(240)-343-2585

  See 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 all attached. Address the following numbered points (1)Compare the various professional activities common to clinical and counseling psychologists and assume the role of an advocate for client in the case 14 study attached. (2) identify systemic barriers, sociopolitical factors, and multicultural issues impacting the client at the micro, meso, exo, and/or macro levels(3)Develop an action plan that outlines how you might advocate for the client at each appropriate level of the ecological model(4)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: [email protected]

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

372

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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.,

374 HEINOWITZ ET AL.

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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). …

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Cohen, Karen R;Lee, Catherine M;McIlwraith, Robert
Canadian Psychology; Aug 2012; 53, 3; ProQuest Central
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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: [email protected]

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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

187

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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188 HILL

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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190 HILL

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 …

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 [email protected]

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.

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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, &
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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
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Fox, R. E. (2006). Training for prescriptive authority for psychologists. In
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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.
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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 …

Journal for Social Action in Counseling and Psychology
Volume 3, Number 1 Spring 2011

© 2010 Journal for Social Action in Counseling and Psychology ISSN 2159-8142

5

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

Journal for Social Action in Counseling and Psychology 6

© 2010 Journal for Social Action in Counseling and Psychology ISSN 2159-8142

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 …

“CASE 14

Antisocial Personality Disorder

Checklist

Antisocial Personality Disorder

1.

Persons repeatedly disregard and violate the rights of other people in 3 or more
of the following ways:

(a) Little or no adherence to social and legal norms.

(b) Deceitfulness.

(c) Impulsivity or poor planning.

(d) Irritability and hostility marked by repeated fights.

(e) Careless disregard for safety of self or others.

(f) Failure to behave responsibly in the spheres of work or finances.

(g) No regret for hurting or mistreating others.

2.

Persons are at least 18 years old, but showed signs of conduct disorder before
they were 15 years old.

(Based on APA, 2013.)

Jack was a 22-year-old single man, admitted to a state psychiatric hospital in a
large midwestern city with complaints of depression and thoughts of suicide. He
was admitted to the hospital after arriving there one evening appearing
completely distraught. He told the psychiatrist on call that he could not bear life
any longer and was thinking of ending it all. Jack said he had spent the past hour
standing on the overpass of a nearby highway, staring down at the traffic and
trying to gather enough courage to jump. He eventually decided he could not do it
and, realizing he was near a hospital, pulled himself together enough to “get
some help instead of running away from my problems.”

Most of the individuals with antisocial personality disorder are not interested in
receiving treatment. Those individuals who receive treatment typically have been
forced to participate by an employer, their school, or the law (McRae, 2013).

In relating these events, Jack seemed deeply upset. Occasionally he would stop
speaking and bury his face in his hands. When the psychiatrist asked what sort of
difficulty he was experiencing, Jack replied, “You name it, I’ve got it.” He said that
he had recently lost both his job and his girlfriend, and now his mother was
gravely ill, among other things. He feared that unless he got some help, he was
going to “go off the deep end.”

Jack Disturbed or Disturbing?

The psychiatrist was concerned that Jack would consider suicide again, so decided
to admit Jack to the psychiatric ward and place him on suicide precautions. An
orderly escorted the young man to the admitting desk, where the clerk took down
pertinent information. After that, Jack surrendered his valuables—a wallet with
no identification, $3 in cash, and an earring—and was escorted to a locked ward.

When they arrived at the door to the ward, the orderly took out an enormous
skeleton key, opened the large metal door, and escorted Jack inside.

The orderly brought him to the nurses’ station, a large semicircular area enclosed
in safety glass, where a half-dozen staff members were busily typing patients’
notes into the computers. Upon seeing Jack, a nurse exited the station,
introduced herself, and took him to his room, one of 15 down a long, bare
corridor reserved for male patients (female patients occupied an identical
corridor on the other side of the floor). At the room, the nurse gave Jack some
pajamas and a hospital-issue daytime outfit; she informed him that a relative
could bring another set of his own clothes tomorrow, if he preferred. She also
told Jack that she would have to take his shoelaces, since the admitting physician
had ordered suicide precautions, and she gave him a pair of slippers to use as
footwear.

After the nurse left, Jack flopped down on his bed and buried his face in his
pillow. An hour later, a house physician came by to give Jack a routine physical
examination, which seemed to perk him up a little. Jack greeted the physician
with a friendly, “Hi, Doc,” and the doctor examined the young man’s heart, lungs,
blood pressure, and other vital signs. To make conversation, he remarked on an
“interesting” tattoo that Jack had on his chest, a crude picture of a nude woman
striking a pose that left nothing to the imagination. With obvious pride, the
patient explained, “Yeah, I got it in honor of my girlfriend.” After the physician
left, Jack donned his hospital pajamas, got into bed, and slept soundly through
the night.

The next morning, he joined the other patients in the day area, where breakfast
was being served. As he took his place at the table, he announced that he was
“hungry as a horse,” and began chowing down with abandon. After he finished his
own food, he glanced over at a patient across the table and noticed that the man,
a patient with schizophrenia, had only nibbled at his eggs and toast. “Hey, old-
timer,” Jack called out, “you don’t mind if I take some of your grub, do you?” The
man just stared, glassy-eyed, while Jack, without waiting for a response, took his
plate and started scraping its contents onto his own dish.

The terms sociopathy and psychopathy denote a psychological pattern similar to
antisocial personality disorder, although some distinctions have been drawn

between these disorders. Typically, psychopathy is seen as a more severe form of
antisocial personality disorder (Coid & Ullrich, 2010).

Another patient sitting at the table reprimanded Jack for having taken the older
patient’s food. “We’re not supposed to share food. It’s against regulations.
Besides, that fellow is pretty sick. He’s been throwing up for days. You wouldn’t
want to eat anything he’s touched.”

Jack was unimpressed by the patient’s disapproval. “Who appointed you hall
monitor?” he asked. “I guess you want all the food for yourself. Well, sorry, pal, I
beat you to it.”

Antisocial personality disorder is as much as three times more common among
men than women. Women with antisocial personality disorder have been found
to have more frequent parent-related adverse events in childhood, such as
emotional and/or sexual abuse, and more adverse events as an adult (Alegria et
al., 2013).

Jack in Treatment Using Therapy to His Advantage

Later that morning, Dr. Selina Harris, a staff psychiatrist, arrived to conduct an
evaluation of Jack. Dr. Harris found the young man standing at a pool table in the
day area, playing a game of eight-ball with another patient. As soon as the
psychiatrist approached, Jack looked up and smiled. He had an appealing, cheerful
quality, and at first Dr. Harris wasn’t sure she had the right patient. She was
expecting someone deeply depressed, as specified in the admitting note. This
patient, however, was extending the warmest, happiest greeting.

“Hey, Doc. Good to meet ya,” he said. “I’m just shooting a little game of pool
here.”

Dr. Harris explained that she would be Jack’s doctor while he was hospitalized,
and had him accompany her to her office on the unit floor. Once inside, she asked
Jack to take a seat and told him that she wanted to know all about the troubles he
had been having and why he had been contemplating suicide. Jack confirmed that
he was “real depressed” and didn’t know if life was worth living. When the
psychiatrist asked what he was depressed about, the patient replied, “Everything
and anything.” He went on to explain that it was mainly his girlfriend but,

basically, he “just felt like giving up.” He said, “Frankly, Doc, it’s too painful to talk
about.” Jack didn’t look particularly pained, however.

Dr. Harris told him that they would have to discuss these matters eventually, if he
was to get any help. At this, Jack said he didn’t think that talking would do any
good. “Don’t they have meds for depression?” he asked. “What’s there to talk
about when all you got to do is take a pill? How about giving me some Prozac?”

“Did you ever take Prozac?” Dr. Hams asked.

“Me? Oh, no.”

“Did you ever take any psychiatric drugs?” she asked.

“No,” Jack insisted, “This is my first time in the loony bin, or even talking to a
shrink.”

“How about street drugs? Did you ever try those?” the psychiatrist asked.

People with antisocial personality disorder have higher rates of alcoholism and
substance-related disorders than do the rest of the population (Brooner et al.,
2010; Reese et al., 2010).

‘’To be perfectly honest with you, I have tried marijuana—but who hasn’t? I stay
away from the harder stuff, though.”

Since Jack would not discuss his depression, Dr. Harris tried a different tack,
asking the young man about his living situation, his work, and his family. Jack
replied simply that he had been living with his girlfriend, but “she’s real sore at
me now.” He explained that he had recently lost his job at a loading dock after
another employee had stolen some goods and then blamed the theft on Jack. Dr.
Harris tried to inquire more about that matter, but Jack said he was getting tired
and wanted to go lie down.

Before he departed, the psychiatrist asked him whether he was still having
thoughts of suicide. Jack replied that he was feeling more secure now that he was
in the hospital, and he was hopeful that Dr. Harris could help him. The psychiatrist
explained that, in order for her to help him, he would have to talk more about his
feelings. The patient promised that, in time, he would. He just had to develop “a
little rapport” with Dr. Harris first.

Jack got up and opened the door to leave, but then paused in the doorway as if
having second thoughts. He said he really appreciated the time that the
psychiatrist had given him, and hoped that they could talk more. As the young
man spoke, Dr. Harris observed his hand slip down the edge of the door, and push
the button that unlocked the door handle, allowing entry from the outside. For a
moment, she considered confronting Jack with what she had just seen, but
decided to let the matter ride.

Jack said goodbye, and after he had rounded the corner, Dr. Harris pushed the
button to lock the door once again. As it was getting late, she packed up her
briefcase and left for the day.

The next morning she sought Jack for another interview. This time she found him
seated in the television viewing area. He apparently was enjoying himself
immensely, laughing loudly at a situation comedy, while the other patients stared
glumly at the same set. As Dr. Harris approached, the young man looked up and
greeted her with a cheery, “Hey, Doc! I’ll be ready in a minute, as soon as this
show is over.” The psychiatrist waited for Jack in her office.

A few minutes later he ambled in, closed the door, and sat down. Then he began
telling Dr. Harris that she had upset him, that she had hurt his feelings by locking
her door after he had unlocked it; it showed she didn’t trust him. Going even
further, he told her that it was underhanded and dishonest of her. The
psychiatrist was momentarily dumbstruck. Jack was accusing her of dishonesty for
relocking her own door!

Twelve-month prevalence rates of antisocial personality disorder range from 0.2
percent to 3.3 percent. The prevalence is highest (up to 70 percent) among
individuals with substance abuse and criminal histories (APA, 2013).

“What were you trying to do by unlocking my door?” she asked.

Jack replied that he just didn’t like locked doors. “Speaking of which,” he added, “I
can’t take being cooped up in here all day and night. I know I was suicidal before,
but I think I’m coming out of it. Can’t I have grounds privileges?” Then he went
on, “Look, I’m sorry about the lock thing. It was a stupid prank I pulled. I’ve just
been upset about having to be in a hospital—even though I know I need to be
here,” he quickly added.

Dr. Harris explained that in order for anything to change in Jack’s hospital status—
the lifting of suicide precautions, conferring grounds privileges, or whatever—he
would have to discuss his situation more openly.

Jack’s attitude then changed, and he said he was ready to speak frankly. First, he
apologized profusely for any trouble he had caused. He said that if he was
sometimes crude, it was a front he had developed out of fear that others might
take advantage of him if he didn’t act like he could take care of himself. He
admitted to Dr. Harris that he had spent 6 months in prison for a “stupid petty
theft”; while in prison, he was bullied constantly because of his small stature. That
experience had hardened him, he said, and now he sometimes “acted like a jerk,”
even among people who had his best interests at heart.

Jack went on to admit that he hadn’t really considered suicide; he had simply
claimed that to gain admission to the hospital. In his opinion, however, it was no
exaggeration to say that he was at the end of his rope. He said that since being
paroled, he had had tremendous difficulty finding and keeping a job. He had tried
everything, from mechanic to electrician to drill press operator, at various auto
plants, but in each case he was laid off within a few weeks because of his low
seniority in the union.

In one study, clinical psychologists viewed videos of statements made by
individuals and evaluated their truth or falsehood. The clinicians were able to
identify 62 percent of the lies, a performance similar to that of federal judges
(Ekman et al., 1999). Interestingly, a more recent study discovered that men, but
not women, with high levels of psychopathy also performed better than chance in
terms of detecting real-life emotional lies (Lyons, Healy, & Bruno, 2013).

In addition, he explained, his mother’s heart condition had worsened
considerably, forcing her to be hospitalized. Because neither one of them was
now working, they lost their apartment. And his girlfriend, with whom he
sometimes lived, had gotten fed up with his losing jobs and his inability to
contribute to the rent, and had demanded that he leave. After being kicked out,
he had gone to a homeless shelter before being hounded out of there by
“ruthless thugs” who stole whatever money he had left. Feeling that he was losing
this daily struggle for survival, he had come to the hospital.

Jack said he was sorry if he had offended anyone with his charade for getting
admitted, but he felt he was suffering as much as any patient, and his false claim
of suicidal thoughts showed just how desperate he was. He said he felt he was
experiencing a “crisis of confidence” and he needed some intensive therapy to
help him through this period. “Look,” he concluded, “I could tell you that I still
want to commit suicide, but I’m trying to be honest with you now in the hope that
I’ll get the right kind of help.”

Dr. Harris listened to Jack’s story with an open mind. Although skeptical about his
claims, she decided against recommending immediate discharge. Instead, she
decided to proceed with a complete pretreatment evaluation, which included a
mental status exam, an electroencephalogram, psychometric testing, and an
occupational evaluation. His case conference would be held in 5 days, at which
point the treatment team would decide whether to discharge him or proceed
with treatment. In the meantime, the psychiatrist removed Jack’s suicide
precautions, but reminded him that he would still be restricted to the locked unit
for at least the next several days.

A mental status exam is a structured interview in which the clinician asks about
specific symptoms, such as anxiety or hallucinations; observes other symptoms,
such as emotional expression or motor activity; and tests certain cognitive
capacities, such as memory or abstract reasoning.

Jack thanked her profusely for “understanding” and said he would cooperate with
the evaluation procedures and make less of a pest of himself. During the next
several days, the patient seemed true to his word. He was well-behaved and
cooperated fully with all the evaluation procedures. But then, the day before his
case conference, he disappeared. The building was searched, but there was no
sign of Jack. A few hours later, Dr. Harris received a call from the state police
saying they had picked up a patient—obviously Jack—for possession of a stolen
vehicle, hers. Jack had also been charged with driving without a license, driving
while intoxicated, speeding, and failure to heed a stop signal. The police said they
were calling to investigate Jack’s claim that the psychiatrist had lent him the car.
Dr. Harris explained that she certainly had not done this, but was nevertheless
willing to drop any charges. The police replied that they already had enough

outstanding warrants on Jack to hold him “from here to doomsday,” and he was
arraigned on the other charges.

With Jack unable to return to the hospital, his next of kin—his mother—was
contacted to pick up his personal articles. His mother was in perfect health, in
spite of Jack’s dramatic story of her grave heart condition and recent
hospitalization. After picking up her son’s belongings, she spoke with Dr. Harris
and supplied some details about his background.

A Parent’s Tale Watching Antisocial Behavior Unfold

“In most of us, by the age of thirty, the character has set like plaster, and will
never soften again.”—William James (1890)

Jack’s mother, Marlene, told Dr. Harris that everyone who encountered Jack as a
toddler immediately fell in love with him. “He was such a sweet child, and he had
a smile that could win over anyone.” However, “as soon as he was old enough to
go to school, the trouble started.”

At about the time that Jack entered first grade, he seemed to develop a “thing”
for jewelry or, more accurately, for stealing it. For example, he would take items
from Marlene’s jewelry case and sell them one by one to classmates or to older
boys in the neighborhood, often for no more than pocket change, which he would
spend on candy or trading cards. Marlene and her husband learned what Jack was
doing after he tried to sell a pair of genuine pearl earrings to his second-grade
teacher for $5.00. At first, his parents just scolded him. When the behavior
continued, the scoldings turned into beatings. Eventually, they decided that the
only way to deal with the situation was to keep their valuables—bills, coins,
jewelry—under lock and key.

Jack’s parents provided him with a generous allowance in an effort to reduce his
desire for spending money. However, this desire could never be satisfied. By the
age of 8, the boy began breaking into neighbors’ houses to steal items to sell. In
many ways, he became quite ingenious in these break-ins. He learned to pick
locks, disable alarms, and slip into small openings. At the same time, however, the
way in which he would dispose of the stolen items often seemed remarkably
stupid, according to his mother. His most spectacular bungle occurred when he

tried to sell jewelry to members of the very same household from which it was
stolen.

This triggered his first arrest, at age 10, but he was remanded to the custody of
his parents, who told the judge that they would figure out a way to control him.
They did indeed try to control his antisocial ways by keeping a more careful eye
on him. When Jack went to school, for example, they would actually escort him
into the building to make sure that he was attending classes. But the boy was not
beyond slipping out in the middle of the day, inevitably to get into some kind of
trouble.

Jack’s stealing soon took a more serious turn. He joined up with a group of
teenagers who made a profession of shoplifting. They saw in Jack an opportunity
to acquire stolen goods with a reduced risk of detection, since Jack was much
younger and less likely to be suspected. Typically, one of the teenagers would
case a store, locate items of interest, and then send Jack inside to remove the
items according to their instructions. The gang would then sell the items to a
regular fence who paid them in cash, drugs, and alcohol.

Associating with these older boys led Jack to develop more varied and
sophisticated interests and a precocious sexual awareness. The turning point in
his antisocial career came when, at age 12, he lured a 10-year-old neighborhood
girl into some woods behind her house, undressed her, and tried to perform sex
acts with her. When she started screaming, her mother came running and was
confronted with the horrifying scene. Jack at first claimed that the girl had lured
him into the woods. When that didn’t work, he offered the girl’s mother $5.00 “to
keep her mouth shut.” As it became apparent that the woman was not warming
to the negotiations, 12-year-old Jack finally tried threats, telling the mother she
had better take the money or she would get the same treatment.

With this incident, Jack entered the world of serious legal trouble and was
sentenced to a year in reform school. There, he learned more advanced methods
of taking advantage of others. As soon as he was released, he embarked on a
career of auto theft. He could now hot-wire a car in 30 seconds, and would do so
whenever he needed cash or transportation. Why take the bus, he reasoned,
when there were cars all around? Jack’s mother estimated that he hot-wired 50

cars before finally getting caught in the act, leading to another term in reform
school, this time for 2 years.

Antisocial personality disorder was called “moral insanity” during the nineteenth
century.

When he was released, at almost 15 years old, his parents tried to persuade him
to return to school and pay enough attention to his studies to get a high school
diploma. The teenager agreed to attend a trade school to learn how to repair
electrical systems and electronic components. His mother now realized that her
son had probably favored this route because he had hoped to become more
skilled at disabling alarm systems; also, with electronics training, he thought he
might get jobs that would bring him into contact with equipment worth stealing.

Jack actually stayed with his electrical studies, and after receiving his certificate at
age 17 found employment at an auto plant, assisting in the installation of
electrical systems. He seemed to work hard for several months, and Marlene
marveled at his capacity to apply himself. But it all came to an end when he was
later caught stealing electrical supplies on a massive scale. Somehow, he had
gained access to the plant’s supply depot where he had been removing switches,
wiring, batteries, and other electrical supplies for sales to competing auto plants.
He eventually got caught when, in a manner reminiscent of his childhood error,
he tried selling some of these supplies back to his own plant.

Thus, at age 18, Jack was sentenced to 3 years in a state penitentiary. Not being
the violent sort, he was paroled after 18 months for good behavior. Upon his
release, he stunned his former colleagues by applying for employment at the very
same auto plant where he had been caught stealing. He expressed outrage and
hurt, seemingly sincere, when they refused to take him back. For the next several
months, Jack hitchhiked around the country, bouncing from one job to the next.

People with antisocial personality disorder tend to respond to warnings or
expectations of stress with low brain and bodily arousal, such as slow autonomic
nervous system arousal and slow electroencephalogram waves (Gaynor & Baird,
2007; Perdeci et al., 2010). This may help explain the inability of many such
individuals to experience constructive levels of fear or to learn from negative
experiences.

As for his love life, Jack’s mother reported that he had been married at least
twice, although she doubted he had ever been divorced. He met his first wife at
age 21, while hitchhiking around the country after his release from prison.
Marlene had never met the woman, but learned from Jack that she was a 45-
year-old divorcée who had picked the young man up as he was hitchhiking
through her town. Jack later told his mother that this woman completely repulsed
him: she was dull and unattractive, according to his description. Nevertheless, he
felt a sexual stirring while riding in the car with her and proposed sexual
intercourse. The woman replied, half teasingly, that he would have to marry her
first. Jack immediately agreed, and they drove nonstop to a western state where
they found a justice of the peace to perform the ceremony. Then they paid for a
motel room where Jack got what he’d asked for hours before.

The next morning, the couple drove back to the bride’s hometown, and Jack
moved into her house. He resided there for a few weeks, until she started nagging
him about finding work. At this, he decided he had hung around long enough, and
he departed for home, hitchhiking and hot-wiring his way there.

Once back in his home state, Jack acquired several girlfriends, one of whom he
married under similar circumstances. In each such involvement, Jack showed no
concern about the age, appearance, or character of the woman. Rather, his
interest in women seemed largely a matter of housing and, to a lesser extent, sex.
No sense of love or attachment was ever involved.

At the time that Jack had sought admission to the psychiatric hospital, he was,
according to his mother, in truly desperate straits. She and Jack’s father—fed up
with having to hide their valuables constantly—had refused to allow him entry
into their home and his latest girlfriend had locked him out. Marlene suspected
that in seeking hospital admission, her son was simply looking for a place to stay,
although he may also have considered the prospect of obtaining psychiatric drugs,
either to use or sell, as an added bonus. Typically, Jack would become bored with
his schemes when they could not be executed immediately; this was probably
why he ran off with Dr. Harris’s car rather than continue his stay at the hospital.
Marlene, an old hand at Jack’s behaviors, encouraged the psychiatrist not to take
the car theft personally, explaining that he probably chose her vehicle only
because her name on the reserved space had caught his eye.

A number of structural brain abnormalities have been found among individuals
with antisocial personality disorder and psychopathy (for example, deficits in the
frontal gray matter, amygdala, uncinate fascisculus, and hippocampus, and
increased size of the corpus callosum). Although consistent differences have been
difficult to find, researchers are now able to identify structural brain differences
between “successful” and “unsuccessful” psychopaths (that is, the ones who
don’t get caught and the ones who do) (Pemment, 2013).

Jack’s mother then signed for her son’s belongings—the wallet, the $3, and the
earring—and departed.

Jack No Success with Therapy

Marlene’s departure marked the end of Dr. Harris’s involvement with Jack. The
young man had left the psychiatrist’s professional life as suddenly as he had
entered it. And the therapist was certain she had made little or no impact on him.
This failure of treatment did not surprise her, although it did cause her
disappointment. During her short time working with him, she had come to
suspect that Jack manifested antisocial personality disorder, a pattern that is
notoriously unresponsive to treatment. Based on her talks with Jack and with his
mother, Dr. Harris felt that he clearly met the DSM-5 criteria for a diagnosis of this
disorder. That is, he failed to conform to social norms; also, he was deceitful,
impulsive, reckless, irresponsible, and remorseless. And, as the DSM-5 criteria
stipulate, he would have met the criteria for conduct disorder well before the age
of 15.

The DMS-5 requires that there be evidence of conduct disorder prior to the age of
15 in order to meet the diagnostic criteria for antisocial personality disorder.

Although many people with this personality disorder exhibit criminal behavior,
their brand of criminality is often marked by idiosyncratic qualities. For one, their
criminal acts often seem to be inadequately motivated. The individual may, for
example, commit a major crime for very small stakes. In this regard, Dr. Harris
recalled that Jack tried to sell his mother’s pearl earrings for $5. Also, the criminal
acts of these individuals often seem to be committed without much sense of self-
preservation. They may fail, for example, to take obvious precautions against
detection when carrying out their crimes. Here, again, Dr. Harris recalled Jack’s
attempts to sell items to the very source from which they were stolen.

In short, Jack showed the disorder’s classic overall pattern of long-standing …

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 New York, NY: Worth Publishers. Retrieved from https://redshelf.com.Case 14: Antisocial Personality Disorder.