Editor’s note: This commentary is by Dr. Rick Barnett, a clinical psychologist and addiction specialist in private practice in Stowe who founded CARTER Inc. to expand addiction-related resources in Vermont. He is legislative chair and a past president of the Vermont Psychological Association, and serves as a member of several state health, mental health and addiction policy groups.
“A psychiatrist in Windsor County is like a unicorn, they only exist in our imagination!”, proclaimed a mental health provider in that region. The number of psychiatrists is declining across the country making recruitment of new psychiatrists to Vermont both difficult and expensive. Their solution is telehealth — except that there’s a shortage of psychiatrists nationwide. We desperately need another approach.
Fortunately, there are alternatives. The number of psychologists with a doctoral degree in psychology and a master’s degree in clinical psychopharmacology, who are expert in mental health assessment, diagnosis and treatment — is growing. They are careful and competent prescribers of psychiatric medications when and only when it is appropriate.
This highly skilled workforce is providing integrated psychotherapy and pharmacotherapy in all branches of the military and in five states (New Mexico, Louisiana, Illinois, Idaho and Iowa). Legislation sits in the House Health Care Committee and the Senate Health and Welfare Committee to authorize and bring this workforce here to Vermont. But it is being opposed.
If it’s good enough for our men and women in uniform and our sister states, why can’t we have it here?
The Vermont Psychiatric Association, in partnership with its guild organization the Vermont Medical Society, is blocking access. Access to better and more integrated mental health care at a lower cost than recruiting psychiatrists from out of state is being held to ransom. Why?
Psychiatrists and medical associations claim that prescribing psychologists have serious deficits in the necessary training for prescriptive authority and thus are a threat to society. That’s a hard argument to keep making and the same one they’ve used against psychologists for a long time. From the 1950s through the 1970s, psychiatrists argued that it was not safe to permit psychologists to practice outpatient psychotherapy without medical referral or supervision. Despite the enormous need for better mental health care for the elderly, the American Psychiatric Association desperately, but unsuccessfully, fought to defeat measures to allow the elderly direct access to psychological care under the Medicare program. (OBRA, 1989)
Here we are again with the psychiatric establishment with its incredible influence for better or worse, backed by the establishment guild, fighting against progress and the evolution of health care. For the past 75 years, organized medicine has reflexively and automatically opposed threats to their monopoly over prescriptive authority, warning of dire consequences to patients. First it was dentists, osteopaths and podiatrists followed by optometrists, nurse practitioners, naturopaths, and now psychologists.
Organized medicine has always fought against other providers entering the health care workforce. The groundbreaking Pew Health Professions Commission, Task Force on Health Care Workforce Regulation Report (1996), concluded that “[the] ostensible goals of professional regulation … has created serious shortcomings that include limited public accountability, support for practice monopolies that limit access to care and lack of national uniformity.” The commission further stated that “medicine can (and frequently does) see every request for regulatory change from any other profession as a challenge requiring confrontation. Organized medicine has no institutional incentive to compromise …”
It’s also not ideal when most psychotropic medications are prescribed by non-mental health or addiction trained providers, such as family doctors. Look at the opioid crisis. Look at prescribing patterns for psychotropics. We need balance and collaboration. Thankfully, advocates on the frontlines of health care practice and policy support prescriptive authority for psychologists because they know it leads to better prescribing practices. Prescribing psychologists emphasize patient-centered care not a symptom-focused “medication-only” approach, and it offers better quality and delivers better outcomes.
Psychiatry could be a real leader in the evolution of health care rather than playing politics at the expense of the most vulnerable. Esteemed psychiatrist Daniel Carlat, MD, writes in his blog, “the prescribing psychologist is the best thing that can happen to psychiatry.” David Satcher, M.D., Ph.D., United States Surgeon General (2000), stated, “If we can demonstrate that psychologists have the training to prescribe, then they should be allowed to prescribe.”
There hasn’t been a single incident of harm done by a prescribing psychologist in over 20 years. Psychiatrists know that their psychologists’ extensive education and clinical training meets or exceeds standards of safety, efficacy and competence. The only thing to do is embrace change rather than fight against it, especially under false claims. The workforce is ready and waiting. Let’s give up on finding more unicorns and make real mental health support available to all Vermonters who so desperately need it.
