In the relatively near future, the absence of a substantial increase in the unification of clinical psychologists, especially those who practice psychotherapy, will lead to our permanent place as adjuncts to those professionals who provide comprehensive behavioral health care to their patients. There will be little practical, societally recognized difference between a psychologist and any other clinician offering psychotherapy. We are way past the time when we need to aggressively address the problem of the weakening of the position of psychologists in the arena of mental health care.
Let me be clear, I believe in the efficacy of psychotherapy and, as a researcher, have seen the failure of efficacious psychopharmacologic agents because of the absence of psychotherapy in a patient’s treatment plan. I also believe that no other profession is as prepared as are psychologists in the provision of psychotherapy. In my view, no other profession offers the range of unique, evidence-based skills for patients suffering from behavioral health disorders. The major problem is that we have failed to make our case to legislators, insurance executives, others with authority over our profession, and our society at large.
My Journey to Psychology
Experience determines perspective, so, first, allow me to reveal my journey to psychology. I am a psychologist and identify as a psychologist. I saw my first patient as a nurse around 1959. Having trained as an army medic, I qualified to meet the requirements as a LPN and this enabled me to work my way through college. Once I graduated, not knowing exactly what I wanted to do, at the suggestion of a friend, I decided to apply for an MSW. Like nursing, there were very few males applying to schools of social work and, as a result, I was quickly accepted.
Over the course of earning my social work degree, my interest in things clinical blossomed and, as a result, decided to seek a DSW. It is important to note that this was before psychologists were licensed in Massachusetts. My clinical interests grew even more over the time it took to complete my DSW and, about a year later, I enrolled in a full-time two year fellowship program in neuropsychology. That piqued my interest even further and, as part of my fellowship program, I was allowed to enroll in a number of medical school courses.
In the absence of licensure and the general absence of insurance reimbursement, I figured that was enough. I considered finishing medical school for a change in identification to psychiatry but it just didn’t seem to make sense at the time. In those days of psychoanalytic dominance, it did not appear to be a road that was necessary to travel.
Then came psychology licensing. With a doctorate in an allied field and completion of a neuropsychology fellowship, I met the “grandfathering” requirements to be a psychologist. The transition from social work to psychology was easy. The next major occurrence was Medicare’s acceptance of psychologists as reimbursable mental health clinicians. The problem was that Medicare’s requirement was for a Ph.D. Much to my chagrin, at the time, there was no choice but to earn a Ph.D in psychology.
Completing that, I was able to continue in my chosen career as a psychologist and be paid by Medicare. Then, good grief, the movement for psychologists to prescribe came about, requiring additional post-doctoral coursework. I figured it was just as easy to go back to medical school and finish my MD, which I did.
Surely, having an MD would have to be the equivalent of post-doctoral training for psychologists and, when prescriptive authority came to Massachusetts, I could not imagine I would not qualify! Alas, prescriptive authority never came to Massachusetts. I did not do an internship or residency, though I was fully qualified to do so. Alternatively, I chose to maintain my identification, with pride, as a psychologist and, now, on documents that need the clarification, I post “practice limited to psychology” after my degrees.
The primary professional advantages of having the MD is that it has qualified me to be a principal investigator in clinical research studies.
Few States Allow Psychologists to Prescribe
I was active for many years in the RxP movement, both nationally and in Massachusetts, but it was clear that it never gained traction in Massachusetts. Sadly, it hardly gained traction in the country with only five states and several federal agencies allowing psychologists to prescribe.
Over the years, however, we have seen the weakening of clinical psychologists as those perceived to have the most expertise in psychotherapy, though it seems to me that there are thousands of our colleagues who haven’ t noticed it. And that’s the trouble. In addition to psychologists, psychiatrists, psychiatric nurse practitioners, social workers, mental health counselors, pastoral counselors, applied behavior analysts and others, all claim equivalent psychotherapy skills.
Although slow in achieving it, the professional advanced nursing associations are still moving in the direction of requiring a doctorate as their minimum degree requirement. Once that happens, psychologists will no longer have the unique protection of the title, “doctor,” to differentiate us from all others, except psychiatrists. But, doctorate or not, psychiatric APRNs are legally authorized to provide the full range of mental health services, which we are not. Incidentally, as “qualified healthcare providers,” they are even able to administer and score psychological and neuropsychological tests.
Look at the facts. Nurse practitioners worked hard and in unity over a period of many years to achieve their status. When I was active in RxP and the president of the Massachusetts Psychological Association, I cannot tell you how many times I heard the argument that we cannot press for RxP because we will alienate the psychiatrists.
Why is it that nurses weren’t worried about alienating physicians? What was the professional cost to nurses for pursuing statutory authority for something that virtually all organized medicine opposed? The answer is… none, and their professional gains have been enormous. Those gains have allowed them to be all the more relevant and helpful to their patients. At this point, in many states, APRNs no longer need physician collaboration; they have independent hospital admitting privileges and are reimbursed by virtually every insurance carrier with full access to all the procedure and diagnostic codes.
I want to be clear that I have nothing but respect for nurse practitioners. Their educational and training regimen starts with the longstanding curriculum to prepare to be qualified registered nurses. Those that become psychiatric nurse practitioners are required to return to a graduate degree program, along with completing required direct clinical care, to obtain the psychological and psychiatric knowledge necessary to practice. They pay the price, make the sacrifices necessary to do so and, as a result, are able to provide much needed, competent services to their patients.
Is there some reason that psychologists cannot do the same thing in reverse? Recognizing that most psychologists do not possess the medical knowledge necessary for unrestricted behavioral health patient care (i.e., prescriptive authority), there are viable ways to achieve that knowledge without the need to change one’s professional identification. Psychiatric nurse practitioners are still nurses. Prescribing psychologists are still psychologists. Is there something I don’ t understand that causes psychologists to be unable to learn details of the life sciences?