr. SIsK. Fine. That is a legal question the committee will have to make a. determination on. SECTION 20. NON-INTERFERENCE WITH OTHER PRoFEssIoNs see a. rewrite of Section 20. That concludes, I understand, the differences here. As passed by the Senate, it read: SEC. 20. (A) Nothing in this Act shall be construed as rcstrict- ing the use of tools, tests, instruments, or techniques usually denominated "psychological," provided that the user does not represent himself or itself in a manner prohibited by this Act. (B) Nothing in this Act shall be construed to prevent qualified members of other professions from doing work of a psychological nature consistent with their training and with the code of ethics of their respective professions: Provided, That they do not hold themselves out of the public by any title or description incor- porating the words "psychological," "psycimlogist," or "psy- chology," unless licensed under this Act, and except as provided in section 5(D) of this Act. As proposed to be amended, it would read: SEC. 20. Nothing in this Act shall be construed to limit or re- strict qualified members of other professions in the practice of their respective professions: Provided, That they do not hold themselves out to the public by any title or description stating or implying that they are practicing psychologists or are licensed to practice psychcdogy as defined in this Act. Dr. Cummings, quickly on the rewrite of Section 20. Dr. Cimr~nNGs. Yes. We are determined that the psychologist II- censing bill shall in no way interfere with the professional activities of colleague disciplines, as long as members of these other professions operate within their code of ethics. The psychiatrists' rewriting of this section omits reference to this important matter of ethics and is thus seen as slightly inferior to Section 20(B) in the original, which it was intended to replace. Section 20(A) in the original was dropped by the psychiatrists, and we accept its elimination. PAGENO="0141" 137 We are willing to drop Section (A) but we would prefer to see our wording of Section 20(B) retained in place of the psychiatrists' wording. Mr. SI5K. Do you gentlemen feel strongly on that or would you want to compromise on that issue in line with Dr. Cummrngs' sugges- tion, elimination of (A) and retention of (B) ? Dr. LEGATJLT. The wording we followed here was at the sugges- tion of Congressman Whitener. We feel that it is quite adequate. I don't think it is a big argument, however. Mr. SISK. All right. That is something I think the committee will have to make a determination on. Gentlemen, I appreciate very `much your appearance here. This probably seems a little out of order a~s a matter of procedure but, frankly, it only indicates the concern of this committee and the hope that out `of this we might write some legislation that will improve the situation that we understand everyone agrees `does need some im- proving. I do appreciate the attitude and atmosphere, and recognize the difference of opinion `as we have it `on `committees every day. I do appreciate your kindness in `being `here. The hearing is closed. The subcommittee stands adjourned. (Whereupon, at 12: 20 p.m., the subcommittee adjourned.) PAGENO="0142" PAGENO="0143" APPENDIX REQUIREMENTS FOR PSYCHOLOGISTS DISTRICT OF COLUMBIA PSYCHOLOGICAL ASSOCIATION, Washington, May 29, 1968. The Honorable JOHN M. ZWACH, Room 1208, Longworth House Office Building, Washington, DXI. DEAR MR. ZWACH: At the hearing of HR 10401 (a bill to license psychologists in the District of Columbia) on May 20, 1968, you raised the important question concerning the training of psychologists. I am. happy to bring information to you here which may be of help In answering this questiOn. I am enclosing two pieces of material. One is entitled Criteria for Evaluating Training Programs in Clinical or in Counseling Psychology, a reprint from the American Psychologist. This article is general, in the sense that it describes the targets to which graduate departments of psychology must measure up if they are to be approved as doctoral training centers. I `believe it will give you the most convenient overview of what is involved in `the preparation of clinical and counseling psychologists. The second enclosure describes a specific doctoral training program, that of the Department of Psychology at The George Washington University here in Washington. An interesting exercise is to compare this description with the more general `statement, to see how the one reflects the guidelines laid down by the other. I read an article just yesterday about how many pieces of legislation you gentlemen have to consider each year, and it's a staggering figure. In the inter- est of taking a minimum of your time, I am keeping this communicatioi~'brief. However, if you should desire further information of any kind on this (or any other feature of HR 10407), do not hesitate to ask me for it. Very sincerely yours, JONATHAN W. CUMMINGS, Ph. D., Chairman, Legislative Committee. DEPARTMENT OF PSYCHOLOGY, THE GEORGE WASHINGTON UNIVERSITY, PROGRAM IN CLINICAL PSYCHOLOGY LxaniNG TO PH. D. DIxmm~ REQUIREMENTS (1) 48 course credit hours. (2) Basic Practicum: Sixteen hours a week for two semesters performing clin- ical assessment activities under supervision. Practicum agencies used for training are: St. Elizabeths Hospital, D.C. Gen- eral Hospital, Naval Medical Center, and G.W.U. Psychological Clinic. (3) Internship: Pull year, 40 hours a week away from University performing assessment, psychotherapy and research under supervision of psychologists and other mental health professionals. Primary internship training sites include, St. Elizabeths Hospital, D.C. General Hospital, Naval Medical Center, Hillcrest Children's Center and V.A. Hospital. Typically in 3rd or 4th year of graduate work. (4) Advanced Practicum: Sixteen to twenty hours a week during 3rd, 4th, or 5th year of graduate work. Student selects emphasis on either individual psy- chotherapy, group psychotherapy, or clinical research.. Supervised. . (5) Comprehensive Examinations in five fields. One field must be Clinical Psy- chology and one must be General Psychology. Other possibilities include psycho- pathology, psychotherapy, behavior change, clinical assessment, child or devel- opmental, etc. . (139) PAGENO="0144" 140 (6) Examinations in two foreign languages or one foreign language and statistics. (7) Second year level research: original piece of experimental research suit- able for Master's Thesis or journal article. (8) Doctoral Dissertation: original piece of experimental research at the doc- toral level. Includes a final oral examination in defense of the dissertation. COURSE CURRICULUM FOR CLINICAL STUDENTS (Does not include electives from other subfields) Psych 202: Psychological Research Methods and Procedures. Psych 203-4: Experimental Foundations of Psychology. Psych 211: Assessment of Cognitive Functioning. Psych 212: Personality Assessment by Projective Techniques. Psych 215: Personality Assessment by Multiple Procedures. Psych 218: Seminar: Systems of Psychotherapy. Psych 219A: Community Mental Health. Psych 219B: Professional and Ethical Issues. Psych 220: Seminar: Abnormal Psychology. Psych 226: Clinical Psychology of Childhood and Adolescence. Psych 221-28: Variations in Psychotherapeutic Approach (4 semesters). Psych 229: Principles of Behavior Change. Psych 206: Methods of Clinical and Personality Research. Psych 272: Theories of Personality. Psych 290: Seminar: Special Problems in Personality Research. Stat. 105: Statistics in the Behavioral Sciences and Education. GRITERIA FOR EVALUATING TRAINING PROGRAMS IN Cr~IcAL OR IN COUNSELING PsYcHoLoGY The original statements from which this summary was prepared were published earlier in various places, but questions coming to the Educa- tion. and Training Board and to the Committee on Evaluation indicate that these statements are not familiar to many or are vague in the minds of many members of the APA. Therefore, the standards used in evaluation are repeated here in brief outline. UN~ERSITY PROGRAMS Standards for university training programs in clinical psychology were de- scribed in two articles in the American Psychologist (1947, Vol. 2, June, 199-205; and 1947, Vol. 2, December, 539-558) and in Training in Clinical Psychology (New York: Prentice-Hall, 1950). For counseling psychology, the standards were published in the American Psycholegist (1952, Vol. 7, June, 175-181). These standards serve as criteria for evaluating programs submitted for approval as doctoral training programs. These criteria are summarized briefly here, but per- sons applying for approval of a training program are urged to read the references cited above. Since many of the requirements for training are the same in both clinical and counseling psychology, they will be treated together, with the differences noted. I. Staff The quality of the staff is the most important factor in any doctoral program. There must be a minimum of seven qualified (PhD or Diplomate) persons on the staff. 1. Basic staff. At least four different persons must contribute to graduate non- clinical and noncounseling teaching, and their total time assigned to this teaching must be the equivalent of at least 2.0 full-time graduate teachers. 2. Clinical or counseling staff. (a) Three persons for regular teaching of graduate students in clinical (or counseling) psychology. One of these must be primarily in clinical or in counsel- ing psychology and cannot be counted for both, and must be on the department budget for at least half-time. (b) Their combined graduate teaching load is the equivalent of not less than one full-time graduate teacher in clinical or in counseling psychology. PAGENO="0145" 141 II. Content Areas This is not a list of coui ses and it is liberally interpreted w hen applying it in an evaluation of a pi~ogram. 1. General psychology: (a) General, physiological, and comparative; (b) History and systems or theory; (c) Developmental or child psychology; (d) Social psychology. 2. Psychodynamics of behavior: (a) Theory of personality and motivation; (b) Psychopathology. 3. Diagnostic methods. 4. Psychotherapy and counseling: (a) Psychotherapeutic theory and methods, or (b) Techniques of guidance and counseling. 5. Research methods: (a) Experimental psychology; (b) Advanced statistics and quantitative methods; (c) Research in dynamic psychology; (d) Dissertation, preceded by master's thesis or a research project. 6. Related disciplines. Not all of the following are necessary, but it is expected that the graduate program in psychology will be a part of a strong graduate school with graduate studies in supporting areas, such as- (a) Physiological sciences; (b) Study of social and economic environment, including occupational information. This is important for counseling psychologists. (c) Cultural anthropology; (d) Philosophy of science. III. Facilities and Equipment 1. Offices and classrooms for effective instruction and personal conferences. 2. Laboratory `space and equipment with shop for repairs and `construction of apparatus; calculators for `statistical work. 3. Practicum facilities: (a) Ongoing clinic on campus or nearby for experience under intensive supervision at laboratory and clerkship levels; equipped with one-way vision observation rooms and recording equipment; (b) Definite arrangements made for internships. 4. Library well-stocked for psychology and easily accessible to the students. 5. A student seminar or reading room and lounge where students can get together, educate each other, and learn to communicate. IV. Overall Atmosphere of tite Department 1. Faculty accessible to students, `and the student-faculty ratio making it pos- sible for the students to receive adequate counsel and supervision. 2. Ongoing research projects `conducted by both faculty and `by the students, providing an atmosphere that challenges the student to participate and undertake research; quality of research evidenced by list of research `articles accepted and published in psychological journal's. 3. Planning and growth in the department, giving evidence of vision and initia- tive on the part `of the faculty, who do not wait for specific suggestions on what to do in order to develop a good department. INTERN5HIP5 Standards for practicum training in clinical psychology were described in the American Psychologist (1950, Vol. 5, November, 594-609) and for counseling psy- chology in the American Psychologist (1952, Vol. 7, June, 182-188). These stand- ards, with slight modification, will serve as criteria for evaluating internships or trainee assignments to be approved as adequate for doctoral training programs. These criteria are summarized briefly here to indicate what will be looked for; but persons applying for approval of an agency are urged to read the references cited above. 04-755-68----iO PAGENO="0146" 142 I. Staff 1. The student's work is planned with him and supervised by a psychologist who is qualified in clinical or counseling psychology as indicated by a diploma from ABEPP, or by a PhD plus experience. 2. This supervisor or advisor must be regularly on the job at least half-time. 3. The supervision and guidance ~s supplemented by specialists from other pro- fessions and by a representative from the student's university. II. Prerequisites of Students Accepted 1. The agency accepts only those students whose background of training is sufficient to enable them to incorporate and integrate their practicum experience in such a way as to further their ow-n scientific and professional development. 2. Students at the intern level must have had some practicum training before being accepted as interns. 3. Interns may not be accepted for less than half-time in the formal internship or trainee assignment. III. Content and ilctliods of Practicum Training 1. The student has contact with the u-hole variety of patients and clinical prob- lems in the agency. 2. The student is informed of the purposes and the organization of the agency and is made acquainted with the special services of the professional personnel. 3. The student attends case conferences and teaching seminars, and he learns the theory and practice of the other professions. 4. The student is given supervised training in at least two of the three functions of diagnosis, therapy, and research, which include activities in- (a.) Observation and interviewing; (5) The use of a variety of diagnostic testing procedures; (C) Report writing; (d) Counseling or psychotherapeutic procedures; (e) Any other special treatment procedures used by psychologists; (1) Research and validation studies. IV. Facilities for Study and Research 1. A desk in a room with some privacy is provided for each student so he can study, write reports, work on research, and carry on his professional work. 2. Recorders and other equipment for psychological work are available to the student. 3. A professional library with research publications is provided and serviced to keep it in usable condition. 4. Research projects are in progress by staff and students. EDUCATION AND TRAINING BOARD, BRUCE V. Mooia~, Eccecutive Officer. REQUIREMENTS FOR PSYCHIATRISTS GEORGETOWN UNIVERSITY, DEPARTMENT OF PSYCHIATRY, Wa.shington, D.C., June 6, 1968. The Hon. JOHN ZWACH, House of Representatives, Washington., D.C. Da~.i~ MR. ZWACH: In response to your request at the hearings before Subcom- mittee Number 5 on HR. 10407 on June 3. I am enclosing for your information material that describes the three year residency training program in psychiatry at the Georgetown University Medical Center. I am also enclosing a description of the residency training program at St. Elizabeths Hospital since this isalso a large training center for psychiatrists. I realize that you are au-are that prior to beginning psychiatric residency training the physician has received an M.D. degree as a result of four years of medical education and has completed a one year internship. I hope this material u-ill `be of value to you. Sincerely, RICHARD A. STEINBACH. M.D., Professor and Cli airm an. PAGENO="0147" 143 DEPARTMENT OF PSYCHIATRY, GEORGETOWN UNIVERSITY, WASHINGTON, D.C. INTRODUCTION The primary goal of any effective psychiatry training program must be the establishment of the beginnings of a comprehensive professional identity. In a constantly dynamic profession in an equally dynamic world society, this identity should never become too rigid or too amorphous. In addition to the attainment of experience, techniques, and personal matura- tion necessary in all medical practice, the training of the psychiatric resident at Georgetown aims toward the development of particular skills and attitudes. Psychiatric skills and attitudes can be outlined as specific abilities: 1. to diagnose and treat emotional illness with a comprehensive view of the patient's disorder, including emphasis on related somatic factors; 2. to maintain an interest, orientation, and awareness of the sociological, anthropological, psychological, and psychoanalytical concepts which are an essential component in the understanding of psychic function in health or disease; 3. to recognize and appreciate the relative effectiveness of presently avail- able treatment techniques and constantly to be receptive to now concepts and modes of therapy; 4. to maintain an interest, orientation, and awareness of the biochemical- biophysi'cal aspects of the syndromes of emotional disturbance; 5. to stimulate curiosity and participation in research as it applies to the areas of endeavor in which human functioning is involved; 0. to increase one's capacity to impart to medical colleagues, students, in- terns, and residents knowledge of the role of emotional factors in human illness; 7. to evaluate effectively community needs in social problem areas and to seek remedies that contemporary psychiatry may contribute, and, 8. to collaborate `with personnel in all appropriate aspects of the com- munity and to `develop consultative, preventive, and treatment programs de- signed to improve individual and community mental `health. Every few years it is necessary to expand the goals or alter the emphases in any statement of the purposes of psychiatric training. This fact furnishes addi- tional testimony to the ever growing and ever evolving role of the psychiatrist. RESIDENCY TRAINING PROGRAM General description The psychiatric residency training program of the Georgetown Urilversity Medical Center offers a rich opportunity for the development of a broad approach to the problems of current psychiatric endeavor. The program enables the resident through a variety of selected experiences to develop his own potential as a psychiatrist. The scope of the training qualifies him for a future career in general psychiatry, social psychiatry, psychosomatic medicine, research, or academic teaching and for training in a psychoanalytic institute. He develops considerable skill as a psychotherapist with competence in intensive, relationship, and sup- portive treatment. Although eclectic in design, it is the c,onviction of the program that to become differentiated as a psychiatrist, the resident must develop a thorough under- standing `of phychodynamics and the ability to apply this knowledge. This is accomplished by a proper balance of teaching conferences, close personal super- vision, and actual experience throughout the training program. In becoming a psychiatrist, the resident develops and expands his primary orientation as a physician. His background in the understanding of the doctor- patient relationship, the principles of physician responsibility, and the treat- ment and care of the sick individual is the core of his developing role as a psychiatrist. The philosophy of the Georgetown program emphasizes this aspect of the resident's identity. This is applied not only in his liaison and consultative activities with non-psychiatrist physicians but in all areas of his work in a variety of diagnostic, therapeutic, consultative, and teaching situations. These activities include the diagnosis and psychotherapy of the emotional dis- orders of children and adults, family and group therapy, the somatic and drug, therapies, adolescent and college student health consultation and treatment, forensic psychiatry, liaison and consultation with medical, pediatric and surgical PAGENO="0148" 144 services, diagnosis and treatment of neurological disorders, and consultative activity with schools, social agencies, and other community resources. To provide facilities for this type of comprehensive training, the Department utilizes George- town University Medical Center, the District of Columbia General Hospital. the Washington Veterans Administration Hospital, Sibley Memorial Hospital, and the Department of Public Health Adolescent Clinic. The program is approved for three years of general psychiatry training and two years of child psychiatry training by the American Medical Association and the American Board of Psychiatry and Neurology. Close supervision is provided at all levels of training. This supervision, coupled with increasing responsibility for patient care, contributes to the resident's growth and maturation. As the resident develops in his capacity for independent thought, he is encouraged to impart his knowledge by assuming the role of teacher with nurses, medical students, interns, and residents. To foster the type of constructive critical objectivity which is essential in his work as a psychiatrist, the resident is expected to participate in supervised research and to report on this activity prior to the completion of his training. In summary, the Georgetown program-with psychodynamics as its basic science-provides a comprehensive experience with abundant opportunities for the development of the individual interests of the future psychiatrist physician. As in all educational endeavors the primary aim of this period of training is to impart a scientific attitude that fosters continuing inquiry and curiosity, flexi- bility, and a receptivity to changing concepts and roles. First Year 01 Resideiwy During the first year of residency training, the emphasis is upon carefully selected didactic exercises and a sequence of intensive clinical experiences with a wide variety of patients for whom the resident assumes major responsibility under circumstances of maximum supervision and day by day instruction. There are three clinical facilities, all closely affiliated with Georgetown, where the resident is assigned in rotation for varying lengths of time. The three facilities include: the Acute Psychiatric Service of the District of Columbia General Hos- pital, two active wards at the Washington Veterans Administration Hospital. and the psychiatric unit at Sibley Memorial Hospital, a private community `hospital. The first year begins with a planned series of orientation and introductory meetings for the resident group in its entirety. These meetings take the form of lectures, discussions, films, tours and visits to significant places in the metro- politan area of Washington. The resident is encouraged to apply his early know-l- edge of the elements of psychiatry to the social and physical environment in which he will spend three years pursuing his postgraduate education. Considerable attention during `the first year is given to psychopathology and clinical diagnosis. Included undei~ the latter are: the interview- as a diagnostic instrument, psychological techniques, paramedical diagnostic procedures, the critical evaluation of clinical information `and its formulation, and the com- munication of `diagnostic conclusions in verbal and written reports. The begin- ning resident is introduced to the major treatment modalities: chemotherapies and physical therapies, milieu therapies, and the spectrum of psychotherapies. The continuous individual psychotherapy of selected patients is encouraged early in the training year and for this type of work additional supervision is provided. Patients seen for diagnosis and treatment by residents during their first year tend to be inpatients at the participating facilities; however, day-care patients, out-patients, and emergency patients are also seen. Clinical experiences are thoroughly and continuously supervised with the resident working side by side with full-time Georgetown faculty members in nearly all `first year assignments. Case conferences and planning and management conferences are conducted daily under circumstances ranging from very informal to elaborately formal. The first year resident assumes some responsibility for `the instruction and supervision of third year medical students on elerkships from Georgetown Uni- versity School of Medicine. This teaching `responsibility is shared with visiting and full-time psychiatrists. Opportunities for special experience in clinical re- search, forensic psychiatry, in-patient child psychiatry, problems of addiction, and art therapy are available during the first year of training. PAGENO="0149" 145 Teaching sessions for first year residents Introductory Didactic Conference Series: (80 hours. July through September. Staff of the Department) Hours Psychopathology 25 Personality Development 25 Techniques of Interviewing 10 Principles of Psychological Evaluation - 10 Hospital and Ward Management 10 Continuous Conferences: Ward Walks. Daily. Interdisciplinary Diagnostic Conference. Weekly. Dr. Perman and Staff. Case Conference. Weekly. Dr. Steinbach, Dr. Jaffe. Neurology Conference. Weekly. Neurology Staff. Literature Seminar. Alternate Weeks. Dr. Ryan. Theory and Practice of Interviewing. Alternate Weeks. Dr. Grande, Dr. Meltzer. Ward Conference. Weekly. Visiting Staff. Residents Conference. Weekly. Dr. Novak. Art Therapy Seminar. Monthly. Miss Ulman. Joint Conferences. (See separate schedule.) Second year of residency In the second year of the program, the emphasis of the resident's activities is diagnostic `and therapeutic work `with outpatients at Georgetown University Hospital. The patients, from varied socioeconomic backgrounds, present a di- versity of symptoms and manifestations of psychic di~tutbanc'e. The treatment techniques range from intensive individual psychotherapy to brief psychotherapy to crisis intervention. The resident spends fifteen hours weekly in the treatment of outpatients an'd has two `h'ours of individual supervision from senior faculty. As the resident is developing his skills as an individual psychotherapist, he is introduced to the pritmiples of group process and group psychotherapy. He attends a weekly seminar on group dynamics and throughout the year observes an outpatient group conducted by a staff member or third year resident. In addi- tion, there are group therapy sessions in a hospital s'dtting which initially are observed and later conducted by the re~ident. The basic concepts of intra-family dynamics and family psychotherapy are presented through an on-going conference. T'here are also demonstrations `of family interview's. This is a preparation for the resident's actual clinical experi- ence as a family therapist in the third year of training. Each resident `also follows patients in the Drug Clinic. Patents chosen present difficulties `which are considered most effectively treated by `drug `m'an~genient and brief supportive therapy. Throughout the year, emergency room conisultations by the resident on a rotating on~call schedule provide experience with the treat- ment of people in crisis. In addition there are rotations through various clinical services in which the resident spends fifteen to twenty hours per week. These rotations are usually for a three-month period. Individual supervision and conferences are scheduled for each service. These rotation's include: 1. CLINICAL STUDY UNIT. This unit is a medical research ward at George- town sponsored by the National In~tiJtute `of Health. The psydhiatric resident is an integral member of the ward team, performing personality evaluations on most admissions and participating in group meetings with staff and patients. He gain's invaluable experience with a wide range of psychosomatic ~nd somato- pyschic problems and with the application of the principles of a therapeutic community to a non-psychiatric unit. 2. GEORGETOWN OUTPATIENT DIAGNOSTIC SERVICE. This includes diagnosti'c evaluations of, and treatment planning for, adults and children through two outpa'tient clinids. (a) Adult Psychiatric Clinic. Applicants `for this clinic `are evaluated in depth by the realdent. His `psychiatric findings are presented to the clinic director at a weekly tea'm conference in which the social Worker, psychologist, and psychiatric nurse participate. PAGENO="0150" 146 (ii) Children's Diagnostic and Development Center. This is a multidis- ciplinary cffiuic in which the departments of Psychiatry, Pediatrics, Neu- rology, Physical Medicine, and Social Service work jointly in the diagnosis and treatment of retarded and handicapped children. The resident partici- pates in the evaluation of these children and attends the weekly staff conference. 3. WALK-IN PSYCHIATRIC CLINIC. Patients in crisis who need emergency consultation are seen at Georgetown for a maximum of six visits. The orienta- tion of the clinic is to enable the resident to evaluate a large number of patients under acute stress and to learn techniques of crisis-oriented therapy. 4. INTENSIVE PSYCHOTHERAPY WITH HOSPITALIZED PATIENTS. The resident treats several patients with severe ego pathology who are hospitalized at the Washington Veterans Administration Hospital. Through this experience, the resident has the opportunity to treat intensively psychotic and borderline psychotic patients requiring long-term hospitalization. 5. INPATIENT NELTROLOGY. The resident actively participates in the diag- nosis, treatment, and management of patients hospitalized on the Neurology Service of the Washington Veterans Administration Hospital. This service includes patients with a wide variety of neurological disorders. Teaching rounds and conferences emphasize basic neurology and the inter-relationships between neurology and psychiatry. Teaching sessions for second year residents Continuous Conferences: Case Conference. Weekly. Dr. Steinbach. Psychology Seminar. Weekly. Dr. Reidy and Staff. Ego Psychology Seminar. Weekly. Dr. Inwood. Literature Seminar. Weekly. Dr. Bogdan. Group Therapy Conference. Alternate Weeks. Dr. LaTendresse. Drug Therapies. Alternate Weeks. Dr. von Mendelssohn. Introduction to Child Psychiatry. Monthly. Dr. Kessler. Disorders in Adolescence. Monthly. Dr. Inwood. Psychopathology Seminar. Alternate Weeks. Dr. Salzman. Joint Conferences. (See separate schedule.) Third year of residency The third year of training in general psychiatry is an expansion in breadth and depth of the residents training experiences. He develops further his basic understanding of psychodynamic principles and his skills as an indivic1unl and group psychotherapist while extending his activities to broader areas of psy- chiatry. He can now apply his knowledge and previous experience to the field of child and adolescent psychiatry. consultative and liaison activity with i~on- psychiatric physicians, programs of prevention and early detection of emotional disorders. and community consultations with the personnel of schools, social agencies. and other community facilities. There is sufficient flexibility during this phase of training for each resident to spend a significant amount of time in an area of special interest to him. Close individual supervision continues for the resident's work in individual. group. and family psychotherapy. Increasing responsibilities in the area of teach- ing continue with the rasident's participation in the department's academic pro- gram for medical students. He conducts small group discussions for freshman and sophomore students and supervises the psychotherapeutic work of senior medical students. The staff of the Children's Psychiatric Services provides training in child psychiatry for the third year resident. The gei~eral resident joins the fellows in child psychiatry in the initial orientation program and in various clinical activi- ties. The program includes diagnostic evaluations, therapy with children and parents. didactic and case conferences. literature seminars, guest lecturers, and both individual and group supervision. The program consists of twelve to fourteen hours per week throughout the year. Those interested may participate in other aspects of the fellowship program. Each resident spends approximately ten hours per week for six months on the Consultation-Liaison Service at the Georgetown TJniversity Hospital. There is emphasis on the role of the psychiatrist as consultant to the non- psychiatric physician. and the resident has the experience of learning in depth about psychosomatic disorders and various emotional responses to medical ill- ness. The psychiatric resident accompanies medical residents. interns and medical PAGENO="0151" 147 students on rounds on specific wards of the hospital. This is considered an im- portant and significant training experience for further emphasizing the role of the resident as both physician and psychiatrist. S Throughout the remaining six months of the year, the resident spends ten hours per week at the District of Columbia Department of Public Health Adolescent Clinic, which is jointly operated by the Georgetown Department of Psychiatry and the District of Columbia Department of Public Health and is located a few blocks from the Georgetown campus. Here the resident encounters the problems of adolescents from all socioeconomic groups and works closely with schools and community agencies in establishing treatment programs. Al- though there is some participation in individual psychotherapy, the treatment focus of the Clinic is on group and family psychotherapy and work with corn- mnunity resources. During this time each resident serves as a consultant to one of the Divisions of the Family and Child Services of the District of Columbia. Each third year trainee is encouraged to continue and complete a research project, which has been undertaken with the approval and supervision of the departmental Research Committee. The resident is required to complete a paper either reporting on his research activity or describing iii depth a specific clinical experience. The basic third year experience is modified to meet the individual interests and needs of each resident. For example, those with a particular interest in the problems of the college student may spend a significant amount of time throughout the year in the Student Health Service of Georgetown University under the direction of the Student Health Psychiatrists. Those with special interests in community psychiatry may work in a neighborhood center which is a part of the Area C Community Mental Health Program. In this setting the resident's activities include home visits, work with neighborhood groups, super- vision of public health nurses and mental health aides, and involvement in epidemiological studies. Teaching sessions for third year residents Continuous Conferences: Child Psychiatry Diagnostic and Treatment Conference. Weekly. Dr. Kessler and Staff. Child Psychiatry Continuous Case Conference. Alternate Weeks. Dr. Kessler and Staff. Child Psychiatry Literature Seminar. Alternate Weeks. Dr. Jessiler, Dr. Sheridan. Psychology Seminar. Weekly. Dr. Reidy and Staff. Seminar on Psychotherapy. Weekly. Dr. RichmoncL Family Therapy Conference. Weekly. Dr. Bowen. Group Therapy Conference. Alternate Weeks. Dr. LaTendresse. College Student Health Conference. Weekly. Dr. Clark. Joint Conferences. (See separate schedule.) Joint Conferences For first and second year residents: Psychotherapy Seminar. Weekly. Dr. Varney. Continuous Case Conference. Weekly. Dr. Perman. For second and third year residents: S Professional Attitudes Conference. Alternate Weeks. Dr. S'teinbac'h. Application of Psychoanalytic Theory. Alternate Week's. Dr. Barterneier. Neurology Conference. Weekly. Neurology Staff. Psychopathology of Schizophrenia. Monthly. Dr. Searles. For first, second, and third year residents: Departmental Reserach Conference. Monthly. Staff. Visiting Lecturer Series. Weekly. OUTLINE OF THE TRAINING CURRICULUM IN PSYCHIATRY, NATIONAL INSTITUTE or MENTAL HEALTH, SAINT ELIZABEITHS HOSPITAL, WASHINGTON, D.C. PSYCHIATRIC RESIDENOY TRAINING PROGRAM In August, 1967, Saint Elizabeths Hospital became a part of the National Institute of Mental Health. This merger brought new opportunities and training PAGENO="0152" 148 resources to the Hospital's Psychiatric Residency Training Program, and stimu- lated a revision of Program organization as outlined below. For the first two years of training, the clinical base of the Residency Program will be located at Saint Elizabeths Hospital, during which time basic profes- sional skills and knowledge will be provided. The third year of training offers outstanding placements in various appropriate facilities of the Institute. Training is conducted by a full time teaching staff of ten psychiatrists, plus consultants drawn from the National Institute of Mental Health and the Wash- ington, D.C. psychiatric community. The First Year Psychiatric Residency Program In the first year the emphasis will be on clinical evaluation, diagnosis, inter- viewing, somatic and environmental treatment. disposition awl after care of both acute and chronic patients. Experience in child psychiatry and neurology will be included. First year academic seminars will be closely related to clinical work and include the following: 1. General Clinical Psychiatry.-Psychiatry Training Staff: This includes the discussion of fundamentals of psychiatry and will draw on personnel from the various operating programs of the National Institute of Mental Health (alco- holism. suicide, drug abuse, crime and delinquency, etc. )~, as well as the training staff of the Hospital. 2. Integrated Psychodynamics.-Edward I. Kushner, M.D., Teaching Analyst, Washington Psychoanalytic Institute. A course which will introduce dynamic concepts in the frame work of working with patients and include interviewing techniques. 3. Personality Developnient.-Psychology Training Staff: This will include normal psychological growth and development, as well as other fundamental aspects of psychology. 4. Clinical Nenrology.-Harold Stevens, M.D., Professor of Neurology, George Washington University, School of Medicine. Clinical demonstration of neurologic entities with relevant didactic material. 5. Resident Identity Conference.-Ralph E. Wittenberg, M.D., Director, Psy- chiatric Residency. Training Program. Group exploration of attitudes of professional identity. The Second Year Psychiatric Residency Program The second year of residency will be located on a long-term treatment unit where each resident will be assigned patients for intensive individual and group psychotherapy. Each resident will treat more than four patients at a time, three times a week; or in lieu of the fourth patient, a small group. Supervi- sion will be provided one hour per week per patient, plus supervision of the administrative care of patients on the unit being treated by other residents. Second year residents are also assigned to the George Washington University Hospital Outpatient Clinic for experience in therapy of neuroses and milder character problems. Individual supervision and a continuous case conference are included. Second Year Conferences 1. Basic Sciences: (a) Social Sciences and Psychiatry: Archibald F. Ward, Ph.D., Director Program in Sociology. (b) Learning Theory and Behavior Modification: Harold Weiner, Ph.D., Director, Operant Conditioning Laboratories. (c) The Brain and Behavior: Francis N. Waidrop, M.D., Director, Be- havioral and Clinical Studies Research Center. 2. Literatvre of Psychoanaiysis.-Edward I. Kushner, M.D., Teaching Analyst, Washington Psychoanalytic Institute. Review of classic articles relating to clinical work. 3. Psyclmotherapy.-Oscar Legault, M.D., Teaching Analyst, Washington Psy- choanalytic Institute. Literature and clinical material on theory and practice of individual psy- chotherapy. 4. Group Dynamics and Theory.-John Borriello, Ph. D., Psychology Staff. Literature and clinical material on theory and practice of group psychotherapy. 5. Forensic Psychiatry.-Glenn D. Legler, M.D., Training Officer-Psychiatry. Distinguished guests who are experts in various aspects of the field, as well PAGENO="0153" 149 as Hospital staff from the forensic services discuss legal and psychiatric issues of the offender-group of patients. 6. Community Psychia.try.-Beryce MacLennan, Ph. D., Chief of the Consulta- tion and Community Liaison Section-Mental Health Studies Center and Roger Peele, M.D., Chief of Service, William A. White Division. Prinicples, literature, and applications of community psychiatry. 7. Child Psychopathology.-Child Psychiatrist. Review of pathology from infancy through adolescence-National Institute of Mental Health Staff, and guests. Active clinical rounds and conferences are conducted in treatment areas during both years with outside consultants and training staff. The Third Year Psychiatric Residency Program The third year of residency training will be spent largely at the Mental Health Studies Center of the National Institute of Mental Health. The resident will have a varied experience with treatment teams of the Mental Health Studies Center in providing consultation in the community and evaluating and treating outpatients, including adolescents and family groups, marriage problems, etc. Experience at the Center will include individual supervision, group reviews of video tapes of patient interviews, and seminar discussions with the staff of the Center. The residents will also be assigned to one of four children's services in the Washington, D.C. area for one day per week experience in child psychiatry. These placements will include appropriate conferences. Opportunities for elective work in other facilities of the National Institute of Mental Health are planned. Third Year Conferences 1. Research.-Thomas D. Reynolds, M. D., Program Director, Experimental Psychiatry. Directed towards learning how to approach the psychiatric research literature in a critical way. 2. Special Issues in Psychiatry.-Paul Chodoff, M.D., Teaching Analyst, Wash- ington Psychoanalytic Institute. Discussions of a variety of topics, such as: private practice, hypnosis, family therapy, etc., with distinguished guests. 3. Psychotherapy.'-Oscar Legault, M.D., Teaching Analyst, Washington Psy- choanalytic Institute. Literature and clinical material on theory and practice of individual psychotherapy. 4. Case Conference-Harvey Steinberg, M.D., Training Officer-Psychiatry. Group discussion of individual patients in current treatment with residents. 5. Evaluation and Disposition Conference.-Wflliam Polk, M.D., Director of Training, Mental Health Studies Center. Review of the techniques of the evaluative process with clinical examples drawn from patients seen at the Mental Health Studies Center. PROPOSED AMENDMENTS [Following are the proposed amendments of the D.C. Medical Society, the Medico- Chirurgical Society, D.C., the Washington Psychiatric Society, and the Wash- ington Psychoanalytic Society, as submitted to the Committee] PROPOSED AMENDED H.R. 10407, SUBMITTED AT THE REQUEST OF SUBCOMMITTEE No. 5. COMMITTEE ON THE DISTRICT OF COLUMBIA, HOUSE OF REPRESENTATIVES, BY THE D.C. MEDICAL SOCIETY, MEDICO-OHIBITRGICAL SOCIETY, D.C., WASHINGTON PSYCHIATRIC SOCIETY AND WASHINGTON PSYCHOANALYTIC SOCIETY A BILL To define and regulate the practice of psychology in the District of Columbia Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, That this Act may be cited as the "Practice of Psychology Act." 1 Because present intermediate residents did not have this course, It will be available for third year residents as well. PAGENO="0154" 150 SEC. 2. The practice of psychology in the District of Columbia is hereby de- dared to affect the public health, safety, and welfare, andto be subject to regula- tion and control in the public interest to protect the public from the unauthorized and unqualified practice of psychology, and from unprofessional conduct by per- sons licensed to practice psychology. SEC. 3. As used in this Act- (A) "Commissioner" means the Commissioner of the District of Columbia or his authorized agent or agents. (B) "Person" includes an association, partnership, or corporation, as well as natural persons. (C) "Accredited college or university" means any college or university which, in the Commissioner's determination, offers either an acceptable full-time resi- dent graduate program of study in psychology leading to the doctoral degree. or a comparable program. In making his determination concerning domestic educational institutions, the Commissioner shall accredit those institutions included in the listings of approved academic institutions published by the United States Office of Education; in determining w-hat foreign educational institutions shall be accredited the Commissioner may take into account the published lists of accrediting agencies and of professional associations. (D) "The practice of psychology" is the rendering of or offering to render to the public for a fee, monetary or otherwise, any service involving the application of established methods and principles of the science and profession of psy- chology, except as provided in Sections 5 and 20 of this Act. These principles and methods are concerned w-ith understanding, predicting, and changing behavior, and they include, but are not restricted to, the use of counseling and psycho- therapy w-ith groups or individuals having adjustment problems in the areas of work, family, school, and personal relationships; measuring, testing, and assessing aptitudes, skills, public opinion, attitudes, emotions, personality, and intelligence; teaching or lecturing in psychology and doing research on problems relating to human behavior. (B) For purposes of this Act, references herein to "the practice of counseling and p~~iehotherapy" mean the offering by an individual of services involving the appl~ra tion of the principles and techniques of counseling and psychoth era.py, indiridually and in groups, to nidividuals with personal complaints and/or symptoms. SEC. 4. (A) The psychologist w-ho engages in practice shall assist his client in obtaining professional help for all aspects of the client's problem that fall outside of the boundaries of the psychologist's own competence, and in the case of clients for counseling and psychotherapy who are not medical referrals, shall mahc procision for the diagnosis and. treatment of medical problems by an appropriately qualified medical practitioner. (B) ~othing in. this Act shall be construed as permitting the administration or prescription of drugs, surgery, or any manual or mechanical treatment what- soccer. by any person. not certified under the Healing Arts Practice Act, District of Columbia, 1928. as amended, nor as permitting a licensee to engage in the practice of the healing art as defined in said Healing Arts Practice Act. ecocept a licensee may engage in. the treatment of disease as defined in said Healing Arts Practice Act by means of counseling and psychotherapy, when the primary responsibility for the diagnosis and treatment of the disease devolves upon a physician. certified under said Act and there is provision for effective collabora- tion. between. the licensee and the physician. SEC. 5. It shall be unlawful for any person to practice or to offer to practice psychology, or to represent himself to be a psychologist, unless he s/tall have a valid. unecopired. unrevolced. and. unsuspended license pursuant to this Act, and for any person. to practice, or to offer to practice, or to represent himself to practice. counseling aiid psychotherapy unless he shall have an appropriate valid, unerpired. unrevolced and unsuspended license to do so, endorsed pursuant to section 7(B), ececept as hereinafter provided. (A) Nothing in this Act shall be construed to limit the activites of and use of the title "psychologist" by a person in the employ of any governmental agency, academic institution, charitable agency. research laboratory, or business cor- poration: Provided, That the services performed by such an employee are a part of his office or position, are provided only within the confines of the organization or offered to like organizations, and are not the practice. of counseling and psycho- therapy. Persons providing services to the public through governmental or- ganizations, such as clinics. who are compensated by their employer rather than PAGENO="0155" 151 their clients are also exempted under the Act. Persons coming under the ex- emptions established by this subsection may offer lecture services to the public for a fee but may not offer other psychological services to the pi~blic for a fee without having obtained a license. (B) Nothing in this Act shall be construed to limit the activities of a. student intern, or resident in psychology, pursuing a course of study or research with an accredited college, university, or training center: Provided, That such activities are supervised as part of his course of study, and he is designated by such title as `psychology intern," "psychology trainee," or other title clearly indicating trainee status. (C) Nothing in this Act shall prevent the eniployment by a person furnishing psychological services for remuneration, of an individual not licensed as a psy- chologist under the provisions of this Act to assist in the performance of psy- chological services, other than of counseling and psychotherapy, if such individual works under the supervision of a licensed psychologist who assmnes full respon- sibility for his acts, and if such individual is not in any manner held out to the public as a psychologist. Sze. ~i. (A) The Commissioner shall be responsible for reviewing the applica- tions of persons seeking licensure or certification for the practice of psychology in the District of Columbia, for the granting and renewal of such licenses and certif- icates, for the preparation and administration of oral and written examinations, and for other matters related to the purposes of this Act. (B) The Commissioner may appoint a Board of Psychologist Examiners. Each member shall be a citizen of the United States, licensed under the provisions of this Act, who shall either be a resident of the District of Columbia or have w-orked in the District of Colmnbia for at least two years preceding appointment to the Board. The initial appointees shall be psychologists eligible for licensure under provisions of this Act. (C) The Commissioner shall maintain: (1) a record of licenses granted and refused and of licenses revoked or suspended which record shall be available to the public; and (2) a complete record of all hearings conducted pursuant to sec- tion 15(B) in connection with the denial, suspension, or revocation of a license. A transcript of an entry in a record of hearing, properly certified, shall be prima fade evidence of the facts therein stated. SEC. 7. (A) The Commissioner~ shall grant a license to practice psychology to each applicant who submits satisfactory proof that- (1) he is of good moral character; (2) he holds either (a) a doctoral degree in psychology from an accredited college or university and has completed two years of accredited postgraduate experience acceptable to the Commissioner, such two years not to include terms of internship, or (b) a doctoral degree in a field related to psychology from an accredited college or university, plus two years of accredited post- graduate experience: Provided, That his experience and training are con- sidered by the Commissioner to be comparable to the requirements set forth in (2) (a) of this subsection; (3) he has passed an examination, written or oral or both, the scope and form of which shall be determined by the Commissioner: Provided, That at any given examination session all examinations shall be uniform; and (4) his application has been accompanied by the necessary fees. (B) The Commissioner shall endorse a license to practice psychology as en- titling the licensee additionally to practice counseling and psychotherapy, in the case of each applicant entitled to a license to practice psychology under Sec- tion 7 hereof, (1) who in addition shall pass an examination, written or oral, or both, which shall examine specifically with respect to the practice of coun- seling and psychotherapy, the scope and form of which shall be determined by the Commissioner: PROVIDED, That at any examination session, all such ex- aminations shall be uniform; and (2) the applicant shall have had at least one year's internship and two years of accredited postgraduate experience in coun- seling and psychotherapy acceptable to the Commissioner. SECTION. 8. Within one year from an.d after the effective date of this Act, a license to practice psychology, and one endorsed with respect to counseling and psychotherapy, as appropriate, shall be issued without examination to any ap- plicant who is of good moral character, who either maintains a residence or office, or participates in psychological activities, as determined by the Commis- sioner, within the District of Columbia, who has submitted an application for license accompanied by the required fee, and who holds- PAGENO="0156" 152 (A) a doctoral degree in psychology from an accredited college or univer- sity or other doctoral degree acceptable to the Commissioner, and has com- pleted at least two years of postgraduate experience not including terms of internship; and (B) a master's degree in psychology from an accredited college or univer- sity, or comparable training as determined by the Commissioner, and has engaged in psychological practice acceptable to the Commissioner for seven years after the attainment of his highest degree. (C) The license shall state whet/icr the licensee may practice counseling and psychotherapy if the training and ewperience of the applicant is in counseling and psych otherapy as determined by the Commissioner. SEC. 9. The Commissioner may, in his discretion, grant a license with or with- out an endorsement to practice counseling and psychotherapy, as appropriate without examination, on payment of the required fee, to any person who at the time of application is licensed or certified under the laws of a State or territory of the United States, or of a foreign country or province whose standards, in the opinion of the Commissioner, were substantially equivalent at the date of such certification or licensure, to the requirements of this Act. SEC. 10. A psychologist who is not licensed under the provisions of this Act, but (1) who is licensed or certified under the laws of a State or territory of the United States or of a foreign country or province whose standards. in the opinion of the Commissioner, were substantially equivalent, at the date of his certification or licensure. to the requirements of this Act or (2) who meets the requirements of subsections (A) (1) and (A) (2) of section 7, and., if he wishes to practice counseling and psychotherapy. subsection (B) (2), and resides in a State or territory of the United States, or in a foreign country or province which does not grant licences or certificates to psychologists, may be employed or invited by a person who is a resident of or maintains a place of work in the District of Columbia to offer professional services in said District for a total of not more than sixty days in any calendar year without holding a license issued under this Act. Upon arrival in the District of Columbia, such a psychologist shall report to the Commissioner with respect to the nature and duration of his professional activities in the District as well as the name of the person who has requested him to render services. A psychologist claiming exemption under the provisions of this section who offers professional services in the District of Columbia for more than twenty days in any calendar year shall file with the Commissioner evidence of his right to such exemption. Upon proof of that right, to the satisfaction of the Com- missioner, the Commissioner shall enter the name of the applicant in a register kept for that purpose and shall issue to the applicant a certificate in evidence of such registration. SEC. 11. The Commissioner may, in his discretion, waive all or part of the examination required under sections 1(A) (3) or (B) (1) of this Act when the applicant has been certified by a national examining board: PROVIDED. That the examination given by the national examining board was as effective for the testing of professional competence as those required in the District of Columbia. SEC. 12. The District of Columbia Council is authorized to make regulations to carry out the purposes of this Act, including, after public hearing, (A)to fix, increase, or decrease fees to be charged for services performed by the District Government pursuant to the provisions of this Act in such amounts as may, in the judgment of the Council, be reasonably necessary to defray the approximate cost of administering this Act; and (B) to establish standards for the ethical practice of psychology. SEC. 13. Every person licensed or certified to practice psychology who de- sires to continue the practice of psychology shall annually pay the required fee for which there will be issued a renewal of licensure or certificate. The Commissioner shall provide a w-ritten reminder of the renewal date to every person licensed or registered under this Act, which reminder shall be mailed at least one month in advance. A license or certificate not properly renewed as herein provided shall lapse. The Commissioner shall have the right to reinstate a lapsed license or certificate upon payment of the renew-al fee plus a penalty fee. A psychologist who wishes to place his license upon an inactive status may do so by submitting notice thereof to the Commissioner. Such a psychologist may reactivate his license by payment of the renewal fee herein required unless his license has been inactive for a period exceeding five years, in which case he will be required to furnish the Commissioner with evidence as to his com- PAGENO="0157" 153 petence to continue or resume the practice of psychology, and if desired, coun- seling and psychotherapy. SEC. 14. The Commissioner may refuse, revoke, or suspend licensure or certi- fication if the person applying or the person licensed or certified be- (A) convicted of a crime involving moral turpitude; (B) found to be using any drug or any alcoholic beverage to an extent or in a manner dangerous to himself, any other person, or the public, or to an extent that such use impairs his ability to perform the work of a psychologist with safety to the public; (C) convicted of a violation of any provision of this Act or of the regu- lations or rules promulgated pursuant thereto; (D) determined to be a mental incompetent by a court with proper juris- diction; or (E) found guilty of the unethical practice of psychology in violation of standards to be established by the District of Columbia council. SEC. 15. (A) Proceedings leading toward the suspension or revocation of a license or certificate shall be begun by petition, setting forth good cause therefor, filed with the Commissioner and served on the respondent. The Commissioner may determine whether a license or certificate shall be sus- pended or revoked, and if it is to be suspended the duration of such suspension and the conditions under which such suspension shall terminate. Revocation of a license shall not preclude the issuance after the passage of at least five years of a new license or registration to the offender, provided such person can show that he has complied with the provisions of this Act. (B) Before revoking, suspending or refusing to issue a license or endorsement for any cause under the provisions of this Act, the Commissioner shall give the person whose right to practice psychology is challenged an opportunity to be heard in person or by attorney, and to produce witnesses on his behalf. After such hearing, should the Commissioner decide to refuse, revoke, or suspend licensure or endorsement, he shall set forth in writing his reasons for so doing, and shall include detailed findings of fact. (C) Any person who feels aggrieved by a decision of the Commissioner under subsection (B) of this section may, within thirty days after receiving notice thereof, seek review of said decision in the District of Columbia Court of Appeals. Such review shall be subject to appeal to the United States Court of Appeals for the District of Columbia Circuit. (D) In hearings conducted pursuant to subsection (B)' of this section, the attendance and testimony of witnesses may be compelled by subpoena. Any person refusing to respond to such a subpoena shall be guilty of contempt of court and may be punished as other persons guilty of contempt of court are punished. Sec. 16. Any person who shall violate any of the provisions of this Act shall, upon conviction of such violation, be punished for the first offense by a fine of not more than $500 or by confinement in jail for not more than six months, or both; for the second offense, by a fine of not more than $1,000 or by imprisonment for not not more than one year, or both; and for the third and subsequent offenses, by a fine of not more than $5,000 or imprisonment for not more tJ~an five years, or both. SEC. 17. The unlawful practice of psychology or counseling and psychotherapy as defined in this Act may be enjoined by the United States District Court for the District of Columbia on petition `by the Commissioner, upon a finding that the person sought to be enjoined is guilty of a violation of the provisions of this Act. In any such proceeding it shall not be necessary to show that any person is individually injured by the actions complained of. If the respondent is found guilty of the unlawful practice of psychology or conseling and psychotherapy, the court shall enjoin him from so practicing unless and until he has been duly licensed. The remedy by injunction hereby given is in addition to criminal prose- cution and punishment based thereon, and not in lieu thereof. SEC. 18. It shall be the duty of the Commissioner of the District of Columbia to enforce the provisions of this Act. SEC. 19. Title 14, D.C. Code, § 307 (77 Stat. 519) is amended by adding the words "or psychologist" after the word "surgeon" and before the word "may" in the first sentence thereof. SEC. 20. Nothing in this Act shall be construed to limit or restrict qualified members of other professions in the practice of their respective professions: Provided, That they do not hold themselves out to the public by any title or de- scription stating or implying that they are practicing psychologists or are licensed to practice psychology as defined in this Act. PAGENO="0158" 154 SEC. 21. There is hereby authorized to be appropriated out of the revenues of the District of Columbia such sums as may be necessary to pay the expenses of administering and carrying out the purposes of this Act. SEC. 22. If any section of this Act. or any part thereof. shall be adjudged by any court of competent jurisdiction to be invalid, such judgment shall not affect. impair, or invalidate the remainder of any section or part thereof. SEC. 23. This Act shall become effective ninety days after the date of its enactment. DISTRICT OF COLUMBIA PSYCHOLOGICAL ASSOCIATION RESPONSE TO PROPOSED Rtvisiox (By PSYCHIATRY) OF H.R. 10407- JTNE 19. 1968 As part of their testimony before Subcommittee No. 5 of the House District of Columbia Committee, the representatives of the local psychiatric organizations submitted a proposed revision of the psychologist licensing bill, HR 10407. In the following remarks. we of the D.C. Psychological Association Legislative Coin- mittee will comment upon this proposed revision. section by section. In these re- marks. let 5. 1864 (in the form in which it was passed unanimously by the Senate on April 24. 1968) be the reference point. Typically, we shall note how- the points raised by the psychiatrists differ from the original form of the bill and how the points which we are proposing bear on their suggested changes. SEcs. 1 & 2. No differences. SEC. 3. The psychiatrists have replaced 3(E) (a medical disclaimer statement) with a new 3(E) which is a definition of counseling and psychotherapy. In our discussion of the next two sections (below-), w-e will be expressing our dissatis- faction with (a) linking these tw-o activities together and (b) separating out from the rest of the practice of psychology these two activitives which are, in truth, only two of many tools and techniques used by psychologists. Some states have deffned the term psychotherapy in their statutes; if the psychiatrists sug- gest that this be done here, we are happy to comply but would suggest for specific wording the definition of psychotherapy which is contained in the North Carolina psychologist licensing act: SEC. 3(E) "Psychotherapy" within the meaning of this act means the use of learning or other psychological behavioral modification methods in a professional relationship to assist a person or persons to modify feelings, attitudes, and be- havior which are intellectually, socially, or emotionally maladjustive or ineffect- ual. (Note that the section number is HR 10407's.) For reasons stated below-, this definition refers only to psychotherapy and not to psychotherapy and counseling. We do feel that the medical disclaimer statement which was removed contains very important material bearing on the prevention of psychologists from practic- ing medicine and should remain in the bill. We have made it part of our suggested Section 4. SEC. 4. It is very clear that here is an area of genuine difference of opinion between the tw-o professional groups. Space does not permit reviewing again the bases for this difference, beyond stating again that they inrolve the nature of the terms "mental illness," "treatment," and "counseling and psychotherapy." We join such eminent psychiatrists as Dr. Thomas Szasz and Dr. Allen S. Mariner in doubting that the present level of understanding In the mental health field per- mits the degree of definiteness contained in the psychiatrists' rendition of Sec. 4. At the, same time, w-e feel most strongly that the psychologist~s client must be assisted in securing the help of any and all persons who might conceivably assist that client: law-, medicine, engineering, educational and vocational specialists, and so forth. Thus, you will find this point strongly enunciated in our suggested Sec. 4, which follows: SEC. 4. (A) The psychologist who engages in practice shall assist his client in obtaining professional help for all aspects' of the client's problem that fall outside of the boundaries of the psychologist's own competence, such as, for example, in medical or legal matters. In those instances when a medical problem is involved. there must be effective collaboration with an appropriately qualified medical practitioner. (B) Nothing in this act shall be construed as permitting the administration of drugs, surgery, or any manual or mechanical treatment whatsoever, by any per- PAGENO="0159" 155 son not `certified under the Healing Arts Practice Act of the District of Columbia, approved Feb. 27, 1929 (45 Stat. 1326), as amended. Note that we have included the Subcommittee's (particularly. Mr. Whitener's) suggestion to replace the somewhat weaker "is expected to" with the word "shall", before the word "assist" in the first sentence of Sec. 4. SEC. 5. Throughout this and other sections of their proposed bill, the psychia- trists have separated psychotherapy and counseling from. the remainder of the, practice of psychology. We understand their concern with psychotherapy, since it represents an area of overlap and mutual concern to both professions. But there are a number of problems here. For one thing, we rigorously reject the notion that all psychotherapy by definition involves the idea of disease and illness. Some, indeed, does; in such instances we would hope that Sec. 4 would clearly show the psychologist's responsibility to maintain genuine collaboration with a phy- sician when he participates in the treatment process here. In other cases, however, it is widely felt (by psychiatrists, psychologists, and others, as evi- denced in the psychologists' licensing bills passed in the other states) that the psychologist is well prepared to independently assist the client in. exporation of attitudes, re-learning more adaptive behavior patterns, improvement of inter- personal relationships, development of more effective means of dealing with the stresses of living, and so forth. Where the term "counseling" is concerned, we would voice a heartfelt, friendly warning to the psychiatrists that they may well be bringing down a torrent of objections from a host of other precincts by attempting to bring "counseling" into the practice of medicine. The activities of vocational advisers, various eclu- cational personnel, and advisers on marital problems-not to mention the activi- ties of lawyers, ministers, and many others-sit squarely in the middle of this term without having anything remotely to do with medicine. One more point. Psychotherapy and counseling, important though they may be in the practice of psychology, are only part of that practice. We view such other activities as employee selection, industrial consulting, consumer analysis, human factors engineering, manned systems analysis, and advising on experimental de- sign (to name but a few) as being just as significant as counseling and psycho- therapy. No suggestions have been put forth by these other groups to regulate or treat them separately, and we would suggest that the protective controls for the public which are built into HR. 10407 as amended are sufficient for psyco- therapy and counseling also. Thus we recommend that special references to these two activities be taken from Sec. 5 and from the remainder of the bill, with one eamception. We thank our psychiatrist colleagues for the suggestion that the psychological "assistants" re- ferred to in Sec. 5(C) be prevented from engaging in psychotherapy. We accept this suggestion. We also accept with .thanks their somewhat expanded wording of the first sen- tence of Sec. 5 (through the word "Act" (page 4 of their proposed draft)). To summarize our reactions to suggestions concerning Sec. 5, we would recoin- mend tha.t the section be returned to its 5. 1864 form, with the following two exceptions: (1) the psychiatrists' superior wording of `the first part of the first sentence of .the section be retained; and (2) the suggested enjoining of psycho- therapy by unlicensed persons in the employ of licensed psychologists (Sec. 5(C)) be retained. SEC. 6. No differences. SEO. 7. The psychi'atrists have suggested .the `additon of a subsection applying specifically to counseling and psychotherapy, where examinations are concerned. For reasons stated above, we reject this subsection. We would respectfully observe th.at Sec. 7(C) allows for the ta'iloring of examinations to the various types of specialties within the practice of psychology. SEC. 8. We would reject the reference to counseling `and psychotherapy in the opening .sentence of the section. We would `also reject `the proposed added 8(C). However, we accept with thanks the very good suggestions by the psychia'trists pertaining to the experience requirements: from one to two years in (A) and from five to seven years in (B). SEC. 9. We would return to the original wording, eliminating special reference to counseling and psychotherapy. SEC. 10. Return to original word'ing, for same reason. SEC. 11. We accept the psychi.atrists' suggestion to remove the "eminence" clause (Sec. 11 (1)), retaining `the remainder of the original. PAGENO="0160" 156 SEC. 12. We accept the psychiatrists' addition of a specific reference to the establishing of standards for the ethical practice of psychology. We are particu- uarly grateful to Mr. Whitener for pointing out the inconsistency (Commissioner vs. Council) between the wording in this section and that of Sec. 14 and to the psychiatrists for correcting this error in their proposed draft. SEC. 13. We would reject the last six words (". . . and, if desired, counseling and psychotherapy.") for reasons stated previously. SEC. 14. No differences, save the important matter of substituting "Council" for "Commissioner" in Sec. 14(E). SEC. 15. No differences. SEC. 16. No differences. SEC. 17. We reject the specific references to counseling and psychotherapy in the first and in the next-to-last sentences of this section. SEc. 18. No differences. SEC. 19. The psychiatrists have removed the original Sec. 19 and have replaced it with one referring to an existing District of Columbia statute. We are exploring this matter at present. We presume that the statute to which they refer is related in content to the matter of privileged communication, which is the subject matter of the original Sec. 19. Without knowing the exact wording of this statute, we are able to state that we would like to see the original Sec. 19 retained, since it was designed precisely with psychologists' clients (and the circumstances under which the practice of psychology occurs) in mind. Also, we feel that clarity would be served by specific provision in the law, rather than an unclear reference to another statute. SEC. 20. We are determined that the psychologist licensing bifi shall in no way interfere with the prvfessional activities of colleague disciplines, as long as mem- bers of these other professions operate within their code of ethics. The psychia- trists' re-writing of this section omits reference to this important matter of ethics and is thus seen as slightly inferior to Sec. 20(B) in the original, which it was intended to replace. Sec. 20(A) in the original was dropped by the psychiatrists, and we accept its elimination. No differences exist between the original and the psychiatrists' proposed bill on the remainder of the sections. 0