by Judy E. Hall, Ph.D.
Registrants describe their practice in many ways - by ages served, areas of expertise chosen, and credentials attained - with all of these descriptors available online for use by the public and other relevant professionals and health organizations. As would be expected, Registrants often identify practice areas which have been acquired or enhanced since graduation. As psychology’s half life expires approximately every five - ten years, it is an ongoing task for psychologists to keep up with the scientific/practice knowledge and new skill sets available. To do so, psychologists pursue postdoctoral education and training and acquire expert supervision in new areas. While CE or other formal education courses can introduce concepts that are new, training and supervision may be needed to put those skills into practice.
One example of a newer area of expertise, which does not constitute an extension of current practice, is psychopharmacology, a proficiency approved by APA in 1995. There are three levels of education and training available for psychologists: Level One, Level Two and Level Three. The definition of education and training in psychopharmacology occurred in the 1990’s when the APA Board of Educational Affairs (BEA) approved a two curricula model (Level One and Level Two). This was followed by approval in 1996 by the APA Council of Representatives of the Recommended Postdoctoral Training in Psychopharmacology for Prescription Privileges for Psychologists (Level Three).
While some psychologists may never want to prescribe, they may want to become sufficiently educated and trained in psychopharmacology to provide collaborative health care. Psychologists seeking to acquire this level of expertise could turn to the curricula (Level One and Level Two) recommended by BEA for guidance. Level One addresses prerequisites for Level Two and involves more than what is typically included in a doctoral program (biological bases of behavior). Here most psychologists need additional education prior to admission to a postdoctoral program for Level Two education. These psychologists may never want to become a “Prescribing Psychologist” about which we hear so much at the state association level. However, they do want to participate in the healthcare evaluations regarding their patients so as to blend their expert knowledge of behavior with knowledge of pharmacotherapy. They may do this in concert with a medical practitioner within a consultation/liaison model. Thus, they choose a Level Two education/training program.
Other psychologists want to pursue the extensive education, training and credentialing needed to become a psychologist with prescription privileges as defined in state law, now, or in the future. This expanded practice opportunity is available to those psychologists who are willing to make the additional commitment required by a Level Three education and training sequence at the postdoctoral level.
Based upon the Registrant survey reported in prior issues of The Register Report, only 27% of psychologists responding have no interest in either Level Two or Level Three education and training or credentialing in psychopharmacology. Given the interest in psychopharmacology by the substantial segment of those responding (73%), and given that this initiative has been an interest of the National Register Board of Directors for some time, we devote this issue of The Register Report to (1) examining the arguments, -pro and con - from the professional and legal perspective, (2) providing program examples of current education, training and credentialing, and (3) informing our readers about treatment issues specific to pain, some of which may involve pharmacotherapy.
It is likely that legislators, physicians and others may ask your opinion regarding the necessary and sufficient conditions for education, training and experience for psychologists wishing to prescribe (Level Three) or to provide collaborative care (Level Two). As a Registrant, we thought you would want to know more details about recommended education and training levels and the discourse surrounding this issue. We will therefore conclude with what has happened more recently with regard to the efforts of the Association of State and Provincial Psychology Boards (ASPPB) the National Register and others.
Education and Training Levels
Level One: Foundation. Level One is the additional education that typically follows upon completion of a doctoral program in psychology (or may be included partially or wholly in the doctoral program). While an acceptable program at the doctoral level includes the biological bases of behavior, Level One basic psychopharmacology education is more extensive than that. There are nine modules outlined in the BEA didactic curriculum for Level One which may be combined and satisfied in a number of ways. However, acquisition of this education can occur in many settings. It is described as “adaptable readily to a variety of learning settings…which include doctoral programs, predoctoral internships, postdoctoral residencies, or integrated series of Continuing Education (CE) workshops.” In other words, psychologists should have demonstrated knowledge of human biology, anatomy and physiology, biochemistry, neuroanatomy and basic psychopharmacology before embarking upon the postdoctoral education and training in psychopharmacology.
Level Two: Didactic Postdoctoral Program in Basic Education for Collaborative Care in Psychopharmacology. Level Two is available to those who are interested in being educated and trained for collaborative care. This second level provides “in-depth, advanced knowledge of the pharmacology of psychoactive medication and the medications used to treat their untoward effects, and the pharmacology of abuse. It also includes advanced knowledge of psychodiagnosis, physical assessment, physical function tests, and drug interactions important for particular populations or chronic disorders. Training for Level 2 competence includes both didactic and supervised, practical training.” (Smyer, Balster, Egli, et al., 1993). While the BEA Curriculum and the APA 1996 guidelines specify a minimum of 300 contact hours of didactic instruction, most programs and state legislation exceed that number. The didactic courses are provided by a “regionally-accredited institution of higher learning or another appropriately accredited provider of instruction and training.” While these psychologists would not qualify for the proficiency of psychopharmacology until they have completed the practicum training for Level Three, they would be qualified to work in the interests of their own patients by collaborating formally with healthcare practitioners who have prescribing privileges.
Level Three: Education and Training Postdoctoral Program for APA Recognized Proficiency in Psychopharmacology. Level Three follows the completion of Level Two by integrating the didactic instruction into the clinical practicum which is “designed to be an intensive, closely supervised experience involving exposure to a range of patients and diagnoses.” A minimum of 100 patients is the goal of that training, with “the patient mix relevant to the psychologist’s current and future practice.”
It is important to note that this sequence of education and training from Level One to Level Three is designed to meet the needs of the practicing psychologist and not simply follow traditional medical education. At the same time, educational programs decide whether to provide Level One, Level Two or Level Three education and training, especially as legislation is successful in their own jurisdiction. To date, only NM and LA have implemented legislation which accord psychologists the authority to prescribe under certain conditions. Before other states approve legislation that creates even more variation on what is acceptable in education and training, it is important that the criteria for Level Two or Level Three postdoctoral education and training programs be codified and programs in existence begin to be reviewed for adherence to those national standards. Accordingly, for the past year ASPPB and the National Register have collaborated on developing postdoctoral program designation criteria to parallel the doctoral programs designation criteria implemented by the ASPPB/NR Designation Project.
Criteria for ASPPB/National Register Designation of Postdoctoral Program in Psychopharmacology
ASPPB and the National Register have established national standards for psychopharmacology education and training using available guidelines and criteria from a number of national organizations and with the advice from many different constituencies. BEA endorsed the ASPPB/National Register criteria last November and later clarified that the 1996 APA policy document described the type of setting where education and training must take place. As there is not yet consensus on the Criteria, and there are of the concerns from two important constituencies - training programs and already trained psychologists - we wish to describe these issues and how we have resolved each.
Training Programs: Representatives of the programs have asked for an approval process that allows programs to designate the level at which they educate and train (Level Two vs. Level Three). We have revised the criteria to accommodate those concerns rather than requiring all programs be reviewed at Level Three. This recognizes that some programs have not yet developed the practicum component of training. Programs have also been concerned about the resources needed to monitor the 100 patient practicum. Under the current criteria, the programs which do not want to or do not believe they can meet that standard can still apply for approval at Level Two. Over time, and with state legislation passed, more practicum sites for psychologists will become available - especially with state-approval of national standards for education and training. In some cases practica have been developed by the trainees, such as the example in this issue and those mentioned in the two program descriptions. For those trainees, their transcript will reflect a Level Three designation. This allows the individual trainee to decide when they seek to complete the practicum requirement.
Grandparenting Provisions: Previously trained psychologists have expressed concern that their training program could not meet the ASPPB/National Register program designation criteria. As credentialing of individuals at the state level is not the purview of program review standards, ASPPB is developing a model grandparenting (or waiver) policy
for member boards to use when they adopt the ASPPB/National Register Designation Criteria for a Postdoctoral Program in Psychopharmacology. Both are needed: program criteria and trainee criteria. Thus, individual psychologists who completed a program before it was designated would still be eligible to apply for recognition during the state grandparenting period.
The Role of Continuing Education Providers: CE providers which are not affiliated with an accredited institution would be able to provide Level One training, as outlined in the BEA curriculum. This would be in addition to the CE education that they could provide to psychologists who are already credentialed and must update their knowledge periodically. They could continue to apply for and be recognized by APA as CE Sponsors, assuming they meet those criteria and procedures.
This summary is meant to be an introduction to the complexities involved. However, having national program standards and model legislative language for psychologists will enable those so qualified to achieve the right to practice psychopharmacology at whichever level they are educated and trained.