According to the U. S. Bureau of Labor Statistics, in 2019, the median yearly salary for all nurse practitioners was about $110,000. Psychiatric nurse practitioners earn significantly more and the only group earning more are those working in emergency settings. In 2019, the median salary for psychologists was about $79,000./year. The argument has been made that prescriptive authority will bring about an “inevitable decline” in our ability to practice psychotherapy (John M. Grohol, PsyD, PsychCentral 5/24/19).
Though acknowledging that psychologists could double our salaries by gaining prescriptive authority, Dr.Grohol believes that psychologists will be too influenced by money and, therefore, it will change the nature of our profession. He states, “Psychiatry went from primarily doing psychotherapy to primarily prescribing medications in the course of a few decades.”
When I started my career, osteopaths could not practice in hospitals, there was no such thing as a nurse practitioner, optometrists could not prescribe eye medications, pharmacists could not give flu shots, etc..Those professions changed because they worked together to advance their practice authority. Agreed, psychology has also changed. We did not worry about the concerns of institutional medicine/psychiatry when we gained the authority for involuntary transport for psychiatric evaluation for potential of psychiatric hospitalization or to be able to certify lack of capacity and need for guardianship or any of the other progressive changes that have occurred over the years.
Why so Hesitant About Prescribing?
Why are we so hesitant about prescriptive authority? At this point, we know much more about the biology of behavioral disturbances than was the case when I saw my first patient in 1962. There is myriad research to show that patients make the most progress when treated with psychotherapy and medication. Why have we not accommodated those advances in our formal knowledge base?
Are we being fair to our patients to make them go to someone else, with the attendant cost and inconvenience, to get their medication? How many times have many of us simply not been able to find someone to prescribe for our patients? How many patients have you seen who are being treated with the wrong medication? Is it even ethical for us to be so persistently apathetic about those issues?
Psychotherapy is required for successful treatment of most psychiatric conditions. There are numerous studies that have shown that many patients fail to make significant progress while being treated with a medication but without psychotherapy. I am not an advocate of medicationÂ only treatment and I believe the practice, primarily of PCPs, of authorizing psychiatric medication refills over years and years is wrong. It is equally wrong for a psychiatric prescriber to be refilling prescriptions with only a 15-rninute medication check every two or three months.
Massachusetts just went through a process of making major legislative changes to mental health care. One of the primary driving forces behind the changes was the lack of ability of people to obtain effective, or even ineffective, mental health care. We all know that a huge proportion of practicing psychiatrists will not accept any insurance payments. Of those that accept insurance, even fewer will accept Medicaid.
The new Massachusetts mental health statutes represent major improvements but why is it that organized psychology did not use the opportunity to address the need for prescriptive authority for psychologists? I think I know the answer. It is because organized psychology does not have the backing of practicing psychologists to make that a priority.
Think of the number of psychologists who don’ t even bother to join APA or their state organization but will certainly take advantage of the changes brought about by their advocacy efforts. Thus, I am not blaming organized psychology for failing to deal with this issue. I am, however, very distressed about the passivity of my psychology colleagues when I see the practice of psychology, a career which I have cherished, become amalgamated with all of the other professions that present themselves as psychotherapists but are less prepared than we are.
One last point: Going back to Dr. Grohol’s perspective, there are two elements that need to be addressed. First of all, I have more faith in the integrity of my colleagues than to think we will be able to be prostituted by the pharmaceutical companies. Becoming a qualified psychologist is rarely driven solely by an economic decision.
Secondly, Dr. Grohol is correct when he states that a large percentage of psychiatric professionals with prescriptive authority maintain practices that are essentially medication-only. I would simply point out that they have little choice. Most psychiatric prescribers have full practices, with long waiting lists or are so full that they cannot accept new patients. Simply put, if there were more psychiatric prescribers, those prescribers would have more time to also see their patients for psychotherapy and, incidentally, also have the authority to discontinue medications that are inappropriate.
I reached typical retirement age more than 15 years ago. I had no inclination to stop working and still haven’t quite done so. As some lucky people say, “Why would I want to retire when someone pays me to get up every morning and do what I love to do?” It has been a great ride.
Unfortunately, when asked by a new college graduate wanting to be a therapist, what I think they should do, I cannot enthusiastically point them to psychology. That is such a sad statement for me to have to make but, as long as psychology is dominated by the passivity of so many of our colleagues, I fear that psychologists will increasingly be seen as adjuncts to the primary mental health caregivers, i.e., psychiatrists and psychiatric nurse practitioners. I wish it were otherwise.