John C. Norcross, PhD
The published debates on prescription privileges for psychologists border on professional histrionics. Witness the competing titles of journal articles: Psychology's new frontier versus its siren call; a new era or a Pandora's box; psychology's logical evolution versus psychology's Jurassic Park; psychology's natural extension versus becoming what you had previously despised; responding to society's needs or a case of the tail wagging the dog; and psychology's ethical necessity versus psychology's drug problem. And I assure you that the private clashes among mental health professionals are far more vociferous and contentious than the published debates.
I entered these raging waters of the prescription privileges debate gingerly - dipping in a toe, gauging the temperature of the water, casting nervous glances around at my colleagues' reactions, gradually introducing my limbs, until at last I felt comfortably immersed in the water. This ambivalent introduction to the water parallels that of many of my scientist-practitioner colleagues. On the one hand, we endorse the evolution and expansion of the profession and are committed to improving patient care. On the other hand, we are suspicious that prescription privileges may detract from our distinctive identity, dilute psychological training, and advance the medical model over a psychological one. While I speak today as an advocate for prescription privileges for psychologists, my plunge into the waters has not been an easy or rapid one.
This prefatory confession organizes the twin themes of my presentation: First, separating the weak from the strong arguments for prescription privileges; and second, subjecting the expansion of psychological practice to prescriptive privileges to empirical scrutiny. Before canvassing what I believe are the weak and strong affirmative arguments in the debate, let me begin by defining some terms and parameters.
Defining The Terms
When we debated matters of grave importance in graduate school, the clashes would frequently deteriorate into accusatory posturing that one or both of the partisans had failed to adequately define the subject matter. Thus, I have been socialized - or traumatized - to define my terms early. The contentious debates on prescription privileges have been characterized by confusing terminology, and I hope we do not lapse here into semantic chaos.
For me, prescription privileges for psychologists in the United States refers to:
- doctoral-level, licensed psychologists
- completing formal postdoc training in psychopharmacology
- securing supervised experience in psychopharmacology receiving state authority under licensure/certification acts to prescribe a limited formulary of medications (psychoactive or those with psychoactive effects)
The latter may prove to be an important distinction. For example, Depakote (Divalproex sodium) and Tegretol (Carbamazepine) are technically anticonvulsants, yet used widely and effectively as mood stabilizers.
One means of safeguarding our professional identity will be to maintain the specific training for psychopharmacology practice at the postdoctoral level. In this way, we will prevent undermining core training in psychological science at the graduate level and will maintain our fundamental orientation as behavioral scientist-practitioners. In this way, too, prescriptive authority will remain a proficiency for a few psychologists, rather than being a basic skill for all (McGrath et al., 2004).
Defining terms identifies not only what is in (inclusion criteria) but also what is out (exclusion criteria). Please note the logical converse of these parameters: not all health care psychologists would be trained to prescribe; not all psychologists would be required to prescribe; not all states will authorize legislation; and not all medications will be available as part of the limited formulary.
In a nutshell, my argument is that prescription privileges for psychologists will provide more accessible, psychologically oriented, and integrated care to the populace. That is why we should acquire prescription privileges.
However, multiple arguments abound that we can or could prescribe. These weak arguments confuse whether we could secure prescription privileges with whether we should do so. Or the arguments confuse the steps to secure prescription authority with the reasons to do so.
1. Psychologist competence: With additional training, we will be able to safely and effectively prescribe psychoactive medications and therefore we should prescribe. Multiple, small experiments in the 1970s and 1980s demonstrated that psychologists with additional training could indeed prescribe successfully (Gutierrez & Silk, 1998). In the interest of science and in the interest of convincing policy makers that we could do so, the larger Department of Defense Psychopharmacology Demonstration Project (PDP) successfully demonstrated that licensed psychologists can provide safe, high-quality pharmacological care (Newman et al., 2000). Thousands of patients have been treated without injury and with high satisfaction with prescribing psychologists. It was crucial in counteracting physicians' outrageous allegation that psychologists' prescriptive authority would constitute a public health hazard.
But why we should acquire privileges is not addressed by the finding that we can do it. Psychologists with additional training, I submit, could safely and effectively extract teeth, construct skyscrapers, harvest green beans, remove appendices, draft legal briefs, and perform all sorts of complicated professional activities. But that misses the point of why we should acquire prescription privileges.
2. Psychologist affluence: Psychologists in the United States are losing money, patients, and positions due to managed care, which favors subdoctoral-level providers and medications. Prescription privileges will reclaim some of our losses. American psychologists, especially those in private practice, have taken a managed care bath. The industrialization of health care has restricted access to psychotherapy, limited the amount of reimbursable psychotherapy, relied primarily on short-term, symptom-focused psychotherapies, and restricted patient's freedom of choice in providers and treatments. Psychologists' incomes are decreasing because industrialization minimizes labor costs; adjusted for inflation, 5% less net income per year over several years.
But money is rarely a compelling moral justification. Moreover, continued calls for financial relief through prescriptive authority only fan the critics' suspicion that the movement is largely about financial gain.
3. Nonphysician precedents: Numerous nonphysician health care professionals have acquired prescription privileges in recent years and so can we. Yes, nurse practitioners, physician assistants, optometrists, pharmacists, and podiatrists have obtained legal means to prescribe limited formulary or in limited circumstances. Advanced practice psychiatric nurses, for example, can prescribe independently in 15 states and in collaboration with a physician in another 27 states (Feldman et al., 2003). But again, this is rampant confusion of the could and the should. Their experiences do not divine that we should do it. Monkey see, monkey do is a paltry excuse for changing the face of American psychology.
4. Organizational support: The American Psychological Association, in a rare demonstration of convergence between the scientist and practitioner factions, is wholeheartedly supporting prescription privileges. A nearly unanimous vote of the APA Council of Representatives formally endorsed prescription authority for appropriately trained psychologists and initiated the development of model legislation and model training curriculum. A heartening development to be sure, but not a strong argument.
5. Practitioner preference: The robust majority of practicing psychologists, graduate students, and predoctoral interns now support prescription privileges so we should pursue and obtain them. 65% to 70% of the psychologists surveyed using various methods favor or strongly favor prescriptive authority (Sammons et al., 2000), reflecting a consensus of support. One wag (Bieliauskas, 1992) humorously noted the flaw in this argument. Many people desire things they should not be allowed: young children crave excessive candy and adolescents want to pilot airplanes. But majority opinion is not a meritorious argument for granting prescriptive authority. We should not base our collective decision on prescription privileges on public opinion.
I do not intend to dismiss the importance of these five arguments in laying the groundwork for prescription privileges. Indeed, these factors are probably necessary preqrequisities for obtaining prescription privileges: we must demonstrate to the world that we can safely and effectively prescribe, that there are numerous and successful precedents, that organized American psychology is united behind the initiative, and that psychological practitioners embrace the initiative. And these essential prepatory steps have indeed been taken, thanks in no small part to the efforts of Robert Resnick and his APA colleagues. But these are quite different from compelling reasons why we should acquire prescription privileges, to which I now turn.
The following four strong arguments are based on sound principles of science and practice and are, in my view, strong arguments precisely because they serve the common good.
1. Public accessibility: Psychologists' prescription privileges will promote increased public access to trained prescribers of psychotropic medications. The United States is harshly confronted with unmet mental health needs of underserved populations, especially the elderly, institutionalized, children, and the chronically mentally ill. Rural America represents a great societal need: there are few or no trained prescribers of psychoactive medications.
The two traditional sources of psychoactive medications do not - and will not - meet societal need. First, general practitioners prescribe about 70 - 75% of psychotropic medications, but these professionals have little training in psychopharmacology and virtually none in the diagnosis and treatment of mental disorders (Fowler, 1999). General practitioners' education in psychopathology, psychotherapy, and psychoactive medications is significantly less than psychologists'. Second, psychiatrists are limited in number and distribution, and the longitudinal data are clear that fewer still are being trained. The number of US medical graduates entering psychiatry residency has gradually declined to about 600 per year, a number woefully inadequate to serve the pharmacological needs of the 18 to 23% of the population suffering from a diagnosable mental/behavioral disorder.
By contrast, psychology has far exceeded psychiatry as the largest doctoral-level mental health profession in the United States. There are approximately 95,000 licensed psychologists versus 45,000 psychiatrists. Psychologists are the primary providers of mental health care and, in many communities, psychologists are the only doctoral-level mental health professionals. Rural and inner city residents, for example, often do not have access to psychiatrists but do to psychologists. Physician specialist shortages are most apparent among pediatric and geriatric demographic groups.
Thus, by virtue of wider accessibility and specialized training, psychologists have an opportunity - perhaps a responsibility - to meet the mental and behavioral health needs of the population, which may include assuming primary responsibility for prescribing psychotropic medications. And several external evaluations of the PDP showed that psychologists trained in pharmacology improved access to treatment (Newman et al., 2000).
2. Psychological model: Psychologists will use - or choose not to use - pharmacotherapy based on a psychological model of treatment in contrast to a medical one. Dr. Russ Newman has long maintained that prescribing psychologists will use medication in a qualitatively different manner than psychiatrists or internists. We have a different culture and a wider set of skills.
The psychological model is systems-oriented, relativistic, holistic, and integrative. Psychological training is broad and comprehensive, far more than a medical curriculum. Psychologists are trained to view people as whole humans in context and pursue treatment on that level. It assumes medication, when appropriate, is but one aspect of treatment and will be employed as an adjunctive measure. The psychological model is more likely to empower clients to engage in active collaboration, as opposed to a largely passive recipient of care. Psychologists possess and exercise their relational skills, appreciating the centrality of the therapeutic alliance, which accounts for a surprisingly high proportion of the outcome variance in pharmacotherapy trials. Psychologists embrace and practice a wider array of treatments, as opposed to solely medication and ECT.
Our historical and distinctive strengths in assessment, psychotherapy, relationships, consultation, and research methods will compliment our use of medications and the evaluation of medication effects. The data on these propositions are preliminary but supportive. By acquiring prescriptive rights, psychologists can materially impact the manner in which psychotropic drugs are administered. If psychologists can avoid the financial lure of 15-minute medication checks and ignore the siren calls of pharmacotherapy alone, a truly psychological model - or biopsychosocial model - of medication may finally appear.
The ability to prescribe is also the ability to discontinue the use of inappropriately or ineffectively prescribed medications by other providers. As experts on both behavior change and research methods, psychologists may well be those best positioned to critically examine the research literature on the efficacy of medications in general, and their effects on individual patients in particular. Psychologists have largely undertaken the sobering reanalyses of medication effectiveness, for example, the negligible effect of SSRIs for children and the high placebo rates for antidepressants. Prescriptive authority allows us to take patients off medications as well as put them on.
3. Integrated treatment: Psychologists' prescriptive authority will enhance the sophisticated and efficient integration of psychotherapy and pharmacotherapy. A huge body of evidence overwhelmingly points to the complex and reciprocal interaction of environment and biology in mental disorders (Sammons & Schmidt, 2001). An enhanced scope of practice will enable a psychologist, in one person, to offer comprehensive services, including assessment, consultation, psychotherapy, and yes, medication when indicated. Combination treatments, particularly in severe and chronic mental disorders, are generally more effective than either medication or psychotherapy alone (Pampallona et al., 2004; Sammons & Schmidt, 2001; though the evidence is mixed on many other disorders).
Integrated in another sense, too. Prescribing psychologists will provide better continuity of care for their own psychotherapy patients and potentially be more cost-efficient by reducing health care costs. Instead of patients seeing one person for psychotherapy and one for medication, prescribing psychologists can combine the two in a way that saves time and money. While few studies on combined treatments have tested whether a 1-person or 2-person treatment is more effective, there are obvious benefits to the 1-person model (Gabbard & Kay, 2001).
Ideally, this integration would occur in opposite direction. That is, a larger cadre of medication-prescribing psychiatrists would be prepared or retrained with psychotherapy competence and psychological orientation. Alas, all the evidence suggests the contrary. Fewer physicians are entering psychiatry, fewer psychiatrists are being trained, a higher percentage of foreign medical graduates are entering residency, the hours of psychotherapy training for psychiatric residents are diminishing, and the practice data all converge in showing that fewer psychiatrists conduct psychotherapy. The ascendancy of neuroscience and the remedicalization of psychiatry are almost complete.
4. Evidence-based care: Prescribing psychologists are more likely to understand, adhere, and apply the scientific literature. As both a science and a profession, psychology pulls double duty in our training and activities. Both academic - research courses and practical - clinical training. For this reason, psychologists are known as the "scientists among the professionals and the professionals among the scientists."
This dual emphasis should translate into increased frequency of applying the scientific literature in prescriptive patterns and integrated care. This may be a fanciful leap of faith, but we are inarguably more competent, as a group, in statistical matters, research methods, evaluation strategies, and critical thinking than other prescribers. We are accustomed to the scientist-practitioner injunction to let science guide us when possible. We are leaders in evidence-based practice, though I do not mean to imply that other professions are not heading in that direction. And we would certainly add an impressive cadre of professionals to psychopharmacology research, not only the thinly disguised practitioner grants. The promise here is better prescribing patterns through the production and application of better science.
A necessary corollary is that we must empirically evaluate our own professional practices and pharmacotherapy propositions with the same empirical scrutiny. In this regard, I humbly confess that the latter strong argument is a promissory note backed by a string of supporting documentation, not controlled outcome studies.
Having ambivalently swum in these turbulent waters for many years now, I have arrived at a few definite conclusions, which serve as my summing up. The debate on prescription privileges has been characterized by professional histrionics, confusing terminology, weak arguments, and several strong arguments. The prescription privileges debate must be decided on the basis of scientific and practice evidence pertaining to patient care, not on professional rivalries, not on emotional reactions, not on financial motives. Adding medication to psychologists' armentarium will entail tradeoffs in our identity, training, and scope of practice; whoever argues to the contrary is either deluded or mendacious. Indeed, even among those psychologists who support prescriptive authority, 78% agree "the identity of psychologists will change" as a result of the authority (Sammons et al., 2000).
At the same time, prescription privileges promise more accessible, psychological, integrated, and empirically supported care for the populace. And those, my friends, are scientifically and morally compelling reasons to acquire prescription privileges for psychologists.
John C. Norcross, Ph.D., is Professor and former Chair of Psychology at the University of Scranton, Scranton, PA, a clinical psychologist in part-time practice, and an internationally recognized authority on behavior change and psychotherapy. Dr. Norcross is a member of the National Register Board of Directors.
An abbreviated version of this article originally appeared in the International Clinical Psychologist.
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