Of Paradoxes, Politics, and Patient Needs: Why Professional Stasis Hurts the Nation

Photo of Morgan T. Sammons, PhD, ABPP, who wrote this article.

This month’s issue of Health Affairs has a couple of articles of extraordinary importance to psychologists—with the paradox that the word “psychologist” appeared only once in either article.

Why is this a paradox? Let me give you a teaser: “One established driver behind…unmet need is a shortage of specialty mental health providers with prescribing privileges, such as psychiatrists…Between 2003 and 2013 the number of psychiatrists per 100,000 US population declined 10.2%. The shortage is projected to widen over time, with a projected national shortage of 14,000-31,000 psychiatrists in 2024” (Cai et al., 2022). As you might expect, there was a counterpoint to the decline in psychiatrists’ numbers: an extraordinarily rapid increase in the number of psychiatric mental health nurse practitioners. As you also might expect, there is not a single mention in the article of psychologists with prescriptive authority. One can’t really blame the authors for this omission. Despite the fact that five states, the DoD, and the IHS have allowed prescriptive authority by psychologists, there simply aren’t enough of us (as yet) to make a difference.

But let’s look at what happens when another profession takes the revolutionary step of increasing their scope of practice. Here is what Cai and colleagues found: from 2011 to 2019, the number of advanced practice nurses grew from 4,546 (slightly fewer than the number of doctorates in psychology produced every year) to 11,929, an increase of 162 percent, and the number of office visits by nurse practitioners more than doubled. Psychiatrist numbers dropped 6%. In the same issue of Health Affairs, Spetz and colleagues discovered that the vast majority of the increase in numbers of providers able to provide buprenorphine treatment to opiate dependent patients was driven by nurse practitioners and physician assistants.

What these articles, in spite of the truly jaw-dropping numbers they report, do not capture is the number of beneficiaries who received psychotherapy along with medication. I will be bold enough to suggest that psychotherapy was offered far less frequently than medication services. It must be said that mental health nurse practitioners have a background in nursing, and this gives them a more holistic perspective than those trained in allopathic medicine, so there is a somewhat higher chance that their patients received systematic psychotherapy along with medication than had they been treated by a psychiatrist. At the same time, no profession (bar none) has more in-depth training in psychodiagnosis and psychotherapy than doctoral-level health care psychologists. We are, then, depriving millions of patients who will likely benefit most from combined therapy from the very thing that’s likely to lead to improved health. We are. All of us, but especially psychologists.

Psychologists who oppose prescription privileges for the profession are doing far more damage to patient care than they realize. By refusing to admit that psychologists can, with modest additional training, be well prepared to provide this service, they ignore the fact that prescribing psychologists can provide the service patients need most—a combination of pharmacological and psychotherapeutic interventions, which for most disorders is a superior treatment to drugs alone. By arguing against allowing some psychologists to seek prescriptive authority, they are doing the profession a disservice, essentially cutting off their professional noses to spite their faces. But even if we don’t care what their faces look like afterwards, we should care what happens to the many hundreds of thousands of patients who go without adequate treatment because of opposition to prescriptive authority from both within and outside the profession.

Psychiatry has held for decades that either there really isn’t a significant shortage of psychiatrists or that while a shortage might exist replacement troops are on the way in the form of substantially increased enrollment in psychiatric residencies. Neither of these assertions is true. There are not and there will never be enough psychiatrists to adequately treat the number of citizens with mental disorders, period. There certainly are not sufficient numbers of child and adolescent psychiatrists, whose low numbers reveal them to be no more than a statistical anomaly and not a significant addition to the mental health work force, no matter how badly their services are needed. Nor will there ever be enough adequately trained prescribing psychologists, nor will there ever be enough psychiatric mental health nurse practitioners. This is a national crisis that calls for new thinking and new collaboration by all mental health professionals. It’s time to leave these disputes behind and unite to create a uniform, expedited curriculum for mental health prescribers. The allopathic model for the treatment of mental disorders has never been demonstrated to be uniquely effective, and given the length of training involved it certainly isn’t a desirable model to adopt in the face of a nationwide crisis. Non-allopathically trained nurse practitioners have assertively demonstrated this by treating increasingly large numbers of patients with positive outcomes. A small number of willing participants from psychiatry, psychology, and nursing (and perhaps other professions) could easily develop a curriculum to train a larger number of mental health prescribers.

Nothing other than revolutionary thinking about education, training, and scope of practice of psychologists and other mental health practitioners is going to allow us to create a sufficient pipeline of providers to meet the need. Yet few if any of our leading educators or policy makers seem willing to engage in this kind of thinking. This is disastrous for our future. Whether or not you philosophically agree with prescriptive authority for psychologists, Pat DeLeon did something truly revolutionary when he advocated for acquisition of this skill for the profession (and that’s all it is—it’s not a different profession, it’s simply the acquisition of another tool psychologists can use to treat patients). Hundreds of psychologists in the DoD, HIS, and five states have heeded that revolutionary call.

But that’s not sufficient. Most of us do not have the flexibility of abandoning or curtailing our established careers to do something revolutionary, say, like pursuing a post-doctoral masters in psychopharmacology. So it’s up to our leaders to make the revolutionary commonplace and more broadly accessible to members of the profession—for example, by including much of postdoctoral training in psychopharmacology in the doctoral curriculum. Whether or not it is psychopharmacology or the acquisition of another skill set that will extend our scope of practice, our leaders in education and policy have not proven able to meet this challenge.

It’s not just our leaders in academia and accreditation that must take heed. In our inefficient, state-centric patchwork quilt scope of practice system, the nurses understand that only effective advocacy at the state level will expand scope of practice, and no one but a state-level professional association (with appropriate assist from national practice organizations) can make this happen. Yet professional psychologists seem to be abandoning their state associations at the very time we need their legislative advocacy most. So it’s up to each and every one of us—on behalf of future psychologists and the millions of Americans who go without needed mental health services every year—to hold ourselves accountable for the future of our profession and to ensure that our leaders make the needed revolutionary steps in our education and training to do so.

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