Mental Health Care Professionals in Washington
Given that a major goal for health care in Washington State was to promote the collaboration between physical and mental health care, it is common to find mental health care workers in physical health care facilities. Mental health care providers are also found in facilities specially designed to cater for persons with mental disorders. Although most mental health care practitioners are identifiable through their names, it is difficult to identify mental health care providers who avail of their services in physical health settings. Mental health care providers in Washington State include counseling psychologists, mental health counselors, certified peer counselors, psychiatrists, and psychiatric advanced registered nurse practitioners.
Heisler & Bagalman (2015) poised that there are various criteria researchers can use to identify and define mental health care providers. The scholars argued that one might depend on existing licensing statutes to define these professionals or examine their roles and responsibilities. Washington uses the following factors three factors to define and distinguish mental health care provides:
- Individuals providing health care in institutions whose sole purpose is to provide mental health care.
- Health care personnel providing mental care alongside their primary duty of availing physical health care.
- Individuals who provide different aspects of mental care as part of the integrated health team in various care settings.
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Currently, Washington had 24 licensed categories of mental health care professionals to cater to the mentally ill. Washington’s definition of mental health care professionals is broad enough to include Speech-Language Therapists (SLPs) and Occupational Therapists (OT) as part of the mental health care team (Gattman et al., 2016). The behavioral workforce includes both independent health professionals and affiliates who provide care while under supervision. Although the behavioral workforce in Washington is composed of different medical professionals, most of these professionals require post-secondary education, except for peer counselors.
Given that the mental health care workforce is made up of different professions, the providers can be grouped into four groups based on the services they provide. The four groups include highly educated providers, social service providers, general mental health providers, and informal volunteers. Mental treatment and care in different settings ranging from hospitals, outpatient centers to informal settings. The complexity and nature of the patient’s mental disorder determine the setting in which treatment will be offered. For instance, a patient who has schizophrenia will require a different treatment setting from a patient battling with an eating disorder. 25
Highly educated mental health care providers include professionals such as psychiatrists, psychiatric nurses, and Psychiatric physician assistants. Although these professionals require specialized education for one to obtain the license and accreditation to practice, the state still requires these individuals to advance their education. Psychiatrists are recognized as independent physicians who have the capacity to offer psychiatric services and have the authority to prescribe psychotropic medication (American Psychological Association, 2017). Psychiatrists in Washington engage in consultation sessions with patients to diagnose their mental illness and design the best-fit treatment plan. In addition to prescribing medication to the patients, they also provide psychological treatment and participate in various therapy programs with their patients.
Given that psychiatrists are initially doctors, they must first complete a four years bachelor’s program. After the degree program, the psychiatrists then go through four years in medical school to obtain their medical license. Before sitting for the psychiatric certification, the physicians must complete four years of residency (American Psychiatric Association 2017). Even with a license to practice, the psychiatrist can further their training into different subspecialties (American Board of Medical Specialties, 2017). The board identifies the following subspecialties within mental health care settings: pain or sleep medication, forensic, child and adolescent psychiatry, and psychosomatic medicine.
Psychiatric nurses are well versed with biopsychosocial and psychopharmacology knowledge that enables them to account and advocate for best-fit care for their patients. For psychiatric nurses to provide care to mentally ill patients, they are required to complete a doctorate program in psychiatric-mental health nursing. Their high-level training enables them to assess and evaluate severe mental disorders. The American Nurses Association has been at the forefront advocating for the inclusion of qualified nurses in the provision of direct and indirect health care in managed mental health care systems. Volunteers can either be peer counselors or support groups. Unlike the other health care providers, volunteers receive no licenses to practice and are therefore not required to expand their education. In their 2017 journal, Skillman & McCarty reported that out of the 610 advanced registered psychiatrist nurses, only 4% of them practiced in Washington’s rural areas.
Although psychologists are not allowed to prescribe medication to mentally ill persons, they are licensed to independently diagnose mental health issues and provide treatment to emotional, behavioral, and learning disabilities. Most scholars identify school psychologists as part of the mental health care workforce, although their educational training is different from that of clinical psychologists (“Washington State Behavioral Health Workforce Assessment,” 2017). Psychologists who practice in school settings receive their credentials from the Office of Superintendent of Public Instruction while psychologists in clinical settings acquire their licenses from Washington’s Department of Health.
According to Washington’s State data on licenses and permits, in 2017, Washington had 2716 active and licensed psychologists. In addition to most of them being female, they had a median age of 52. According to Washington’s state legislation of 2009, psychologists are required to complete 300 hours of direct patient interaction experience under their authorized supervisors for them to acquire a practicing license. The psychologists must also comply with the 2017 legislature that requires the supervised internship must occur within two years after completion of their doctoral degree.
General mental health providers include medical personnel like pediatricians and nurse practitioners. Since these providers are experts in general health care, they offer general health care to mentally ill persons. In a setting where the highly educated mental personal is inadequate, the general providers step up and avail the much needed mental care. Pediatricians have the primary task of availing mental health care to young children. Given that their training specializes in the treatment of children, they are capable of handling children battling autism, mood disorders, among other mental illnesses. In situations where the mentally ill person is brought to the ER, the general practitioners stabilize their condition before the patients get the chance to see mental health specialists.
Washington’s classified its social workers into two: Licensed Advanced Social Worker (LASW) and Licensed Independent Clinical Social Worker (LICSW). Their roles vary according to their specialties and settings of practice. Although LASW is not licensed to provide mental care in clinical settings, they have the mandate to manage patient cases, engage in biopsychosocial assessments, community advocacy, and organization. LASWs can only provide talk therapy while under the supervision and assistance of highly skilled mental health care professionals. Unlike the other category, LICSW is mandated to independently diagnose and treat mental disorders (Washington State Legislature, 2013).
By 2017, Washington had 134 active advanced social workers (LASW) and 4,027 licensed independent clinical social workers (LICSWs). In addition to the existing LICWs, Washington’s state had granted 1641 individuals conditional licenses to practice as LICWs. Social service workers include criminal justice workers and school-based counselors. Akin with other mental providers, social providers are required to continue enhancing their training, although not necessarily in the medical field. Social services avail mental care in non-clinical settings such as schools. Their services can either be used as complementary services to what the specialized team offers, or they can provide primary mental care to individuals with acute mental disorders (Skillman & McCarty, 2017).
Mental health counselors are also considered part of the mental health care workforce. Mental health counselors have the authority to screen, diagnose, and treat both behavioral and emotional disorders. Mental health counseling in Washington involves the implementation of the learning theory, psychotherapy, and principles of human development to individuals, groups, families, and couples. (Washington State Legislature, 2001). For one to qualify as a mental health counselor, he/she must have attained a master’s degree. Given that Washington uses an integrated behavioral and physical care model, the mental health counselors in this set offer direct counseling to patients. The mental health counselors take part in the management of the patient’s case (Skillman, Snyder, Frogner, & Patterson, 2016).
By April 2017, Washington State had a total of 6531 licensed mental health counselors and 1870 counselors with conditional licenses. Akin with other mental health professionals, 94.6% of the licensed counselors and 95.9 % of those with conditional licenses resided in urban areas. Although Washington doesn’t require mental health counselors to have graduated from counseling programs, it needs proof that the individuals are well versed in the core counseling and mental health subjects. These core subject competencies include ethics, diagnosis, counseling therapy, among others (Washington State Department of Health, 2017).
Conditional licenses are offered to mental health counselors who have graduated from their master’s programs and are yet to complete their supervised experience hours. Holders of conditional licenses are only allowed to offer their services while under the supervision of licenses counselors. For one to obtain a practicing license, one must complete 3000 hours of post-graduate supervised counseling. Out of the 3000 hours of supervised internship, 100 hours must be spent under immediate supervision while another 1200 hours are spent providing direct counseling to families, couples, or individual persons. Upon completion of the supervised experience hours, the associate mental health counselors must then pass in one of the two exams offered by the National Board of Certified Counselors (NBCC) exams (Washington State Legislature, 2017).
In addition to differentiating the mental health care workforce according to their roles and responsibilities, they are also recognized through their prescription powers. Although all individuals of the mental health care workforce are involved in the treatment of mentally ill persons, only specific professionals can prescribe the appropriate medication to these patients (McCarty, Schwartz, & Skillman, 2016). While advanced psychiatric nurses, psychiatrists, and pediatricians have the authority to prescribe medication treatment, other members of the workforce lack this authority (“Pharmacy Commission: Washington State Department of Health,” n.d.). Although psychiatric and advanced psychiatric can prescribe medication to mentally ill patients, they are not authorized to provide talk therapy to the patients (“Types of Mental Health Professionals,” n.d).
Due to the sensitive nature of buprenorphine medication, Washington State requires Physicians practicing in mental care settings to participate in an eight-hour online course for them to acquire prescribing authority (SAMHSA, “Medication-Assisted Treatment (MAT),” 2016). While physician assistants and nurses in urban areas can participate in the online course, apply and receive the waiver to prescribe buprenorphine within 24 hours, those in rural areas expressed that they weren’t accorded the same luxury. According to Andrilla, Coulthard, & Larson (2017), physicians and nurses in rural areas are unable to acquire the prescribing waivers due to lack of psychosocial services to support them in prescription and administration of buprenorphine. The scholars also reported that the few prescribing mental health care personnel in rural areas lack the confidence to prescribe buprenorphine to opioid dependant individuals.
Amount of mental providers
According to Cohen (1997), a shortage of mental providers is defined as the portion in the unmeet needs of mentally ill individuals is represented. Lack of adequate mental health care providers has been a significant barrier in access to mental care in Washington. According to Morrissey J, Thomas K, Ellis A, & Konrad T (2007), the inadequate number of mental care providers occurs in two forms; lack of prescriber professionals or inadequate non –prescriber personnel. In their report, Baldwin et al. (2006) identified that out of the 20,365 mental professionals in Washington; only 670 were psychiatrists. Among the remaining 19,655 professionals, only 11,593 were registered counselors. The scholars also poised that the majority of the registered counselors had not acquired formal mental health education.
Although minority groups in the state are more vulnerable to lack of access to mental health care, this menace cuts across the entire Washington population; hence analyzing geographical disparities in the workforce effectively represents all population groups. The majority of the counties in Washington experience a shortage of mental health personnel who can prescribe medication. Unlike the other counties, Grant and Adams experience a shortage of non-prescriber personnel. Rural areas and locations reporting low per capita income experience the highest levels of mental personnel shortage (Bird et al., 2001). While San Juan and King County report the highest per capita income, they also exhibit even and adequate distribution of mental health providers, unlike Adams and Grant counties that experience low capita per income and shortage of mental health professionals.
Given that Medicaid is the core funder of community-based health care, the program has the authority to determine capitation rates for mental care providers. Funds availed through Medicaid determine the number of community based mental health care that will be hired and recruited. In situations where Medicaid provides limited funds, the number of community health care providers significantly reduces. As a result of the low reimbursement rates by Medicare, numerous independent psychiatrists and counselors opt for cash-based services. Rejection of Medicaid members puts a huge strain on the already limited mental health professions who now have to avail services to patients who cannot afford the cash-based services (McCarty, Schwartz, & Skillman, 2016).
The high turnover rate of mental health care professionals is a significant cause of the shortage of mental health providers in Washington State. Barriball et al. (2015) poised that high turnover rates decrease the accessibility of mental health care and result in the overworking of the current health team. The scholars also argued that high turnover rates increase the costs of services while simultaneously reducing the quality of mental health care. In support of Barriball, et al.’s notion Jones and Gates 2007 argued that for every nurse turn over; a hospital spends between $ 22,000 -$54,000 to replace the nurse. High turnover rates reduce the quality of mental health care being offered by disrupting the client-provider relationship and also inhibiting the implementation of evidence-based practice (Clay 2004).
Given that wages are the core influencers of turnover, scholars argue that the low reimbursement rates by Medicaid are the main cause of the professional shortage. The low uncompetitive wagers offered by Medicaid make mental health providers decline, offering services in Medicaid listed institutions and shift to private hospitals and institutions with high wages. Barriball et al. (2015) poised that in addition to the low wages, lack of formal mentorship and supervision in community mental facilities also contributes to the high turnover rate. According to the scholars, the majority of community mental facilities in Washington hire fresh graduates as their mental health professionals and then offer them the needed supervision for them to acquire licenses. Upon acquiring their licenses, the graduates then shift to private institutions that offer better wages compared to Medicaid.
As a result of inadequate mental health providers, individuals battling with mental disorders fail to acquire the necessary treatment for them to live a quality life (Kessler et al., 1994). The shortage of mental workforce also results in the overworking of general medical person and informal volunteers who have to step up and fill this gap (Regier et al., 1993). According to Regier, the gap created by a lack of prescribing mental health professionals in rural areas has led non-psychiatric mental health personnel to provide 60% of mental care in their respective regions. By 2016, Washington had a total of 727 psychiatrists, but only 3.3% of them provided their services in rural areas (Skillman & Dahal, 2017). According to Cowley et al. (2016), the shortage of psychiatrists in rural areas as a result of Psychiatrists’ inclination to practice in geographical areas that they had attended and completed their residency. To justify this notion, Skillman & Dahal stated that while 41.4% of psychiatrists completed their residency in Washington’s urban settings, only 15.3% of the psychiatrists attended residency in rural areas.
Although most states surrounding Washington report a psychiatric rate of 11.6 psychiatrists per 100,000 patients, Washington reports a rate of 10. 1. Although Washington State reported an increase in the ratio of physician specialties for every 100,000 patients, it reported a 10.2 % decrease in psychiatric ratio from 2013 to 2016 (Bishop, Seirup, Pincus, & Ross, 2016). Scholarship by Larson, E. H., Patterson, D. G., Garberson, L. A., & Andrilla, C. H. (2016 indicate that the shortage will likely advance as most psychiatrists practicing are above 55 years and almost retiring. Similarly to psychiatrists, the Washington psychologist population is unevenly distributed among rural and urban areas. Urban areas reported a psychologist population of 96%, with 22 counties having an average of 10 psychologists. The shortage of psychologists is a huge menace in Washington, given that 22% of the state’s counties have no licensed psychologists.
Scholars have identified ineffective training and educational programs as a significant factor that has increased the shortage of mental health care professions. Currently, several institutions and facilities in Washington offer different educational programs that address mental health care. Despite the existence of these training institutions, the mental health care workforce is still overwhelmed and understaffed. The effectiveness of these institutions is measured by the mental health workforce able to provide adequate and quality mental care (“Washington State Behavioral Health Workforce Assessment,” 2017). According to the report, although the state has established enough training institutions, the stigma associated with mental illnesses, perspectives of low wages, and lack of exposure to mental health professionals limit the number of students who enroll in the institutions. Projections indicate that with only a few individuals willing to train as mental health care professionals, then the health care workforce will continue to experience a shortage of professionals.
Olfson (2016) posited that although the Washington state government has established training and educational facilities for mental health care professionals, the number of institutions is inadequate. According to him, the training and the educational process determines the confidence and morale of the professionals as they provide mental health care. Mental health professionals who experience low confidence are likely to provide inferior mental health. For the state to maintain a sufficient and well trained mental health care workforce, it must ensure the training provided suites the needs of most mentally ill patients. By providing evidence-based skills and up to date competencies, the state can significantly reduce mental health care turn over (Arah, & Heinemann, 2012).