Dr. James Bray traveled to Lincoln, Nebraska, in February 2010 where he delivered the 2010 Fawl Lecture to the students and faculty of Nebraska Wesleyan University. Dr. Bray's accomplishments and research in the areas of stepfamilies and alcohol use among adolescents are considered to be landmark contributions to the field of psychology. He is an associate professor of family and community medicine at Baylor College of Medicine and adjunct professor of psychology at the University of Houston. He served as president of the American Psychological Association in 2009 and is a lifetime member of Psi Chi. He has over 125 publications and currently is a practicing clinical psychologist. During his visit to our campus, we had the honor of meeting him and experienced the privilege of interviewing him about his thoughts on the future of psychology.
Student: What was life like as an undergraduate? Did you ever imagine you would become the APA president?
Dr. Bray: I had an interesting undergraduate history. I was supposed to go to Brown University, and I was accepted at Brown. At the last minute, I decided that I was going to go to the University of California-Santa Barbara. I went from there to the University of Hawaii. I then decided to get serious about my education, so I went to the University of Houston and that's where I got all of my degrees. When I moved back, I was interested in psychology, particularly when I got to the University of Houston. I had the good fortune of working with George Howard, an assistant professor at the University of Houston, and did an honors thesis. I learned a lot from him and got really motivated. But being APA president wasn't on my radar screen at that time.
Student: You spoke of the APA Presidential Summit on the Future of Psychology Practice. Tell us about the summit's conclusions and the role you played in helping to create it.
Dr. Bray: That was one of my major presidential initiatives. It was a huge success! It was in San Antonio and it took a tremendous amount of work for me to get it funded. When I ran for president, there had been an idea floating around the practice community about how we needed a national summit to focus on where we were going to head as a profession. We had all these problems, and we needed to pull the practice community together. I had been thinking about doing something similar, yet different - focusing on the future of psychology - because, I felt, we were at a transition point. When I was elected, I decided I was going to have a summit with my Future of Psychology Practice Task Force. For psychology, it's a very unique meeting because we had 150 people there; 120 were psychologists and 30 were outside of psychology. We had politicians, people who worked on Capitol Hill, insurance executives, consumers of our services, and physicians. One of my pet peeves about psychologists is we spend too much time talking to each other and not enough time talking to the public and the people we serve. If you're going to transform your profession, you need to know who you're going to serve and what they want from you. I was committed to doing this differently. It was a very successful start at transforming our profession, but as we said at the Practice Summit: "What happened in San Antonio, can't stay in San Antonio."
Student: What do you think undergraduate and graduate psychology students can do to better prepare themselves for the changing healthcare system? Do you think more sciences like biology will be needed?
Dr. Bray: With advances in genetics and neuroscience, you're going to have to understand more about sciences like biology. If psychology is going to continue to be relevant and provide treatments and move into integrated healthcare, you have to be able to speak the language of biomedicine. We are the only profession who doesn't speak biomedicine. Many people who go through clinical programs never even have a biopsychology class on brain and behavior. Clearly with our advances in neuroscience, we're beginning to understand how the brain works. People are being treated with medications, so we need to understand how that impacts people. Even if you don't prescribe, you need to understand what's going on.
Student: How will graduate programs be forced to make significant changes in the years to come? What changes do you think are essential for the successful integration of physicians and psychologists into primary settings?
Dr. Bray: You have to train in primary care settings. Most psychologists are not trained in health care settings, particularly in primary care. Most are trained in traditional mental health settings. If you look at the number of people who have mental disorders, or mental health problems, about 70% of them are treated in primary care and about 30% are treated by mental health specialists. So, why don't you want to go where the majority of people are? It's a huge growth area! If I have a private practice, I see people usually for 50 minutes or an hour and we do traditional psychotherapy. But when I work over in primary care, I practice more like I would in a medical center. I see people for 15 to 20 minutes. People are knocking on my door while I am doing therapy with a patient saying, "We've got an emergency; take care of this problem!" You just have to figure out a way to work around that. The advantage is if one of my patients needs a medication, I can walk down the hall and talk to one of my physician colleagues and get them to prescribe it right there so the patient doesn't have to wait 3 months to get an appointment. From the patients' perspectives, they really love it. The other big piece around integrated healthcare is the use of electronic health records. We have electronic health records where everybody shares all the information, and you can see it online immediately. It's incredibly helpful and that's where we're headed. You'll notice that last year the Obama administration put $13.2 billion into the development of electronic health records. We don't have a standard right now. There are about 200 record systems out there. If psychologists don't get into those systems, and the information that we need to have in there is different than what physicians do, then we are going to be left out.
Student: With regard to the health care reform, there has been a lot of talk about the need to integrate primary care physicians and psychologists. What can be done as undergraduates to ensure a stable career in psychology?
Dr. Bray: If you want to get a doctorate in psychology, it's a good idea to make sure you train in a place where they'll support you and help you learn what you need. In the field of psychology, we have an area called health psychology. If you think about medicine, there are primary care specialists, and then there are the other specialists like cardiologists and orthopedic surgeons. Those people look at one body system very narrowly and comprehensively. Health psychologists are kind of like those specialists. Typically, health psychologists work in specialty care medical settings. They usually get narrowed and focused, whereas primary care psychology is a generalist area like primary care. You need to be able to know a little about everything and know what your limits are and when to refer. I'm not sure health care reform will pass (interview conducted prior to legislation) but there are things that are in the works that, because of all the attention to primary care and the attention to healthcare reform, people are enacting anyway. For example, I'm on weekly telephone calls with a group that's promoting the concept called the Patient Centered Medical Home. It's the wave of the future in primary care. The idea is that every person should have a medical home that is in primary care, where your basic medical needs are taken care of. That is the model that the Obama administration is pushing, and they pretty much excluded behavioral health until we advocated for behavioral health in the medical home. Many physicians support psychologists' participation in the medical home. Patient Centered Medical Home is being sponsored by corporations like IBM, Walmart, and John Deere. The largest employers in the United States are paying for this, and they are already committed to implementing it.
Student: At times, especially at the undergraduate level, the other sciences like biology and chemistry don't necessarily see psychology as a science, but more as a social study. How can we as undergraduates, and psychology as a whole, combat that?
Dr. Bray: I think a lot of it is that they don't really realize the breadth and depth of psychology. If you walk down the street and you ask the average person what a psychologist does, he or she may not know or may say the psychologist treats mental health problems. People don't understand about all the science that's involved. Part of that's our own fault because we're so insular and work in silos. We don't interact and collaborate. The clear change that is happening in the future in terms of psychological science, or all of science, is that it's going to be more multi-disciplinary and collaborative. And that's a real shift in the last 20 years. This shift requires that you be able to work with different disciplines. When faced with those who don't see psychology as a science, this is what I do. I ask those people, "Well, what kind of problems do you solve in your science?" They'll go, "Oh well, we send people to the moon." I say, "Well, could you please explain to me why a woman would drown her children. Can your science answer that question?" That's the kind of problems we study.
Student: Will undergraduate research studies have collaboration between departments? Is this something you would recommend?
Dr. Bray: I wrote about this in one of my presidential columns. It is titled "Where Have All the Psychologists Gone?" What you see is that, when psychologists collaborate, they forget they're a psychologist and don't stand up for their discipline. Therefore, they just get absorbed into this other team. The example is in neuroscience. I work in a medical school where there are lots of neuroscientists. If you ask a physician, "What are you?" They say, "I'm a doctor; I'm a physician." They never forget they are a physician. Psychologists just say, "I am a neuroscientist." They forget they're a psychologist. And that has important implications for the field. Biologists never forget they're a biologist, they will tell you that. Psychologists just lose their title, and they lose their discipline. And that's where we shoot ourselves in the foot, because then people don't realize who we are. It's an identity issue. You need to be proud of who you are. And if we don't do that we're going to get absorbed.
Student: As psychology undergraduates, what should we be doing to prepare ourselves to have prescription privileges? Will we need a doctoral degree to obtain these privileges?
Dr. Bray: The ball that's in play right now is that you basically have to get another master's degree after your PhD. You get your PhD in psychology and then you get a master's in clinical psychopharmacology. I think that that's really too much. There are some complicating factors; we're not physicians. Before I would recommend medication, I would really want to talk to somebody about what medications might interact with the patient's other medical problems. That's collaborative care. Psychiatrists get criticized inside medicine because they don't always consider the whole person and they prescribe medicines that sometimes interfere with the patient's other medical problems. I have a lot of colleagues who live in states where they can't prescribe, but their whole practice is centered on consulting with physicians. They get a lot of diagnostic referrals. They see the patients, evaluate them, make medication recommendations, and send them back to their physician for treatment. Then they usually see the patient and monitor the medication. If psychologists have prescriptive authority, then can just consult with the physician about other medical problems and treat the mental health issues.
Student: As future psychologists, what are the important things we should know about where the field is going and what to look for?
Dr. Bray: One thing we haven't talked about is technology. It's going to be a big part of the future. Doing therapy over the Internet is a part of our future. The problem is that you can't ethically do that because the Internet is not secure. Even if you saw somebody in your state where you were licensed, you couldn't provide therapy because you can't guarantee confidentially. However, if you get all the wavers and confidentiality agreements signed, this might be an option. To provide therapy across state lines is probably illegal, unless you are licensed in both states. You're only allowed to practice in the state you're licensed in. Technology, and how we will use it in the future of our practices, is something of which we need to be aware.
As future psychologists, we appreciated the opportunity to learn from Dr. Bray, who is a practicing psychologist and leader in the field. The collective conclusion from our experience with him is that what we have been handed by the past is set, but what we will make of it in the future is up to us.
The Student Interview Panel consisted of eight students from Nebraska Wesleyan University's undergraduate psychology program. The students are senior psychology majors whose future interests span a variety of career paths including clinical psychology, mental health law, biopsychology, pastoral ministry, and child development. The Student Interview Panel was supervised by Dr. Jerry Bockoven, PhD (psychology department chair).