President's column

Treating the underserved: Comorbidity a norm

Prescribing psychologists serve populations considered medically underserved, indigent, isolated, frontier and marginalized.

By Michael R. Tilus, PsyD

DISCLAIMER: This does not represent the opinion of a federal agency or Native American community. 

Prescribing psychologists have, or are, serving populations that are considered medically underserved, indigent, isolated, frontier and marginalized. By virtue of where we serve, we treat very complicated comorbid patients of every age, in various life stages, every day, all day, and all the time. While testifying recently for both North Dakota and Idaho legislative RxP bills, antagonists beat on us with the same drum beat alleging we are both “not trained and ignorant in treating these kinds of identified comorbid patients.” I found some Army adjectives swelling up within my chest, wondering where these antagonists practice, as I had not seen any of them in the fields and dirt roads around my duty station. Yet, the truth is, we are, have been, and remain actively treating them in our many different clinical platforms. Within the public sector communities, we consult, collaborate and get concurrence with our fellow medical providers for our rural primary and mental health care patients.

In my mind's eye, the prescribing psychology movement was born within the public service psychology womb. Following their inner heart and call, our RxP pioneers found an underserved population; fell in love with the work and the people; committed themselves to the task; upgraded their skills, embedded themselves in the community, enlarged their capacities and gave their life resources to serve. Many of these experience-rich pioneers are still serving in their communities while others have transitioned to academia, policy makers, and administration, but still serving.

In my review of the rural mental health literature, a la “serving the underserved,” I found some good reads. Of note: Ax et al (2008) piece “Prescriptive Authority for Psychologists and the Public Sector: Serving Underserved Health Care Consumers” in Psychological Services could have been our featured piece as they update the prescriptive authority movement in multiple public sector domains, both in the U.S. and Canada. Sammons' chapter (2003) “Nonphysician Prescribers in Rural Settings: Unique Roles and Opportunities for Enhanced Mental Health Care” in B. Hudnall Stamm's (2003) seminal work “Rural Behavioral Health Care An Interdisciplinary Guide” reads as if it was drafted this year. (For states with RxP legislation hopes, this may be a good reference work.)

Stamm et al. (2003) documented the many challenges to providing psychological care in rural and frontier areas. But, much of the published data that I've read appears to be voices speaking from the colorless world of statistics or the inquiring researcher. The personal voice of the practicing prescribing psychologist speaking from their lived experience in frontier America is missing. “Serving the underserved” for me translates into an applied prescribing practice that assumes a patient's comorbid baseline includes trauma, substance abuse, psychiatric disturbance and accompanying uncontrolled general medical conditions. Any delivery of psychological services is therefore embedded within addiction medicine, traumatology and primary care. But, often, this is the easy part.

One of the great disparities I see in the literature is the lack of viable and reliable informants and information given to these researchers, on the impact of working within “third-world-country agencies.” This lack of collaborative data positions much of the reported data as suspect, in my rural mental health literature strikes me as being unusually culturally naïve and barren, especially in the face of what is claimed as a higher level of cultural competency.

Much of the rural mental health literature appeared to be a Pollyanna-spiced up version with a taste of rural heaven present and a bit of Eden hiding around the next bite. However, serving in rural America did not satisfy my thirst for a divine drink after wading through a particularly harsh piece of practice life. In like manner, drinking the literature with hopes of receiving sturdy Shiraz tasted more like a Montana watering hole that held touches of the last nights' rain stirred with the natural earthy sulphuric ground.

This kind of watering hole, as a primary source of nourishment, is damaged and damaging — the paralyzing consequence to “serving the underserved.” Sulphuric Shiraz-like agencies that both titillate with opportunity while murderously poison.

Most prescribing medical psychologists serving in frontier America face this scenario every day.

Given an impossible mission with overwhelming mental and medical health needs, limited to no resources, insufficient licensed and qualified providers, limited to no supportive agency infrastructure, limited logistical planning with often no logistical agency, legal and ethical concerns, budgeted to fail, misidentified mission capacity, fatally flawed administrative intel, and toxic leadership, Frontier America health care and systems of care often meet developing nations' identifiers no matter whose definition.

Providing care to developing nations' populations through their agencies provides a more transparent and congruent perspective to the medical psychologists practice realities and contextual environments. This developing nation coupling of violence and nourishment cuts through and defines what we do in our clinical practice, and, what our clinical practice does to us.

I think this edition of TheTablet will gather some first-hand voices of prescribing medical psychologists who been serving the underserved. It is within this context that prescribing psychologists continue to do what we do best. We consult, collaborate and seek concurrence.

Honor to Serve!


Ax, R. K., Harowski, K., Nussbaum, D., Bigelow, B. J., Meredith, J. M., & Taylor, R. R. (2008). Prescriptive authority for psychologists and the public sector: Serving underserved health care consumers. Psychological Services, 5 (2), 184-197.

Sammons, M.T. (2003). Nonphysician prescribers in rural settings: Unique roles and opportunities for enhanced mental health care. In B. Hudnall Stamm (Ed.), Rural behavioral health care: An interdisciplinary guide (pp. 121-131) . Washington, DC: American Psychological Association.

Stamm, B. H. (Ed.). (2003). Rural behavioral health care: An interdisciplinary guide. Washington, DC: American Psychological Association.