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Prior to beginning work on this discussion read Hill (2013) “Partnering with a Purpose: Psychologists as Advocates in Organizations,” Cohen, Lee, & McIlwraith (2012) “The Psychology of Advocacy and the Advocacy of Psychology,” Heinowitz, et al. (2012) “Identifying Perceived Personal Barriers to Public Policy Advocacy within Psychology,” Lewis, Ratts, Paladino, & Toporek (2011) “Social Justice Counseling and Advocacy: Developing New Leadership Roles and Competencies,” and Fox (2008) “Advocacy: The Key to the Survival and Growth of Professional Psychology” articles.

For this discussion, you will compare the various professional activities common to clinical and counseling psychologists and assume the role of an advocate for a client in one of the case studies from Case Studies in Abnormal Psychology (Gorenstein & Comer, 2015)Select a case study that has not been covered in this course or in the PSY645 course, and identify systemic barriers, sociopolitical factors, and multicultural issues impacting the client at the micro, meso, exo, and/or macro levels. Develop an action plan that outlines how you might advocate for the client at each appropriate level of the ecological model. Identify two potential partnerships that you would establish in order to support your client and those like him or her outside of the therapeutic environment.

Identifying Perceived Personal Barriers to Public Policy Advocacy Within Psychology

Amy E. Heinowitz, Kelly R. Brown, Leah C. Langsam, Steven J. Arcidiacono, Paige L. Baker, Nadimeh H. Badaan, Nancy I. Zlatkin, and Ralph E. (Gene) Cash

Nova Southeastern University

Public policy advocacy within the profession of psychology appears to be limited and in its infancy. Various hypothesized barriers to advocacy within the field are analyzed in this study. Findings indicate that those who advocate do so regardless of whether the issue is specific to the profession of psychology or specific to another field. Furthermore, several components, including disinterest, uncertainty, and unawareness, were identified as barriers to advocacy. However, all barriers were subsumed by a lack of awareness of public policy issues. By identifying barriers to advocacy in psychology, programs promot- ing advocacy could be fine-tuned to address the lack of knowledge, which inhibits students, profession- als, and clinicians from engaging in the essential role of public policy advocacy.

Keywords: advocacy, public policy, professional involvement

Supplemental materials: http://dx.doi.org/10.1037/a0029161.supp

There is an urgent and growing need for professional and social justice advocacy within the psychological community (Ratts & Hutchins, 2009; Kiselica & Robinson, 2001; Ratts, D’Andrea, & Arredondo, 2004; Toporek, Gerstein, Fouad, Roysircar, & Israel, 2006). Psychology, as a field as well as a profession, aims to reduce negative treatment outcomes and to enhance personal well- being through research and practice (Council of Specialties in Professional Psychology, 2009; American Psychological Associa- tion, 2010b). The viability of the profession and its capacity to provide fundamental and essential services are directly affected by legislation and regulations (Barnett, 2004). As a result, advocacy is integral to the roles of all psychologists, with the future and success of their profession and careers depending on their incor- poration of advocacy into their professional identity (Burney et al.,

2009). Despite the recognition and high appraisal of advocacy, little information is known about how, why, and to what degree individual professionals within the psychological arena participate in public policy advocacy.

The essential question is what does the advocacy role entail? That is the first concern that negatively influences advocacy rates—the vague, ill-defined, and at best multifaceted definition applied to this concept (Trusty & Brown, 2005). It is likely that the act of advocating is conceptualized in markedly distinct ways from one practitioner to the next and, in some cases, may even be inaccurate (Lating, Barnett, & Horowitz, 2009). Lating et al. (2009) describe advocacy as “a process of informing and assisting decision makers, [which] entails developing active ‘citizen psy- chologists’ who promote the interest of clients, health care sys-

This article was published Online First July 2, 2012. AMY E. HEINOWITZ is currently a fourth year PhD student at Nova Southeast- ern University. She previously received her Master of Arts in Psychology from Adelphi University. Her areas of professional interest are in developmental psychology, attachment theory, contextual approaches to trauma resolution, substance use, and professional issues in advocacy work. KELLY R. BROWN is currently a fourth year PhD student at Nova Southeastern University, where she previously received her Master of Science in Clinical Psychology. Her areas of professional interest include advocacy advancement and stigma reduction, child and family psychology, crisis intervention, peer victimization and youth violence, and suicide prevention. LEAH C. LANGSAM is a fifth year PsyD student at Nova Southeastern University, where she also received her Master of Science in Clinical Psychology. Her areas of professional interest are in child and adolescent trauma, the assessment of psychopathology in youth, and professional issues in advocacy work. STEVEN J. ARCIDIACONO is currently a fourth year PhD student at Nova Southeastern University where he also received his en route Master of Science in Psychology. His primary areas of research and practice include youth physical fitness, behavioral issues in adolescents, research method- ology, and advocacy in psychology.

PAIGE L. BAKER is currently a second year PsyD student at Nova South- eastern University. She previously received a Bachelor of Arts in Psychol- ogy and in Women & Gender Studies from Georgetown University. Her areas of professional interest include multicultural and diversity issues, military psychology, and professional issues in advocacy work. NADIMEH H. BADAAN is currently a third year PsyD student at Nova Southeastern University. She obtained her Masters of Arts in Forensic Psychology from John Jay College of Criminal Justice. Her professional interests are in forensic psychology, battered women syndrome, posttrau- matic stress, child sexual abuse, and the psychology of advocacy. NANCY I. ZLATKIN is a fifth year PsyD student at Nova Southeastern University. She holds her Master of Science degree from Nova Southeast- ern University as well. Her professional interests include substance abuse, bullying, solution focused therapies, telehealth, and professional advocacy. RALPH E. (GENE) CASH received his PhD in School Psychology from New York University. He is an associate professor and director of the School Psychology Assessment and Consultation clinic at Nova Southeastern University. His areas of research and practice include suicide prevention, the psychology of public advocacy, and school psychology. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Amy E. Heinowitz, Center for Psychological Studies, Nova Southeastern University, 3301 College Avenue, Fort Lauderdale, FL 33317. E-mail: ah916@nova.edu

Professional Psychology: Research and Practice © 2012 American Psychological Association 2012, Vol. 43, No. 4, 372–378 0735-7028/12/$12.00 DOI: 10.1037/a0029161

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tems, public health and welfare issues, and professional psychol- ogy” (p. 201). Trusty and Brown (2005) offer a streamlined summary of the various descriptions of advocacy as “identifying unmet needs and taking actions to change the circumstances that contribute to the problem or inequity” (p. 259). Regardless of definition, advocacy remains a necessary component of the psy- chology profession (Burney et al., 2009; Fox, 2008).

Advocacy can be divided into three sectors: public policy, social justice, and professional advocacy (see Figure 1). Public policy advocacy is defined as the attempt to influence practice, policy and legislation through education, lobbying and communication with legislators and elected officials. Social justice advocacy, most broadly, involves championing for the basic human and civil rights of all people regardless of race, class, gender, or socioeconomic status. In the context of psychology, however, social justice advo- cacy can more aptly be understood as the recognition “that fairness and justice entitle all persons to access to and benefit from the contributions of psychology and to equal quality in the processes, procedures, and services being conducted by psychologists” (American Psychological Association Code of Ethics, 2010a). Lastly, professional advocacy is a synthesis of both public policy and social justice advocacy. Professional advocacy in the field of professional psychology demands that clinicians advocate not only for fair access to appropriate services but also for the important legislative changes necessary to enhance the quality of life of patients and at-risk populations.

The literature cites several important triumphs within the field (e.g., mental health parity) that can be attributed to the efforts of diligent advocates. Perhaps one of the greatest events was the combined advocacy effort of individual psychologists working with the National Association for the Advancement of Colored People (NAACP) in response to the Brown v. Board of Education Supreme Court case in 1954 (Benjamin & Crouse, 2002). Aware- ness of these accomplishments is important to understanding psy- chology’s roots in public and social advocacy and to provide

impetus for continuing advocacy efforts. However, it should be noted that a great deal more work is still necessary (DeLeon, Loftis, Ball, & Sullivan, 2006; Fox, 2008). Expanding and pro- tecting markets, maintaining funding, providing education and training, and disseminating important information to the public are just a few current initiatives requiring ongoing advocacy (Fox, 2008). Fox (2008) advised, “addressing such an agenda will re- quire efforts far beyond the scope and magnitude of all our past efforts put together” (p. 634).

Despite the acknowledgment of advocacy as an essential re- sponsibility for psychologists, many individuals remain unin- formed and uninvolved. With regard to financial support, psychol- ogists rank among the lowest contributors when compared with other medical professions (Pfeiffer, 2007). Furthermore, psychol- ogists have maintained poor political representation at the national level (DeLeon et al., 2006). Of utmost concern resulting from this lack of involvement is the forfeiture of opportunities to provide input on critical issues. This, in turn, would affect the overall future of the profession as well as the future careers of individual psychologists and the well-being of clients.

Previous research has identified a number of potential barriers to public policy advocacy, which reinforces the immediate need for further research, not only to identify obstacles, but also to pave pathways of enhanced efforts. Myers and Sweeney (2004) initially introduced an exploration of obstacles to professional advocacy via a survey of 71 professionals in the counseling community in local, regional, or national leadership positions. Fifty-eight percent of respondents cited inadequate resources as their primary obstacle to advocacy. Additionally, 51% indicated there was opposition by other providers, 51% noted a lack of collaboration, and 42% suggested a lack of training was responsible for insufficient advo- cacy efforts. While these findings highlight important structural and fiscal challenges, it is prudent to examine the personal barriers, which may further hinder psychologists’ participation in advocacy.

Individual experiences and personality traits may impede psy- chologists’ participation in advocacy in significant ways. Previous literature highlights the impact of awareness (Gronholt, 2009) and professional agendas (Lating et al., 2009) on psychologists’ par- ticipation in advocacy endeavors. More specifically, Gronholt (2009) revealed that despite active participation in academia, stu- dents and faculty cited an absence of interest in advocacy and inadequate awareness of advocacy issues and opportunities as the most significant factors inhibiting participation. These findings suggest that a lack of training or education is a considerable and consistent obstacle in advocacy participation.

When assessing the impact of awareness and training upon psychologists’ underrepresentation in the advocate role, it is nec- essary to evaluate the perceived personal sacrifices associated with some advocacy efforts. According to Chang, Hays, and Milliken (2009) there are numerous perceived personal costs. For example, they cite burnout, job loss, and harassment from other profession- als who may have the belief that client difficulties are not system- ically related. Additionally, psychologists are likely to contextu- alize their chosen advocacy issues as either inappropriate or incongruent with their professional agenda (Chang et al., 2009; Lating et al., 2009). Similarly Benjamin and Course (2002) suggest “psychologists’ aversions to political or social pronouncements have a long history in American psychology, grounded in part in the belief that science and application are separate activities and in

Professional advocacy

Public policy

advocacy

Social jus�ce

advocacy

Figure 1. Three facets of advocacy roles for professional psychologists. Social justice advocacy entails those efforts that are aimed at facilitating the fair, beneficent, and just treatment of all individuals. Public policy advocacy addresses the more legislative and governmental efforts. Lastly, professional advocacy encompasses both social and public policy advo- cacy.

373PERCEIVED BARRIERS TO PUBLIC POLICY ADVOCACY

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the long-standing prejudices held against applied work” (p. 46). In other words, some psychologists experience difficulty aligning their professional identities and values with larger, sociopolitical issues and may fear professional ramifications.

In addition to these perceived challenges, advocacy literature must articulate the personal attributes that influence effective in- volvement in public policy advocacy. Interestingly, an identified barrier to psychologists’ participation in advocacy relates to the nature of the person drawn to the profession. Psychologists are likely to focus their attention on the interpersonal issues that affect clients rather than considering the larger, systemic issues contrib- uting to pathology (Chang et al., 2009; Lating et al., 2009). In fact, it may be that psychologists view advocacy on an individual-level rather than global-level. For example, fostering development of self-advocacy skills and encouraging clients to be resourceful may be a primary focus rather than becoming an advocate for the clients or the field (Waldmann & Blackwell, 2010). Perhaps this tendency precludes psychologists from identifying or promoting the need for social change.

Despite the helpful studies previously conducted on advocacy, there are distinct limitations to the current state of advocacy research. The literature related directly to advocacy within psy- chology is underdeveloped. There is an immediate need for re- search assessing perceived barriers to participation in advocacy via the development of “rigorous assessment tools to evaluate practi- tioner awareness, knowledge, and skills related to advocacy coun- seling efforts” (Green, McCollum, & Hays, 2008, p. 26). This study not only moves forward the field of research assessing perceived barriers to psychologists’ involvement in public policy, but it also suggests important implications for guiding enhance- ment of professional advocacy efforts and directing training pro- grams.

Statement of Problem

Advocacy within the profession of psychology appears to be limited and in its infancy. Strikingly, research shows that other fields engage in high rates of advocacy. This study seeks to understand what the perceived barriers are to advocacy within the field of psychology. Further, it strives to elucidate whether there are differences between those who advocate specifically on behalf of psychological issues versus those who may advocate in other related domains.

Method

Participants were recruited via a mass email sent to the graduate psychology department of a private southeastern university. Those who decided to participate completed an anonymous online survey created with the purpose of understanding barriers to advocacy. The survey contained a total of 18 items that included demo- graphic information, rates of advocacy involvement, and attitudes toward various types of advocacy efforts. Items followed a four- choice response scale measuring frequency of behavior (e.g., “I advocate for issues within my specific field of psychology”: very frequently, somewhat frequently, rarely, never), and belief in per- sonal effectiveness (e.g., “I do not believe my participation will generate much of an effect”: very relevant, somewhat relevant, somewhat irrelevant, very irrelevant”). Items were chosen based

off of the literature review, which identified several barriers to advocacy within the field of psychology. The portions of the survey that were used for the current analysis can be found in the online-only data supplement.

Participants ranged in age from 18 to 64 years, with most between the ages of 18 and 34. The majority of participants were students (63.5%), with the remaining sample consisting of alumni, staff, and faculty members. Of those who endorsed being a student affiliate, almost 60% were working toward a postgraduate degree (masters or doctorate).

Pearson correlations, a stepwise linear regression, and a princi- pal components analysis were used to examine the data.

Results

Descriptives

Participants included 85 adults from the previously mentioned university. However, only 59 participants completed demographic information. The sample was predominantly composed of females (94.8%). Participants were asked to select their age via different ranges: 20.3% were between the ages of 18–24, 44% were be- tween the ages of 25–34, 11.9% were between the ages of 35–44, 20.3% were between the ages of 45–54, and 3.4% were between the ages of 55–64. The percentages reported were rounded to the nearest tenth; as such, the valid percent equals 99.9%. The sample consisted predominately of students (91.5%) currently working toward a master’s degree (38.6%) or a doctoral degree (38.6%) in psychology or a closely related field. The remainder of the sample consisted of university faculty (3.4%), alumni (3.4%), and clinical staff (1.7%). The self-described political orientations of partici- pants varied among very liberal (20.7%), somewhat liberal (27.6%), moderate (37.9%), somewhat conservative (12.1%), and very conservative (1.7%).

Pearson Correlations

To investigate the influence of barriers to advocacy within psychology, several statistical analyses were conducted on re- sponses to the online survey. Pearson correlations between self- reported relevance of potential barriers and advocacy in psychol- ogy are presented in Table 1. Results indicated that those who advocate more frequently tend to believe that the relevant barriers are having a poor past experience (r � �.261, p � .048) and not believing one has enough knowledge to discuss issues competently (r � �.348, p � .007). Meanwhile, feeling as though not being aware of current public policy issues was a relative inhibitor to advocacy was significantly correlated with less advocacy (r � .404, p � .001). Additionally, significant correlations were present between several potential barriers, indicating a considerable degree of consistency among items.

Stepwise Linear Regression

Although some barriers to advocacy were individually cor- related with advocacy participation, the overlap of variance among items can make it difficult to determine which barriers are most important in predicting advocacy. Thus, a stepwise linear regression was used to determine which predictors (i.e.,

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barriers) work in combination with one another to predict advocacy involvement within one’s specific field of psychology most effectively. The following nine predictor variables were entered into the model: unawareness of public policy issues, lack of belief in the effect one’s participation will have on issues, lack of time, disinterest, belief that one is not persuasive enough, poor past experiences, lack of awareness of opportu- nities to become involved, belief that there is no need for advocacy, and belief that one does not have enough knowledge to discuss such issues competently.

After conducting a stepwise linear regression analysis, it can be concluded that the overall model significantly predicts public policy advocacy, F(1, 54) � 17.270, p � .001 (A statistical table summarizing the results is available in the online-only data sup- plement). Results of the stepwise linear regression procedure in- dicated that the only significant barrier present, after considering overlap of variance among variables, was awareness of public policy issues (r � .492, R2 � .242).

Principal Components Analysis

To investigate the constructs behind lack of advocacy within psychology, a principal components analysis (PCA) with varimax rotation was conducted. The results of these analyses are available in the online-only data supplement. Using Kaiser’s eigenvalue- greater-than-one-rule, three components were extracted from the 10 barriers. Items loaded onto each component were considered if they had a correlation (i.e., loading) of at least .4 with a given component. Given these criteria, the first component yielded could be named “disinterest,” the second component could be named “uncertainty,” and the third component could be named “unaware- ness.”

The three components accounted for 60% of the total variance after performing a PCA. The first component contributed 28% of the variance, the second component contributed 21%, and the third component contributed 11%. These three factors were reproduced on the Extraction Sums of Squared Loadings, indicating that only these factors had eigenvalues that were greater than or equal to one.

The first component included not having an interest in partici- pating, not believing there is a need for advocacy, not believing that participation will generate an effect, having a poor past expe- rience, and not wanting to give out information (termed “disinter- est”). The second component included not having enough knowl- edge and not feeling persuasive enough (termed “uncertainty”). Finally, the third component included lack of awareness of public advocacy issues as well as opportunities to advocate (termed “unawareness”).

The results of the PCA taken in tandem with the results of the correlation and regression analysis indicate that there are three distinct components regarding barriers to advocacy (disinterest, uncertainty, and unawareness); however, the influence of several barriers (e.g., poor past experience, lack of knowledge) are sub- sumed under the impact of unawareness of public policy issues.

Discussion

Results indicate that those who advocate do so regardless of whether the issue lies within or outside of their specific field. More simply, those who advocate, advocate. This finding may be indic- ative of unique personal characteristics of those who are involved in advocacy efforts. Relative to other health professions, those drawn to professional psychology may be more interested in individual issues rather than larger sociopolitical concerns (Lating et al., 2009). In other words, psychologists may more readily advocate for individuals but advocate less for larger platforms. This advocacy pattern may be further influenced by the tendency for public policy issues to be presented in polarized views, in contrast to the tendency for psychologists to view things in shades of gray.

Results further revealed that several barriers were independently correlated with psychologists’ participation in advocacy; however, a substantial overlap of variance was also indicated. Considering poor past experiences with advocacy as a barrier was, ironically, associated with greater participation in advocacy. This suggests that negative past experiences do not deter people from advocating in the future. It is also likely that those who advocate are more apt

Table 1 Pearson Correlation Matrix Among Barriers to Advocacy Efforts and Self-Reported Public Policy Advocacy

1 2 3 4 5 6 7 8 9 10 11

1. No time 1 2. Unaware of opportunities �.205 1 3. Lack of interest .158 �.169 1 4. Belief that there is no need for

advocacy .104 .077 .546�� 1 5. Belief that participation will be

ineffective .078 �.168 .393�� .371�� 1 6. Poor past experiences .153 .039 .331� .423�� .479�� 1 7. I do not want to give out my

information .274� �.097 .365�� .286� .313� .343�� 1 8. Lack of knowledge to discuss issues �.264� .223 �.055 .017 .309� .060 �.008 1 9. Belief that person lacks persuasiveness .065 �.107 .152 .326� .352�� .149 .024 .394�� 1

10. Unaware of current issues �.096 .475�� .065 .252 .053 �.017 �.194 .504�� .404�� 1 11. Advocating for issues within one’s field

of psychology .225 �.176 �.250 �.115 �.044 .261� .201 �.348�� �.234 �.404�� 1

� p � .05. �� p � .01.

375PERCEIVED BARRIERS TO PUBLIC POLICY ADVOCACY

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to have negative (as well as potentially positive) experiences than those who do not advocate.

The overall regression model with nine predictor variables entered in was deemed statistically significant. The only significant barrier, however, was awareness of public policy issues. In other words, much of the predictive influence of the assessed barriers to advocacy was actually subsumed under the barrier of feeling unaware of public policy issues for which to advocate. For example, not believing one has enough knowledge to discuss issues competently inhibits public policy advocacy, but not over and above the influence of not being aware of public policy advocacy issues in the first place. These results suggest that lack of awareness of advocacy issues strongly inhibits involvement in psychology advocacy. In fact, the impact of some other speculated barriers might actually be better accounted for by this lack of awareness. For instance, psychologists or psychology students may feel as though they lack adequate knowledge to discuss public policy issues simply because they are in the dark about what the issues are.

Furthermore, areas previously assumed to be relevant barriers to advocacy, (e.g., unawareness of opportunities to become involved, lack of time) appear less important than expected. Instead of emphasizing awareness of avenues for advocacy or suggesting time-efficient opportunities, interventions should be aimed primar- ily at improving education with regard to current, relevant public policy concerns. Lating et al. (2009) indicated that 60% of psy- chology programs do not offer specific advocacy training. How- ever, the authors note that 88% cover advocacy issues in class. This suggests that improvements in education are slowly develop- ing and perhaps will someday result in full-fledged advocacy training as an integral part of psychology programs.

Although lack of awareness was found to be the most meaning- ful barrier, moderate semipartial correlations (i.e., correlations after considering the impact of other investigated barriers) suggest future studies are needed to establish the roles of variables to assess interest in participating in as well as the belief in a need for public policy advocacy. In the current study, these variables failed to meet statistical significance as predictors of advocacy; however, increased sample size in future replications may provide the power necessary to yield a significant result.

After performing a PCA, three components emerged. The three components accounted for 60% of the total variance. The first component contributed 28% of the variance (not having an interest in participating, not believing there is a need for advocacy, not believing that participation will generate an effect, having a poor past experience, and not wanting to give out information). The second component contributed 21% (not having enough knowl- edge and not feeling persuasive enough), and the third component contributed 11% (lack of awareness of public advocacy issues as well as opportunities to advocate).

The three components identified by the PCA (disinterest, un- certainty, and unawareness) as barriers to advocacy corroborate the findings of previous advocacy research (Myers & Sweeney, 2004; Gronholt, 2009). The first component, termed “disinterest,” in- cluded not having an interest in participating, not believing there is a need for advocacy, not believing that participation will generate an effect, having a poor past experience, and not wanting to give out information. Though this is a complex and multifaceted com- ponent, results remain consistent with previous research suggest- ing that advocacy is not a priority among many psychologists due

to a general lack of interest (Myers & Sweeney, 2004). More explicitly, the authors found that 28% of clinicians did not view advocacy as a priority. Furthermore, 27% of clinicians reported that they did not have any interest in advocating (Myers & Sweeney, 2004). Other studies have used the lack of “motivational spark” as a synonym for the disinterest in participating experi- enced by professionals (London, 2010).

The second component, termed “uncertainty,” included items such as not having enough knowledge and not feeling persuasive enough. The lack of knowledge identified by our participants is likely related to a lack of training in advocacy. Myers and Sweeney (2004) established that 41% of their sample found a lack of training to be a significant barrier in advocacy work. When psy- chology programs fail to emphasize advocacy, students are likely to graduate without the confidence and tools necessary to advocate effectively. According to London (2010), a lack of confidence impacts motivation and the manner in which psychologists con- ceptualize problems and the need for change.

Finally, the third component, termed “unawareness,” included lack of awareness of public advocacy issues as well as opportuni- ties to advocate. Again, our results corroborate the findings of Myers and Sweeney (2004) that suggest a lack of awareness of advocacy issues is a significant barrier to participation in advo- cacy.

There are several limitations inherent in the design of the current study. For one, the sample was drawn from one university in the southeastern region of the United States. There may be issues with generalizability to the population of the United States as a whole. Additionally, the small sample size (N � 86) may further reduce applicability to the general population of professional psycholo- gists. As such, the results should be interpreted within the context of existing within an exploratory framework. Further research is needed to examine characteristics in more diverse samples. Fur- thermore, the survey used was exploratory at best. Future studies ought to expand on the current template to include questions with greater variability in responses, as well as to include additional items or perceived barriers.

Participation in advocacy within the profession of psychology is essential because public policy drives professional functioning. The future of the field and of the people served by psychologists depends on advocacy efforts. Consequently, a careful consider- ation of the interaction among the three components identified in our study can provide valuable insight into improving advocacy within psychology. First, advocacy must become a valued asset to the field. As previous research has indicated, nearly half of psy- chologists admit that advocacy is not a priority (Kindsfater, 2008). Before the other barriers to advocacy can be addressed, psychol- ogists need to perceive advocacy as an integral part of their profession. Once advocacy is valued, the lack of preparation and awareness can be addressed through graduate training programs and continuing education courses. Ideally, the increased valuation of advocacy, combined with the necessary tools and avenues to pursue it, will ignite motivation for psychologists to take their roles as advocates seriously.

Implications

Advocacy is a major component of psychology and mental health awareness. Although no significant trait or construct differ-

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ences were found between participants who advocate within or outside their own field, this study did illustrate the essential need for advocacy training. This finding is crucial because it illustrates that lack of motivation or unwillingness to advocate is not primar- ily responsible for preventing advocacy; rather it is a deficiency in understanding or simply being aware of relevant issues. This lack of knowledge implies that the psychological community should seek to enlighten individual members not only about advocacy procedures, how they work, and the vast benefits that can emerge, but also about specific issues. Psychology students and profes- sional practitioners are typically unaware of how much their indi- vidual contributions can actually help. People may not spend time or money advocating if they do not believe any results will emerge from their efforts. Hence, steps should be taken to highlight positive advocacy experiences and successful policy changes.

If professional psychologists actively supported relevant issues regarding mental health, the field of psychology would advance at a faster rate. To initiate this, implementing advocacy education in continuing education classes, mandatory seminars, and yearly con- ferences would compel psychologists to hear the relevant issues at hand. Professional psychologists may be overwhelmed with a heavy workload and not have time to individually research and participate in public policy advocacy. However, when made aware of significant concerns related to mental health, by nature, profes- sional psychologists will be unable to ignore them.

As for spreading the importance of advocacy among profes- sional facilities outside of the psychological field, companies can provide in-house training to employees to increase comfort and familiarity with the advocacy process. Because there are numerous areas in which individuals are interested, education can be pro- vided according to the relevance of each specific institution. Peo- ple in general are more likely to support issues that have meaning to them. Tailoring advocacy education in this manner may not only attract a greater amount of people but may also make the under- standing of advocacy more simplistic.

Furthermore, there is a lack of awareness among society about which issues are most pertinent to be advocated for. It is therefore critical to provide timely information pertaining to relevant public policy issues for which the public can advocate. Creating public advocacy groups can also help disseminate information and in- crease opportunities for positive experiences. Increasing layman’s confidence in advocacy can be accomplished by providing training opportunities via open workshops to create collaborative advocacy endeavors.

The findings presented in this study carry valuable implications for efforts aimed at enhancing participation in advocacy. Lating et al. (2009) suggest that the continued separation of professional and educational agendas in the training of psychologists may contrib- ute to the profession’s deficient involvement in advocacy. Specif- ically, psychology is the only major health profession to maintain an academic training model despite the creation of professional training programs. The lack of advocacy training appears to con- tribute to the development and maintenance of barriers such as lack of awareness of and lack of perceived competence in discuss- ing public policy issues.

Efforts to increase psychologists’ participation in public policy advocacy must begin early on and be integrated throughout their curricula. Pertinent public policy issues fit well into courses on ethics, diversity, assessment, and even intervention. Similarly,

discussion about and training in the advocacy role may be rein- forced through clinical training and supervision. In addition to incorporated teaching lessons, specific coursework in public policy advocacy might aid students in developing skills used to advocate, while increasing comfort, enhancing familiarity, and expanding knowledge of current issues.

References

American Psychological Association. (2010a). Ethical principles of psy- chologists and code of conduct (2002, Amended June 1, 2010). Retrieved from http://www.apa.org/ethics/code/index.aspx

American Psychological Association. (2010b). Public description of clin- ical psychology. Retrieved from http://www.apa.org/Ed./graduate/ specialize/clinical.aspx

Barnett, J. E. (2004). On being a psychologist and how to save our profession. Independent Practitioner, 24, 45–46.

Benjamin, L. T., Jr., & Crouse, E. M. (2002). The American Psychological Association’s response to Brown v. Board of Education: The case of Kenneth B. Clark. American Psychologist, 57, 38–50. doi:10.1037/ 0003-066X.57.1.38

Burney, J. P., Celeste, B. L., Johnson, J. D., Klein, N. C., Nordal, K. C., & Portnoy, S. M. (2009). Mentoring professional psychologists: Programs for career development, advocacy, and diversity. Professional Psychol- ogy: Research and Practice, 40, 292–298. doi:10.1037/a0015029

Chang, C. Y., Hays, D. G., & Milliken, T. F. (2009). Addressing social justice issues in supervision: A call for client and professional advocacy. The Clinical Supervisor, 28, 20–35. doi:10.1080/07325220902855144

Council of Specialties in Professional Psychology. (2009). CoSPP bylaws. Retrieved from http://cospp.org/bylaws

DeLeon, P. H., Loftis, C. W., Ball, V., & Sullivan, M. J. (2006). Navigating politics, policy, and procedure: A firsthand perspective of advocacy on behalf of the profession. Professional Psychology: Research and Prac- tice, 37, 146–153. doi:10.1037/0735-7028.37.2.146

Fox, R. E. (2008). Advocacy: The key to the survival and growth of professional psychology. Professional Psychology: Research and Prac- tice, 39, 633–637. doi:10.1037/0735-7028.39.6.633

Green, E. J., McCollum, V. C., & Hays, D. G. (2008). Teaching advocacy counseling within a social justice framework: Implications for school counselors and educators. Journal for Social Action in Counseling and Psychology, 1, 14–30.

Gronholt, J. M. (2009). An exploration of the differences in psychology faculty and graduate students’ participation in mental health legislation and barriers to advocacy. Dissertation Abstracts International: Section B. Sciences and Engineering, 70, 2.

Kindsfater, H. C. (2008). Factors related to psychologists’ participation in professional advocacy (Unpublished dissertation). The University of South Dakota: South Dakota.

Kiselica, M. S., & Robinson, M. (2001). Bringing advocacy counseling to life: The history, issues, and human dramas of social justice work in counseling. Journal of Counseling & Development, 79, 387–397. doi: 10.1002/j.1556-6676.2001.tb01985.x

Lating, J. M., Barnett, J. E., & Horowitz, M. (2009). Increasing advocacy awareness within professional psychology training programs: The 2005 National Council of Schools and Programs of Professional Psychology Self-Study. Training and Education in Professional Psychology, 3, 106–110. doi:10.1037/a0013662

London, M. (2010). Understanding social advocacy: An integrative model of motivation, strategy, and persistence in support of corporate social responsibility and social entrepreneurship. Journal of Management De- velopment, 29, 224–245.

Myers, J. E., & Sweeney, T. J. (2004). Advocacy for the counseling profession: Results of a national survey. Journal of Counseling & Development, 82, 466–471. doi:10.1002/j.1556-6678.2004.tb00335.x

377PERCEIVED BARRIERS TO PUBLIC POLICY ADVOCACY

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Ratts, M., & Hutchins, A. M. (2009). ACA advocacy competencies: A social justice advocacy at the client/student level. Journal of Counseling & Development, 87, 269–275. doi:10.1002/j.1556-6678.2009.tb00106.x

Toporek, R. L., Gerstein, L., Fouad, N., Roysircar, G., & Israel, T. (2006). Handbook for social justice in counseling psychology: Leadership, vi- sion, and action. Thousand Oaks, CA: Sage Publications.

Trusty, J., & Brown, D. (2005). Advocacy competencies for professional school counselors. Professional School Counseling, 8, 259–265.

Waldmann, A. K., & Blackwell, T. L. (2010). Advocacy and accessibility standards in the new Code of Professional Ethics for rehabilitation counselors. Rehabilitation Counseling Bulletin, 53, 243–248. doi: 10.1177/0034355210368866

Received December 20, 2011 Revision received May 7, 2012

Accepted May 9, 2012 �

378 HEINOWITZ ET AL.

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Advocacy: The Key to the Survival and Growth of Professional Psychology

Ronald E. Fox The Consulting Group of HRC

Active participation in professional advocacy activities is essential for psychology to have a viable future. Advocacy efforts thus far in professional psychology are reviewed, and a discussion of how strong advocacy efforts will be required to advance the interests of the profession in the future is presented. Making psychology a true health profession, securing legislative authority to prescribe in all states, confronting and overcoming business and regulatory constraints on practice, and providing sufficient services to meet the growing diversity of the general population are discussed as examples of professional issues whose resolution will require significant advocacy efforts. Recommended steps are provided for developing a strong, national advocacy program.

Keywords: advocacy, political action, prescriptive authority, professional involvement

The very survival of psychology as a profession may well depend on the development and implementation of a successful advocacy program. Without it, psychology is destined to remain a minor player in the nation’s heath care market. Unfortunately, psychology is poorly positioned to conduct the comprehensive, coordinated, and expensive effort that is needed.

Despite their many political successes over the past several decades, psychologists remain reluctant participants in the advo- cacy process (DeLeon, Loftis, Ball, & Sullivan, 2006). For the present purpose, advocacy is defined as the use of political influ- ence to advance the profession through such means as political giving, legislative lobbying, and other active participation in the political decision-making process. Psychologists’ level of giving for advocacy has not increased with their growth in numbers and remains far below that of comparable health care professions (Pfeiffer, 2007). The need is manifest, the potential rewards are there for the taking, but the will to act often lies dormant.

Successfully addressing each and every one of the issues dis- cussed in this special section of the journal are cases in point. Establishing psychology as a primary health care profession al- ready has required a great deal of advocacy effort and even more will be needed in the future (Wright, 2001). The same is true for prescriptive authority (RxP) legislation and the management of its impact on both society and the profession. Managed care and the evidence-based practice movements have brought major opportu- nities and threats to psychology that will require strong political advocacy to establish appropriate boundary conditions for cost and

accountability measures whose unintended consequences can be disastrous. The increasing diversity of patients requires expanded skills and training for practitioners and the creation of better access to services.

Political action will be necessary to put in place the policy changes and funding opportunities needed. The future of our profession can be bright. The road to it runs directly through the social and political arenas. A brief review of some of the history and background of these issues will help clarify why the need for major advocacy mechanisms is so critical to the future develop- ment of the profession of psychology.

Psychology as Health Care Profession

Several presidents of the American Psychological Association (APA) have created initiatives to help establish psychology as a health profession (e.g., Jack Wiggins, Pat DeLeon, Norine John- son, Ron Levant), which is very good and necessary. But much remains to be done. In order to make psychology a true health care profession providing services that are both accessible to the gen- eral public and affordable, those services will need to be reimburs- able in the same manner as other health care. This requires the inclusion of psychological care in the myriad health and rehabil- itation services reimbursed by public and private carriers.

Early advocacy efforts to gain recognition and reimbursement were first initiated in the 1970s by a group of activist practitioners known as the “Dirty Dozen” (Fox, 2001). This group also founded psychology’s first advocacy organization outside of APA, the Council for the Advancement of the Psychological Professions and Services, or CAPPS (not to be confused with CAPP, or the Committee for the Advancement of Professional Practice, the oversight group for the APA Practice Directorate, which was established much later). These psychologist advocates also suc- cessfully pressured APA to establish a Committee on Health Insurance (COHI) and ultimately an advocacy program within APA itself, thus recognizing the legitimacy of such efforts by psychologists.

RONALD E. FOX received his PhD in clinical psychology from the Univer- sity of North Carolina in Chapel Hill. He is executive director of The Consulting Group, a division of HRC (a multidiscipline practice in Chapel Hill, Durham, and Raleigh, North Carolina), and a clinical professor at the University of North Carolina. His areas of professional interest include professional education, practice standards, advocacy, and professional de- velopment. He is a past president of the American Psychological Associ- ation (APA) and a member of the APA Council of Representatives. Dr. Fox may be contacted by e-mail at drronfox@nc.rr.com

Professional Psychology: Research and Practice Copyright 2008 by the American Psychological Association 2008, Vol. 39, No. 6, 633-637 0735-7028/08/$12.00 DOI: 10.1037/0735-7028.39.6.633

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The numerous successes brought about by these early pioneers, which remain impressive over 40 years later (Fox, 2001), include passage of the first “freedom of choice” legislation, ultimately enacted in numerous states, requiring insurance carriers doing business in a state to reimburse for the services of psychologists if they reimburse other providers for mental health care; convincing a major carrier for federal employees’ comprehensive health plan to cover psychological services; a class-action lawsuit forcing the U.S. Civil Service Commission to recognize psychologists as independent and reimbursable providers in their contracts; pres- suring the Civilian Health and Medical Plan for the Uniformed Services (CHAMPUS) to reimburse psychologists for both outpa- tient and inpatient services (subsequent legislation extended the same access to beneficiaries of deceased veterans) (Wiggins, 2001); passage of the 1975 Vocational Rehabilitation Act, placing mental health on a par with physical health and granting parity to psychologists for reimbursement; and the establishment of psy- chology’s first full-fledged doctoral program explicitly devoted to training practitioners, the California School of Professional Psy- chology (Cummings, 2001). Many similar schools, which were subsequently established in other states, award the Doctor of Psychology (PsyD) degree. In 1976, Cummings convened the first meeting of what was to become the National Council of Schools of Professional Psychology (NCSPP), which 20 years later became the first national training council to identify “advocacy training” as a core professional value for the professional graduate curriculum.

More recent APA advocacy successes include the modification of Social Security administrative law to allow psychologists to qualify as “medical examiners,” thus legitimizing a major role of psychologists in preventing or ameliorating the disabling effects of physical illness and injury (Wiggins, 2001). In 2002, advocacy led to the creation of the Graduate Psychology Education Program within the Bureau of Health Professions of the U.S. Department of Health and Human Services as the first and only federal program dedicated solely to the education and training of psychologists (Wiggins, 2001). In recent years, the APA Practice Web page (www.apapractice.org) has announced congressional approval for the Department of Defense Graduate Psychology Education Pro- gram to address the behavioral health care needs of service mem- bers and their families; the creation of new treatment codes for psychological assessments and neuropsychological testing; and approval for payment of neurobehavioral examinations, which is an acknowledgement of the advanced training and skills of psy- chologists, to mention only a few examples.

As gratifying as these successes may be, much more remains to be done. Psychological care is almost unique in its ability to help patients retain, enhance, or gain their functionality throughout the health care spectrum: prevention, detection, diagnosis, treatment, and rehabilitation. To capitalize on this potential, psychology must institute a variety of efforts to cement, expand, and protect new markets. Funds for training, demonstration projects, and new treat- ment centers will be required in both the public and private sectors. Extensive education efforts will be needed to inform the public about the effectiveness of psychological care. Treatment and di- agnostic codes must be revised, federal and state agencies must be changed, new laws enacted, and so on. Addressing such an agenda will require social and political advocacy, political giving, and coordinated public information programs far beyond the scope and magnitude of all of our past efforts put together. Without them, the

health care market, which is changing rapidly, may well pass the psychology profession by.

Prescription Privileges

Prescriptive authority for psychologists has come to be viewed by many practitioners as the major vehicle for securing the pro- fession’s role as a major health care profession. See Fox (2003a, 2006) for a brief review of the history of RxP efforts by psychol- ogists. The lifting of the U.S. Food and Drug Administration’s ban on direct marketing of drugs to the public in the 1990s increased the public demand while accelerating the push for prescriptive authority by several other health professions and increasing the pressure on psychology to do the same.

APA’s Committee for the Advancement of Professional Practice (CAPP) has assumed the challenge at the national level to coor- dinate and assist state efforts to secure the right of appropriately trained licensed psychologists to prescribe. Impressive and persis- tent grass roots efforts with the assistance of grants and informa- tion sharing and education from CAPP helped advocacy efforts that successfully passed enabling legislation in New Mexico, Lou- isiana, and Guam. Ongoing, well-organized initiatives to pass similar legislation in a dozen other states were underway by 2007. In 1996, APA’s Council of Representatives adopted a model curriculum for RxP training as well as model licensing laws to encompass the new practice parameters. Most of the points made earlier regarding the need for advocacy in establishing psychology as a health profession obviously apply here as well.

Provider Restraints

The rapid rise in health care costs over the past half-century has taken a tremendous toll on the nation’s fiscal resources and placed U.S. businesses in an increasingly unfavorable competitive posi- tion in world markets due to the ever higher costs of employee health plans. Unable to agree on the basic changes needed in the health care system as a whole, insurers and the government have used various efforts to control costs without addressing the under- lying problems in the health care system as a whole.

The most prominent, and perhaps most widespread, cost-control strategy has been the “managed care” systems devised by insur- ance carriers and sold to employers for their company health care plans. Through such means as reducing benefits, tightening pro- cedures, lowering provider reimbursement, requiring second opin- ions, and transferring approval of claims from the providers to insurance company employees (who may or may not be health care providers), carriers succeeded in holding down and sometimes lowering health care costs in the short term. But the demand for services, the increasing availability of new and expensive proce- dures, and the press for ever higher profit margins for the carriers have tempered the initial claims of success, leaving patients with more barriers to care, providers with less compensation, markedly higher administration costs, and a health care system that is easily the most expensive of any nation on Earth without evidence that it is also the best. In fact, the United States now ranks last among industrialized nations on most measures of good health care (e.g., infant life expectancy; Commonwealth Fund Commission on a High Performance Health System, 2006).

634 FOX

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Managed care, higher co-pays, and provider restrictions and accountability may be useful tools to control costs when used appropriately and judiciously, but they often have been misused and abused to the detriment of patients, providers, and society. APA, along with other professional groups, patient advocates, and some states, has brought successful lawsuits to force some man- aged care firms to cease various egregious practices. But the fact of the matter remains that the nation’s health care system is broken and in need of a major overhaul, rather than the piecemeal tactics discussed here.

Health Care System in Disarray

A recent report by The Commonwealth Fund Commission on a High Performance Health System, 2006) documents the fact that the United States ranks near the bottom on numerous health indices when compared with other wealthy nations in everything except cost. We pay far more for care and get less in return. We rank last on all measures of equity. Below-average income workers are much less likely to see a physician when sick and are more likely not to get a recommended test, treatment, or follow-up care; not to fill a prescription; and not to see a dentist when needed because of the cost.

Our wealthy citizens do not fare much better, despite seeking care early and showing better follow-through with treatment rec- ommendations. The United States and Canada rank lowest on prompt accessibility of appointments with physicians, but Canada achieves the same rank at less than half the cost! According to the report, the U.S. system is so poorly organized that much of what would be good care is negated despite the huge amounts of money poured into health care. The U.S. health care system is technolog- ically and organizationally backwards.

Other countries are further along in using information technol- ogy and a team approach to manage chronic conditions and coor- dinate care. In countries such as Germany, New Zealand, and the United Kingdom, modern information systems enable a physician to better identify and more efficiently treat and monitor chronic care patients. Physicians also are able to print out lists of the medications that all physicians have prescribed for a patient. In the United States, primary care physicians and specialists are typically poorly informed or not up to date on what other health providers are doing due to a lack of mutually accessible medical records. Records are not computerized in the United States, forcing physi- cians to rely on written records in a computer age. According to the report, the U.S. Department of Health and Human Services esti- mates that as much as 30% of U.S. health care spending (about $300 billion) is inappropriate, redundant, or unnecessary, and the U.S. Institute of Medicine estimates that 98,000 people die each year from medical errors—both of which would be significantly reduced with a nationwide, integrated, computerized patient infor- mation system.

The only area in which the United States was not ranked last was in preventive health care, although it still trailed Canada and Australia. The bottom line is that despite spending nearly $2 trillion annually, the United States consistently underperforms on most dimensions of performance related to other countries (Com- monwealth Fund Commission on a High Performance Health System, 2006).

The point of this rather lengthy discussion of the current state of U.S. health care is that most informed observers now seem to agree that the United States needs a new, integrated national health care system and that fundamental changes are likely. As all the forces and influence groups marshal their resources to debate the relative merits of government-based health insurance versus some form of public and private insurance, psychology must be an active par- ticipant. The profession cannot afford to watch from the sidelines as a new system is put into place and then spend the next several decades trying to modify what has been done to allow our partic- ipation as happened when Medicare was first established. Psychol- ogy must move boldly to be included from the start in whatever new system is developed if we truly intend to be a major health care profession. It will require organized advocacy on a national scale to make it happen, but it can be done.

Diverse Patients, Diverse Providers

The increasing diversity of the U.S. population requires no documentation and must be taken into account in future advocacy plans of the profession. In terms of a national strategy, it will be necessary to address the broad challenges that the changing com- position of the population presents: appropriate access to services, recruitment of more minority students, and enhanced training for all providers.

Major public education efforts designed to reach specific cul- tural and ethnic populations will be needed to promote better, more responsible psychological care; to provide information on where and how to secure help; to reduce resistances; and to encourage psychologically healthy prevention measures. Like any other pub- lic health program, the cost of such efforts will far exceed the resources of a single profession. Public funds and support must be a significant part of the mix, but they are unlikely to be put in place unless psychologists themselves take the lead in advocating for them.

It is hard to disagree with the idea that a greater diversity of psychology practitioners will be required to meet the needs for services in the future. Some progress has been made as the results of previous advocacy efforts at both the state and federal levels to increase the number of minority psychologists through targeted scholarships and training programs. Though laudable, it seems unlikely that we will be able to train enough ethnic minority practitioners, and even if it were possible, it will be decades before enough students are recruited and trained to meet current demands. Therefore, it is clear that many current practitioners must gain the knowledge and skills required to work effectively with a diverse patient base. Obviously, major funding will be required for retool- ing current practitioners to deal with both current and immediate future realities. In addition, a quantum leap in funding for schol- arships and demonstration projects for services targeted to minor- ity clients will be essential.

The social need for a diverse profession with programs for a diverse population and the potential benefits to society as a whole are obvious. Once again, it is not conceivable that the commitment of the financial and human resources required will ever be put in place without the strong advocacy and leadership of the profession.

635ADVOCACY FOR THE GROWTH OF PSYCHOLOGY

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Looking Ahead

Up to now, psychology as a profession has done far too little advocacy to achieve its aim of being a major health, or even mental health, profession. Few psychologists actually participate in any form of advocacy, let alone political giving. Unfortunately, we have the poor results to show for our lack of effort (Barnett, 2003).

A look at political giving as one indicator or our advocacy record provides a good measure of where we stand and how far we have to go. During the 2005 and 2006 biennium, psychology ranked 12th among 15 health care provider groups in contributions and 10th in average contribution per member per year (Pfeiffer, 2002).

Of course, several professions that contribute far more total dollars than psychology also have far more members (i.e., physi- cians, nurses, social workers, dentists, and audiologists). The rank- ings according to contributions per member per year are more revealing about where we stand. At a giving rate of $5.58 per member per year, psychology ranks 10th. Podiatrists, nurse anes- thetists, and optometrists rank 1st, 2nd, and 3rd, respectively, in average contributions per member and give more total contribu- tions than psychologists despite the fact that their professions have far fewer members than psychology. Podiatry has 11,000 mem- bers, optometry 23,000, and nurse anesthetists 29,500 compared with psychology’s 40,000 special assessment payers (Pfeiffer, 2002). Despite relatively small numbers, podiatrists’ total contri- butions were almost twice as much as psychologists and six times as much per member per year. Optometrists contributed more than twice the total contributions of psychology and more than three times as much per member per year. Nurse anesthetists, with fewer than 30,000, gave three times as much overall as psychologists and almost four times as much per member per year. Clearly, our profession has a long way to go. Barnett (2004) makes the case about as directly and simply as it can be made:

We work so diligently to obtain our degrees and become licensed and then risk it all when we don’t become active advocates. How else can we ensure the viability of the profession we work so hard to join?. . .To entrust our profession’s and our personal future to others seems foolhardy when we consider the competing needs and agendas of many of those groups. . .[which] are working hard to advance their own agendas. . . .[I]n Pennsylvania alone there are 550 lobbyists actively representing 1550 organizations. (p. 45)

In order to create the large-scale, orchestrated, and effective advocacy effort that is needed, psychology must do the following and more:

1. Develop a comprehensive database that lists all licensed psychologists in the United States, including a way to identify those who are members of APA and/or a state association. This will take time and money, but it is critical that the profession be able to quickly and easily contact and mobilize its practice base.

2. Adopt some of the lessons and methods used by successful political groups. For example, an accurate, current information base should be developed regarding the most critical professional issues for segmented portions of psychologists so that targeted messages can be crafted that speak directly to their concerns when requesting advocacy help. Psychology practice is highly diverse. The important issues are not necessarily the same for full-time and part-time providers, or for those who work in independent settings

compared with those who work in institutions, or for government service workers compared with those who work in university settings, and so forth. Psychologists are not all the same. Messages that speak most directly to the specific concerns of each segment must be developed. Targeted messages have worked so well for some conservatives that they have been able to gain control of the Republican party and win both state and national elections with a membership that is an actual minority in their own party.

3. Increase psychologists’ participation in political advocacy. This will not be easy as the usual and inexpensive techniques for doing so have been tried to little avail. Only 2%–3 % of practi- tioners provide the total of psychology’s political contributions at the national level (Fox, 2003b). It is time to look to other methods for increasing participation such as more extensive and expensive personal contacts through telephone banks, frequent contacts by local colleagues, and more frequent and targeted mailings. Creat- ing the ability to do such things on a national or even state level takes resources, organization, technical expertise, and dedicated workers. Increasing the rate of participation is the key to our success. “If all special assessment payers gave just $45 per year, just 87 cents a week, psychology could raise $1.8 million per year,. . .second in size only to medicine among all health care professions” (Fox, 2003b, p. 3).

4. It is essential that the profession of psychology train and mentor our present generation of undergraduate and graduate stu- dents and create in them a culture of advocacy involvement in the profession in order to help create the next generation of psychol- ogy advocates. This involves working with educators, clinical supervisors, and others to integrate a focus on advocacy involve- ment as part of the professional identity of those entering the profession. We must demonstrate the importance of advocacy to students, personally involve them in our ongoing advocacy efforts, and mentor them to help preserve the viability of the future of our profession.

These goals are achievable. They do not involve methods, techniques, resources, or sacrifices beyond our ken, but they do require psychologists to shuck their complacency and act. The future of the profession and the livelihoods of its members are at stake. More important, society needs a vigorous psychology pro- fession in the forefront of the national health care delivery system. The social need is there; psychologists have but to lead the way. But nothing will happen unless they do so. The good news and the bad news are both the same: the outcome is up to the profession.

References

Barnett, J. E. (2003). Saving our profession one psychologist at a time. The Maryland Psychologist, 48, 20.

Barnett, J. E. (2004). On being a psychologist and how to save our profession. The Independent Practitioner, 24, 45–46.

Commonwealth Fund Commission on a High Performance Health System (2006, September). Why not the best? Results from a national scorecard on U.S. health system performance (Vol. 34). New York: Author.

Cummings, N. A. (2001). The rise of the professional school movement: Empowerment of the clinician in education and training. In R. H. Wright and N. A. Cummings (Eds.), The practice of psychology: The battle for professionalism (pp. 70–103). Phoenix, AZ: Zeig, Tucker, & Theisen.

DeLeon, P. H., Loftis, C. W., Ball, V., & Sullivan, M. J. (2006). Navigating politics, policy and procedure: A firsthand perspective of advocacy on behalf of the profession. Professional Psychology: Research and Prac- tice, 37, 146–153.

636 FOX

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Fox, R. E. (2001). Impact of the Dirty Dozen and increased practitioner professionalism on the American Psychological Association. In R. H. Wright and N. A. Cummings (Eds.), The practice of psychology: The battle for professionalism (pp. 104–115). Phoenix, AZ: Zeig, Tucker, & Theisen.

Fox, R. E. (2003a). Early efforts by psychologists to obtain prescriptive authority. In M. T. Sammons, R. F. Levant, & R. U. Paige (Eds.), Prescriptive authority for psychologists: A history and guide (pp. 33– 45). Washington, DC: American Psychological Association.

Fox, R. E. (2003b, Summer) From the Desk of the Chair: The cold hard facts. Advance: Newsletter of the Association for the Advancement of Psychology, p. 3.

Fox, R. E. (2006). Training for prescriptive authority for psychologists. In T. Vaughn (Ed.), Psychology licensure and certification: What students need to know (pp. 155–164). Washington, DC: American Psychological Association.

Pfeiffer, S. (2002, Spring). Comparison of health care professions political giving performance. Advance: Newsletter of the Association for the Advancement of Psychology, p. 6.

Pfeiffer, S. M. (2007, Spring). Political giving by health professions. Advance: Newsletter of the Association for the Advancement of Psychol- ogy, p. 12.

Wiggins, J. G. (2001). A history of the reimbursement of psychological services: The education of one psychologist in the real world. In R. H. Wright and N. A. Cummings (Eds.), The practice of psychology: The battle for professionalism (pp. 215–250). Phoenix, AZ: Zeig, Tucker, & Theisen.

Wright, R. H. (2001). The rise of professionalism within American psychology and how it came to be: A brief history of the Dirty Dozen. In R. H. Wright and N. A. Cummings (Eds.), The practice of psychology: The battle for professionalism (pp. 1– 69). Phoenix, AZ: Zeig, Tucker, & Theisen.

Received October 4, 2007 Revision received January 17, 2008

Accepted February 14, 2008 �

Members of Underrepresented Groups: Reviewers for Journal Manuscripts Wanted

If you are interested in reviewing manuscripts for APA journals, the APA Publications and Communications Board would like to invite your participation. Manuscript reviewers are vital to the publications process. As a reviewer, you would gain valuable experience in publishing. The P&C Board is particularly interested in encouraging members of underrepresented groups to participate more in this process.

If you are interested in reviewing manuscripts, please write to the address below. Please note the following important points:

• To be selected as a reviewer, you must have published articles in peer-reviewed journals. The experience of publishing provides a reviewer with the basis for preparing a thorough, objective review.

• To be selected, it is critical to be a regular reader of the five to six empirical journals that are most central to the area or journal for which you would like to review. Current knowledge of recently published research provides a reviewer with the knowledge base to evaluate a new submission within the context of existing research.

• To select the appropriate reviewers for each manuscript, the editor needs detailed information. Please include with your letter your vita. In the letter, please identify which APA journal(s) you are interested in, and describe your area of expertise. Be as specific as possible. For example, “social psychology” is not sufficient—you would need to specify “social cognition” or “attitude change” as well.

• Reviewing a manuscript takes time (1–4 hours per manuscript reviewed). If you are selected to review a manuscript, be prepared to invest the necessary time to evaluate the manuscript thoroughly.

Write to Journals Office, American Psychological Association, 750 First Street, NE, Washington, DC 20002-4242.

637ADVOCACY FOR THE GROWTH OF PSYCHOLOGY

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Partnering With a Purpose: Psychologists as Advocates in Organizations

James K. Hill Waypoint Centre for Mental Health Care

To ensure that psychological issues are on policymakers’ agenda, psychologists often focus pro- fessional advocacy efforts in the political and social realm. Psychologists working in organizations, however, also have a role in ensuring that professional issues rise into the consciousness of organizational decision makers. In an era of health care reform, the advent of program-based management, limited resources, and managed care, psychologists are under increasing pressure to show their worth inside organizations and often have limited ability to communicate with organi- zational leaders. Psychologists typically report to nonpsychologists who may have only a general understanding of what psychology offers and can often misunderstand requests from psychologists about patient care alternatives, time for research, ability to present at conferences, and so forth. Advocacy is one avenue for increasing effective communication of psychologists’ perspectives and interests that can serve to educate leaders about the value of psychology and how to best use psychological expertise. A major benefit of organizational advocacy is learning advocacy skills in a known environment, which can then be transferred to broader social advocacy. The article discusses the development of advocacy skills in organizations and suggests possible advocacy activities that are consistent with the professional role. It is argued that clarity of the message and partnering with decision makers are important as psychologists advocate for the role of psychology in service delivery.

Keywords: organizational advocacy, professional psychology, collaboration, communication

Psychologists do not do a good job at advocating (Fox, 2008), and they certainly do not advocate as well as other professions (DeLeon, Loftis, Ball, & Sullivan, 2006; Lating, Barnett, & Hororwitz, 2010). This argument is the theme in almost every article that discusses professional advocacy within the disci- pline. Myriad reasons are put forth that explain why psychol- ogists do not promote, or even defend, our discipline. Lack of time, lack of training in/understanding of advocacy, no guar- antee of success, or finding professional satisfaction in other elements of the role may all partially explain psychologists’ disinterest in advocacy. Another barrier that may thwart many psychologists is that social advocacy seems so monumental that it is easier to focus on more familiar tasks. Most professional associations have some form of advocacy committee, but psy- chologists may not have the time or organizational support to join such groups. Advocacy within the workplace offers an

initial step for psychologists who want to promote their disci- pline but are daunted by the unfamiliar territory of political advocacy (i.e., lobbying government, political contributions). By working with partners and promoting a clear message, psychologists in organizations can present their issues to deci- sion makers.

Advocacy is a process of communicating benefits and ensur- ing that policymakers can access high-quality information. Fox (2008) defined advocacy as “the use of political influence to advance the profession through such means as political giving, legislative lobbying, and other active participation in the po- litical decision-making process” (p. 633). Often the goals are to influence social policy funding and decision making that relate to issues core to the practice of psychology. Other efforts might be to highlight research findings applicable to public policy. Finally, advocacy may simply involve collaborating with others to better meet common goals.

In the workplace, psychologists can refine advocacy skills in an environment that builds on already established positive relationships that are part of their professional role. This is especially true in organizations in which psychologists are not supported by a departmental model but are simply another professional on the team. There may also be an immediate and tangible benefit to advocacy efforts by an increased potential of seeing one’s actions effect change. Once psychologists hone their advocacy skills within a familiar workplace environment, these skills can generalize to political and social advocacy. This article highlights the importance of organizational advocacy in developing skills to promote the profession of psychology as essential to effective client care.

This article was published Online First July 15, 2013. JAMES K. HILL earned his PhD in psychology from the University of Saskatchewan. He currently works at Waypoint Centre for Mental Health Care and has previously worked in independent practice, hospital, com- munity, and government settings. His areas of interest include professional practice issues, improving clinical standards, psychologically healthy workplaces, and knowledge translation. I GRATEFULLY ACKNOWLEDGE Milton Almeida and Lara Robinson for their helpful comments on versions of this article. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to James K. Hill, Bayview Dual Diagnosis Program (5th floor), Waypoint Centre for Mental Health Care, 500 Church Street, Penetanguishene, ON L9M 1G3 Canada. E-mail: james@drhill.ca

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Professional Psychology: Research and Practice © 2013 American Psychological Association 2013, Vol. 44, No. 4, 187–192 0735-7028/13/$12.00 DOI: 10.1037/a0033120

187mailto:james@drhill.cahttp://dx.doi.org/10.1037/a0033120

Organizational Advocacy1

For the present purpose, organizational advocacy is the process by which professional members influence organizational change so that the discipline’s clients, goals, programs, and interests can be met within the broader organization. This can be done within a structure that includes a psychology department, but even the sole psychologist on a team can engage in advocacy. Table 1 summa- rizes some professional activities that offer potential for organiza- tional advocacy, including the target audience commonly associ- ated with the activity. Advocacy efforts can target both client services and the profession as a whole (Fox, 2008; Lating et al., 2010). Psychologists interested in organizational advocacy would typically target their employer or contracting agency; however, there may be opportunities to advocate in partner organizations. For example, when receiving a consultation request or a referral, psychologists can take the opportunity to provide more details regarding the role or service options provided by the discipline. Many familiar professional issues could be advocated at the orga- nizational level, such as clinical services, retention issues, evidence-based practice, or ethical issues.

In discussing advocacy, Safarjan (2002) noted that there are four prerequisites in advocating change: (a) identifying a clear problem, (b) assessing the goal, (c) developing a strategy, and (d) imple- menting a plan. Of note, this is often psychologists’ approach when providing clinical services. Psychologists have a goal of helping clients change, moving from assessment to intervention to reach agreed-on goals. In fact, everyday clinical skills relate to advocacy: writing (Radius, Galer-Unti, & Tappe, 2009), relation- ship building and maintenance (DeLeon et al., 2006; Lating et al., 2010), public speaking (Lating et al., 2010), and high-level ana- lytical skills to synthesize information. Clinical psychologists are also accustomed to providing clear, unbiased information and recommendations to decision makers regarding diverse clinical issues. When psychologists make recommendations, they are ad-

vocating for a specific plan; they use data to direct those recom- mendations. In social advocacy, psychologists report believing that they will have little effect, do not feel knowledgeable, or are simply unaware of key issues (Heinowitz et al., 2012). It is unlikely that these factors will be as pervasive at work. A positive intermediary step to building confidence would be to highlight how many skills psychologists use every day in the workplace related to advocacy.

In organizational advocacy, the target of change is ensuring that clients have access to prompt and effective psychological services within the organization. This may be easy in some organizations (e.g., hospitals with psychology departments), but can be a chal- lenge if the system itself does not have clear psychology leadership (e.g., program-based systems). Thus, the goal in organizational advocacy is the promotion of psychological services within the organization, not as peripheral services or consulting, but as a vibrant discipline essential to client well-being. This strategy fo- cuses on leveraging a psychologist’s activities with professional promotion and advocacy. To use this strategy, psychologists would highlight and celebrate their unique contribution to the team and organization. Of course, the success of this strategy depends on whether the organization facilitates such efforts or whether the barriers to change outweigh the psychologist’s ability and energy to advocate.

It is within organizations that psychologists can test their skills, use their expert role, set aside time to advocate, and see the fruits of their efforts. Psychologists often informally advocate in their organization and on their team. Organizational advocacy is part of the role, but can benefit from more structure and emphasis. Psy- chologists engaged in organizational advocacy must assertively educate leaders about psychology’s role and value in effective service delivery while maintaining professional integrity by using solid evidence grounded in theory and research.

Advocacy and the Professional Training Model

It is often noted that psychologists do not tend to include advocacy as part of their professional model (Radius et al., 2009; Thompson, Kerr, Dowling, & Wagner, 2011). Physicians and nurses trained in professional schools are better at advocating for their patients while promoting their role as being essential to providing quality services (DeLeon et al., 2006; Lating et al., 2010). These professions see the benefit of having their members at planning, policymaking, and leadership tables and support those interested in these leadership roles. Psychologists, on the other hand, seem content to focus on professional tasks related to a specific client or limited to issues related to their clients. Lating et al. (2010) point out that psychology is one of the few professions with a high-level academic training model as the norm (i.e., doctorate). Thus, training focuses less on developing a profes- sional identity and more on developing an academic portfolio; publications and research often outweigh professional practice issues within universities. This bias may also explain why aca- demic psychologists do not often discuss professional issues such as advocacy and the presence of psychology as a profession, and

1 This article focuses on health care environments, but the arguments are equally applicable to other settings: schools, correctional facilities, busi- nesses/organizations, and human resource departments.

Table 1 Summary of Organizational Advocacy Activities

Activity Advocacy target

Highlight unique contribution Team members Supervisor/manager

Provide timely and effective consultations Referral agent Team members Supervisor/manager

Provide research information for key decisions/discussions

Team members Referral agent All managers

Sit on committees Committee members Supervisor/manager Senior management

Create standard business plans for making a case for new psychology positions

Supervisor/manager Other managers Human resources Senior management

Coordinate a message with partners (other disciplines) All levels

Fill in service gaps All levels Clearly say, “This is what psychology offers”

rather than allowing people to assume the skills are unique to the individual psychologist All levels

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practitioners facing clinical demands often do not have time to write journal articles.

Lating et al. (2010) note the duality with respect to professional advocacy:

Fostering an attitude of advocacy is instilling the notion that as psychologists we may need to be the active voice for those who cannot speak for themselves. At other times, we may need to be the active voice that advances and protects our profession. (p. 203)

This duality is central to professional advocacy; psychologists advocate in those areas in which they believe their role will improve service quality. This concept needs to be more central to our professional training model and stated explicitly. Although advocacy seems central to our professional role, and provision of excellent services is a subtle form of advocacy, overt advocacy efforts are often minimized or ignored in our training and practice. In essence, psychologists need to see advocacy as consistent with, and perhaps essential to, their professional role (Burney et al., 2009).

Finally, in understanding advocacy barriers, psychologists should be clear on their partners and their message. What unique contribution does psychology bring to the partnership? What ben- efits are there to the client, team, service, and organization of having a psychologist instead of another professional? Psycholo- gists need to have the answers to these questions as they advocate so that they know their role in the partnership. For example the scientist–practitioner approach, which is often unique to psychol- ogists, promotes critical evaluation and debate. Other professionals may not understand this cultural norm in psychology, which can result in misinterpretation. Those unused to this norm may per- sonalize debate or dismiss psychologists as overly critical or not team players. A simple discussion around the traditional psychol- ogist training model can clarify some misunderstandings. For example, the debating of ideas is a positive strategy that psychol- ogists use to get to the best solution; it is unrelated to interpersonal conflict. Once this professional value is clear, it may be easier to highlight the benefits of fostering spirited discussion and debate with psychologists’ partners in the organization. Thus, this ability to be impartial and critical becomes a key role within advocacy partnerships instead of a professional liability.

Organizational Advocacy as Partnering

A collaborative approach to advocacy can be beneficial, with advocates educating others in the organization about the value of psychological services. Under this perspective, the goal of advo- cacy ceases to be convincing others to the psychological perspec- tive but, rather, increasing potential partners’ understanding and support of psychology issues. By creating a partnership, psychol- ogists position themselves as key players in solutions that meet the collective goals of the partnership. Even when the final goal is not what one first envisioned, the fact that the psychological perspec- tive was part of the process is a positive outcome, and reasonable goal, of a successful advocacy partnership.

If psychologists believe they have something to offer, they need to offer it and take credit for its benefits, especially in the current social and economic climate. Psychologists in independent prac- tice often need to show the benefits of their role by providing timely, effective, and targeted consultative services; those in or-

ganizations would be well served to adopt a similar approach. This might include prompt return of phone calls, efficiently completing written reports, providing summaries in user-friendly language, or including follow-up consultation meetings so that clients/teams/ referring agents can ask questions once they have received the report. These approaches are good business in independent prac- tice, and can be good business in organizations as psychologists use these methods to become more integrated with the team, decision makers, and organization. Under this perspective, judi- ciously using professional activities as opportunities to promote the discipline becomes the core avenue of advocating for psycho- logical services. These avenues might also include providing clin- ical, research, or ethical consultations, which show psychology’s value to the organization at large. Thus, other disciplines become partners and advocates, arguing for inclusion of psychology in key sectors while lessening the likelihood that psychologists’ advocacy efforts will be perceived as self-serving (Cohen, Lee, & McIl- wraith, 2012). In my experience, having those outside psychology making such arguments has met with the most success in advo- cating for service change and improvement of psychological ser- vices. Thus, partnering can be essential to advocacy, especially in sectors in which psychology has less voice.

In discussing the health sector, Safarjan (2002) notes, “Psychol- ogists have the knowledge, expertise, and experience necessary to change health care delivery system, yet in state hospitals, they are not positioned to easily promote change” (p. 949). This is true because psychologists often find themselves focused on service delivery, a role for which they trained and in which they feel comfortable. It is through partnering at the organizational level, however, that psychologists can position themselves to effect change and provide broader support for the discipline. Cohen et al. (2012) identify getting more involved in health care administration as one way to become better positioned. For example, psycholo- gists sitting on committees within the organization automatically raise the profile of the discipline. Natural committees for psychol- ogists often involve research and ethics, but other committees on professional issues or specialty populations are also good options. This helps to position psychologists as key stakeholders in orga- nizational improvement and allows them to identify new organi- zational priorities. The key in working on committees is not simply promoting a psychological perspective, but also supporting other views that help improve services; this is also advocacy. Another opportunity is to identify and, if possible, fill service gaps. This raises psychology’s status as an essential service partner while providing an opportunity to advocate for both clients and the discipline. If psychologists cannot fill the gap, one can advocate by diplomatically noting the limitation of current resources and show how changes in psychological services might help meet ever- changing needs.

Another way to position oneself through partnering is to become the content expert on key service issues (e.g., competency models, evidence-based practice, trauma-informed care). Whether through a committee process or not, psychologists can provide organiza- tional leaders with information that helps decision making. This education role, to which psychologists are accustomed, might be as simple as forwarding a research article or as complex as writing a briefing note or longer report. As psychologists build their repu- tation as an essential discipline in improving decision making, their influence improves. In organizations in which psychology has

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189ORGANIZATIONAL ADVOCACY

a strong history, such efforts may be more welcomed and effective. Often, when there is a limited history, good work can often be dismissed as being specific to that psychologist. Thus, it is essen- tial for psychologists to explicitly state that their work is consistent with the discipline and not simply a skill unique to the individual psychologist. Psychologists interested in organizational advocacy would be well served to assess their specific skill sets and status within the organization and be realistic in choosing advocacy activities that fit their strengths. Advocacy efforts should empha- size natural relationships and grassroots partnering when one feels one has less influence on the broader organization or when work- ing outside a departmental model.

Psychologists can view partnership as part of working for im- provement in service delivery. Focusing on areas of growth is essential to moving forward and initiating change. Many have noted that senior management is often ignorant about problem areas within their organization (Jurkiewicz, Knouse, & Giacalone, 2002; Tourish, 2005; Tourish & Robson, 2006), and the respectful sharing of information may be invaluable to leaders. Psycholo- gists’ skills in partnering and motivating are useful in highlighting difficult messages. This is the point of advocacy: If leaders already agreed, then there would be no need to advocate. Yet being too open in sharing negative information may have an equally negative impact on one’s position in the organization (Eisenberg & Witten, 1987); open communication and advocacy come with some risk. The key elements of reducing risk when sharing criticism in the organization are to (a) use a professional approach, avoid person- alizing; (b) build on already established relationships; and (c) be transparent and accountable.

By maintaining a respectful, professional approach to providing constructive feedback, the target audience may be more willing to listen. Furthermore, building on positive relationships already de- veloped via the professional role can be important to targeting the message. Kassing (2001) labeled open dissent to organizational decision makers as articulated dissent. People perceive articulated dissenters as being less argumentative and verbally aggressive than those who use more passive ways to dissent. Furthermore, observ- ers assessed articulated dissenters as having high-quality relation- ships with supervisors and believing that the organization would welcome input. Much depends on the organizational culture. Do leaders encourage open discussion, or do they ignore the construc- tive nature of the process and dismiss criticism? Correctly assess- ing the culture helps to identify key partners for relationship building. Psychologists should partner with leaders in the organi- zation who meet goals by encouraging autonomy, manageable workloads, work–life harmony, service accessibility, and valuing relationships (Robertson & Tinline, 2008).

On establishing a receptive audience within the organization, it is essential that there is a clear message to communicate. Inter- views with current staff, surveys, focus groups, and so forth can serve as data-gathering devices to highlight core issues faced by psychologists in the organization. Questions can focus on two related areas: (a) Internal: What can the discipline do to support its members; and (b) External: What organizational issues impact professional psychology practice? These questions could be added to a psychology meeting agenda or, depending on the situation, a more formalized interview process may be necessary to cover all issues. Using a formalized process to gather the information re- flects systematic data gathering. A formalized process communi-

cates the goals and priorities of the initiative so that people can make an informed choice regarding participation. A formalized process also sends a signal to the rest of the organization that the results reflect the professional nature of the activity and should be taken seriously. The power of documentation also means that psychologists will need to be careful about how they conduct any data-gathering process and report the results; however, these skills are generally part of the psychologist’s repertoire.

Organizational Advocacy as Communication

Identifying partners and having a clear message are elements of building a cogent communication strategy. Safarjan (2002) de- scribes several principles for advocates, three of which are partic- ularly relevant to organizational advocacy and communication: (a) Improve quality of life, (b) do not make assumptions, and (c) speak their language. The goal in organizational advocacy is the im- provement of services and quality of life of clients, the discipline, and professional service partners. Psychologists need to educate administrators and management about their unique contribution and not assume leaders already know how psychology helps them meet organizational targets. Psychologists can also use leader language by understanding and linking corporate goals and pres- sures to their core interests. Advocacy at its best creates win–win solutions to complex problems. Thus, psychologists also need to recognize the organizational and social realities of what can be improved and ensure that their advocacy efforts fit within those realities, giving decision makers room to interpret messages so that everyone can have success (Eisenberg & Witten, 1987). For ex- ample, advocating for increased assessment services might allow several solutions (hiring a psychologist, hiring a psychometrist, increased part-time/contract use, use of overtime, improved tech- nology), whereas advocating for a new psychologist may end with no change. Being clear on the goal but vague on the solution allows effective communication to build collaborative partner- ships.

Informal avenues of communication can be successful depend- ing on the willingness of leaders to hear and act on concerns. Many psychologists, however, do not provide information in a way that is useful to leaders. At best, an informal conversation can serve to vent frustration, brainstorm ideas, or even plan in a targeted meeting. Savvy psychologists might follow up informal meetings with an e-mail to highlight issues, but these rarely rise to contain- ing the level of information managers need to understand and become partners in advocacy efforts. Communication must be- come two-way, with both management and psychologists working together to meet common goals. Motivating leaders to listen can be a big challenge in organizational advocacy, especially when psy- chologists are not decision makers. Not listening may not be disinterest, but simply a reflection of workload demands or not truly understanding what leaders can do to facilitate change.

An easy way to support and motivate managers, especially in large organizations, is to help managers meet their goals. For example, if managers are focused on best practices and meeting externally set targets, a briefing note on the research evidence related to key practices may be welcome. If management is dealing with a professional ethical issue, such as dual relationships, then psychologists might provide a description of how they grapple with that professional issue. Another useful strategy to highlight

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commonalities is targeted messaging (Fox, 2008). By targeting communication to specific groups, psychologists can have a greater influence. The central element of targeted messaging is to merge psychologists’ interests with the interest of the target audi- ence, similar to lobbying in the political realm (Galer-Unti, Tappe, & Lachenmayr, 2004). For example, if a manager is working on a 3-year plan, it can be useful to provide clear easily understood information about psychology’s activities and workload projec- tions. For example, I maintain a generic psychologist position business case that can be modified in partnership with managers to highlight why their specific service might want to add a psychol- ogist. Communicating solutions can be a much more effective form of advocacy than simply indicating deficits (Cohen et al., 2012).

By clearly identifying the discipline’s role in meeting objectives and emphasizing leadership, psychologists may counter manage- ment’s natural tendency to dismiss criticism (Tourish, 2005). Fox (2008) notes that accurate and current information is important in advocacy, but that targeted messages that speak to leaders’ con- cerns can be effective in gaining influence. Targeting efforts by directly linking psychologists’ issues to the corporate vision, mis- sion, and core values can increase the likelihood they will be heard. One might briefly review how the issue is consistent with stated corporate values and how it diverges. Corporate values are often aspirational, so identifying areas of growth can be helpful in understanding how to progress. One might also show how proper support and use of psychologists increase the chances of meeting stated goals. By engaging leadership partners in a collaborative discussion, psychologists become allies in meeting goals and any requests are not dismissed as more demands on limited resources. Most leaders understand that they are responsible for leading the organization to live stated values.

Finally, communicating results can have an impact on the suc- cess of advocacy efforts. If the target audience ignores a detailed report, psychologists could provide a one-page briefing note. If a full business case is overwhelming, they can provide a one-page cost–benefit analysis. If leaders are uninterested in the issues important to psychology, they can ensure that reports go to col- leagues or potential partners in the organization. Deciding whether a written report should be detailed or simply a brief one-page highlight depends on two interrelated elements: (a) the message and (b) the audience. If the message is clear and concise, a brief report might be best. In these cases, the hope is that those reading the report will want to follow up, giving an opportunity to provide more detail in person. Providing clear information that helps busy audiences quickly understand key points also gives structure to any future discussions. This approach also helps to “plant a seed” so that even if there is no immediate follow-up meeting, the disci- pline’s issues are now known. Complex issues or messages may warrant a more detailed report, allowing discussion of the conflict- ing issues. Although psychologists might find the issues interest- ing, others may not; psychologists should motivate the audience by highlighting common ground. Interested audiences are more likely to read and absorb a detailed report if it helps reach goals. Part of having an effective message is having something to say; the remainder is how it is communicated.

Psychologists should target and coordinate the message and identify the paths of least resistance so that ideas can build mo- mentum. They should avoid making an end run around managers

and ensure that sharing the information is constructive criticism not venting frustration. If a report is too critical, they should tone down those elements so that some goals are met and be realistic in what one can achieve. As DeLeon et al. (2006) point out, “. . . half a loaf really is better than none” (p. 150). Advocacy is about coordinating a message to increase its chances of being heard and then working to improve the system for clients and psychologists. If one’s voice is discounted at the outset, or the message is seen as offensive, one is unlikely to see the change one hopes to achieve.

Conclusion

Organizational advocacy offers a strategy for psychologists to develop political advocacy skills within a known environment: their own workplace. By trading on their positive professional relationships, psychologists can look at honing their communica- tion and partnering skills to serve their clients, their discipline, and the organization as a whole. This can be especially important to psychologists who work outside a departmental model, who might struggle with raising professional service issues beyond their im- mediate team. One motivator to this targeted form of advocacy over political advocacy is that psychologists may enjoy immediate feedback as they see their efforts improve their daily work. A key part of communicating a targeted message is to base the message on solid data and partnering with the audience and key decision makers. Linking to corporate goals helps psychologists partner with leaders and promote the discipline while improving their workplaces and client service. If psychologists are to be seen as a core constituency in society, they must promote themselves as a core constituency within their organizations.

References

Burney, J. P., Celeste, B. L., Johnson, J. D., Klein, N. C., Nordal, K. C., & Portnoy, S. M. (2009). Mentoring professional psychologists: Programs for career development, advocacy, and diversity. Professional Psychol- ogy: Research and Practice, 40, 292–298. doi:10.1037/a0015029

Cohen, K. R., Lee, C. M., & McIlwraith, R. (2012). The psychology of advocacy and the advocacy of psychology. Canadian Psychology, 53, 151–158.

DeLeon, P. H., Loftis, C. W., Ball, V., & Sullivan, M. J. (2006). Navigating politics, policy, and procedure: A firsthand perspective of advocacy on behalf of the profession. Professional Psychology: Research and Prac- tice, 37, 146–153. doi:10.1037/0735-7028.37.2.146

Eisenberg, E. M., & Witten, M. G. (1987). Reconsidering openness in organizational communication. Academy of Management Review, 12, 418–426.

Fox, R. E. (2008). Advocacy: The key to the survival and growth of professional psychology. Professional Psychology: Research and Prac- tice, 39, 633–637. doi:10.1037/0735-7028.39.6.633

Galer-Unti, R. A., Tappe, M. K., & Lachenmayr, S. (2004). Advocacy 101: Getting started in health education advocacy. Health Promotion Prac- tice, 5, 280–288. doi:10.1177/1524839903257697

Heinowitz, A. E., Brown, K. R., Langsam, L. C., Arcidiacono, S. J., Baker, P. L., Badaan, N. H., . . . Ralph, E. (2012). Identifying perceived personal barriers to public policy advocacy within psychology. Profes- sional Psychology: Research and Practice, 43, 372–378. doi:10.1037/ a0029161

Jurkiewicz, C. E., Knouse, S. B., & Giacalone, R. A. (2002). Are exit interviews and surveys really worth the time and effort? Review of Public Personnel Administration, 22, 52– 62. doi:10.1177/ 0734371X0202200103

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191ORGANIZATIONAL ADVOCACYhttp://dx.doi.org/10.1037/a0015029http://dx.doi.org/10.1037/0735-7028.37.2.146http://dx.doi.org/10.1037/0735-7028.39.6.633http://dx.doi.org/10.1177/1524839903257697http://dx.doi.org/10.1037/a0029161http://dx.doi.org/10.1037/a0029161http://dx.doi.org/10.1177/0734371X0202200103http://dx.doi.org/10.1177/0734371X0202200103

Kassing, J. W. (2001). From the looks of things: Assessing perceptions of organizational dissenters. Management Communication Quarterly, 14, 442–470. doi:10.1177/0893318901143003

Lating, J. M., Barnett, J. E., & Hororwitz, M. (2010). Creating a culture of advocacy. In M. Kenkel & R. L. Peterson (Eds.), Competency-based education for professional psychology (pp. 201–208). Washington, DC: American Psychological Association. doi:10.1037/12068-011

Radius, S. M., Galer-Unti, R. A., & Tappe, M. K. (2009). Educating for advocacy: Recommendations for professional preparation and develop- ment based on a needs and capacity assessment of health education faculty. Health Promotion Practice, 10, 83–91. doi:10.1177/ 1524839907306407

Robertson, I., & Tinline, G. (2008). Understanding and improving psycho- logical well-being for individual and organisational effectiveness. In A. Kinder, R. Hughs, & C. L. Cooper (Eds.), Employee wellbeing and support: A workplace resource (pp. 39–49). Hoboken, NJ: Wiley. doi:10.1002/9780470773246.ch3

Safarjan, B. (2002). A primer for advancing psychology in the public sector. American Psychologist, 57, 947–955. doi:10.1037/0003-066X.57 .11.947

Thompson, A., Kerr, D., Dowling, J., & Wagner, L. (2011). Advocacy 201: Incorporating advocacy training in health education professional prepa- ration programs. Health Education Journal. Advance online publication. doi:10.1177/0017896911408814

Tourish, D. (2005). Critical upward communication: Ten commandments for improving strategy and decision making. Long Range Planning, 38, 485–503. doi:10.1016/j.lrp.2005.05.001

Tourish, D., & Robson, P. (2006). Sensemaking and the distortion of critical upward communication in organizations. Journal of Manage- ment Studies, 43, 711–730. doi:10.1111/j.1467-6486.2006.00608.x

Received February 1, 2012 Revision received March 1, 2013

Accepted March 19, 2013 �

Members of Underrepresented Groups: Reviewers for Journal Manuscripts Wanted

If you are interested in reviewing manuscripts for APA journals, the APA Publications and Communications Board would like to invite your participation. Manuscript reviewers are vital to the publications process. As a reviewer, you would gain valuable experience in publishing. The P&C Board is particularly interested in encouraging members of underrepresented groups to participate more in this process.

If you are interested in reviewing manuscripts, please write APA Journals at Reviewers@apa.org. Please note the following important points:

• To be selected as a reviewer, you must have published articles in peer-reviewed journals. The experience of publishing provides a reviewer with the basis for preparing a thorough, objective review.

• To be selected, it is critical to be a regular reader of the five to six empirical journals that are most central to the area or journal for which you would like to review. Current knowledge of recently published research provides a reviewer with the knowledge base to evaluate a new submission within the context of existing research.

• To select the appropriate reviewers for each manuscript, the editor needs detailed information. Please include with your letter your vita. In the letter, please identify which APA journal(s) you are interested in, and describe your area of expertise. Be as specific as possible. For example, “social psychology” is not sufficient—you would need to specify “social cognition” or “attitude change” as well.

• Reviewing a manuscript takes time (1–4 hours per manuscript reviewed). If you are selected to review a manuscript, be prepared to invest the necessary time to evaluate the manuscript thoroughly.

APA now has an online video course that provides guidance in reviewing manuscripts. To learn more about the course and to access the video, visit http://www.apa.org/pubs/authors/review- manuscript-ce-video.aspx.

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192 HILLhttp://dx.doi.org/10.1177/0893318901143003http://dx.doi.org/10.1037/12068-011http://dx.doi.org/10.1177/1524839907306407http://dx.doi.org/10.1177/1524839907306407http://dx.doi.org/10.1002/9780470773246.ch3http://dx.doi.org/10.1037/0003-066X.57.11.947http://dx.doi.org/10.1037/0003-066X.57.11.947http://dx.doi.org/10.1177/0017896911408814http://dx.doi.org/10.1016/j.lrp.2005.05.001http://dx.doi.org/10.1111/j.1467-6486.2006.00608.x

  • Partnering With a Purpose: Psychologists as Advocates in Organizations
    • Organizational Advocacy<xref ref-type=”fn” rid=”fn1″>1</xref>
    • Advocacy and the Professional Training Model
    • Organizational Advocacy as Partnering
    • Organizational Advocacy as Communication
    • Conclusion
    • References

Jongsma Jr, A. E., Peterson, L. M., & Bruce, T. J. (2014). The Complete Adult Psychotherapy Treatment Planner: Includes DSM-5 Updates (Vol. 296). John Wiley & Sons.

“Quick Guide to the Dissociative Disorders

Dissociative symptoms are principally covered in this chapter, but there are some conditions (especially involving loss or lapse of memory) that are classified elsewhere. Yep, the link indicates where a more detailed discussion begins.

Primary Dissociative Disorders

Dissociative amnesia. The patient cannot remember important information that is usually of a personal nature. This amnesia is usually stress-related.

Dissociative identity disorder. One or more additional identities intermittently seize control of the patient’s behavior.

Depersonalization/derealization disorder. There are episodes of detachment, as if the patient is observing the patient’s own behavior from outside. In this condition, there is no actual memory loss.

Other specified, or unspecified, dissociative disorder. Patients who have symptoms suggestive of any of the disorders above, but who do not meet criteria for any one of them, may be placed in one of these two categories.

Other Causes of Marked Memory Loss

When dissociative symptoms are encountered in the course of other mental diagnoses, a separate diagnosis of a dissociative disorder is not ordinarily given.

Panic attack. Some patients panic may experience depersonalization or derealization as part of an acute panic attack.

Posttraumatic stress disorder. A month or more following a severe trauma, the patient may not remember important aspects of personal history.

Acute stress disorder. Immediately following a severe trauma, patients may not remember important aspects of personal history.

Somatic symptom disorder. Patients who have a history of somatic symptoms that cannot be explained on the basis of known disease mechanisms can also forget important aspects of personal history.

Non-rapid eye movement sleep arousal disorder, sleepwalking type. Sleepwalking resembles the dissociative disorders, in that there is amnesia for purposeful behavior. But it is classified elsewhere in order to keep all the sleep disorders together.

Borderline personality disorder. When severely stressed, these people will sometimes experience episodes of dissociation, such as depersonalization.

Malingering. Some patients consciously feign symptoms of memory loss. Their object is material gain, such as avoiding punishment or obtaining money or drugs.

INTRODUCTION

Dissociation occurs when one group of normal mental processes becomes separated from the rest. In essence, some of an individual’s thoughts, feelings, or behaviors are removed from conscious awareness and control. For example, an otherwise healthy college student cannot recall any of the events of the previous 2 weeks.

As with so many other mental symptoms, you can have dissociation without disorder; if it’s mild, it can be entirely normal. (Perhaps, for example, while enduring a boring lecture, you once daydreamed about your weekend plans, unaware that you’ve been called on for a response?) There’s also a close connection between the phenomena of dissociation and hypnosis. Indeed, over half the people interviewed in some surveys have had some experience of a dissociative nature.

200Episodes of dissociation severe enough to constitute a disorder have several features in common:

•  They usually begin and end suddenly.

•  They are perceived as a disruption of information that is needed by the individual. They can be positive, in the sense of something added (for example, flashbacks) or negative (a period of time for which the person has no memory).

•  Although clinicians often disagree as to their etiology, many episodes are apparently precipitated by psychological conflict.

•  Although they are generally regarded as rare, their numbers may be increasing.

•  In most (except depersonalization/derealization disorder), there is a profound disturbance of memory.

•  Impaired functioning or a subjective feeling of distress is required only for dissociative amnesia and depersonalization/derealization disorder.

Conversion symptoms (typical of the somatic symptom disorders) and dissociation tend to involve the same psychic mechanisms. Whenever you encounter a patient who dissociates, consider whether such a diagnosis is also warranted.

F48.1 [300.6] Depersonalization/Derealization Disorder

Depersonalization can be defined as a sense of being cut off or detached from oneself. This feeling may be experienced as viewing one’s own mental processes or behavior; some patients feel as though they are in a dream. When a patient is repeatedly distressed by episodes of depersonalization, and there is no other disorder that better accounts for the symptoms, you can diagnose depersonalization/derealization disorder (DDD).

DSM-5 offers another route to that diagnosis: through the experience of derealization, a feeling that the exterior world is unreal or odd. Patients may notice that the size or shape of objects has changed, or that other people seem robotic or even dead. Always, however, the person retains insight that it is only a change in perception—that the world itself has remained the same.

Because about half of all adults have had at least one such episode, we need to place some limits on who receives this diagnosis. It should not be made unless the symptoms are persistent or recurrent, and unless they impair functioning or cause pretty significant distress (this means something well beyond the bemused reflection, “Well, that was weird!”). In fact, depersonalization and derealization are much more commonly encountered as symptoms than as a diagnosis. For example, derealization or depersonalization is one of the qualifying symptoms for panic attack.

Episodes of DDD are often precipitated by stress; they may begin and end suddenly. The disorder usually has its onset in the teens or early 20s; usually it is chronic. Although still not well studied, prevalence rates in the general population appear to be around 1–2%, with males and females nearly equal.

201

Essential Features of Depersonalization/Derealization Disorder

A patient experiences depersonalization or derealization, but reality testing remains intact throughout. (The definitions are provided in the previous section.).

The Fine Print

The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, mood or anxiety disorders, psychotic disorders, trauma- and stressor-related disorders, other dissociative disorders)

Francine Parfit

“It feels like I’m losing my mind.” Francine Parfit was only 20 years old, but she had already worked as a bank teller for nearly 2 years. Having received several raises during that time, she felt that she was good at her job—conscientious, personable, and reliable. And healthy, though she’d been increasingly troubled by her “out-of-body experiences,” as she called them.

“I’ll be standing behind my counter and, all of a sudden, I’m also standing a couple of feet away. I seem to be looking over my own shoulder as I’m talking with my customer. And in my head I’m commenting to myself on my own actions, as if I were a different person I was watching. Stuff like ‘Now she’ll have to call the assistant manager to get approval for this transfer of funds.’ I came to the clinic because I saw something like this on television a few nights ago, and the person got shock treatments. That’s when I began to worry something really awful was wrong.”

Francine denied that she had ever had blackout spells, convulsions, blows to the head, severe headaches, or dizziness. She had smoked pot a time or two in high school, but otherwise she was drug- and alcohol-free. Her physical health had been excellent; her only visits to physicians had been for immunizations, Pap smears, and a preemployment physical exam 2 years ago.

Each episode began suddenly, without warning. First Francine would feel quite anxious; then she’d notice that her head seemed to bob up and down slightly, out of her control. Occasionally she felt a warm sensation on the top of her head, as if someone had cracked a half-cooked egg that was dribbling yolk down through her hairline. The episodes seldom lasted longer than a few minutes, but they were becoming more frequent—several times a week now. If they occurred while she was at work, she could often take a break until they passed. But several times it had happened when she was driving. She worried that she might lose control of her car.

Francine had never heard voices or had hallucinations of other senses; she denied ever feeling talked about or plotted against in any way. She had never had suicidal ideas and didn’t really feel depressed.

“Just scared,” she concluded. “It’s so spooky to feel that you’ve sort of died.”

Evaluation of Francine Parfit

The sensation of being an outside observer of yourself can be quite unsettling; it is one that many people who are not patients have had a time or two. What makes Francine’s experience stand out is the fact that it returned often enough (criterion A1) and forcibly enough to cause her considerable distress—enough to seek an evaluation, at any rate (C). (She was a little unusual in that her episodes didn’t seem to be precipitated by stress; in many people, they are.) Notice that she described her experience “as if I were a different person,” not “I am a different person.” This tells us that she retained contact with reality (B).

202Francine’s experiences and feelings were much like those of Shorty Rheinbold, except that his occurred as symptoms of panic disorder. A variety of other conditions include depersonalization as a symptom: posttraumatic stress disorder, anxiety, cognitive, mood, personality, and substance-related disorders; schizophrenia; and epilepsy (D, E). However, Francine did not complain of panic attacks or have symptoms of other disorders that could account for the symptoms.

Note a new feature in DSM-5: Francine could also have received this diagnosis if she had experienced only symptoms of derealization. With a GAF score of 70, her diagnosis would be:

F48.1 [300.6]

Depersonalization/derealization disorder

Though it goes unmentioned in DSM-5, a collection of symptoms called the phobic anxiety depersonalization syndrome sometimes occurs, especially in young women. In addition to depression, such patients, not surprisingly, have phobias, anxiety, and depersonalization. This condition may be a variant of major depressive disorder, with atypical features.

F44.0 [300.12] Dissociative Amnesia

There are two main requirements for dissociative amnesia (DA): (1) The patient has forgotten something important, and (2) other disorders have been ruled out. Of course, the central feature is the inability to remember significant events. Over 100 years ago, clinicians like Pierre Janet recognized several patterns in which this forgetting can occur:

Localized (or circumscribed). The patient has recall for none of the events that occurred within a particular time frame, often during a calamity such as a wartime battle or a natural disaster.

Selective. Certain portions of a time period, such as the birth of a child, have been forgotten. This type is less common.

The next three types are much less common, and may eventually lead to a diagnosis of dissociative identity disorder (see below):

Generalized. All of the experiences during the patient’s entire lifetime have been forgotten.

Continuous. The patient forgets all events from a given time forward to the present. This is now extremely rare.

Systematized. The patient has forgotten certain classes of information, such as that relating to family or to work.

DA begins suddenly, usually following severe stress such as physical injury, guilt about an extramarital affair, abandonment by a spouse, or internal conflict over sexual issues. Sometimes the patient wanders aimlessly near home. Duration ranges widely, from minutes to perhaps years, after which the amnesia usually ends abruptly with complete recovery of memory. In some individuals, it may occur again, perhaps more than once.

DA has still received insufficient study, so too little is known about demographic patterns, family occurrence, and the like. Beginning during early adulthood, it is most commonly reported in young women; it may occur in 1% or less of the general population, though recent surveys have pegged it somewhat higher. Many patients with DA have reported childhood sexual trauma, with a high percentage who cannot remember the actual abuse.

203Dissociative Fugue

In the subtype of DA known as dissociative fugue, the amnesic person suddenly journeys from home. This often follows a severe stress, such as marital strife or a natural or human-made disaster. The individual may experience disorientation and a sense of perplexity. Some will assume a new identity and name, and for months may even work at a new occupation. However, in most instances the episode is a brief episode of travel, lasting a few hours or days. Occasionally, there may be outbursts of violence. Recovery is usually sudden, with subsequent amnesia for the episode.

Dissociative fugue is another of those extraordinarily interesting, rare disorders—fodder for novels and motion pictures—about which there has been little in the way of recent research. For example, little is known about sex ratio or family history. This is a part of the reason (after its general rarity) that accounts for the demotion of dissociative fugue from an independent diagnosis in DSM-IV to a mere subtype of dissociative amnesia in DSM-5. DSM-5 notes, by the way, that the greatest prevalence of fugue states is among patients with dissociative identity disorder.

Essential Features of Dissociative Amnesia

Far beyond common forgetfulness, there is a loss of recall for important personal (usually distressing or traumatic) information.

The Fine Print

The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, cognitive disorders, trauma- and stressor-related disorders, dissociative identity disorder, somatic symptom disorder, ordinary forgetfulness)

Coding Note

If relevant, specify:

F44.1 [300.13] With dissociative fugue

Holly Kahn

A mental health clinician presented the following dilemma to a medical center ethicist.

A single 38-year-old woman had been seen several times in the outpatient clinic. She had complained of depression and anxiety, both of which were relatively mild. These symptoms seemed focused on the fact that she was 38 and unmarried, and “her biological clock was ticking.” She had had no problems with sleep, appetite, or weight gain or loss, and had not thought about suicide.

For many months Holly Kahn had so longed for a child that she intentionally became pregnant by her boyfriend. When he discovered what she had done, he broke off contact with her. The following week she miscarried. Stuck in her boring, unrewarding job as a sales clerk in a store that specialized in teaching supplies, she said she’d come to the clinic for help in “finding meaning for her life.”

The oldest girl in a Midwestern family, Holly had spent much of her adolescence caring for younger siblings. Although she had attended college for 2 years during her mid-20s, she had come away with neither degree nor career to show for it. In the last decade, she had lived with three different men; her latest relationship had lasted the longest and had seemed the most stable. She had no history of drug abuse or alcoholism and was in good physical health.

204The clinician’s verbal description was of a plain, no longer young (and perhaps never youthful), heavy-set woman with a square jaw and stringy hair. “In fact, she looks quite a lot like this.” The clinician produced a drawing of a woman’s head and shoulders. It was somewhat indistinct and smudged, but the features did fit the verbal description. The ethicist recognized it as a flyer that had recently received wide distribution. The copy below the picture read: “Wanted by FBI on suspicion of kidnapping.”

A day-old infant had been abducted from a local hospital’s maternity ward. The first-time mother, barely out of her teens, had handed the baby girl to a woman wearing an operating room smock. The woman had introduced herself as a nursing supervisor and said she needed to take the baby for a final weighing and examination before the mother could take her home. That was the last time anyone could remember seeing either the woman or the baby. The picture had been drawn by a police artist from a description given by the distraught mother. A reward was being offered by the baby’s grandparents.

“The next-to-last time I saw my patient, we were trying to work on ways she could take control over her own life. She seemed quite a bit more confident, less depressed. The following week she came in late, looking dazed. She claimed to have no memory of anything she had done for the past several days. I asked her whether she’d been ill, hit on the head, that sort of thing. She denied all of it. I started probing backward to see if I could jog her memory, but she became more and more agitated and finally rushed out. She said she’d return the next week, but I haven’t seen her since. It wasn’t until yesterday that I noticed her resemblance to the woman in this picture.”

The therapist sat gazing at the flyer for a few seconds, then said: “Here’s my dilemma. I think I know who committed this really awful crime, but I have a privileged relationship with the person I suspect. Just what is my ethical duty?”

Evaluation of Holly Kahn

Whether Holly took the baby is not the point here. At issue is the cause of her amnesia, which was her most pressing recent problem (criterion A). She had been under stress because of her desire to have a baby, and this could have provided the stimulus for her amnesia. The episode was itself evidently stressful enough that she broke off contact with her clinician (B).

There is no information provided in the vignette that might support other (mostly biological) causes of amnesia (D). Specifically, there was no head trauma that might have induced a major neurocognitive disorder due to traumatic brain injury. Substance-induced neurocognitive disorder, persistent would be ruled out by Holly’s history of no substance use (C). Her general health had been good and there was no history of abnormal physical movements, reducing the likelihood of epilepsy. Although she had had a miscarriage, too much time had passed for a postabortion psychosis to be a possibility. Some patients with amnesia are also mute; they may be misdiagnosed as having 205another medical condition with catatonic symptoms. And, just to be complete, we should note that her loss of memory is far more striking and significant than ordinary forgetfulness, which is what we humans experience all the time.

There was no history of a recent, massive trauma that might indicate acute stress disorder. If she was malingering, she did it without an obvious motive (had she been trying to avoid punishment for a crime, simply staying away from the medical center would have served her better). It certainly wouldn’t appear to be a case of normal daydreaming. Holly was clear about her personal identity, and she did not travel from home, so she would not qualify for the dissociative fugue subtype diagnosis. Although we must be careful not to make a diagnosis in a patient we have not personally interviewed and for whom we lack adequate collateral information, if what material we do have is borne out by subsequent investigation, her diagnosis would be as below. I’d give her GAF score as 31.

Dissociative amnesia

John Doe

When the man first walked into the homeless shelter, he hadn’t a thing to his name, including a name. He’d been referred from a hospital emergency room, but he told the clinician on duty that he’d only gone there for a place to stay. As far as he was aware, his physical health was good. His problem was that he didn’t remember a thing about his life prior to waking up on a park bench at dawn that morning. Later, when filling out the paperwork, the clinician had penciled in “John Doe” as the patient’s name.

Aside from the fact that he could give a history spanning only about 8 hours, John Doe’s mental status exam was remarkably normal. He appeared to be in his early 40s. He was dressed casually in slacks, a pink dress shirt, and a nicely fitting corduroy sports jacket with leather patches on the elbows. His speech was clear and coherent; his affect was generally pleasant, though he was obviously troubled at his loss of memory. He denied having hallucinations or delusions (“as far as I know”), though he pointed out logically enough that he “couldn’t vouch for what kind of crazy ideas I might have had yesterday.”

John Doe appeared intelligent, and his fund of information was good. He could name five recent presidents in order, and he could discuss recent national and international events. He could repeat eight digits forward and six backwards. He scored 29 out of 30 on the MMSE, failing only to identify the county in which the shelter was located. Although he surmised (he wore a wedding ring) that he must be married, after half an hour’s conversation he could remember nothing pertaining to his family, occupation, place of residence, or personal identity.

“Let me look inside your sports jacket,” the clinician said.

John Doe looked perplexed, but unbuttoned his jacket and held it open. The label gave the name of a men’s clothing store in Cincinnati, some 500 miles away.

“Let’s try there,” suggested the clinician. Several telephone calls later, the Cincinnati Police Department identified John Doe as an attorney whose wife had reported him missing 2 days earlier.

206The following morning John Doe was on a bus for home, but it was days before the clinician heard the rest of the story. A 43-year-old specialist in wills and probate, John Doe had been accused of mingling the bank accounts of clients with his own. He had protested his innocence and hired his own attorney, but the Ohio State Bar Association stood ready to proceed against him. The pressure to straighten out his books, maintain his law practice, and defend himself in court and against his own state bar had been enormous. Two days before he disappeared, he had told his wife, “I don’t know if I can take much more of this without losing my mind.”

Evaluation of John Doe

John Doe was classically unable to recall important autobiographical information—in fact, all of it (criterion A). It is understandable—and required (B)—that this troubled him.

Neither at the time of evaluation nor at follow-up was there evidence of alternative disorders (D). John had not switched repeatedly between identities, which would rule out dissociative identity disorder (you wouldn’t diagnose the two disorders together). Other than obvious amnesia, there was no evidence of a cognitive disorder. At age 43, a new case of temporal lobe epilepsy would be unlikely, but a complete evaluation should include a neurological workup. Of course, any patient who has episodes of amnesia must be evaluated for substance-related disorders (especially as concerns alcohol, C).

Conscious imitation of amnesia in malingering can be very difficult to discriminate from the amnesia involved in DA with dissociative fugue. However, although John Doe did have legal difficulties, these would not have been relieved by his feigning amnesia. (When malingering appears to be a possibility, collateral history from relatives or friends of previous such behavior or of antisocial personality disorder can help.) A history of lifelong multiple medical symptoms might suggest somatic symptom disorder. John had no cross-sectional features that would suggest either a manic episode or schizophrenia, in either of which wandering and other bizarre behaviors can occur.

Epilepsy is always mentioned in the differential diagnosis of the dissociative disorders. However, epilepsy and dissociation should not be hard to tell apart in practice, even without the benefit of an EEG. Epileptic episodes usually last no longer than a few minutes and involve speech and motor behavior that are repetitive and apparently purposeless. Dissociative behavior, on the other hand, may last for days or longer and involves complex speech and motor behaviors that appear purposeful.

Although John Doe’s case is not quite classical (he did not assume a new identity and adopt a new life), he did travel far from home and purposefully set about seeking shelter. That sets up the specifier for his diagnosis. And by the way, his GAF score would be 55.

F44.1 [300.13]

Dissociative amnesia, with dissociative fugue

Z65.3 [V62.5]

Investigation by state bar association

207

Note that the fugue subtype has a different code number than plain old dissociative amnesia. This reflects the fact that, in ICD-10 and in ICD-9, a fugue state is a diagnosis separate and apart from dissociative amnesia. So the number change isn’t a mistake.

F44.81 [300.14] Dissociative Identity Disorder

In dissociative identity disorder (DID), which previously achieved fame as multiple personality disorder, the person possesses at least two distinct identities. Ranging up to 200 in number, these identities may have their own names; they don’t even have to be of the patient’s own gender. Some may be symbolic, such as “The Worker.” They can vary widely in age and style: If the patient is normally shy and quiet, one identity may be outgoing or even boisterous. The identities may be aware of one another to some degree, though only one interacts with the environment at a time. The transition from one to another is usually sudden, often precipitated by stress. Most of them are aware of the loss of time that occurs when another identity is in control. However, some patients aren’t aware of their peculiar state until a close friend points out the alterations in character with time.

Of particular diagnostic note are states of pathological possession, which can have characteristics similar to DID. They may be characterized by the patient as a spirit or other external being that has taken over the person’s functioning. If this behavior is part of a recognized, accepted religious practice, it will not usually qualify for diagnosis as DID. However, a person who has recurrent possession states that cause distress and otherwise conform to DSM-5 criteria may well qualify for diagnosis. Of course, we would not diagnose DID in a child on the basis of having an imaginary playmate.

Affecting up to 1% of the general population, DID is diagnosed much more commonly by clinicians in North America than in Europe. This fact has engendered a long-running dispute. European clinicians (naturally) claim that the disorder is rare, and that by paying so much attention to patients who dissociate, New World clinicians actually encourage the development of cases. At this writing, the dispute continues unresolved.

The onset of this perhaps too-fascinating disorder is usually in childhood, though it is not commonly recognized then. Most of the patients are female, and many may have been sexually abused. DID tends toward chronicity. It may run in families, but the question of genetic transmission is also unresolved.

Essential Features of Dissociative Identity Disorder

A patient appears to have at least two clearly individual personalities, each with unique attributes of mood, perception, recall, and control of thought and behavior. The result: a person with memory gaps for personal information that common forgetfulness cannot begin to explain.

The Fine Print

The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, mood or anxiety disorders, psychotic disorders, trauma- and stressor-related disorders, other dissociative disorders, religious possession states accepted in non-Western cultures, childhood imaginary playmates/fantasy play)

208Effie Jens

On her first visit to the mental health clinic, Effie cried and talked about her failing memory. At age 26—too young for Alzheimer’s—she felt senile on some days. For several months she had noticed “holes in her memory,” which sometimes lasted 2 or 3 days. Her recall wasn’t just spotty; for all she knew about her activities on those days, she might as well have been under anesthesia. However, from telltale signs—such as food that had disappeared from her refrigerator and recently arrived letters that had been opened—she knew she must have been awake and functioning during these times.

On the proceeds of the property settlement from her recent divorce, Effie lived alone in a small apartment; her family lived in a distant state. She enjoyed quiet pastimes, such as reading and watching television. She was shy and had trouble meeting people; there was no one she saw often enough to help her account for the missing time.

For that matter, Effie wasn’t all that clear about the details of her earlier life. She was the second of three daughters of an itinerant preacher; her early childhood memories were a jumble of labor camps, cheap hotel rooms, and Bible-thumping sermons. By the time she reached age 13, she had attended 15 different schools.

Late in the interview, she revealed that she had virtually no memory of the entire year she was 13. Her father’s preaching had been moderately successful, and they had settled for a while in a small town in southern Oregon—the only time she had started and finished a year in the same school. But what had happened to her during the intervening months? Of that time, she recalled nothing whatsoever.

The following week Effie came back, but she was different. “Call me Liz,” she said as she dropped her shoulder bag onto the floor and leaned back in her chair. Without further prompting, she launched into a long, detailed, and dramatic recounting of her activities of the last 3 days. She had gone out for dinner and dancing with a man she had met in the grocery store, and afterwards they had hit a couple of bars together.

“But I only had ginger ale,” she said, smiling and crossing her legs. “I never drink. It’s terrible for the figure.”

“Are there any parts of last week you can’t remember?”

“Oh, no. She’s the one who has amnesia.”

“She” was Effie Jens, whom Liz clearly regarded as a person quite different from her own self. Liz was happy, carefree, and sociable; Effie was introspective and preferred solitude. “I’m not saying that she isn’t a decent human being,” Liz conceded, “but you’ve met her—don’t you think she’s just a tad mousy?”

Although for many years she had “shared living space” with Effie, it wasn’t until after the divorce that Liz had begun to “come out,” as she put it. At first this had happened for only an hour or two, especially when Effie was tired or depressed and “needed a break.” Recently Liz had taken control for longer and longer periods of time; once she had done so for 3 days.

“I’ve tried to be careful, it frightens her so,” Liz said with a worried frown. “I’ve begun to think seriously about taking control for all time. I think I can do a better job. I certainly have a better social life.”

209Besides being able to recount her activities during the blank times that had driven Effie to seek care, Liz could give an eyewitness account of all of Effie’s conscious activities as well. She even knew what had gone on during Effie’s “lost” year, when she was 13.

“It was Daddy,” she said with a curl of her lip. “He said it was part of his religious mission to ‘practice for a reenactment of the Annunciation.’ But it was really just another randy male groping his own daughter, and worse. Effie told Mom. At first, Mom wouldn’t believe her. And when she finally did, she made Effie promise never to tell. She said it would break up the family. All these years, I’m the only other one who’s known about it. No wonder she’s losing her grip—it even makes me sick.”

Evaluation of Effie Jens

Effie’s two personalities (criterion A) are fairly typical of DID: One was quiet and unassuming, almost mousy, whereas the other was much more assertive. (Effie’s history was atypical in that more personalities than two are the rule.) What happened when Liz was in control was unknown to Effie, who experienced these episodes as amnesia. This difficulty with recall was vastly more extensive than you’d expect of common forgetfulness (B). It was distressing enough to send Effie to the clinic (C).

Several other causes of amnesia should be considered in the differential diagnosis of this condition. Of course, any possible medical condition must first be ruled out, but Effie/Liz had no history suggestive of either a seizure disorder or substance use (we’re thinking of alcoholic blackouts and partial seizures here). Even though Effie (or Liz) had a significant problem with amnesia, it was not her main problem, as would be the case with dissociative amnesia, which is less often recurrent and does not involve multiple, distinct identities. Note, too, the absence of any information that Effie belonged to a cultural or religious group whose practices included trances or other rituals that could explain her amnesia (D).

Schizophrenia has often been confused with DID, primarily by laypeople who equate “split personality” (which is how many have come to characterize schizophrenia) with multiple personality disorder, the old name for DID. However, although bizarre behavior may be encountered in DID, none of the identities is typically psychotic. As with other dissociative disorders, discrimination from malingering can be difficult; information from others about possible material gain provides the most valuable data. Effie’s history was not typical for either of these diagnoses.

Some patients with DID will also have borderline personality disorder. The danger is that only the latter will be diagnosed by a clinician who mistakes alternating personae for the unstable mood and behavior typical of borderline personality disorder. Substance-related disorders sometimes occur with DID; neither Effie nor Liz drank alcohol (E). Her GAF score would be 55.”

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In the Special Issue on Multicultural Social Justice Leadership Development Guest Editor: Carlos P. Zalaquett, University of South Florida

Social Justice Counseling and Advocacy: Developing New Leadership Roles and Competencies

Judith A. Lewis Governors State University

Manivong J. Ratts

Seattle University

Derrick A. Paladino

Rollins College

Rebecca L. Toporek San Francisco State University

Abstract

The fusion of scholarship and activism represents an opportunity to reflect on ways in which counselors and psychologists can begin to address the multilevel context faced by clients and client communities. Counselors and psychologists have embraced, and sometimes resisted, the wide range of roles including that of advocate and activist. This article reflects on a process that engaged workshop participants in examining the American Counseling Association Advocacy Competencies and exploring the possibilities of advocacy on behalf of their own clients. Further, the article presents recommendations for actions developed by participants through application of workshop principles regarding social action in the larger public arena. The workshop was a part of the National Multicultural and Social Justice Leadership Academy in 2010. Keywords: advocacy, social justice; political action; change promotion, leadership development

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Kelman (2010), in a discussion of psychology and social responsibility, suggested that there are two ways in which psychologists can carry out their social responsibilities: via psychology and in psychology. Kelman’s conceptualization implies that a psychologist can use his or her work as a vehicle for bringing about social change. It also implies that the psychologist has a responsibility

to change the nature of the profession itself, moving individual psychologists and the discipline as a whole toward a fusion of activism with scholarship. These ideas are clearly as relevant to counselors and other helping professionals as they are to psychologists.

The purpose of this article is to propose a fusion of among scholarship, professional practice, advocacy, and leadership and provide recommendations for the application of advocacy in

leadership. The content and process of a workshop focusing on developing new leadership roles and competencies given through the National Multicultural and Social Justice Leadership

Academy in 2010, provides the basis for our discussion. In this workshop, the authors broadened the concept of fusion, helping participants to perceive and plan for action through a process that led toward this goal. The process began with an introduction to the social justice

counseling paradigm, including a review of the American Counseling Association (ACA) Advocacy Competencies and a discussion of social action in the larger public arena. Two

interactive exercises led the workshop participants to connect theory to practice exploring the possibilities of advocacy on behalf of their own clients and making recommendations for actions that might take the helping professions in positive new directions. The workshop took place in

the context of an American Counseling Association conference where participants largely defined themselves professionally as counselors, counselor educators, or counselors in training.

The language used throughout the event focused on counseling practice and the social justice counseling paradigm, but the authors recognize that the counseling profession is not alone in the steady movement toward an emphasis on social justice. The process described, and the

content, may help to advance advocacy across disciplines. Across the helping professions, a social justice perspective represents a shift from traditional,

individually-focused models. The history of community psychology, for example, exemplifies a change in worldview from established psychological traditions. “Psychology has traditionally

focused on the individual level of analysis…This is a very western view that puts the individual in the foreground over the collective…In contrast, CP is the study of people in context” (Nelson & Prilleltensky, 2005, p. 5). The vanguard of each of the helping professions has embraced the

concept of social justice (Toporek, Gerstein, Fouad, Roysircar, & Israel, 2006; Sowers & Rowe, 2006). Within the counseling profession, the cutting edge is exemplified by the social justice counseling paradigm. The Social Justice Counseling Paradigm

Counselors who believe in the possibility of a humane world incorporate a social justice perspective into their work with clients. The social justice counseling paradigm “uses social

advocacy and activism as a means to address inequitable social, political, and economic conditions that impede the academic, career, and personal/social development of individuals,

families, and communities” (Ratts, 2009, p. 160). Social justice counselors contend that human development issues cannot be understood simply by assessing a client’s affective, behavioral, or cognitive development or by requiring that change come exclusively from the client. Instead,

counselors need to view client problems more contextually and use advocacy to remove oppressive environmental barriers.

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According to Adams, Bell, and Griffin (2007), achieving social justice is both a goal and a process. The goal of social justice counseling is to ensure that every individual has the

opportunity to reach her or his academic, career, and personal/social potential free from unnecessary barriers. This perspective is rooted in the belief that every individual has a right to

a quality education, to healthcare services, and to employment opportunities regardless of race, ethnicity, sex, sexual orientation, gender identity, gender expression, economic status, and creed, to list a few. The process for achieving social justice should be one that involves the

client throughout the counseling process. Counseling should be a collaborative experience where clients are a participatory part of the process. Clients should have input in the direction of the therapeutic process and they should be equipped with the awareness, knowledge and

skills needed to navigate their world successfully.

The social justice counseling paradigm brings many benefits to the helping professions. A counseling paradigm rooted in social justice provides a theoretical framework for understanding the debilitating impact oppression has on clients’ ability to reach their potential. The paradigm

encourages counselors to develop a more balanced perspective between individuals and their environment and expands the repertoire of skills counselors have at their disposal. Rather than

being limited to working in the traditional office environment, counselors can also work in the settings that contribute to client stress. As a theory unto itself, the social justice counseling paradigm has altered how client problems are conceptualized, has revolutionized the counselor

role and identity, and has led to avant-garde counseling approaches (Ratts, 2009). The shift in the counseling paradigm is significant because counselors cannot continue to do the same

things if they intend a different outcome. Lorde (1984) stated, “the master’s tools will never dismantle the master’s house” (p. 110). In other words, we cannot rely on theories and ways of helping to dismantle the status quo if the theories we use were built to maintain the social

order. Unfortunately, many traditional counseling and psychological theories have been complicit in maintaining the status quo of White supremacy and patriarchy (Prilleltensky, 1994). Now, more counselors recognize the need for a new counseling paradigm that will heed to

clients’ needs, and as a byproduct, revolutionize the counseling profession. One of the roles and functions recognized by this paradigm is that of client advocate. This role requires using the

skills and knowledge of counselors and psychologists to facilitate change in the environment. The ACA Advocacy Competencies

In recognition of the need for counselors to acknowledge and play critical roles in addressing

barriers faced by clients, ACA adopted a set of guidelines to assist in this process (Lewis, Arnold, House & Toporek, 2002). The ACA Advocacy Competencies integrated the foundations provided by literature in multicultural counseling (e.g., Sue, Arredondo & McDavis, 1992) and

community counseling (e.g., Lewis, Lewis, Daniels & D’Andrea, 1998) and provided a framework through which counselors could identify the various levels of intervention that might be appropriate given client situations. We will provide a brief overview of the model as context

for the exercise and participant experience, however, a more extensive discussion of the ACA Advocacy Competencies model can be found in a special issue of the Journal for Counseling and

Development (Toporek, Lewis & Crethar, 2009) as well as in an edited handbook devoted to the ACA Advocacy Competencies (Ratts, Toporek & Lewis, 2010).

The ACA Advocacy Competencies model organizes advocacy into two dimensions. The first dimension identifies the extent of involvement of client or community in the advocacy process;

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in other words, is advocacy taken with the client or on behalf of the client? The second dimension addresses the level of intervention: individual, systems, and societal level. The

resulting domains describe six different forms of advocacy that counselors may be involved in depending on the needs of the situation. Often, several forms of advocacy may be necessary

and cultural competence and awareness is essential regardless of the type of advocacy. At the individual level, the counselor works with the client or student toward Empowerment. Empowerment may involve facilitating the process of naming the barrier or oppression and working together to develop strategies that the client may use to address the barrier. Sometimes the counselor may facilitate the development of self-advocacy skills or helping the

client locate resources that may help address the contextual problems. It is critical that the counselor have adequate training and understanding of the cultural complexities that may be

involved for the client within and outside his or her community. There are times and situations in which the counselor has access or resources that cannot be transferred to the client. For example, by virtue of their position, counselors tend to receive more credibility and access

within their own or related institutions. In other cases, the cognitive or language skill level of the client may make it difficult for the client to understand or advocate for themselves in some

circles. Similarly, clients or students may face serious repercussions when self-advocating without support of someone who is has institutional power. In these cases, it would be appropriate for the counselor to advocate on behalf of the client or student. The model calls this

Client or Student Advocacy.

At a systems level, the ACA Advocacy Competencies model identifies Community Collaboration as the efforts of counselors to work with a community or school to address some oppression or barrier facing the community. This type of advocacy is similar to empowerment but is working

at a group level using counselors’ skills in group facilitation, prevention, communication, consultation and collaboration. In this way, counselors may help a group to define the problems facing the community or school and then facilitate the group in identifying and planning action

to address these problems. Systems Advocacy identifies advocacy efforts the counselor makes on behalf of a school or community. There may be situations where client groups may fear of

repercussions and hence may not raise issues at a systems level. In other cases, there may not be a cohesive group that identifies a problem, but the counselor sees patterns across a number of clients or students. For example, over the course of a year or two a counselor noted that a

number of students from a particular ethnic background came to her describing incidents of discrimination in a specific college department. The students did not know that others

experienced similar issues and, although some pursued due process, many did not and left the college instead. When counselors see these patterns within their own institutions, advocacy on behalf of those communities would be not only appropriate, but ethically imperative.

When a counselor works in conjunction with a client community on a societal level, the ACA Advocacy Competencies model identifies this as Public Information. Public information describes the work that a counselor, or group of counselors, may do in conjunction with a community to raise awareness about an issue. For example, in a community where there are high rates of

micro-aggressions against a particular marginalized group, the counselor may work with members of the group to identify ways to amplify their voice and presence in the community in a way that would inform the community about the issues as well as build relationships and allies

within the community. Finally, when a counselor advocates on behalf of client communities at a societal level, this is termed, Social or Political Advocacy. In this form of advocacy, the

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counselor directly works with policy makers and legislators to address issues that negatively affect client groups. This often takes place concurrently with other forms of advocacy. The

counselor’s ability to recognize issues facing a population comes from her or his involvement with members of that community and the advocacy should be informed by those community

members. Counselors are in a unique position in that their direct client experience and stories can be blended with statistics and information to create compelling arguments for policy change. Of course ethically, any stories shared must protect the confidentiality of the clients

unless specifically directed by the client. As an example, a group of counselors and psychologists met with a legislative office regarding the need for more training for bilingual mental health services. They presented statistics about mental health needs and disparities as

well as the economic impact of mental health problems on a community. The legislative staff member fastidiously recorded much of the information provided. A pivotal point was reached

when one of the counselors shared a letter that one of her clients had written for this event. The staff member was emotionally moved and firmly stated that she would make sure that this issue was given attention.

Several important aspects of the ACA Advocacy Competencies model are worth repeating here.

First, many situations call for multiple forms of advocacy concurrently. Second, advocacy should reflect the clients’ needs and be informed by clients rather than the counselor determining what the client needs. Similarly, it is not the counselor’s job to “save” the client or client groups.

Rather, the counselor facilitates the client in gaining more skill and power. Sometimes, in addition to this, the counselor may independently need to advocate. Third, multicultural

competence and relevance is of utmost importance. Fourth, interdisciplinary and cross organizational alliances are often necessary in order to advocate effectively. Fifth, counselors have significant skill and training to facilitate their advocacy efforts including group dynamics,

prevention, communication, human behavior and development, and systems knowledge. However, there are areas in which more training would be useful depending on the counselor’s strengths and experience; for example, training in legislative advocacy (Lee, 2009) or

translation of ethical issues when working with communities (Toporek & Williams, 2006).

Social/Political Action Advocacy is not an “add-on” that is separate from the counselor’s work with clients and

students. Advocacy is, instead, a natural outgrowth of the counselor’s empathy and experience.

In the past, most community organizations and social/political advocacy groups functioned in a world apart from individuals who identified themselves as members of the helping professions. Now, however, the separate worlds of counseling and macro-

level advocacy have begun to merge. Community counselors no longer turn their backs on the need for social/political action because they realize that this work is a natural continuation of the counseling process. Helping individuals and dealing with the

social/political systems that affect them are two aspects of the same task. (Lewis, Lewis, Daniels, & D’Andrea, 2011, p. 206)

Lewis, Toporek, and Ratts (2010) suggest that counselors can find their way toward “a seamless connection between what they do in the counseling office and what they do in the

Capitol Building” (p. 241). The best way to make this bond a reality is to begin with the client. The idea of beginning with the client suggests that experiences with clients can help counselors

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choose the most important issues and the best allies for social/political advocacy. Cohen, de la Vega, and Watson (2001) suggest that “effective social movements are built by well-rounded

teams of storytellers, organizers, and ‘experts’ alike” (p. 29). Counselors, almost by definition, have stories to tell and those stories lead the way toward social justice advocacy.

Group Activity: Stories to Tell

Counselors advocate for their clients constantly, but are not always aware of their strengths in this area. Sometimes these behaviors are second-nature, anchored in the altruism possessed by mental health professionals. For example, one of the authors remembers spending hours calling

different inpatient sites trying to find a bed for one of his clients. He was informed that there were no open beds in the state and his client did not “technically” match the requirements for

this level of care. Through persistence and calls to community contacts, this client was finally offered a spot in an inpatient agency. At the time, the author labeled this as simply knowing what the client needed and caring about him, not as advocacy – even though it actually reflects

the principles of advocacy.

Counselors may find that they already possess strong leadership and advocacy skills as they work with clients. One goal of the workshop described in this article was to develop new leadership roles in social justice counseling and advocacy. One of our hopes, as facilitators, was

to illuminate these skills and strategies in a community forum. At this part of the workshop, we aimed at tapping into the micro-level work participants were already involved with. The goal

was to increase the participants’ awareness of their work, reinforce this level of client care and facilitate movement towards a blueprint that operationalizes future social justice and advocacy at the micro and, later in the workshop, macro level.

In the workshop, presenters asked participants to reflect on their advocacy and social justice experiences with specific clients. Participants were asked to break into small groups, particularly

with individuals who were not their own current colleagues. They were provided with discussion questions and asked to take notes on their responses. At the conclusion of this discussion the

presenters proceeded to process the small group work in the larger group. Participants were given the following prompts:

1) Talk about your experiences. a. In what ways have you been successful with advocacy with a specific client?

b. What roadblocks did you traverse? 2) As you look at what has worked for you in advocacy and social justice counseling,

identify strategies and skills that helped you advocate for individual clients.

Eight small groups were formed and reported on the main areas above: Experiences, Roadblocks and Barriers, and Strategies and Skills.

Experiences

Perhaps the most interesting aspect of this exercise was that even counselors who had not viewed themselves as competent advocates did have examples to share. All of the participants,

including students, could give real-life examples of times when they had spoken up on behalf of less powerful others. Although this workshop might have been their first introduction to the

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concept of social justice counseling and advocacy, they could readily see the fit with their own experiences.

The examples shared were quite diverse and demonstrated the wide array of possibilities in

micro-level advocacy. Participants were able to advocate in areas spanning from single-parent families in an American suburb to refugees Burundi, Africa. Experiences with children and youth were especially prevalent. One participant working with a teen boy living with stuttering was

able to advocate successfully for speech therapy. This participant found that a new device could assist this teen, but insurance didn’t cover it. After realizing that traditional methods didn’t work, the counselor was able to arrange for the donation of the device and the client benefited

greatly. Another example involved a six-year-old boy with speech issues in a school counseling setting. The counselor was able to assist the client by shifting perceptions and attitudes through

education on diversity, working with the teacher, and using a backdoor approach including connecting with others and creating allies.

Roadblocks and Barriers

Although the participants in the workshop expressed multiple examples of roadblocks that could impede advocacy and social justice, they showed active energy and passion. Examples of non- successful advocacy efforts reported by the participants are important to highlight. Participants

shared similar struggles as they discussed roadblocks to advocacy and social justice. Among the most common barriers were (a) insurance and funding issues, (b) lack of community support

and resources, (c) unexpected resistance, (d) difficult in building collaborative networks, (e) cultural and language biases, and (f) the counselor’s own limited training in social justice advocacy.

These recollections of struggles were shared by many. It is the collective awareness of roadblocks and shared struggles that can bring mental health professionals together to discover

new ways to increase levels of success. The advocacy and social justice road does not have to be traveled alone. Working alone in advocacy can make these barriers appear quite

insurmountable; however, through the activity the authors discovered that participants offered many solutions as a group. When mental health professionals make connections and collaborate, success is possible.

Strategies and Skills

Participants shared both experienced and proposed strategies for advocacy and social justice at the micro-level. The strategies identified by participants appeared best organized into three

main areas community and colleagues, client, and person-as-counselor: Community and colleagues. This theme reflected the ways in which participants found strength in working with others to advocate for a common purpose. Participants identified who they collaborated with as well as specific actions that took place within the context of these

partnerships. These included:

 Collaboration with other professionals (interdisciplinary)

 Sharing resources and information

 Advocating for other services

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 Educating/information giving regarding cultures to everyone in the environment or

community  Connecting with outside systems—collaboration

 Specific alliances—backdoor approaches  Making advocacy letters to legislatures personal and contacting local legislatures/

lobby to work your way up  Networking (technology, social networking sites)

Client. This theme summarized the ways in which participants worked with clients within the context of advocacy. Most of these examples reflected approaches or intentions of the counselor. Specifically, participants noted the following:

 Understanding the client’s culture

 Looking at, identifying, and celebrating strengths  Empowering your clients

 Education/support—empowerment/education

 Visiting clients’ houses—seeing/experiencing the physical living environment— becoming immersed in context

 Being in environment to educate clients about their rights and things they can do  Gaining trust and respect of the client

 Teaching assertiveness

 Educating clients of their rights—how to obtain them

Person-As-Counselor. This theme focused on comments made by participants regarding the role of the self in acting as an advocate. Some of the participants identified personal challenges and others highlighted the ways in which professional training and identity support advocacy

efforts. The range of discussion points can be seen here:

 Taking the risk to be an advocate  Acknowledging that we have more in common than differences

 Utilizing title of role as counselor

 Using the power for good  Sharing personal experiences with your clients

 Becoming an educator

 Knowing and identifying with our clients  Understanding the needs of the population from the perspective of the population

you are working with  Organization as self-advocacy goals

 More community involvement

 Modeling self-advocacy strategies

The themes expressed by participants rose through shared stories, experiences, and strategies with each other within the context of a small group activity. As facilitators, we observed the power of these small group discussions and noted that, in the large group discussions that

followed, participants created a collegial environment and reported having learned new approaches to advocacy and social justice. For example, a participant noted that “modeling self-

advocacy strategies” occurred in the process. Throughout this activity, we observed participants

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working at the micro-level, looking at themselves and reporting an increase in their awareness regarding advocacy and social justice.

Group Activity: Social/Political Action

As described above, early in the workshop, the presenters asked participants to share their own stories regarding their work with individual clients and students. As the program moved toward

a discussion of social/political action, the workshop participants were asked to revisit those stories and make recommendations for more broad-based actions. In identifying pressing issues for public advocacy, the participants were asked to do the following:

 Start with a client and consider the ways in which this client’s life could be improved if

the social/economic/political environment were to change.

 List ideas for social/economic/political changes that should be accomplished in the larger public arena, with particular focus on the role of the counselor and the counseling

profession. Because the first experiential activity had involved starting with the client, the intent was that participants would be able to move seamlessly toward the larger public arena.

The participants’ action recommendations were shared in the context of the large group and included the following:

1. To use our role as counselors to carry out social action (social justice via counseling):

 Advocate on behalf of ALL marginalized groups—not just the obvious ones. (The example used was deaf and hard-of-hearing clients.)

 Advocate on behalf of returning military. (As many as 50% of returning military are unemployed. Counselors should advocate on behalf of military families,

especially regarding employment.)  In difficult economic times, educate corporate America about the impact of their

decisions on workers.  Carry out advocacy on behalf of workers.

2. To bring about change in the counseling profession as a whole (social justice in

counseling):  Ensure that all committees of counseling organizations have a social justice

charge.  Ensure that advocacy regarding public policy and legislation is included in every

counseling student’s training. As part of their training, all students should be able to develop relationships with legislators.

Some of the participants’ action recommendations grew directly from their exploration of client issues. It is particularly interesting, however, that the participants also recommended actions

that help to move social/political advocacy to the center of the counseling profession. For example, participants recommended that professional associations, such as the American Counseling Association, should operationalize social justice concepts by insisting that all

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committees within the organization are charged with emphasizing social justice. They also recommended that advocacy should play a central role in every student’s preparation for

practice. These ideas reflect an internalization of a commitment toward social justice counseling.

Conclusion

The format of this workshop appeared successful in generating an understanding of, and appreciation for, social justice counseling and advocacy among the participants, many of whom had been unfamiliar with these concepts in the past. By reviewing the social justice counseling

paradigm and the ACA Advocacy Competencies, facilitators hoped to lay the groundwork for the heart of the program, which involved active participation and brainstorming. In the small-group

activity, participants talked about their own personal and professional experiences. Through the discussion with others, they were exposed to these experiences from a different perspective. New perspectives expand counselors’ ability to identify necessary action as well as understand

how these actions relate to, and are appropriate for, professional counselors. Not only the participants but the workshop leaders as well developed clearer views of the fusion among

scholarship, social justice counseling, advocacy, and leadership. Our intent in describing the workshop process, as well as strategies derived from the group activities, is to increase dialogue regarding challenges and positive approaches that can help further the implementation of

advocacy within counseling and psychology. In particular, the future leaders in the counseling and psychology fields will need skills and the strength to advocate for social justice.

Contact information: Judith A. Lewis

Email: Judithalewis@sbcglobal.net

Judith A. Lewis, Ph.D., Governors State University; Manivong J. Ratts, Ph.D., Seattle University; Derrick A. Paladino, Ph.D., Rollins College; and Rebecca L. Toporek, Ph.D., San Francisco State University.

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Kelman, H. (2010, July 17). Becoming a socially responsible psychologist. Presented to the annual conference of Psychologists for Social Responsibility, Boston, MA.mailto:Judithalewis@sbcglobal.net

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