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Friday, January 20, 2012

New York Neuropsychologists Leave State Psychological Association


Neuropsychologist members of the New York State Psychological Association (NYSPA) resigned from the organization en masse in December 2011 after years of conflict within NYSPA regarding the state’s ban on the use of neuropsychology technicians.


The resignations included current and past presidents of NYSPA’s Neuropsychology Division, which led to a vote to formally close the division and to place NYSPA in a position where it no longer represents the voice of neuropsychology in New York State. Many of the neuropsychologists who left are national leaders in the field leaving a gaping hole in the association.

For over 50 years, neuropsychologists in New York, as in the rest of the country, utilized trained technicians to assist with testing services performed under their direct supervision. The tests can be administered by technicians (also known as psychometrists) who work under the licensed psychologist and are trained to strictly adhere to manualized test administration procedures with clear and easy to follow instructions. The licensed psychologist always determines the treatment plan including all selection of tests, interpretation of results, report writing consultation with other professionals, and feedback regarding evaluation results. Thus, the technician’s job is purely mechanical, much like a technician who assists in running an X-ray machine. The radiologist does not actually run the x-ray machine but interprets the results.

Technician practice is critical in the access and delivery of health care. If medical doctors were required to collect all of the data necessary for diagnostic evaluations, our health care system would be overly burdened by cost and it would be impossible for patients to access quality care. Unfortunately, this is the current situation in New York State for psychologists trained to practice neuropsychology.

The practice of psychology pertaining to the use of technicians in New York changed in 2003 following passage of the state’s psychology scope of practice law. Despite a documented legislative intent stating that no such change would occur, an idiosyncratic and rigid interpretation of the law by the State Education Department’s (SED) led to a complete restriction on the use of technicians for psychologists throughout the state. Essentially, a parenthetical phrase was included in the scope of practice law stating the practice of psychology includes neuropsychological testing. This was then interpreted to mean that anyone besides a psychologist performing neuropsychological testing was practicing psychology without a license and that any psychologist facilitating this was aiding and abetting criminal behavior. In this way, the new interpretation essentially made it illegal for psychologists to use technicians to assist with testing services.

New York State licensed psychologists trained in the specialty of neuropsychology banded together following the 2003 interpretation with the goal of obtaining a reversal of the SED’s interpretation that would allow a return to the lawful use of neuropsychology technicians. Most initial efforts were made at fighting opposition within NYSPA, particularly from its School Psychology and Clinical Psychology divisions as well as the State Psychology Board, who generally supported the ban imposed by their department. These groups continued to oppose technician use despite being presented with statements from multiple state and national professional organizations, including Division 40 (Neuropsychology) of the American Psychological Association (APA), the National Academy of Neuropsychology, the American Academy of Clinical Neuropsychology, the American Board of Professional Neuropsychology, and the APA Practice Directorate. These groups routinely noted that use of technicians is a standard practice in neuropsychology throughout the country with functions that are recognized and reimbursable under existing national billing codes such as 96119 (neuropsychological testing by a technician).

After years of continued discussion and conflict, neuropsychologists within NYSPA reached a tentative agreement with opposing psychologists and obtained support from the NYSPA Council of Representatives in 2007 to move ahead toward an administrative solution to further clarify SED’s interpretation so that it was more flexible with regard to technician use. In order to reach the 2007 accord with a NYSPA committee tasked to address the issue, neuropsychologists made a major concession towards school psychology that technicians would not be allowed to administer full intelligence tests and would not work in school systems. This concession was made even though technician use in assessment had never been problematic to school psychologists during the lengthy period prior to 2003 when it was legal.

In spite of the concessions by the NYSPA Neuropsychology Division, members of the School Psychology and Clinical Psychology divisions continued to lobby against NYSPA’s support and sought further restrictions for technicians, including attempts to prevent them from working with individuals less than 21 years of age and from administering most existing tests to individuals from any age group. These restrictions were sought by the opposing psychologists without any supporting evidence to back their claim technicians would be harmful to the public. The opposition continued despite clear documented evidence sent to SED (including documentation from an independently appointed advisor to SED to study the issue) that there was a restricted access to care in the state for receiving neuropsychological services. This led to long waiting lists that significantly affected the elderly (i.e., delaying a dementia or depression differential diagnosis which would lead to different treatments) and ethnic minorities, particularly those who spoke another language because there was no longer the ability to employ technicians who spoke the necessary languages to administer the tests.

The issue that eventually led to the recent mass resignations was that, after making concessions and reaching an initial agreement within NYSPA, the organization’s council of representatives returned to the issue four years later and voted against the use of technicians on administering even parts (subtests) of IQ tests, a critical element of almost all neuropsychological assessments. Neuropsychologists use these subtests due to their robust norms and to aid with the diagnostic process.

If neuropsychologists would have accepted the results of the vote, it would eliminate the way the vast number of neuropsychologists practice. This was considered totally unacceptable to neuropsychologists, who concluded that the organization was out of step with national practice standards and that neuropsychology could not have their interests represented by a group composed of so many disparate fractions who do not understand the intricacies of neuropsychological practice, some of whom were actively communicating with SED in an attempt to create further division, opposition, and prevention of a reasonable resolution. Although there were some members of NYSPA who were supportive, including the last three NYSPA presidents, the opposition by the School and Clinical Psychology Divisions led the day.  Mass resignations from NYSPA resulted and the Neuropsychology Division ceased to exist.

Neuropsychologists in New York are fortunate to have another organization to turn to after leaving NYSPA. In 2006, neuropsychologists in the state formed the New York State Association of Neuropsychology (NYSAN). This organization was initially formed on the recommendation of the APA Practice Directorate to establish a professional entity that could receive funding to hire a professional lobbyist to work at overturning the technician ban. Over the years, NYSAN has been supported generously by APA Neuropsychology Division and the other organizations mentioned above to continue its lobbying efforts. However, NYSAN has also branched into other areas of activity including development of an active Professional Affairs Committee (PAC), which has now become a major force within the state for representing neuropsychologists’ interests in negotiations with third party payers. Neuropsychologists in the state are urged to join NYSAN and help it develop as the only voice for neuropsychology in New York State and to continue its fight against opposing factions in Albany and within NYSPA. Neuropsychologists from across the country will surely be watching.

Disclaimer: Dr. Carone is a neuropsychologist who was President of NYSAN for 3.5 years.

6 comments:

  1. Goverment is taking too much from the people. Telling health professionals how they can test patients is a blatant example of uneducated representatives who "educate" themselves by only the people who do not fully understand what is of importance.
    From what I have read, the way goverment is regulating test administration methods is by eradicating the role of the technician. By creating this "safety of health" measure, there could be less psychologists in NY due to ample training and practice opportunities for all who wish to, and are studying mental
    health

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  2. It's quite unfortunate the special interests of a few would have such a large impact on us all. This is a good example of what happens when rigidity and fear are louder than reason.

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  3. Help me understand. What is the opposition's reasoning? Do they seriously take this as a job security threat? Or do they think that tech's are going to "miss something" that a trained neuropsych would identify? I work & train in Mass, & have my tech's admin & score the Wechsler intel & memory batteries, as well as the PAI, but do the rest myself - the ever-important perceptual & motor screening, dx interview, and executive function testing.

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  4. School psychologists are concerned that technicians will replace them in the schools even though this has never happened anywhere else and neuropsychologists in NY agreed not to have techs used in schools. The other concern is that technicians would harm children even though there has never been any evidence offered to support this in NY before 2003 or in any other state. Another argument was that allowing technicians waters down the practice of psychology but allowing non-licensed people to administer tests. However, the tests are standardized and administered in a prescriptive manner. The test selection, interpretation, and report writing all is done by the psychologist. Neuropsychologists believe the arguments are illogical, without merit, and violate national practice standards. Welcome to the state of New York!

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  5. "Another argument was that allowing technicians waters down the practice of psychology by allowing non-licensed people to administer tests."

    Dom, I guess it didn't occur to the opposition that the standardization data was originally gathered by techs?

    JBS, PhD., R.Psych.

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  6. We've brought that up many times but the response would always be that this does not matter because it is different from testing an actual patient in a clinical setting.

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