Winston Churchill famously declared, “Americans will always do the right thing … after they’ve exhausted all the alternatives.” This statement may be even truer in today’s hyper partisan political environment. Churchill’s comment points to the role of advocates in helping policymakers to select and implement effective solutions. Psychologists, as members of a helping profession, are naturally drawn to advocacy on behalf of public well-being and have the skills to succeed as advocates. Yet, many perceive advocacy as “confrontational,” “irrational,” or “unseemly” and, as data presented later will show, psychologists are more averse to political giving than others among health professions.
One of the messages of this chapter, however, is that advocacy takes many forms, most of which are well-suited to the skillsets of psychologists. This chapter gives a brief overview of the motivations and methods of policy advocacy, and helps students and early career psychologists identify ways to engage and integrate advocacy into core professional duties. As professionals serving the public well-being within a representative system, advocacy is one our most important responsibilities to society, the profession, and ourselves.
1. Why Advocate?
Advocacy is the process of influencing policymakers when they make laws and regulations, distribute resources, and make other decisions that affect peoples’ lives. The principal aims of advocacy are to establish, reform, and manage policy implementation. Bruce Reference JanssonJansson (2003) describes three rationales for advocacy that can be categorized as societal values, analytical (or scientific), and political. Given the intellectual underpinnings of psychology training, many psychologists are naturally drawn to societal and scientific motivations, but the political are just as important, if not more so. Ideals and top-notch research are inadequate without action, and political processes (e.g., legislative, regulatory, and other policy-making institutions) are the means to drive change. Integrating societal, scientific, and political considerations toward a common objective can result in powerful contributions to policy making. The societal, scientific, and political rationales are described below within the context of psychology (Figure 22.1).
Figure 22.1 Effective policy advocacy combines societal, scientific, and political rationales for change.
1.1 Societal Rationales
Psychologists are obligated by professional ethics principles and codes of conduct to protect and enhance the wellbeing of individuals and groups. Principles of beneficence, non-maleficence, justice, integrity, and respect for people’s rights and dignity underlie a fundamental responsibility of psychologists to inform and improve public institutions, laws, and cultural influences. Psychologists may engage in advocacy to address issues of individual and professional autonomy, freedom, equality, due process, and societal or collective rights, and to enact visions of a just, humane society.
1.2 Analytical (Scientific) Rationales
Psychologists are trained to evaluate and use empirical data to guide careful and considered decision making. Our ethics code compels psychologists to avoid endorsing or perpetuating assumptions, stereotypes, and falsehoods that harm clients and society. Many psychologists regularly engage in analytical advocacy through research and publishing, as well as debating and dialoguing with others in scientific communities, civic organizations, and the media.
1.3 Political Rationales
Living in a representative government requires an acceptance and awareness that power is unequal and often biased towards special interests groups, corporations, and institutions that have the ability to influence policymakers through large amounts of money and time. Ignoring this reality and failing to engage the political process cedes power to those interests, and allows decision making to be driven by narrow, often short-term, interests that do not support the values and well-being of society.
2. Overview of Advocacy Process
2.1 Identify Problems, Pressure Points, and Solutions
The above rationales provide the foundation to outline and develop an effective advocacy strategy. Societal, scientific, and political considerations should be outlined to evaluate the causes, determine the pressure points, and delineate possible policy solutions. Thinking broadly and flexibly about the causes will help to identify a range of solutions to the policy issue that will be advantageous at different points in the advocacy process. As will be discussed below, opportunities to influence policy making are typically indirect, disjointed, and build upon each other over time to construct a cohesive policy solution. It is critical to thoroughly identify the multitude of factors impacting the policy issue in order to effectively prioritize advocacy activities, and to be prepared for planned and unexpected opportunities (Figure 22.2). Table 22.1 provides a list of questions to consider when outlining the policy problems and needs.
Figure 22.2 Model for developing advocacy plan.
Table 22.1 Outline policy issues
3. Frame the Issue in Simple Terms, then Support with Data
Mark Twain said, “There are three kinds of lies – lies, damned lies and statistics.” Today, it seems we are inundated with another kind of lie: half-truths. Media, interests groups (including professional societies), lobbyists, and politicians abound with half-truths. Debates over policy frequently get stuck on problem assessment and defining the “facts” of the issue. The consequence is that policymakers tend not to move toward problem-solving or proposing solutions when unsure of the facts or key issues to address. Information overload and misuse increasingly overwhelm policymakers and their staff, and paralyze decision-making bodies as interests groups and leaders willfully exacerbate confusion about the problem or the solution. In the meantime, the public suffers the consequences – failing schools; large numbers of uninsured and underinsured; increasing threats to environmental sustainability; and disgust and distrust of public institutions.
Framing the issue, preferably with a human interest angle, is critical to focusing the conversation on the desired policy goal. The above analysis of the policy, community, and political environments provides important information on the motivations and pressure points of key stakeholders. Interest groups and lobbyists succeed when they focus policymakers on what is and isn’t relevant to the issue at hand, bringing clarity to complexity. A powerful vision of the ideal outcome also helps direct the conversation, constrain misuse of data, and filter conflicting information from interests groups and lobbyists.
Within the legislative setting, research data are rarely the final impetus for decision-making but, instead, are more frequently used to support decisions based on other factors. Understanding this basic difference between the role of research data in science and the policy world is an uncomfortable but very important lesson for many psychologists. If psychologists want to put research findings “into play” for policy deliberation, data need to be introduced, explained, or framed in the context of current political exigencies. Through relationship building and persistent engagement, psychologists can begin to educate legislative and executive branch staff on the importance and long-term benefit of data-based decision making derived from quality data. This is a long-term process that underscores the value of fostering a responsive, credible, and steadfast relationship with legislators and administrators so that they will think of and turn to psychologists for assistance in developing and implementing health policy. Data alone almost never motivates change, but when presented within the right framework or vision, data can provide the reassurance and additional justification to change.
3.1 Identifying Spheres of Influence
Psychologists advocate through multiple levels of government to protect and advance the interests of the profession and the populations we serve. Advocacy at local and state levels can be sufficient to address immediate issues of the community, but it is often necessary to engage federal legislative and regulatory processes to address systemic or long-term policy issues. It is helpful to differentiate between primary and secondary target audiences for advocacy activities. Primary audiences include government officials (elected, political appointees, and civilian employees) who have direct decision-making authority, whereas secondary audiences are individuals who can influence the activities of the primary audience. Secondary audiences include lobbyists, interest groups, business leaders, friends, family, or anyone who can provide a way to reach the primary audience that may not be directly available to you. Secondary audiences can include policymakers as well, such as members of Congress who lobby colleagues on key committees or an elected official with oversight and strong connections to an Executive agency.
Table 22.2 provides a framework for identifying key individuals at the local, state, and federal levels. Delineating primary and secondary individuals for each of these areas will help prioritize efforts, identify a timeline for known opportunities, and be ready for unexpected opportunities at different levels of government and community engagement.
Table 22.2 Sample table for documenting key policymakers
| Local | State | Federal | |
|---|---|---|---|
| Legislative branch | |||
| Executive agencies | |||
| Courts | |||
| Allied organizations, foundations, coalitions | |||
| Consumers, public opinion | |||
| Media, PR firms | |||
| Interest groups, lobbyists | |||
| Organized political groups (PACs, unions) |
3.2 Process is Important, but Relationships are Essential
There are an average of 11,000 bills per year introduced in each Congress over the past 45 years, with less than 5 percent becoming law, on average (www.govtrack.us/congress/bills/statistics) and the number of bills passed has declined over the past two decades (Reference TaubererTauberer, 2011), in part because of the increasing use of omnibus legislation to combine multiple measures into one bill. Omnibus legislation is compiled by Congressional leadership in closed-door meetings and the content can be disparate and sweeping. Measures can also be attached as riders to popular or expedient legislations. For example, the recent Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 was signed into law, after a decade of advocacy (Reference RovnerRovner, 2008), when it was attached to the $700 billion Troubled Asset Relief Program under the Emergency Economic Stabilization Act of 2008 (division A), which also included the Energy Improvement and Extension Act of 2008 (division B), and two tax relief acts. In contrast, the number of ceremonial bills (naming post offices and other federal buildings) has risen dramatically, as has the number of bills introduced as a way of establishing a public position on an issue or making a symbolic gesture.
A basic high school civics lesson on how a bill becomes law is clearly insufficient to effect substantive, timely policy change. In fact, most legislators spend a great deal of time finding ways to subvert or work around the process. Psychologists should certainly understand the legislative, regulatory, and judicial processes and timelines (see valuable policy resources below that describe important decision points), but knowing the specific agenda and styles of key policymakers is often more important than the process. Maintaining existing and accessible relationships with legislators is critical to moving policy forward at the right time and place.
Policymakers are human beings, not institutions, and accordingly, personal connections are essential to being heard in advocacy. Fortunately, psychologists are uniquely trained to establish supportive working relationships, to work with individuals across a diversity of perspectives, and to understand the need for compromise. However, being a cerebral profession, there is often a failure to appreciate that it is not the intellectual strength of an argument, nor the persuasiveness of a white paper or written testimony, that will carry the day with legislators. Rather, with all politics being local, nurturing ongoing, productive relationships with policymakers is extremely important. Relationships with key policymakers cannot be forged by one visit to the legislators’ offices, one appearance before a legislative committee, or only engaging with policymakers during times of crisis and need. For our expertise to be appreciated, psychologists must regularly engage in policy debates, participate in political process, and be active in community and media activities that influence policymakers.
3.3 Vision and Persistence
A vision of your ideal state of affairs serves as a driving and reinforcing inspiration for your advocacy activities. Advocacy is rarely linear, and progress is often experienced as a series of victories and setbacks, or more typically, a series of modifications and interpretations of policies by different levels of government and private-sector organizations. Change can also be unsettling, and advocates should expect resistance from policymakers and institutions, even from colleagues. As a result, advocates cannot always perceive personal or even tangible benefits in the outcomes of their efforts (Reference DeLeon, Loftis, Ball and SullivanDeLeon et al., 2006).
In addition to serving as a meaningful framework to make sense of data and how to motivate policymakers, having a long-term vision provides insights on when to apply pressure and share expertise. It is also important to develop a vision for both personal and professional activities in order to identify advocacy strategies that can be incorporated comfortably and reliably into professional duties and sustained over the long haul. Advocacy works best when it is integrated into core roles and responsibilities.
Psychology has been at the forefront of healthcare integration for decades, well before recent reform initiatives ballyhooed integration as a means to simultaneously improve outcomes and reduce costs. The “health and behavior” (H&B) Current Procedural Terminology (CPT) codes, established in 2002, illustrate the profession’s commitment to advancing the practice of psychologists in service of the public well-being. H&B codes allow psychologists to bill for behavioral, social, and psychophysiological services provided to patients with physical health (rather than mental health) diagnoses. Before these codes were implemented, reimbursement was limited in the general health care sector for psychological work with patients without a mental health diagnosis. Developing these new codes involved the combined efforts of the American Psychological Association and the Interdivisional Healthcare Committee (IHC), representing APA divisions 17, 22, 38, 40, and 54. The number of H&B claims submitted by psychologists to Medicare increased over 625 per cent from 64,000 claims in 2002, the first year they were available, to almost a half million claims for H&B services in 2010, rising from $1.56 million in reimbursement for these services to $8.1 million. As a result of many years of advocacy to Medicare and the American Medical Association (which owns and oversees code development for the CPT), these codes constitute a milestone in the recognition of psychologists as health care providers. Further, the codes have positioned psychologists to play a central role in defining and implementing evidence-based practices and integrated care models.
3.4 A Note on Political Gift-Giving
Elections are expensive, and getting more expensive every year. Despite promises of cheaper social networking technologies, grassroots networks still require significant financial investment in order to successfully impact elections. Moreover, campaign advertising is an effective and proven method for winning elections, even more so as access to good and bad information has increased exponentially during the internet age. Representatives campaign and fundraise continuously during their two-year terms, perhaps more than they have time to legislate. Many work nights and weekends, sometimes going weeks without seeing loved ones, to fundraise and meet with constituents. As a result, they kindly remember and feel ingratiated to individuals who help elect and re-elect them. This is likely to remain true regardless of fixes to campaign finance reform, redistricting, term-limits, etc. In a free market society, money will always play a large role in elections.
It is an extreme disadvantage, then, that psychologists rank toward the bottom of professionals that support campaigns, even among healthcare professions with fewer members. Table 22.3 compares political gift-giving among healthcare associations (Government Relations Office, American Psychological Association Practice Organization, personal communication, December 20, 2011). Although the American Psychological Association (APA) and the Association for the Advancement of Psychology (AAP) have made significant strides in this area, the table demonstrates that the profession could be a much stronger player if more psychologists donated to political campaigns, and even more so if the average donation increased only five dollars.
Table 22.3 Comparison of political giving among healthcare professions
| Profession | 2018 PAC Contributions1 | Median Pay |
|---|---|---|
| American Psychological Association | $170,515 | $88,3502 |
| American Speech–Language–Hearing Association | $451,920 | $79,1203 |
| American Occupational Therapy Association | $358,135 | $84,9503 |
| American College of Surgeons | $973,647 | $547,8302 |
| American Psychiatric Association | $483,716 | $306,1002 |
| American Physical Therapy Association | $1,169,679 | $89,4403 |
| American Chiropractic Association | $237,355 | $85,0103 |
| Society of Interventional Radiology | $137,600 | $553,3302 |
| American College of Obstetricians and Gynecologists | $1,240,908 | $233,6103 |
| College of American Pathologists | $432,005 | $351,9002 |
| American Academy of Ophthalmology | $1,130,121 | $203,4503 |
| Society of Thoracic Surgeons | $315,678 | $603,7702 |
| American Society of Plastic Surgeons | $349,737 | $548,0702 |
| American Association of Neurological Surgeons | $434,205 | $882,9902 |
| American College of Radiology | $2,479,437 | $63,1203 |
| American Association of Orthopedic Surgeons | $2,641,958 | $688,3702 |
| American Academy of Dermatology Association | $1,440,651 | $467,3502 |
Source:
1 = Federal Election Campaign data, www.opensecrets.org/political-action-committees-pacs/2018;
2 = 2020 Medical Group Management;
3 = Bureau of Labor Statistics data from 2019 Occupational Outlook Handbook, www.bls.gov/ooh/ (all sites accessed December 15, 2020); PAC = Political Action Committee.
Even with the most compelling issues and best data, psychologists first need to get in the room and build the relationship. While legislators certainly value expert input, legislators are more receptive to those who can also alleviate the time and energy devoted to campaigning. Dismissing this reality as corrupt or unseemly is neither accurate nor helpful. Legislators want to make a difference and contribute to society, but first they have to get in and stay in office. Referring back to the three rationales for advocacy, psychologists are widely respected for our academic credentials, science-based discipline, and commitment to the public good, but psychologists do not have a good track record of demonstrating political will.
4. Getting Started
4.1 Partnerships
Although Hollywood glamorizes the power of forceful individuals who change the system, our political system is constructed to respond to groups of people. This is truer today as policymakers struggle with information overload. A groundswell of public support will always be more compelling than one vocal citizen.
Joining professional associations and interest groups is an ideal way for students and early career psychologists (ECPs) to become active in local and national advocacy. The APA with 54 divisions and 60 affiliated state, provincial, and territorial associations (SPTAs), as well as the Association for Psychological Science (APS), all provide a variety of ways for students and ECPs to engage in advocacy. These associations support grassroots networks; organize Hill Days for psychologists to lobby legislators; host annual leadership conferences that provide advocacy training and facilitate relationships with legislators; and produce e-newsletters to update members on recent policy activities and opportunities to participate. Several societies also offer Congressional and Executive fellowships for ECPs, including the APA, Society for Research in Child Development, and American Association for the Advancement of Science.
APA Divisions and SPTAs are also a great way to participate in advocacy focused on specific issues of direct personal and professional relevance. The APA website provides links to the SPTAs and divisions, as well as regional organizations. APA also supports advocacy networks focused on specific areas of psychology, such as the Federal Education Advocacy Coordinator (FEDAC) grassroots network. In addition, APA, APS, and many SPTAs are affiliated with 501 (c)(6) organizations that can support advocacy networks, engage in fundraising activities, and have expanded capabilities to pursue policy activities (see web resource below for links).
Almost all of these associations also publish online advocacy guides that outline the legislative and regulatory processes relevant to psychology and provides guidance on different advocacy tools. APA has a central advocacy site that lists APA’s current priorities and provides examples of advocacy by letter writing, emails, phone calls, and media interviews (www.apa.org/advocacy).
4.2 Student Advocacy
The American Psychological Association of Graduate Students (APAGS) Committee is charged with assuring the “student voice” is heard within the APA governance system. As the world’s largest organized group of psychology graduate students, APAGS leadership is comprised of both elected and appointed committee members who are responsible for advocating on behalf of the APA student membership. Its governance structure (see www.apa.org/apags/governance/index.aspx) provides a variety of opportunities for involvement, including a Campus Representative program and an Advocacy Coordinating Team (ACT) that supports graduate student participation in federal and state legislative advocacy through collaboration with the APA Services, Inc., a 501 (c)(6) organization focused on advocating for the profession of psychology.
5. Policy-Relevant Resources
5.1 APA Services, Inc. (www.apaservices.org/advocacy)
A 501 (c)(6) companion organization to APA that advocates on behalf of the entire discipline and profession of psychology, supports candidates who have demonstrated their commitment to psychology and psychologists, and promotes psychology-informed federal policy, legislation and research.
5.2 A Psychologist’s Guide to Federal Advocacy (www.apa.org/advocacy/guide/federal-guide.pdf)
This guide, published by the APA, provides general guidelines for advocacy by psychologists, including an overview of the legislative procedures and committees relevant to psychology.
5.3 Bazelon Center for Mental Health Law (www.bazelon.org)
This site is a rich source of information for those psychology students interested in the interface of mental health and the law.
5.4 Directory of State, Provincial and Territorial Psychological Associations (SPTAs) (www.apa.org/about/apa/organizations/associations)
APA Services, Inc. works with its 60 affiliated SPTAs on a broad range of issues affecting the professional practice of psychology.
5.5 National Council for Behavioral Health (www.thenationalcouncil.org)
The National Council represents over 3300 behavioral health organizations (e.g., Community Mental Health Centers) and has an active advocacy agenda supporting recovery and inclusion for individuals with a wide range of addiction and behavioral health disorders.
5.6 PsycAdvocate (www.apa.org/ed/ce/resources/psycadvocate)
Highly interactive advocacy training modules that are available for continuing education credit. Information is in a dynamic learning format that includes interactive Q&A, demonstrations and links to key policy resources.
5.7 Thomas: Legislative Information on the Internet (http://thomas.loc.gov/)
The Library of Congress sponsors this site, and it is an invaluable resource for anyone interested in understanding federal legislation. The site contains clear descriptions of the legislative process, detailed information on roll call votes, listings of the composition of all House and Senate Committees, and easily accessible links to the home pages of all members of Congress. Students can also look up the status of individual bills, searching by number or key words (for example, typing in “Psychology” as a key term will pull up all bills in which the profession and practice of psychology is specifically addressed).
5.8 USA.gov (www.usa.gov)
As the official web portal of the United States federal government, this site is designed to improve the public’s interaction with the US government by quickly directing website visitors to the services or information they are seeking, and by inviting the public to share ideas to improve government.
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