North Carolina is grappling with systemic shortages in mental health care, and regulations are making it worse — often disproportionately hurting veterans and the state’s most vulnerable residents. But that could change.
State regulations mandate life-long supervision for LPAs, so retired U.S. Marine and licensed psychological associate Karen DelPilar couldn’t even volunteer to treat veterans with post-traumatic stress disorder or substance abuse problems.
“[It] felt like a slap in the face, with so many veterans suffering from the effects of serving in war zones, the high rate of suicide among veterans,” DelPilar wrote to protest the regulation, along with almost 80 other providers.
Master’s-level psychologists have labored under life-long supervision for decades, but it could soon become a thing of the past. LPAs could practice independently of doctoral-level psychologists if the N.C. Rules Review Commission approves proposed changes to the N.C. Psychological Practice Act in February or March.
For LPAs, life-long supervision isn’t just costly and time-consuming. Terminal supervision throws them out-of-network for many major insurers, including Tricare, and it can block them from volunteering to treat veterans and hurricane victims. Many insured patients are paying out-of-pocket, or not being seen at all.
DelPilar works six days a week, mostly treating opioid-addicted patients. She gives some patients discounts. But many still cut back on treatment because, for instance, they can’t find a doctorate-level psychologist able to bill their insurance. This can often happen with opioid-addicted mothers, she said.
“It’s frustrating when people are in crisis and they can’t find a provider and they are crying on the phone,” DelPilar said. “How many lives could have been saved if they could have just gotten in sooner? All they have to go do is get the wrong bag of heroin laced with fentanyl, and then they’re dead.”
Almost every N.C. county is flagged for mental health care shortages, and the state only meets about 15% of its need for behavioral health providers, according to the Kaiser Family Foundation, a national nonprofit research organization.
The N.C. Psychology Board hopes to change that. It created an avenue for LPA independent practice after a group of four LPAs hired a lawyer and filed a legal petition with the board.
Under the proposed rule change, LPAs with at least three years’ experience — and 4,500 hours of post-licensure supervised practice — could qualify for independent practice. They would also need average performance ratings, and a recommendation from their most recent supervisor.
“This is very overdue,” said Robert Hill, N.C. Psychology Board chair. “I’m supervising someone right now who is in his early 60s, who is quite competent to practice on his own. … It’s an unfair waste of his money and time.”
But the reform risks running into complications. It is so controversial that the N.C. Rules Review Commission postponed making a decision in January’s meeting. The commissioners will rule on the reform in February or March, but even if they grant their approval, written objections from 10 people could punt the rule change before the General Assembly.
The N.C. Psychology Board backs the change, but the N.C. Psychological Association argues the board doesn’t have the authority to lift life-long supervision.
“[NCPA] supports a pathway to independence for the LPAs. However, the Practice Act, which is more than 50 years old, has always stated that master’s level clinicians have to be supervised by doctoral level clinician,” Martha Turner-Quest, NCPA executive director, said in an email. “NCPA, as an organization, supports the existing Practice Act.”
“You could easily see that as self-serving. Doctoral-level psychologists, who profit from the supervision requirement, might be accused of trying to control the competition,” Hill said. “The other reasons for opposition aren’t very pretty, and they’re not supported by any data. There are no safety concerns, no professional misconduct concerns, no credible reasons to resist this.”
It’s not unusual for entrenched providers to oppose expanding scope of practice laws, says Dr. Jeffrey Singer, Senior Fellow at the Cato Institute.
“There are plenty of excellent therapists who are masters level in training, and there are a lot of behavioral problems in this country today, with increased suicide rates, non-medical drug uses, which is in many cases people self-medicating for depression or other issues,” Singer said. “We don’t want to stand in the way of people who are trained and can give behavioral health services.”
Both social workers and counsellors already enjoy independent practice. Rachel Petrosky, New Hanover program director at Coastal Horizons Center, points this out when describing the patients she has lost to the supervision requirement. Days ago, she had her last session with a man who qualified for Medicare.
“I personally love supervision. I think the fact that it is mandated is difficult,” Petrosky said. “It’s all barriers to health care that sometimes don’t have good reasons to be barriers.”