Could training lay counselors address the therapist shortage?
February 7, 2024 2:46 PM   Subscribe

The problem is using a one-size-fits-all system to gatekeep a profession that needs diverse people to fill a huge array of roles. Pharris, who grew up in Appalachia and saw the need for greater access to care there, wants a credentialing system that provides an array of pathways into counseling that match the array of needs. People suffering domestic violence should have access to care from domestic violence specialists. Recent immigrants might need to talk with someone who understands their particular traumas.

When all the jobs in social work funnel through the same licensure requirements, he added, “We’re all sitting at a four-way stop, and the state needs to put in a roundabout.”
posted by spamandkimchi (29 comments total) 21 users marked this as a favorite

I have only skimmed this so far, but this looks like a great idea - much needed, and well thought out (and, as much as possible so far in these very early days, subjected to useful testing).

I appreciate Rubenstein's stating the two sides clearly up front:
The requirements of traditional licensure make it quite hard to become a therapist — harder, many advocates and scientists contend, than the evidence suggests is necessary.

This is not to say that traditional training and licensure are irrelevant. Licensure exists in part to preserve quality control and prevent charlatans from peddling bogus treatments.
I don't see any mention in here of nurse practitioners in medical care, but it seems like a similar, well-tested approach to a thorny problem - not everybody who's going to order your x-rays or help manage your health care needs to be a full medical doctor. Similarly, not everybody who's going to help you with anxiety or depression or trauma needs to have a graduate degree and years of unpaid intern experience.

This is a really encouraging idea. I'm looking forward to re-reading this more carefully, and thinking about it more, and perhaps contacting my state reps to encourage them to think about plans like this to make health care more available to everyone.

Thank you so much for posting this, spamandkimchi. I'm really grateful for the chance to read it and to know more about this.
posted by kristi at 3:05 PM on February 7 [10 favorites]

So the example given sounds like a psychoeducation group, and lots of hospitals already let bachelor’s level individuals run those. That’s very different from what we traditionally consider to be therapy, though it can be enormously beneficial. And indeed for many cases access to easily digestible science-backed information about psychology and mental illness is the kickstart needed for people to progress on their own. So I would expect expanding access to that to be helpful for a lot of people, though it won’t replace therapy-as-we-know-it.

The thing that concerns me the most in this article is the focus on empathy as the core to therapeutic effects. Anyone can be empathetic. What makes something therapeutic has much more to do with your ability to 1) separate yourself and your feelings from the person in front of you, and 2) put the client’s needs first.

I work with a lot of individuals who have not been trained in concepts like transference and ethics in psychology, but who nonetheless regularly interface with and provide care for mentally ill people daily. A slightly bitter internal quip of mine is, “You realize how embarrassing it is that you are an adult who has beef with a teen in a psychiatric ward, right?”

Because if you aren’t trained in how to avoid it, holy hell is it hard not to take textbook-criteria-you-should-have-memorized symptoms personally. And that is the massive danger in lay counseling—not that they’re not empathetic enough or using unproven treatments, but that they can’t effectively compartmentalize and distance themselves from the painful realities of mental illness. So I would really be curious to know what the training consists of from that standpoint.
posted by brook horse at 3:07 PM on February 7 [74 favorites]

In addition to the self-care/self-preservation issue for providers that brook horse mentions above. As someone with an BS degree in social work, having worked in the field for 8 years (admittedly a long time ago) and having a partner who is an LCSW: learning how to operate effectively and ethically in a near infinite number of situations is incredibly difficult to do, and therefore, by extension incredibly difficult to train.

For example, saying that people suffering domestic violence should have access to care from domestic violence specialists is definitely true but, like almost all areas in the psychosocial realm, comorbidity is a thing. DV issues might be tied up with issues around addiction, food/housing insecurity, job insecurity, all manner of mental illnesses, etc. Many of these issues cannot be treated/managed effectively as isolated concerns. Licensure is about a great deal more than simply keeping the quacks out. There are many people with genuine desires of providing help and support that can (and sometimes do) cause real damage.

I am 100% in agreement that mental health services in this country are in a dire state and/or wholly unattainable for many, many people. I just think we need to proceed with great caution.
posted by BigHeartedGuy at 3:53 PM on February 7 [16 favorites]

This sounds like a great idea, provided of course that there are rules and regulations set in place to prevent poorly trained therapists from doing their clients more harm than good.

I looked into becoming some kind of therapist a year or two ago, with the idea that there might be a way to take some sort of short course and become a low-rent therapist who could treat the more common, everyday sort of problems for an affordable rate. It seemed like a good way to both do some good at a time where there's so much need for mental health care and resolve my own financial difficulties (I'm not earning a living due to my chronic fatigue issues, but I can sit and talk), and well, my friends have often told me I'm good at making practical, insightful suggestions when they talk over their problems with me.

I realized within fifteen minutes of googling that there's no path to becoming a lay therapist. It takes years of training to become a qualified therapist of any kind. I also learned that there isn't actually a shortage of qualified therapists as I had thought -- the problem is so few people can afford to pay for therapy out of pocket and it's so difficult to get any kind of mental health care benefits.
posted by orange swan at 3:54 PM on February 7 [12 favorites]

I thnk there's a deeper structural issue here, because that thread about a clinical psychologist trying BetterHelp from both sides suggested that therapists were already under-paid, while simultaneously being too expensive for most people.

(My own experiences with therapy over the years has made me skeptical of most of the field, and if I turn to someone for help sorting out my emotional shit in the future it'll probably be someone who hangs out their shingle as a coach, or something else, but I'm also... uh... not a market sample.)

But I'm having trouble reconciling the "we need more supply" view of this, with the "demand is low enough that therapists are struggling to pay the bills" of that previous thread.
posted by straw at 3:58 PM on February 7 [6 favorites]

Welp, the insurance companies are at it again. They're going to use these lay counselors like they use mid-levels in medicine; here's inadequate care to start with from a 'physician's assistant' or 'nurse practitioner', and they'll decide if they can handle your case or if you need to see a real doctor, with a ton of incentives to handle it themselves.

Because they're cheaper than actual doctors. Not for you, for the insurance companies.

The big difference being, in my opinion, that mid-levels are supervised by doctors, which means that anything that's prescribed will be reviewed, however cursorily, by an actual doctor. That kind of supervision isn't possible in a therapeutic setting, because you'd need to actually monitor it in real time. What is said in therapy is the prescription; the healing or damage takes place during the conversation with the therapist. If all that's available to whoever is supervising them are notes taken by the lay therapist, that's not actual oversight. And I understand that that's the high-wire act that therapists do every workday, but if you're taking risks with peoples' psyches, you'd better be really, really well-prepared for things going south in a hurry.

The advantage of an extensive professional education is that it prepares you for edge cases and emergencies. Yes, there are a whole lot of people who could probably help with other peoples' problems by listening well and empathizing, but there's a whole bevy of disorders and conditions out there, and they're often difficult to distinguish, and they're often difficult to even spot. What might look to a lay therapist like an average person going through a normal crisis in a healthy way might look to a professional like a desperate cry for help.

What starts out looking like a common-sense way to get help to the easier cases always, always becomes a way for insurance companies to build a bunch of new gates to keep people from care that might impact the company's bottom line.

The solution to this isn't to start giving people less professional therapy. It's to stop giving the money that should go to therapists to the insurance companies instead. It's not hard to figure out why people can't get therapy when the insurance companies are sitting between the patient and the provider, and just sucking all the money out of the transaction.

The healthcare system in this country is monstrous and inhumane. Until we get these predatory insurance companies off our backs, we're going to be talked into more watered-down care at more extortionate prices until we're literally dead.

Universal healthcare fucking now.
posted by MrVisible at 4:46 PM on February 7 [25 favorites]

From the article:
To be effective, researchers say, lay counselors need training in ethics, screening patients for mental health issues, and referring them to appropriate specialists, along with a handful of evidence-based methods such as cognitive-behavioral therapy. They need ongoing supervision by a licensed practitioner.


Thus trained and supervised, lay counselors are best suited to perform certain functions, the researchers and practitioners interviewed for this article said. They can counsel people with mild to moderate symptoms, who are a majority of the people needing mental health care. They can meet with people in non-clinical settings, such as community centers or churches or parenting classes. And they can be particularly effective at delivering time-limited support focused on a particular symptom or behavior.


Lay counselors cannot, however, call themselves therapists, social workers, or psychologists. They cannot diagnose specific mental illnesses. And they cannot bill insurance for their services — an obstacle that limits the ways in which lay counseling programs can be scaled and funded. (At San Ysidro Health, Mishra laments that he cannot pay trained lay counselors more for the new work they’re doing.)
posted by spamandkimchi at 5:19 PM on February 7 [1 favorite]

> here's inadequate care to start with from a 'physician's assistant' or 'nurse practitioner

On behalf of the many nurse practitioners in my life (including the ones I rely on for my medical care), I'm going to push back on that statement. NPs are trained and licensed and have to maintain their credentials and in many cases are able to provide better care than someone with a MD degree. Many of them do have specialty expertise, such as psych NPs, on HIV specialists. They are not categorically providing inadequate care, FFS. Some may be subpar, but so are some fully licensed MDs. There's a lot about nursing training and philosophy that serves us as patients better than how medical doctors are trained.

Full agreement with the need for universal and single payer health care, though.

More on topic, peers have been a key part of behavioral health services for decades, and this feels a bit like recreating a wheel. Making an existing wheel bigger, maybe? That's why there's decades of research on peers, because they've been such a key part of the system for so long.
posted by gingerbeer at 5:20 PM on February 7 [36 favorites]

Here's a wild idea, maybe insurance companies could increase reimbursement levels to reflect qualifications and expertise instead of saying "whelp it looks like women are coming into this field, that must mean we get to lower payscales all round!", and to keep pace with inflation instead of stagnating therapist fees for like decades at a time? And then we could all have more actual qualified therapists instead of qualified clinicians quitting to work at Burger King because it literally pays more than community mental health.

No? We just want to enshittify this professional field too? Okay then.
posted by MiraK at 5:53 PM on February 7 [13 favorites]

Percolating on this a bit more after eating dinner, I have a number of thoughts.

For context, I work at the highest level of care; every day I provide treatment for individuals who are currently actively suicidal, manic, psychotic, etc. I have no problem with individuals without master’s degrees providing mental health treatment; the majority of the team I work with does not and they provide excellent care to our patients.


Thus trained and supervised, lay counselors are best suited to perform certain functions, the researchers and practitioners interviewed for this article said. They can counsel people with mild to moderate symptoms, who are a majority of the people needing mental health care.

20% of individuals with mild to moderate mental illness covered report that they needed mental healthcare but did not receive it; 50% of individuals with severe mental illness report the same. Further, among those with Medicaid coverage, individuals with severe mental illness were more than twice as likely to report needing but not receiving access to treatment as individuals with mild to moderate illness

By the numbers, are there more people with mild to moderate mental illness? Yes. But it is much easier for those individuals to find mental healthcare, as the majority of the behavioral health workforce is dedicated to those individuals. The majority of therapists will not work with individuals with severe and persistent mental illness; thus, while there are more mild/moderate cases, they are not the individuals experiencing the brunt of the mental healthcare shortage. further, all evidence suggests that this is not a matter of clinicians having their time “taken up” by mild to moderate cases; increasing the amount of individuals who can provide services to mild to moderate individuals does not “free up” clinicians to work with severe mental illness.

Does this mean that we shouldn’t increase access for mild to moderate mental illness treatment? Of course not. But it’s disingenuous to pretend this is not further entrenching disparities in healthcare access. I will fully admit my personal bias, but I would far rather see the money spent on education and training for treatment of severe mental illness.

They can meet with people in non-clinical settings, such as community centers or churches or parenting classes. And they can be particularly effective at delivering time-limited support focused on a particular symptom or behavior.

The American Rescue Plan Act funded mobile mental health crisis units that can come to individuals’ homes or other locations in the community in place of police response starting in 2022, and 33 states currently provide these services.

We already have federally funded programs that do this, many of whom utilize peer support specialists and other unlicensed providers who work alongside licensed providers. Many of them are well-established, and they recently got a huge funding boost due to Biden.

Through this division of labor, different roles in mental health care can be performed by people with different levels of training and certification, instead of relying on licensed clinicians to do it all.

Data on unlicensed vs licensed professionals in mental healthcare is wildly difficult to come by (I just trawled through several state analyses of behavioral health workforces which detailed how impossible this is to track) but in my setting the vast majority of individuals providing mental healthcare are not licensed clinicians. These roles include psychiatric technicians, peer support specialists, substance abuse counselors (a degree/license is not required for this role), and a few other roles.

Reinventing the wheel with a 7-week, $5200-per-person course does not seem the best use of time or money. Particularly not when it is clearly set up to mimic traditional therapy (observe the course topics), which simply cannot be taught in 7 weeks at 3 hours a week. Teaching someone to provide a psychoeducation or skill group is vastly different from training them to make clinical judgements, which lay individuals cannot and should not do. These individuals are being framed as capable of treatment planning and suicide risk assessment. I find this frankly unethical for all parties involved. We have plenty of roles for non-graduate-level mental healthcare professionals. We don’t need them to be pseudo-therapists (however you dress it up as ‘counseling’, a term that anyone can legally use).
posted by brook horse at 5:55 PM on February 7 [20 favorites]

On the other hand, congrats to this woman for solving the problem of low therapist pay by achieving a rate of roughly $500 per hour (at the reduced rate for a 20-person group, assuming a generous 20 hours of work per week which is what I needed for a class more than twice that size with the same amount of class time; alas, I did not make $10,000 a week in this position). I make $17 an hour when I supervise bachelor’s level (or lower) mental healthcare workers so perhaps I am just supremely jelly.
posted by brook horse at 6:12 PM on February 7 [7 favorites]

I have so many thoughts about this. So many.
This is long and I'm writing this on mobile so forgive the invetitible misspellings that will appear.

I'm not opposed to peer support and even some basic mental health educational groups being led by people who have a little bit of training and some supervision. I'm really not.

But I have a drug and alcohol counseling cert and a LCSW. And the differences in the quality of care are stark. There is this pseudoscience that creeps in with addiction treatment especially the whole AA abstinence is the only way, some of the boundry issues and people can really harm eachother with words.

Here's a little story:

I was doing my CADC training and I got to tour a substance use treatment unit. I'm already a LCSW , I'm doing the cert for a job promotion. I already have extensive experience in working with addiction. Anyway, our tour guide who works on the unit and working towards getting his CADC to do individual counseling walks past some guys room. His closet is open, his coat is on the bed. He's just a guy chilling in between groups in the space he's got. It's Chicago, having a coat out is 100% a normal thing.

Tour guy is embarrassed. I'm not sure why. He starts berating this guy about the cleanliness of his room. He starts to discuss fire code with the closet door open. He talks about how messy it is. The patient clearly upset about it but reasonably polite and just accepts this is happening. Tour guide then reports he's going to give him a demerit. Apparently three demerits and your non compliant with the program and you lose your treatment spot.

This man was willing to risk someone's possibly life saving treatment over a coat on the bed because his ego was a teeny bit bruised for no reason at all.

The staff was 100% behind this guy. The culture was one where staff had power and those with addictions were less than. I was appalled. The lack of dignity, the lack of trauma informed care, the total unawareness of counter transference, and blatant disregard to the whole point of having substance abuse treatment programs.

People with addictions deserve better. These negative moments do become negative outcomes, these are so so so real and go unmeasured. No one wants to do studies that asks people what went wrong how did it impact you. They want to know what works. And when a little bit of listening and compassion works that is great. But it really only takes a person who thinks they are helpful or a group of people who think they are helpful to perpetuate a lot of harm in a community.

There is much to discuss about master level clinicians and how well they are trained as well. I went with the masters bc the pay difference between the masters and being a psychologist isn't that huge for counseling but the upfront costs are very different. I don't feel like I gained competency in many areas for literal years.

I really worry for people who deserve trained professionals. And I also know some trained professionals who are really really biased in really harmful ways because Licensure isn't perfect. But I also don't think that less training is the answer overall. But there needs to be more discussions about ways of increasing access to low cost programs, decreasing student debt and offering reasonably paid practicums. And that would go a long way into solving the gap of paid professionals.
posted by AlexiaSky at 7:12 PM on February 7 [32 favorites]

Alexia, thank you, that’s exactly what I was trying to get at with my first post—while self-care of clinicians is important, I am primarily concerned with the all-too-common experience of an individual taking behavior personally and acting as you describe. I see it everyday. I supervise as much as I can to help address it. But it’s incredibly difficult to address in a half hour a week supervision without the foundation of education.
posted by brook horse at 7:29 PM on February 7 [8 favorites]

On behalf of the many nurse practitioners in my life (including the ones I rely on for my medical care), I'm going to push back on that statement. NPs are trained and licensed and have to maintain their credentials and in many cases are able to provide better care than someone with a MD degree.

"Trained" is doing an enormous amount of heavy lifting here. An NP has a 4 year bachelor's degree and typically 1-2 years of graduate education, which includes 500 - 750 hours of patient care hours. An MD has a 4 year bachelor's degree, a 4 year medical degree, and a 3-7 year residency, which total 12,000 - 16,000 hours of patient care time. That's sixteen times as much experience in patient care, even using the high end for NPs and the low end for MDs.

"Licensed" is also doing a lot of heavy lifting. A board certified family practice doctor will take ~41 hours of medical license and board exam testing during med school and residency. The NP certification exam is just 4 hours long. For comparison, the MCAT (the medical school entrance exam) is over 6 hours long.

"Maintain their credentials" is also doing a lot of heavy lifting. In addition to the fact that many states require significantly more hours of continuing medical education per year for doctors than they do for NPs, board certified physicians have to retake that 7-10 hour board certification exam every so many years (typically every 10). NPs have no such requirement that I can find.

To bring this back round to the topic at hand: I really, really hope this lay counselor approach takes some serious lessons learned from what's happened in medicine, including the fact that in approximately half of states, NPs are not required to have any oversight by a physician at all.

That said, I'll grant that "in many cases [NPs] are able to provide better care than someone with a MD degree". Doctors are far, far from perfect, and many NPs can provide excellent care within their wheelhouse. The problem is that our for-profit healthcare system has destroyed the promise of more affordable, more accessible care that NPs and PAs were supposed to offer. Instead we pay the same, get (on average) less care, and often don't even have a say in whether we see a doctor, an NP, or PA. Care must be taken that a lay counselor system doesn't go down this same path.
posted by jedicus at 8:15 PM on February 7 [11 favorites]

Jesus, had no clue about NPs only needing 750 client hours. That’s terrifying.
posted by flamk at 10:23 PM on February 7 [2 favorites]

There is this pseudoscience that creeps in with addiction treatment

That’s exactly what I was thinking seeing this thread. I’m a little torn on the idea in the abstract because I do think that a lot of what makes a given talk therapy relationship work does not exactly come down to professional training. But the first example that comes to mind of a field where there is a lot of lay counseling is addiction treatment, and addiction treatment is… kind of notoriously bullshit.
posted by atoxyl at 10:53 PM on February 7 [5 favorites]

My mind immediately went to the dominionist churches abusing this with "christian counseling."
posted by nofundy at 4:31 AM on February 8 [9 favorites]

Universal healthcare fucking now.

Universal healthcare is not a panacea to universal mental health treatment. To pull from the other therapy thread about how Australia, a country with socialized medicine, fucks up mental health treatment:
In Australia the reimbursement rates for a therapy session is A$137.05 (about $90 USD) when the prevailing rate is A$200+ an hour. Oh and you only get 10 of them per calendar year. Oh and you need a GP referral which you also need to pay for since three quarters of GPs charge above the Medicare reimbursement rate.
Supply and the continuing cost of being a therapist is the most important thing. We need to basically make it an earn while you learn to become a therapist in terms of education, training, apprenticeship, to be able to meet the demand. Telling students they need to take out tens of thousands of dollars for loans for a 4 year college, then basically working unpaid as "supervised" for a year, then demanding licensing fees straight out of the gate?

Why isn't it just a five year apprenticeship with a classroom component under a licensed therapist? Or a two year associate's degree, three year apprenticeship with classroom component?
posted by Your Childhood Pet Rock at 4:42 AM on February 8 [2 favorites]

My mind immediately went to the dominionist churches abusing this with "christian counseling."

That’s exactly where my mind went as well.
posted by azpenguin at 5:02 AM on February 8 [3 favorites]

Universal healthcare fucking now.

Universal healthcare is not a panacea to universal mental health treatment.

Similarly, in the UK, if you go via the NHS route and want therapy, you basically have to do CBT until you can demonstrate that CBT is not helping, because NICE considers CBT more evidence-based than other forms of therapy, so they only consider it cost-effective for the NHS to pay for anything else if you've totally exhausted the possibilities of CBT first. If you don't want to be forced to wear out CBT before getting access to other options, you have to pay for private therapy with a provider whose methodology works better for you.

As someone with a complex trauma history, I find the basic principles of CBT triggering, because the idea that my thoughts and behaviours are wrong in a methodology that has no interest in figuring out how they got to be that way sounds exactly like the concepts and language my abusers used to persuade me to pathologise myself while I was growing up. I've had significant mental health challenges since I was 12 years old, and have never once done the free therapy I'm entitled to via the NHS, because I can't handle having to prove that CBT isn't a good fit for undergoing CBT.

Consequently, I've spent a ton of money on my own care over the years. I'm lucky that that's been consistently doable for me, and that at least some of what I've been able to pay for has actually helped; I'm unlucky that I live in a country with universal healthcare that still doesn't manage to meet my needs in an accessible way.
posted by terretu at 6:17 AM on February 8 [10 favorites]

I was going to say: hey, for education too! But, honestly, we do have a set of paraprofessionals in both the public and private sector that do this while being regulated (if not always well-regulated). There are issues with proper compensation for some and wackos filling in the cracks, but it's not just the wild west. When it comes to mental health, it does seem like the blue-blood establishment vs the wackos in the wild.
posted by es_de_bah at 11:09 AM on February 8

An NP has a 4 year bachelor's degree and typically 1-2 years of graduate education, which includes 500 - 750 hours of patient care hours. An MD has a 4 year bachelor's degree, a 4 year medical degree, and a 3-7 year residency, which total 12,000 - 16,000 hours of patient care time.

To push back on this a little, MDs can have a bachelor's in literally any field, and pretty much none of those are going to include any actual medical coursework let alone clinical hours. I say this as someone who teaches pre-meds. Our intro courses lay an important foundation for their future coursework, but we sure don't teach them how to be doctors. Counting the 4 years of an MD's bachelor's as part of their training is disingenuous.

NP MSN programs usually require a BSN, which is a solid 4 years of nursing training including clinical hours (ranging from 500-1000 depending on the program). The MSN is then another 500-1000 depending on the program. MSN programs without a BSN are still rare, and those still require students to complete an RN (including clinical hours) before they can start the MSN, so they can take years longer. Ignoring the NP's BSN experience is disingenuous. Additionally, specialized NPs, like say psychiatric NPs, directly relevant to the topic at hand, often have a doctorate, which is more training and more clinical hours.
posted by hydropsyche at 1:28 PM on February 8 [9 favorites]

An NP has a 4 year bachelor's degree and typically 1-2 years of graduate education, which includes 500 - 750 hours of patient care hours. An MD has a 4 year bachelor's degree, a 4 year medical degree, and a 3-7 year residency, which total 12,000 - 16,000 hours of patient care time.

I truly don't want to add what is perhaps seen as a thread derailing discussion, but I'd like to push back on the push back...on the push back? As someone who is currently in a master's entry nursing program, the education I am receiving at a supposed "master's level" is maybe not even at freshmen STEM levels of discourse. It has serious alarmed me. I am being told constantly that the level of education I am receiving is just as good as the med students in the building next door, and that when we all get our DNPs, isn't it so great that we can do it in two years, all online. A psychiatric NP is perceived as the "easiest" one to get, it's the one you go into if you want the "easy" work of just prescribing. In my state, no physician oversight is needed.

My little sister just passed her boards. She has been in school forever. I will never consider it a comparable education.

I am not trying to bash nurses or NP - I am actively earning my RN! I am joining the profession! I just think that these education comparisons are not taking into account the content of the education. Thank you for listening to my tiny rant
posted by lizjohn at 4:17 PM on February 8 [7 favorites]

hydropsyche has it right on the NP-vs-doctor thing. Have a look at this AMA page: What's the difference between physicians and nurse practitioners? This is the AMA, a supposedly respected group, and yet it's full of disinformation and false equivalencies. Doctors are absolutely critical, and there are times when that's what you need (brain surgery!), but in the U.S. at least we are all still soaking in classism, sexism, and a hierarchical system. I listen to my 90-year-old father brag about how his eye doctor is a "top guy" with an Ivy League education and various journal articles. He'll happy have me drive him an our to Duke (a top eye center) so this guy can look at some eye imaging done by a tech and say "whelp, your retina has reattached", when that sort of surgical follow-up could be done by any number of trained professionals.

A typical doctor's path might be:

parents want them to be a doctor for the respect and money -> prep schools -> undergrad degree in biology or chemistry (no "doctor" training yet; just the same basic science education lots of people have) -> one of the very small number of med school slots -> "patient contact time" that is often going around in groups and observing but not necessarily *doing* anything -> stupidly inhumane hours -> MD -> *then* residency where most of the real patient hours happen. IMPORTANT: The hour comparisons are between a doctor *after* they completed a multiyear residency (3-7 years during which they are *already an MD*) , and NP patient hours *up until* they get their NP.


regular college degree (or not) -> work in healthcare frontlines for years -> become nurse -> more years maybe -> back for a BSN -> maybe more years -> NP program which has a specialty; hours are in that specialty -> back to the working world -> deal with old people and men who are mad they're "only" seeing an NP.

Doctors doing rotations in, say, an ICU get trained by the ICU nurses. They know how all the equipment works. They know all the medications. They know when a patient is going downhill. Etc.

Also, medical school is incredibly expensive, and doctors are just not going into primary care and other first-line roles. Obviously lots of them care about outcomes and patients, but they are also the ones looking for a path to vacation homes, ski vacations, and so forth. Which is why there are no primary care doctors and you're seeing a NP/PA/etc.

NPs are much more likely to have had real, in depth, critical interactions with thousands of patients than doctors. Along with support staff like nurses' aides, they are the ones who get their hands dirty. Doctors (except surgeons, natch) are mostly there to diagnose, create care plans, and think about the big picture.

That linked AMA page says Fighting scope creep: Patients deserve care led by physicians, the most highly trained health care professionals. The AMA fights for physician-led care nationwide at the state and federal levels. Wow. Just wow. They are advocating for doctors, the most highly PAID and RESPECTED healthcare professionals, at the expense of the rest of the team.

(back to mental health) Despite my rant, I don't think it's a good idea to have less-credentialed people providing certain types of mental care. There are already systems in place for less-credentialed people to handle substance abuse, homelessness, helping people to get engaged with our broken healthcare system, etc. And as stated above, doctor/nurse or doctor/np are not good analogues to licensed therapist/lay provider. I spoke to my spouse (a health care provider) and she said even now, when you look for a therapist you have to dodge a minefield of alternate credentials and read the fine print to know if you're getting someone with real, lengthy and valuable training (including ethics). She said something like "there are all these random groups springing up and offering short courses that offer some bogus credential [imitates a man masturbating] so people can hang up a shingle and offer questionable care. A lot of them are overtly Christian or just bullshit."
posted by caviar2d2 at 11:44 AM on February 9 [4 favorites]

It's allllll A Land Of Contrasts.

One of my kids wants to be a PA, or maybe an MD. We went to the open house for the PA program at the university where I work. The speaker was talking about the number of patient care hours required, and then noted that one student has 13,000 PCA! How? They were an EMT for years before deciding to go back to school.

My employer is also starting up an accelerated Bachelor of Science in Nursing program. All those students will already have a college degree and experience. But what degree? Now that's a good question.... :7)
posted by wenestvedt at 12:22 PM on February 9

Regarding NPs: Most graduate programs require 1-2 years of clinical experience before admission.
posted by MrVisible at 7:28 PM on February 9

Doctors (except surgeons, natch) are mostly there to diagnose, create care plans, and think about the big picture.

So I am a (female) physician of 20 years in a specialty (GI) that has a mix of invasive procedures and general bedside/office work where I talk to patients and make a diagnosis and decide on a management plan that includes procedures/medications/consults/other interventions. A big part of my job (and one of my favorite parts) is also educating my patients and helping them make informed decisions about their care.

Of all I do, making the diagnosis and then deciding on the appropriate treatment is the most difficult part, requiring the most background knowledge, experience and skill, as well as time. It is also the one that is LEAST respected and LEAST paid. I kinda get it - the final result is a handful of notes and a prescription/order in the system. It's hard to tell, from the administration's side of things, or the public payer's perspective, whether the plan is even worth anything - you could spend a quarter of the time to "produce" a result that looks similar - a handful of notes and a prescription/order and is actually garbage.

I am much MUCH more handsomely paid for PROCEDURES. Oh, how everyone loves procedures. Even ones that are pretty straightforward to learn, on the technical side. The procedure that pays better than a complex, comprehensive consultation for a third of the effort and half the time, and not nearly as mentally exhausting as talking to a scared elderly patient with unexplained weight loss and a myriad of coexisting diseases, and figuring out steps to diagnosis and ways to navigate our health system to get the steps done as soon as feasible plus reassuring them.

The hardest and most skilled part of my work is largely invisible. It is also the part no-one wants (especially not men). People are running away from the drudgery of it. Who can blame them? If you don't want to burn out, or if you want to maximize your compensation and minimize the exhaustion, the best way is to find moderately difficult yet well-paid "procedures" to do and do a lot of them.

So getting back to the topic of therapists, I have feelings about it that are similar to another poster's above.

People are going to swarm to the "easier", less exhausting and less challenging cases and will leave the challenging, mentally taxing, and difficult work of dealing with severe mental illness to the people with the most expertise, but also the highest pre-existing workload and I am cynical about who gets paid more.
posted by M. at 1:14 AM on February 10 [4 favorites]

Exactly, M. Clinical judgement is the least valued and hardest to learn skill in both medicine and mental health. There is a reason that a psychometrician can administer and score a WAIS, but it takes a psychologist to tell you what that means. I recently had someone getting their master’s degree interview me about assessment work for a class; we spoke very little about the processing of administering testing and a whole hell of a lot about how you decide what to administer and how to interpret it.

Because that’s the part that matters. If you know the how and why, sure, therapy and medicine and everything else are easy enough to do. But you rarely, if ever, know the how and why at the start. Even worse, often you come in thinking you know the how and why and you absolutely do not.

I could send someone in to administer ADHD testing. They would probably do a stellar job. What, though, would they do when the patient’s behavior is bizarre, off, or otherwise doesn’t fit the initial case conceptualization? Would they know what kind of questions to ask, or what to do with the answers? Would they know whether to stop the testing, or to add something else, or if the psychiatrist needed to be flagged down immediately?

This is referencing a case I was asked to assess for what everyone believed to be a straightforward case of ADHD. 20 minutes in it turned out the person was in active psychosis. But they could hold it together just enough that no one knew they were seeing faces in the walls until they were directly asked if they were seeing or hearing things other people weren’t. But I only knew to ask that because there is a particular cadence to conversation with people early in a psychotic episode that is different from ADHD despite being primarily defined by tangentiality and loose association. I also knew I had to ask the question a few times in a few different ways because the primary reason for this conversational quality is a breakdown of language processing, and that a “no” (which was given on the intake screening that asked about audiovisual hallucinations) to the sentence I said
did not necessarily mean a “no” to the question I was asking. I had to start asking what question they thought they had just answered. Frequently it was something that used about 70% of the words I had used, but was semantically and syntactically completely different. Again, in a way that’s different from mishearing, distraction, or auditory processing issues in ADHD.

How did this get missed in the screening process? Well, by definition protocols and screenings push you towards a black or white “yes” or “no.” Because otherwise you need you need clinical judgement to parse out what the answer means. They may have been asked if they heard or saw things that weren’t there, but their brain may have interpreted the question as “Do you have any trouble hearing or seeing?” the answer to which was no. And the intake screener has no education in the conversational qualities of psychosis and thus has no reason to flag it for specialist attention. In fact the only reason I was sent in at all was because the patient requested it because they realized there was something more wrong. Our initial meeting involved a very emotional plea to help them figure out what the hell was going on and why their life was such a wreck.

Giving people treatment only takes a little bit of training and education. Giving people answers takes a lot more, and we are increasingly moving away from caring about the answer before we slap on treatment. That’s why AI medical decisions is such a huge fight right now.

Clinical judgement matters, but it’s expensive and corporations are thrilled to cut that down to the absolute bare minimum because they can pay people less to do generic treatment for more people. Is that a net good? I don’t know. But I’m with M. on it increasing the suffering of the people who need the most help.
posted by brook horse at 8:17 AM on February 10 [8 favorites]

There are already far too many incompetent and only sort of adequate therapists. There's a shortage because the pay is not good enough, and it's hard to practice solo unless you charge a lot to cover insurance costs. It's part of health care in the US being a profit center, not a health care system. People deserve vastly better mental health care.
posted by theora55 at 10:48 AM on February 11

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