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The Pay is the Thing: Re-evaluating Mental Health Reimbursement

This post was written by Dr. Misty Hook, and was originally published on the Counselling Resource website. A licensed clinical psychologist in private practice in Texas, Dr Misty Hook received her PhD in counseling psychology from Ball State University. She was a professor of counseling psychology at Texas Woman’s University for five years where she taught classes in counseling, family psychology, social psychology, the psychology of mothering and gender issues. Her areas of specialization include families, couples, gender issues and giftedness and she has several publications in these areas.

With the new governmental mental health recommendations arriving, it is time for us to think about how paying mental health professionals what they are worth is an important aspect to increasing access to services.

This should have been our moment. After decades of being healthcare’s vastly underfunded red-headed stepchild, mental health was finally getting its due. Many of the talking heads have been discussing the need for better access to mental health and President Obama’s recommendations for gun control even include the need for more mental health services. So this should have been a time of excitement for my field, a time when we eagerly anticipated the ways in which we could reach out and help the communities so direly in need of our skills. Instead, it seems like it’s just going to be more of the same and nothing much will get better. Until we as a nation can truly get behind the value of psychology in general and psychologists in particular, we are headed down the wrong path.

Like many others in my field, I eagerly awaited the Obama administration’s suggestions about increasing access to mental health treatment. There are a variety of them ( but, simply put, the mental health initiative involves identifying mental health issues early and getting these individuals into treatment. Specifically, the administration proposes giving a lot of money and training to teachers and schools so they can refer these students for mental health services. They also propose spending $25 million on state-based strategies supporting people 16 to 25 with mental health or substance abuse issues and another $25 million on violence prevention programs in schools. The government would give $50 million in tuition reimbursement and stipends to train 5,000 new mental health professionals because they noted that there are not enough providers. They also will work to make certain that mental health coverage is at parity (or equal to) coverage for physical conditions.

All this is wonderful and I am in favor of these new regulations but there is one thing that was never addressed that is deeply problematic and will negatively affect the implementation of these recommendations: reimbursement. At no point in the proposals did anyone discuss why it is that close to half of the people suffering from mental illness do not receive treatment. Yes, some of it is that they are not identified as such but the larger problem probably has to do more with the lack of mental health facilities and providers. The Obama administration broached that subject by putting in the recommendation about training new mental health professionals but the number of providers is not the issue. The real problem is our level of reimbursement. President Obama can pay to train additional mental health professionals all he wants but if the pay is not commensurate with the demands of the job, then they will not stay in the profession and we’ll be right back where we started.

As a psychologist, I have six years of formal education and training beyond the bachelor’s degree yet I get paid at a rate similar to that of massage therapists and personal trainers, none of whom have much training beyond a four year degree if they even have that. This is not meant to disparage either of those fields but instead to point out the similarity in what we earn despite the disparate skills, training and level of responsibility. Just as a comparison, most lawyers go to school for three years beyond the bachelor’s while the average physician has an additional seven years of education and training beyond the traditional four year degree. So, psychologists generally have double the education and training of lawyers and one year less than the average physician. However, according to a 2011 Bureau of Labor Statistics report on the national annual mean wage, lawyers earn roughly double what psychologists do while the average physician earns about two and a half times our salary. If you look at the top earners in our fields, the disparity is even greater. This seems wrong.

As a counseling and family psychologist, I must be able to listen and communicate effectively with people of all developmental levels, be compassionate and nonjudgmental, assess and evaluate the problem, and then draw up a treatment plan tailored to the needs of the specific person, couple or family. In order to be effective, I have to be both a mediator and a motivator and be able to understand, explain and persuade competently. My treatment plans must include knowledge about how the current systems in people’s lives (e.g., the legal, educational, and medical systems) affect them, what impact demographic variables (e.g., gender, race, socioeconomic status) have, and what the prevailing research is on old and new treatment strategies. Oh yeah, I also have to be able to remain objective, deal with messy emotions, and as a psychologist in private practice, know how to assign diagnoses, deal with insurance companies, handle money and do the required paperwork.

I don’t know about you but I think that is rather a lot of skills and responsibility that we are required to have yet our pay barely reflects this. And if we are not reimbursed at a level that reflects what it is that we do (not to mention helping to pay off student loans and other professional expenses like malpractice insurance, licensure fees and continuing education hours), then many professionals will either leave the field entirely or find other employment – like working for businesses or life coaching – that will not help alleviate the current mental health crisis.

The issue of funding and reimbursement is the same for mental health facilities. There are not nearly enough community mental health treatment facilities around, probably because of money issues. For those that are available, the staff is often composed primarily of interns, practicum students and those professionals who are new to the field and need the experience. I am not being disparaging about community mental health professionals at all because I have the greatest respect for what they accomplish. However, the pay is just not enough to sustain a family, so the vast majority of mental health professionals tend to go elsewhere. And make no mistake, the lack of mental health facilities is a huge problem because if you want people to get the help they need, there has to be some place they actually can go once they are referred (other than private practitioners of course). So again, the government can spend all this money on training people to identify and refer those suffering from mental illness but if there are few places for them to go or if the staff is not experienced enough to truly help, then we are right back where we started.

I understand that the Obama administration was under the gun (so to speak) to make some good recommendations and actually do something about a major public health issue but they need to actually think things through. By not addressing reimbursement, they are putting the cart before the horse and that will get us nowhere fast. It seems to me that what they need is a good psychologist to help them figure it out.

Hey President Obama, call me!