Almost any mental health practitioner today knows that “something is up” with the “prescription privileges debate thingy,” but for most, that’s about as far as it goes. It may surprise many readers, however, to learn that the prescriptions privileges movement for psychologists is not new; it’s actually about three decades old.
As this movement gets more coverage (and finds success at more state legislatures), it becomes even more important that students and early career psychologists have some familiarity with the “prescription privileges debate thingy.”
I’ve been pleasantly surprised at the number of students I’ve encountered that do know there is such a movement, but who desire more information about it. In a short series of articles, I hope to leave my fellow students (and psychologists largely removed from the RxP debate) with a bit more information.
To get involved, or to find more information than this series offers, contact your state association and inquire as to whether there is an RxP Task Force already in place for your state (there likely is).
What is RxP?
RxP, or the RxP Movement, refers to the professional movement within the field of clinical psychology to provide additional training to psychologists (via a certification or post-doctoral master’s degree) in an effort to increase psychologists’ scope of practice to include prescription writing authority. This movement seeks to improve access to psychotropic care and also enhance the quality of that access by pairing psychological training with additional medical/biological training.
In the mid-80s, Dr. Floyd Jennings was the first psychologist to write a prescription. Santa Fe Indian Hospital was in desperate need of psychotropic providers, and recognizing Dr. Jenning’s already-established familiarity with the psychological aspect of mental health, the Indian Health Service granted him special permission to prescribe. During his first year, he treated 378 patients (with no known adverse outcomes). This unprecedented allowance was quite brazen for both Dr. Jennings, the hospital, and the Indian Health Service, as no law – either state or federal – permitted a psychologist to prescribe.
By the late 80s, the Department of Defense had initiated a program whereby a select few psychologists would undergo training to prescribe psychotropics to military personnel. While the details of this training are highly debated (and will be covered in a later article), the program ultimately produced ten military psychologists, all of whom successfully prescribed for various branches of the armed forces (and now also do so in a civilian capacity for RxP-friendly states). Many of these fine folks are to thank for the progress RxP has made in the last decade or two.
By the 90s, the APA was becoming more involved in researching and publishing its recommendations for psychopharmacological training. Today the APA defines three levels of RxP training, and it is highly active in supporting RxP as a national movement.
At the time this article was published, four states (Louisiana, New Mexico, Illinois, and Iowa) permit psychologists to prescribe in some capacity, as well as the U.S. military, the Indian Health Service, Guam, and Puerto Rico. Anyone interested should consider joining APA’s Division 55 (The American Society for the Advancement of Pharmacotherapy).
Why Should It be on My Radar?
It seems that “integration” is the new buzz word for psychology. More state conferences are offering workshops on integration; more publications are discussing the benefits of integrated care; more doctoral programs are incorporating integrative care into their curricula.
Even if one does not anticipate ever prescribing in their professional career, one would be wise to be minimally versed in psychopharmacological basics. As more early career psychologists make their way into the mental health field, the need to be marketable becomes clear.
Even outside of medical integration and primary care, patients routinely ask psychologists about psychotropic options [1]. Many states have actually codified statutory authority for psychologists to consult on medication.
If the movement toward integrated care and professional marketing aren’t enough to convince you, consider how much benefit each of our patients is offered when they seek services from a professional who has received some additional training in “the other side” of mental health.
Levels of RxP Training
The American Psychological Association has identified three levels of RxP training.
Level 1
This stage, the minimum acceptable level of psychopharmacology education, includes coursework that should already be offered at the doctoral level. The APA has declared that this is the level of education that all psychologists should obtain.
While counseling psychologists may be less inclined to seek out this basic training, any psychologists involved in healthcare should at least possess this fundamental level of psychotropic savvy. Note, however, that not all doctoral degrees require a full course in psychopharmacology; some only offer it as an elective.
At a minimum, a great opportunity for students (and an affordable one!) is to attend CEUs with psychopharmacology as the focus. Refer to marketing materials to select workshops that are appropriate for your level of current psychopharm training.
For example, the University of Cincinnati offers a full day psychopharmacology update that attracts psychiatrists and psychiatric nurse practitioners from across the nation. Having attended this particular conference before, I believe it is more appropriate for level 2 or level 3 practitioners. Students and early career psychologists, like myself, would find it overwhelming (I did). Consider introductory workshops or survey courses.
An additional way to obtain familiarity with psychopharm for students is via practicum. For example, my own experience, and that of student colleagues’, has been invaluable to achieve some basic psychology/psychiatry cross-breeding!
While one of my colleagues obtained some psychopharm introduction via placement in a psychiatrist’s private practice (which has proven valuable to both her and the psychiatrist), I select one day out of the week to shadow the chief psychiatrist at an inpatient psychiatric facility. I’m pleased to report that both she and I have received excellent cross-training, and the psychiatrists with whom we’ve collaborated report equally positive experiences in gaining exposure to psychologically-based interventions.
Level 2
This stage, ideal for those who need more than basic knowledge, but have no intent to directly prescribe, prepares one to collaborate/consult on psychotropic drugs with other prescribers who may seek the counsel of a psychologist (pediatrician, family doctor, nurse practitioner, etc.). The idea is that the hybrid training of a psychologist who is familiar with psychotropics at this level is highly valuable to prescribers with limited (or no) psychological training.
Ideal ways to achieve this level are through either formal programs (like those mentioned below for level 3), or through formal internships which include this aspect in their training curricula (e.g., teaching hospitals which offer collaborative training with the departments of psychiatry).
For level 2, the National Psychopharmacology Update in Cincinnati would be appropriate, as would more advanced (but highly readable) texts, such as the popular materials authored by Stephen Stahl.
Level 3
The most comprehensive level described by the APA, level 3 prepares psychologists for independent prescribing authority – an ability to prescribe without oversight.
To achieve this, psychologists must already hold an active license, as well as complete a post-doctoral master’s or certificate program, and pass the Psychopharmacology Examination for Psychologists (PEP). Of course, with only four states offering psychologists the ability to prescribe, this level may seem unnecessary for many psychologists.
However, already holding such a degree becomes greatly beneficial when (not if) one’s state of practice does pass statutory authority. For example, in the state of Texas, pro-RxP legislation is continuously sought by the prescribing psychology taskforce, and in only my small rural district, six psychologists either already possess, or will soon possess, the training and credentials to prescribe.
An important word regarding state laws: psychologists should take careful note of the wording in statutory guidelines, as “collaborate” and “consult” can have different statutory meanings. The former suggests more agreement between professionals (e.g., psychologist and physician), and the latter suggests that a consultation must take place, but does not require agreement before action. Both of these should be examined on a state-by-state basis.
The Current State of RxP in the U.S.
If in the course of three decades only four states have passed RxP legislation (two of which passed within the last year), it might be fair to say that this movement has been a slow and difficult battle since day one.
However, approximately half the states in the U.S. have proposed such legislation. Many states also include laws on their books permitting psychologists to consult or collaborate with prescribers about psychotropic medication. More and more research is surfacing demonstrating both positive patient outcomes regarding prescribing psychologists, as well as positive physician endorsement.
Today, state psychological associations are seeking to partner with universities to offer more post-doctoral master’s degrees in psychopharmacology. Further, some are looking to combine programs with nursing schools or pharmacy schools. Universities like Fairleigh Dickinson and Alliant International have been offering psychopharmacology master’s degrees for many years, with a blend of online and in-person training which includes didactic and practical experience.
This progress, though, has been slow. Healthcare politics (especially inter-professional politics) can be ruthless. The nursing community, after years of demonstrating safe-prescribing practices, still faces political roadblocks regarding autonomous versus collaborative prescribing. The pros and cons of the RxP movement and the heated debate about it will be the foci of later articles in this series.
**The views and opinions expressed in this article are purely the article author’s, and not necessarily the views and opinions of Time2Track LLC.**
References
[1] VandenBos, G. R., & Williams, S. (2001). Is psychologists’ involvement in the prescribing of psychotropic medication really a new activity? Professional Psychology: Research and Practice, 31, 615-618-doi: 10.1037/0735-7028.31.6.615
- Prescription Privileges for Psychologists: An Introduction - March 20, 2017
I find this blog to be very one-sided and simplistic about a complex and controversial matter in the field. There are many psychologists opposed to prescription privileges for psychologists because they believe that truncated and non-accredited training is inappropriate and risky, posing problems for consumers and the field of psychology. There is an organization of psychologists called Psychologists Opposed to Prescription Privileges to Psychologists (POPPP) that informs psychologists and others about concerns associated with psychologist prescribing. I would encouraged interested readers to link to its website: http://www.poppp.org
There are already programs in place that teach psychologists to prescribe. They are called medical or nurse practitioner school. Psychology should worry more about its relevance in the changing market, not spend time moving into another profession’s turf. Integration is great…..learn to work with trained prescribers.
so it’s OK for psychiatrists who have less training in psychopathology to do a couple of years of psychotherapy and provide therapy? you’re argument doesn’t take into account that the function of prescribing can be taught. again, the medical ivory towers run a protectionist agenda which is not in the interest in the patients.
Ryan’s post provides a broad survey of the general RxP issues, but does not mention some important facts and criticisms of RxP. While APA has strongly advocated for RxP for decades now, no other professional organization supports RxP. NAMI opposes it. A study published in 2016 in the Journal of Applied Biobehavioral Research, “What Oregon Psychologists Think and Know About Prescriptive Authority: Divided Views and Data-Driven Change,” concluded that, even after intense lobbying about an RxP bill in Oregon, most psychologists are not interested in undergoing RxP training. NAMI also concluded, “..there is no current evidence that expanding prescription privileges to psychologists will address (psychiatric workforce) shortages.”
My advice to psychology students and young psychologists: be sure to survey both sides of the RxP discussion before you decide whether to support RxP in your state, or to pursue RxP training. And, obtaining the Level II Training recommended by APA would probably serve you very well (but it is not really RxP, “prescribing privileges”). Level II training would enhance your ability to communicate with patients, families and other health professionals, especially PCPs, and to be part of an interprofessional treatment team.
I’m glad to see some discussion taking shape on this matter. And I thank the commenters so far for their involvement. I would like to remind readers that the intent of this piece is to maintain a fairly simple and generalized look at RxP… discuss its history and some of it’s basic points. I agree that the matter is very complex and controversial, but the point of this article (the first in a series of three) is to introduce folks to prescription privileges (in its various forms). There is a ton of literature on the pros on cons of the movement, and my second article will cover the basics (again, it will be kept light considering the medium) of BOTH sides. I would gladly share my dissertation with interested persons, as it goes into great depth on both arguments as well as the psychological and political mechanisms at play in RxP’s polarization. Most RxP supporters I’ve met are familiar with POPPP. And I think linking to poppp.org is a great idea, and that link is actually included in the draft of the second article of the series (not yet published on T2T). So I would ask that you please keep an eye out for the second article as it gets into many of the points being commented on which this article doesn’t address. To reply to Michael’s comment: many RxPers have worked with NPs and PCPs, and that’s one reason they see the need for advanced training that is specific to Prescribing Psychologists… the paradigm is unique. More on that in the second installment of this article. Richard, as stated, the second series will go deeper than simply a definition and an historical presentation (which even this was pretty lengthy for a simple intro). Btw, the Oregon paper is actually discussed in my dissertation as well. There are some very great RxP-opposition papers in the literature. And even the most die-hard RxP supporter would do well to familiarize themselves with that scholarship as well. Thanks again and please keep following the series, while also keeping in mind its purpose and audience. -R.
While I agree that clinical psychologists should prepare to work in integrative behavioral/somatic health contexts this is a far cry from proposing that RxP is an appropriate direction for the profession to take. The APA has invested millions in this effort, diverting funds away from lobbying insurance companies to more adequately compensate psychotherapies that have been shown to be just as effective (or more effective) than psychotropic medications. They paid out over $9 million dollars to settle a law suit by APA members who were mislead about the mandatory nature of fees to be paid to the APAPO (they were voluntary). One of several incentives to increase these funds which are used for lobbying, was to support state organizations in their push to pass RxP legislation. Four states, only one (Illinois) of which has training requirements commensurate with other non-physician prescribers, with less than 100 prescribing psychologists seems to me to be a costly and misguided effort.
Additionally, if our desire is ultimately to improve mental health outcomes for consumers we need to take a step back and ask the key question: what are the problems and what are some possible solutions to fix them? Proponents describe the need to improve access to mental health care without making the important distinction that access to mental health care does not mean access to psychotropic medications. We need to address systemic issues that favor more aggressive medicine over less intensive interventions when the latter have been shown to be as effective, less costly, and safer (i.e., no side effects that compromise somatic health). There is no reason to assume that prescribing psychologists won’t succumb to the same market pressures that have led most psychiatrists to abandon therapy in lieu of becoming psychopharmacologists. Working along side nurses and physicians, promoting the use of screening tools and algorithms that inform stepped-up care approaches seems a preferable route to become lesser-trained prescribers.
We also need to make sure that when we are dealing with severe mental health issues that warrant medication or combined treatment these services are provided by competent prescribers. In fact, there is a vast discrepancy between psychologists’ preparation relative to other non-physician prescribers. As someone who teaches psychology to undergraduates and teaches at a school that also educates nurses I am deeply concerned about the complete lack of prerequisites required of doctoral-level psychologists to gain entry into Master’s of Clinical Psychopharmacology programs. All professions that prescribe have a basic grounding in the basic sciences prior to pursuing their unique professional training programs. How is it possible to learn (via 7 distance education courses that are graded credit/no credit) about neurochemistry if you have never taken a course in chemistry or biochemistry? Building upon a shaky foundation where even dental hygienists (see attached figure from Robiner et al., 2013 – the full article may be found here: http://digitalcommons.linfield.edu/psycfac_pubs/9/) compare favorably does not inspire confidence. In fact, a recent national survey of the members of the Association for Behavioral and Cognitive Therapies (ABCT) suggests that empirically-driven practitioners share these concerns, with 73% of them reporting that they would not refer clients to prescribing psychologists given their inadequate training.
Proponents have produced no credible evidence to suggest they are prescribing safely or effectively. Recent data from the Part D Prescriber Public Use File (PUF) from the Centers for Medicare and Medicaid Service (CMS) suggests that some medical psychologists from Louisiana and prescribing psychologists from New Mexico have been prescribing beyond the legislative bounds of their licenses. Lawsuits in Louisiana also suggest caution, not hubris should guide the RxP movements.
Finally, I strongly believe that the stigma that surrounds mental illness serves as a more formidable barrier to accessing care than any other factor and is one that would not be addressed by establishing a lesser-trained class of psychologist prescribers. In fact, I would suggest that RxP legislation promulgates the stigma that those suffering from mental health problems currently face. During the legislative process, there is typically wrangling over the bare minimum training acceptable to medically treat the mentally ill. The proposals always start with the bare minimum training and education they believe they can get passed through committees. This race to the bottom echoes the message that is acceptable to provide sub-standard care to folks who suffer from mental illness. It is not. They deserve better care.
You mention “vast discrepancies” on curricular differences between prescribers. I agree that the best literature comparing the curricula of NPs, PA, Non-Psychiatrist Physicians, and RxPhD/PsyD’s has some methodological downfalls, however, I’m curious as to whether you have personally researched how FDU and Alliant compare to MSN programs? I have made a very difficult (and not even yet final) personal choice to not pursue MSN education because I do not believe that is is adequate to train a prescriber. I’m 33 years old, expect to be in this profession for another 33 years, so am at the perfect place to decide MSN vs MS-Psychpharm. The education is similar in nature, but (again in my own opinion from my own research) it is not as rigorous for someone who is already a psychologist. (the online debate is moot as both can be completed online). In two years I could have either an MSN (and I’ve seen the talent produced by MSN programs in my area) or I could have a post-doc psychopharm master’s, which spends MORE time on the hard stuff (based on the programs I have reviewed for my personal academic path). The MSN programs seem to be composed, in roughly 50% of the material WE ALREADY KNOW. Why would you advocate for your colleagues to go through such a program? Why waste their talent? Why not spend the entire two years learning something more applicable? Don’t get me wrong, the nursing programs are good, because nurses don’t already know what we know. But for us, only 50% or so would be “new” knowledge.
One thing we do agree on, is that psychopharm programs should have pre-reqs. This is only my personal opinion and I have no data to back it up.
On the other hand, I WOULD advocate for Ph.D. plus M.D. programs. I very much support this academic path. However, I do believe (as leading RxP-proponent and Psychiatrist Daniel Carlot has commented on numerous occasions) obtaining an MD would be extremely gratuitous and inefficient for the purposes of a prescribing psychologist. However, for those who wish to do so (PhD/MD) regardless, my hat’s off, as I believe this yields the ultimate mental health doctor. But 8 more years of learning MD-ness would not be a good use of my time, and 2 years of NP-ness would be a decent use of my time, but not as good of a use as FDU or Alliant would be, given that the entire two years there is spent learning new, pertinent, appropriate, applicable, material.
I have notes somewhere on the nurse practitioner who also attended the psychopharm program for psychologists… she commented on the comparison of the two (and concluded that as far as content, the psychopharm program was more difficult and pertinent than the MSN program).
Again, this gives me reason to ask, how many members of POPP actually have known (to compare/contrast) a prescribing psychologist to a mid-level psychiatric prescriber or PCP?
This is a very one-sided perspective on a controversial matter that is divisive within the field and is not supported by consumer groups such as NAMI. The training model for psychologists to prescribe is truncated relative to all other prescribing disciplines. It is not accredited and many psychologists believe that it poses unnecessary risks for consumers and is not a good direction for psychologists. It is based on a training model that has been criticized in the literature. There is an organization of psychologists who oppose RxP called Psychologists Opposed to Prescription Privileges for Psychologists. Further information is available at http://www.poppp.org. Below are some of the many relevant citations.
Butt, Z., Robiner, W. N., & Tumlin, T. R. (Fall, 2013). More concerns about prescriptive authority for psychologists: It’s time to redirect the agenda from RxP to collaboration. APAHC Grand Rounds, 3(1), 9-10.
Robiner, W. N., Bearman, D. L., Berman, M., Grove, W. M., Colón, E., Armstrong, J., & Mareck, S. (2002). Prescriptive authority for psychologists: A looming health hazard? Clinical Psychology: Science and Practice, 9(3), 231-248. doi:10.1093/clipsy.9.3.231
Robiner, W. N., Bearman, D. L., Berman, M., Grove, W. M., Colón, E., Armstrong, J., Mareck, S., Tanenbaum, R. (2003). Prescriptive authority for psychologists: Despite deficits in education and knowledge? Journal of Clinical Psychology in Medical Settings, 10(3), 211-222. doi:10.1023/A:1025419114038
Robiner, W. N., Tumlin, T. R., & Tompkins, T. L. (2013). Psychologists and medications in the era of interprofessional care: Collaboration is less problematic and costly than prescribing. Clinical Psychology: Science and Practice, 20, 489-507. doi: 10.1111/cpsp.12054
My view of the RxP movement is that it appeals most strongly to those of our colleagues in psychology who are willing (perhaps eager) to join with psychiatrists in the medical management of cognitive/emotive symptoms, an appeal often due to their not having acquired the clinical protocols and skill sets that would allow them to fulfill psychology’s primary mission of helping their clients get to the root and dispose of such symptoms drug-free and with finality. Many of them subscribe to the erroneous idea that they should be able to do both concurrently. Gwen Olsen, a 15 year pharmacy rep, shares hugely valuable insights in this connection in her short YouTube video. I strongly recommend watching it: https://www.youtube.com/watch?v=UIm8fHxqUAM
Robert, this reply made me sad. You assume a lot of information that there is absolutely no evidence for. In the last few years I have poured myself into the literature on RxP. You basically said in your post that (a) psychologists just want to prescribe because they never mastered real psychology, and (b) psychology cannot be practiced concurrently with psychopharmacology. The first suggestion is quite brazen (thanks for not coming out and saying it directly, though) but have you MET any prescribing psychologists? I know several and non fit your description. The second suggestion seems just uniformed. Why do you think both can’t be done concurrently (especially when studies show positive outcomes, more accurate medication regimes, LESS prescribing resulting in less side effects, and shorter medication regimes (for the non SMI populations)). Why do you think an RxP Psychologist wants anything other than an ultimately drug-free solution? I get the feeling, again, that you know very few prescribing psychologists. Psych-prescribing is currently not done well in this country. Not even close (yes this is my biased opinion, but literature also backs this up). Psychologists advocate that our background, rooted in non-medical treatment, can counterbalance the main reasons why it’s not being done well. Limited research is available empirically proving this, but none exists showing that it’s wrong. I DO NOT want my patients on meds. I certainly don’t want them on the WRONG meds. Their nurse practitioners went through nursing school, then an 18 month program to prescribe (also many online), and I’ve seen the tragedy of what happens when psych meds are being managed by a nurse practitioner. My anecdotal experience (I realize that’s limited in value) has shown me that prescribing psychologists are in a completely different league than mid-levels who currently prescribe, and even other physicians (one patient currently gets her psych meds from her OBGYN). I just want to see my patients truly getting the best service out there. There isn’t very good service out there for psych meds. But I’ve seen how much better it is when someone with 10 years of training in mental health also learns meds, AND works in partnership with a physician.
Regarding the climate of your reply: I think responses should reflect an overall dedication to better patient outcomes/open-discussion, not personal attacks on those with whom we disagree.
Robert, this reply made me sad. You assume a lot of information that there is absolutely no evidence for. In the last few years I have poured myself into the literature on RxP. You basically said in your post that (a) psychologists just want to prescribe because they never mastered real psychology, and (b) psychology cannot be practiced concurrently with psychopharmacology. The first suggestion is quite brazen (thanks for not coming out and saying it directly, though) but have you MET any prescribing psychologists? I know several and non fit your description. The second suggestion seems just uniformed. Why do you think both can’t be done concurrently (especially when studies show positive outcomes, more accurate medication regimes, LESS prescribing resulting in less side effects, and shorter medication regimes (for the non SMI populations)). Why do you think an RxP Psychologist wants anything other than an ultimately drug-free solution? I get the feeling, again, that you know very few prescribing psychologists. Psych-prescribing is currently not done well in this country. Not even close (yes this is my biased opinion, but literature also backs this up). Psychologists advocate that our background, rooted in non-medical treatment, can counterbalance the main reasons why it’s not being done well. Limited research is available empirically proving this, but none exists showing that it’s wrong. I DO NOT want my patients on meds. I certainly don’t want them on the WRONG meds. Their nurse practitioners went through nursing school, then an 18 month program to prescribe (also many online), and I’ve seen the tragedy of what happens when psych meds are being managed by a nurse practitioner. My anecdotal experience (I realize that’s limited in value) has shown me that prescribing psychologists are in a completely different league than mid-levels who currently prescribe, and even other physicians (one patient currently gets her psych meds from her OBGYN). I just want to see my patients truly getting the best service out there. There isn’t very good service out there for psych meds. But I’ve seen how much better it is when someone with 10 years of training in mental health also learns meds, AND works in partnership with a physician.
Regarding the climate of your reply: I think responses should reflect an overall dedication to better patient outcomes/open-discussion, not personal attacks on those with whom we disagree.
Robert, this reply made me sad. You assume a lot of information that there is absolutely no evidence for. In the last few years I have poured myself into the literature on RxP. You basically said in your post that (a) psychologists just want to prescribe because they never mastered real psychology, and (b) psychology cannot be practiced concurrently with psychopharmacology. The first suggestion is quite brazen (thanks for not coming out and saying it directly, though) but have you MET any prescribing psychologists? I know several and non fit your description. The second suggestion seems just uniformed. Why do you think both can’t be done concurrently (especially when studies show positive outcomes, more accurate medication regimes, LESS prescribing resulting in less side effects, and shorter medication regimes (for the non SMI populations)). Why do you think an RxP Psychologist wants anything other than an ultimately drug-free solution? I get the feeling, again, that you know very few prescribing psychologists. Psych-prescribing is currently not done well in this country. Not even close (yes this is my biased opinion, but literature also backs this up). Psychologists advocate that our background, rooted in non-medical treatment, can counterbalance the main reasons why it’s not being done well. Limited research is available empirically proving this, but none exists showing that it’s wrong. I DO NOT want my patients on meds. I certainly don’t want them on the WRONG meds. Their nurse practitioners went through nursing school, then an 18 month program to prescribe (also many online), and I’ve seen the tragedy of what happens when psych meds are being managed by a nurse practitioner. My anecdotal experience (I realize that’s limited in value) has shown me that prescribing psychologists are in a completely different league than mid-levels who currently prescribe, and even other physicians (one patient currently gets her psych meds from her OBGYN). I just want to see my patients truly getting the best service out there. There isn’t very good service out there for psych meds. But I’ve seen how much better it is when someone with 10 years of training in mental health also learns meds, AND works in partnership with a physician.
Regarding the climate of your reply: I think responses should reflect an overall dedication to better patient outcomes/open-discussion, not personal attacks on those with whom we disagree.
I am a retired Emeritus Prof. of Psychology from San Diego St. Univ. This movement has been in existence for many years and I have opposed it from the beginning. The major reason is that we need to make it clear that Psychology offers many alternatives for treatment that do not involve medicating someone. The medical profession already over medicates patients often without exploring what might a factor in their lives causing their symptoms, simply writing a script because it’s demanded. We don’t need more prescription writers prone to over medicate. Also, most of the proposals I’ve seen except for one, provide very poor training with psychotropic medication and very limited hands on practicum. Let those interested go through a Physicians Assistant program for their training.
Dear Colleagues,
Internal and external dialog about this issue is beneficial and necessary. Respect should exist for opinions on both sides with regard to the question of whether or not this is a desired evolution for the field of psychology. However, it is important that, in expressing our opinions, we remain fact-based about our justifications rather than promulgating misinformation on either side of this argument. Surely, everyone – regardless of opinion on this issue – can agree on that. What is troubling to me, is that some of the justifications offered are not factual or are only partial truths.
References to the RxP programs being “unaccredited” is a technical but partial truth. It is a true statement, in that the programs are not accredited by the APA, because the APA only accredits doctoral programs and internships. These programs are post-doctoral masters programs and are, therefore, not eligible for “accreditation.” However, the APA does “designate” these programs and has thus far declared 4 psychopharmacology training programs to be “APA designated.” If we rely upon the APA as the standard of evaluating and approving doctoral programs and internships, it seems logical that we would also trust them to evaluate and approve (via designation) the postdoctoral masters in psychopharmacology training programs. When one only says that these programs are not “accredited” (which is true), it also implies that these programs are not evaluated or regulated (which is untrue).
Another term that frequently appears in criticisms of MSCP programs is “truncated.” Perhaps this criticism is meant as relative to medical school. Yet, psychologists who pursue the postdoctoral masters degree in psychopharmacology already possess doctorates in the field of psychology as opposed to entering these programs directly from undergraduate study. The “truncated” program argument curiously but often appears along with the argument that PA and NP programs are somehow superior models of training that psychologists should pursue instead. In comparison to PA and NP programs, the postdoctoral masters programs in psychopharmacology are not truncated in terms of length of time required to complete the degree. Additionally, it is a fact that psychologists who complete APA designated training programs and acquire a license to prescribe have more education and training experience prescribing psychotropic medications specifically than the other prescribing professions, including PAs, NPs, and non-psychiatrist physicians. Furthermore, the descriptions offered by critics of psychopharmacology programs are not consistent with the program from which I graduated or other APA designated MSCP programs.
It is not factually accurate that the APA is the “only” professional organization that supports prescriptive authority for psychologists. The APA-PO and the National Register of Health Service Providers in Psychology also support prescriptive authority for properly trained psychologists as do several State Psychological Associations.
It is misleading to state that proponents of prescriptive authority for psychologists have presented “no credible evidence” of patient safety. Actually, to date, there have been no documented adverse events in the many years that psychologists have been prescribing in the DoD, Indian Health Services, Guam, or the U.S. states with legislation that extends prescribing to properly trained psychologists’ scope of practice. This is despite a high level of monitoring and scrutiny from opponents of prescriptive authority for psychologists. That would seem in and of itself to be evidence of patient safety. (Note that an adverse event may be inevitable, but that the trajectory of safety documented thus far would logically imply that adverse events would not be occurring at a higher rate than that of non-psychologists prescribing professionals.)
Most psychologists, even proponents of the prescriptive authority movement, agree that psychotropic medications are overly prescribed and often mismanaged. The pursuit of prescriptive authority for psychologists is not merely the power to prescribe. It is the power to NOT prescribe and the power to UNprescribe unnecessary, excessive, or inappropriate psychotropic medications. This directly relates to psychologists’ superior abilities in assessing and diagnosing mental illness (particularly complex differential diagnoses or co-morbid diagnoses) relative to non-mental health trained prescribers.
Lastly, the idea that having prescriptive authority for properly trained psychologists somehow threatens the use of or access to psychotherapeutic interventions like CBT is unfounded. Psychologists who seek prescriptive authority became psychologists (as opposed to psychiatrists) presumably because they value the proven efficacy of non-medication treatment modalities for mental health. Indeed, it is factually accurate to say that certain psychological therapies are equal to or superior to the efficacy of psychotropic medications in certain cases.
The field of psychology has allowed for other specialties such as becoming a Neuropsychologist, which includes a scope of practice that is not extended to all psychologists, and for which the additional education/training required for board certification is a chosen pursuit of a minority. The same type of specialization can exist for Prescribing Psychologists without threatening the psychotherapeutic foundations of psychologists’ professional identities and practice.
In closing, challenging one another and expressing divergent opinions about this important professional issue should be encouraged. However, we should practice doing so with respect and tolerance for those with whom we disagree while also striving to be factually accurate.
Sarah Shelton, PsyD, MPH, MSCP
Licensed Clinical Psychologist – KY & IL
President-Elect, Kentucky Psychological Association
Board of Directors, National Register of Health Service Psychologists
Excellent rebuttal!
As a prescribing psychologist who has been on the faculty of the Southern New Mexico Family Medicine Residency Program for ten years where I teach physicians to manage psychotropic medications as well as to avoid their use when behavioral and psychological interventions will work I find it personally frustrating that there is so much misinformation still being promulgated by a minority of psychologists who oppose RxP. I don’t have the time to answer every misstatement or misrepresentation contained in the postings here, but find Dr. Shelton’s thoughtful reply to be most helpful and thorough. Thank you.
In Vermont, 80% of psychologists surveyed in 2011 support RxP.
From: https://www.researchgate.net/publication/237777181_Psychology_and_psychopharmacology_Natural_partners_in_holistic_healthcare
“The “prescription movement”, involving psychologists gaining prescriptive authority in the United States, is not a new phenomenon. For approximately 25 years, psychologists and outside interested parties have been calling for this movement toward prescriptive privileges. The elected representatives of professional psychology have consistently supported this expansion of practice; voting has overwhelmingly endorsed the development of training models and legislation to enable psychologists with advanced training to prescribe. Since 1994, psychologists have been actively prescribing in the military with no significant negative outcomes and with evidence that they are practicing in a more holistic manner than psychiatric colleagues. Likewise, more recent data for psychologists prescribing in New Mexico, Louisiana, or Guam demonstrate that psychologists can prescribe effectively, and safely, within a biopsychosocial model of healthcare. Of particular note is that psychologists are 8 to 10 times less likely than physicans to prescribe for the same severity and type of presenting mental health conditions. Psychologists have begun to demonstrate that a true biopsychosocial approach, involving psychotherapy, psychological testing, and psychosocial approaches to treating mental illness is viable and effective. Prescribing psychologists view psychotropic medication as only one treatment option among many, permitting increased flexibility and involvement of patient choice. Marked reductions in healthcare cost have been demonstrated and are anticipated to continue due to this holistic approach to mental healthcare. This expansion of practice shows great promise and should be embraced to nurture increased access to cost-effective care and improved quality of mental health care.”
First of all, many thanks to Ryan for writing and posting this information on an important site like Time2Track! The profession is fortunate to have you, Ryan.
I want to echo my colleagues that have detailed that there has been no evidence that prescribing psychologists have posed harm to patients (at least not moreso than our physician counterparts who prescribe psychotropic medication), have engaged in polypharmacy and over-prescribing, or that the RxP movement has distorted the face of the profession of psychology such that non-pharmacologic treatments are de-emphasized or discouraged. In fact, we have seen (at least anecdotally) that prescribing psychologists are more likely to unprescribe medication and therefore reduce the overall number of medications that patients are prescribed.
I won’t go further into the arguments, as my colleague Dr. Shelton has already excellently done so in previous comments.
Derek Phillips, Psy.D.
Licensed Clinical Psychologist: FL & IL
Board of Directors, APA Division 55
Thanks… based on the first few replies, I was starting to wonder. I think it’s easy to miss the fact that the audience is a body of students looking for some basic understand of what RxP is and where it comes from… I didn’t mean for this to turn into a forum for detailed RxP debate, but none-the-less, I think it’s a great place, given that we students can get exposure to both sides (and hopefully judge facts from… non-facts?). Thanks for your comments.
I have been working as a prescribing psychologist for the past nine years embedded in a large family medicine clinic in an Army hospital. The hospital serves active duty service members, dependents and retirees. I know of other prescribing psychologists with similar or more extensive experience. I appreciate all those who have contributed to this dialogue and especially Ryan for posting the article in the first place. I was very excited to join this exchange and add my two cents. However, Dr. Shelton’s post stole my thunder. Dr. Shelton stated the facts very accurately and with more eloquence than I can muster. I refer you to her post for a good summation of the case.
It is not without some amusement that I read debates about whether my profession, that I have been practicing for about a decade, should exist. For those questioning whether psychologists can be trained to be effective and safe prescribers…that train has left the station. As a psychologist who has completed a two year postdoctoral master’s degree in psychopharmacology, taken and passed the Psychopharmacology Exam for Psychologists (PEP), spent one year being supervised by a psychiatrist, followed by two years of being supervised by a family medicine physician, I can honestly say I am well trained to prescribe medication. All of this was conducted in the sometimes hostile, or at least sometimes unfriendly, environment of other professionals (some in my own field of psychology) waiting for me to fail.
In the first years of my practice I read the POPP articles as well as the pro-RxP literature. In an attempt to address the concerns about safety, training and efficacy I conducted an anonymous and confidential survey of almost 50 of my medical colleagues in family medicine who worked with me on a daily basis. No one is better suited to evaluate the medical skill and safety of a prescribing psychologist than professionals practicing physical medicine. These primary care providers are responsible for the total well-being of their patients and see them regularly. Therefore, these providers were in the best position to evaluate my safety and efficacy. I have learned that primary care providers have little time for nonsense. If I didn’t make their patients better and do it safely, I would have been out of a job quickly. The results were positive and I have attached the citation for the article.
I work with many fine PAs, nurse practitioners and psychiatrists. I respect their training and they mine. I do not want to be a “mini-psychiatrist,” a PA or a psychiatric nurse practitioner. As a prescribing psychologist I integrate my robust training as a psychologist with the judicial use of psychotropic medication. The most common question I get from non-psychiatric medical providers is “why don’t all psychologists prescribe?” My answer: not every psychologist should prescribe. This is a very specific subspecialty with a challenging curriculum.
I respectfully submit that there is no longer any “debate” about safety and efficacy of training for prescribing psychologists. That question has been answered…we’ve been doing it safely for decades. Second, let’s stop talking about whether a subspecialty that already exists should exist. I do not challenge the appropriateness of other psychology subspecialties. Rather, let’s focus our considerable intellect and professional energy on growing the field of psychology in all of its manifestations.
My suggestions for fruitful debate:
Should RxP training be embedded in traditional PsyD and PhD training or should it remain a post-doctoral specialty?
Should we parse RxP into subspecialties with demonstrable expertise (.e.g,, addictions specialty)?
Should RxP practitioners be subject to board exams episodically to ensure they are current on best practices?
Shearer, D.S., Harmon, C.S., Seavey, B.M., & Tiu, A.Y. (2012). The primary care prescribing psychologist model: Medical provider ratings of the safety, impact and utility of prescribing psychologist in a primary care settings. Journal of Clinical Psychology in Medical Settings, 19(4), 420-429.
The views expressed are those of the author(s) and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S. Government.
Thanks… I agree that Dr. Thunder-Stealer’s reply was quite eloquent… she makes a fantastic graduate professor, and political leader. I appreciate you adding what you have to this dialogue… it benefits all of us – but especially those of us considering adding RxP as an extra tool to our belt (and not because we haven’t “acquired the clinical protocols and skill sets that would allow [us] to fulfill psychology’s primary mission,” but rather because we want the best for our patients and in many cases, seeing a PCP or NP doesn’t yield very impressive results. I’m a mere student-clinician and I often cringe when I find out what medications my patients are on and how their pharmacological trajectory has evolved (or …devolved might be more accurate?). Thanks. -R.
I have been practicing as a prescribing psychologist for 8 years in New Mexico, and psychologists have been able to prescribe in New Mexico since 2004. During that time, there have been no Board Compliants against a prescribing psychologist associated with patient harm, and there have been no malpractice suits associated with such. The training program that I completed for my Master’s degree in psychopharmacology was rigorous, and approved by the New Mexico Medical Board as adequate. Every day I have patients tell me they appreciate my approach, which they say is different from psychiatric prescribers they have seen who are primarily trained in the medical model. They report that my diagnostic assessments are extremely thorough, and they appreciate the mix of psychotherapy and medication management that I provide. I am also able to integrate formal psychological testing when needed. Although I practice in a city, Santa Fe, I have clients who may drive 3 hours each way from rural areas because of a lack of pychiatric personnel in this state. I truly feel that clients receive a qualitatively different type of prescribing service when they work with someone who had obtained a PhD in psychology, in addition to training in medications. I often spend time helping clients see how situational circumstances or patterns of responding are contributing to symptoms, rather than reactively increasing medication when someone complains about worsening illness. I continue to feel confusion and some dismay at the amount of vitriol directed at our subgroup by other psychologists who are not prescribers. I feel the training and expanded activity has served me and my client base, while others may prefer not to pursue this route. We can certainly agree to disagree about different paths of psychological training and provision of care.
I want to highlight this statement you made, as it sums up my reason AS A STUDENT with a full career ahead of me (Lord will’in), for NOT choosing to go the NP route:
“I truly feel that clients receive a qualitatively different type of prescribing service when they work with someone who had obtained a PhD in psychology, in addition to training in medications.”
I would add, however, that “additional training in medications” should be from a psychologically-informed perspective (in my humble and experience-limited opinion). Nursing schools do not offer me this. Psychiatry doesn’t offer me this. PA school doesn’t offer me this. There is something special about a PSYCHOLOGIST FOREMOST, and prescriber secondarily that results in the comments you describe from your patients. Yes, as a student, I could get my M.S.N. in two years (exactly two years, online). I choose not to because I do not believe the curriculum is as rigorous as the Post-Doc MS (have a look at what Vanderbilt’s Psychiatric MSN program entails), and I also do not believe the paradigm is as beneficial. I could take the easy road, and get an MSN. I don’t want to. I want to be damn good at what I do. NP school (for me) wouldn’t provide that.
Finally, I believe twenty years from now, there will be more research (hopefully my own included) and you statement could read “quantitively” different kind of prescribing service.
I am an Affiliate Faculty at Antioch University, Seatte PsyD Program in Clinical Psychology. I attended UCLA, Utah State, and the University of Washington School of Medicine. I am both a Licensed Clinical Psychologist and Nationally Certified School Psychologist. I recently completed my Postdoctoral MS in Clinical Psychopharmacology from Alliant University. I passed the national APA Psychopharmacology Examination for Psychologists (PEP) in July 2016 and will now be doing some additional training in New Mexico this year.
The psychopharmacology training beyond my PhD has been amazing and eye-opening. I believe that all new psychologists should have this training. I suggest that those psychologists opposed to prescription prescription privileges go through the training first before pumping out another article. I am sure these professionals will become converts and join with us, rather than against us.
I very much support psychologists with prescription privileges. To me the debate is over. We are already prescribing. I would love to talk to anyone entering our field about this. You may email me at: [email protected].
Sincerely,
Steve Curtis, Ph.D., NCSP, MSCP
Licensed Clinical Psychologist
Nationally Certified School Psychologist
Affiliate Faculty at Antioch University, Seattle
First of all: Good job Ryan. Thank you for helping to educate your peers.
My comments have more to do with the lesson to be learned from all of the comments that you have generated in response to your thoughtful work.
The scientific literature is quite clear that many mental illnesses are better treated with psychotherapy than medication AND that some mentally ill patients are so limited by their illness that effective participation in psychotherapy is not possible. It seems to me, therefore, that a very proper use of psychotropic medications is to support the accessibility and effectiveness of psychotherapy and to provide symptomatic relief, where possible, by early medicinal treatment of the most symptomatically limited patients, until such medications may be eliminated or replaced by psychotherapy alone, whenever possible.
Like all of the commenters, I believe that prescribers, whether they be physicians, nurse practitioners, or psychologists, must be properly trained in order to provide safe effective care. You describe one approach to training psychologists to prescribe medications. Of course, physicians have their own way of doing so, and nurse practitioners have there’s. Only someone who has participated in a specific training program understands exactly what it means to do so.
Regardless of one’s preferred approach to or beliefs about pharmacological training of physicians, nurses, or psychologists; safety and efficacy of treatment must be assessed, not by preference, but by outcomes data.
Each profession and licensing Board must evaluate the performance and safety record of its member professionals. In my view, any opinion that regards the safety or performance of physician, nurse practitioner OR psychologist prescribers, but does not cite data from the relevant profession or appropriate Board is meaningless.
I have spoken with members of State Psychological Associations, insurers and licensing boards. Here is the data. At the time I checked, about a year ago and after more 20 years of psychologists prescribing, there have been no malpractice complaints, no complaint settlements, and no licensing Board sanctions. So the statistics collected thus far show zero (0) reported safety or performance problems; 100% safety record. Maybe I missed something? Show me what I missed.
The RxP campaign makes special efforts to hide the details of what it proposes to legislators and to society. The reason for keeping them secret is obvious: They make RxP appear to be grossly inappropriate and dangerous.
The facts are that this political campaign proposes the following: Person with no education or background in the biomedical sciences would be able to prescribe powerful medications, with many risky side effects, based on education that consists of 10 courses (three semester hours each or equivalent) online with no face-to-face interaction or presence in a brick-and-mortar classroom. These 10 online courses would cover all the basics of biomedicine such as chemistry, organic chemistry, biology, physiology and so forth, in addition to all the advanced topics of prescribing drugs to persons of all ages, all disease states, and who are already taking all other medications. Thus, these persons presume to have sufficient education to prescribe drugs for a 4-year-old child, an elderly person with Parkinson’s taking seven other drugs, a pregnant woman with a seizure disorder, and so on, and so on.
Other posters have mentioned Alliant University. This program purports that in an online course of 2.4 semester hours’ credit, the student will learn how to prescribe these drugs for children and adolescents (a specialization that psychiatry relegates to special fellowships and board certification but psychologists can master in only part of an abbreviated course) geriatric populations, persons with developmental disorders, those with chronic pain, (would it be too silly to interject the huckster’s plea – “but wait! there’s more!”) victims of trauma, and persons with personality disorders. This exemplifies the arrogant presumption that beginners wishing to practice psychiatric medicine can learn profoundly complex topics in just a few hours on their laptops.
Would it make matters worse to tell the reader that this program is so lacking in respect for proper education of professionals that the tests are open-book, which guarantee a passing grade?
The RxP campaign misleadingly suggests that this offers psychologists the opportunity to prescribe. In reality, psychologists have had the opportunity to be “properly trained” to prescribe for the past hundred years. What RxP proposes is making the prescription pad available to those who don’t wish to, or can’t, take the same education as physicians, nurse practitioners or physician assistants in order to prescribe medications.It proposes to drastically drop those standards of training without any empirical evidence that it is safe or effective. Without the input of any medical authority on proper medical education … just based on what the APA wants.
Other professions are upgrading their standards. The PharmD. is the new, higher standard of education for pharmacists, and the clinical doctorate is becoming the standard for nurse practitioners. Sadly, the politicians at APA who value market-expansion and economic opportunity over patient care and safety are working hard to dumb-down the standards of practice for those who don’t want to take the trouble to get a solid education in a complex profession.
RxP is an embarrassment to the great profession of psychology and the great tradition of the APA. RxP leaders were those involved in the APA’s 10 years of defrauding its entire membership, fooling them into thinking they had to donate funds to the APAPO’s political coffers, when that was a lie. And they were also involved in the scandal involving APA in the torture of detainees, something that brought shame to American psychology. And yet, they continue to pursue economic and political advantages regardless of ethical and professional standards. Shame on them.
As a supporter of the prescriptive authority subspecialty in clinical psychology, I echo Sarah Shelton’s remarks, the remarks of others supporters, and the legitimate criticism of the detractors, and also David Shearers questions. We should be asking the tough questions and it will be through the process of rigorous inquiry that the answers will come, and more questions emerge. Science is not necessarily a perfect process but a rigorous application of its principles to the tough questions will lend the needed authority to the identity of the prescription privilege subspecialty of clinical psychology,……. or not.
AND as Ryan’s Dissertation Chair, I’m looking forward to the next manuscript (you knew I was going to do that publicly right?)
Thank you, Ryan, for this introduction to this topic. Indeed, the history of RxP is longer and richer than many recognize. The first set of comments to your post were, unfortunately, rather expected. POPPP is a small group of psychologists who have made it their mission to seek out and oppose all RxP efforts. Unfortunately, they use distortion as a tool. They don’t speak for the profession, and have no right to present themselves as such. Their numbers are rather minuscule, but they project themselves as speaking for the majority, even for NAMI. The reality is much more nuanced. NAMI chapters have sometimes spoken again, sometimes for, and sometimes remained neutral in state efforts toward RxP. The same is true about various medical groups. In fact, the only medical group uniformly opposed to RxP is psychiatry, for rather obvious reasons. So, the reality is not what POPPP portrays.
For me, the bottom line can be summarized as follows:
1) It is unequivocally clear, at least from my vantage point, that some patients benefit, sometimes very significantly, from psychotropic medications. This is not a replacement for psychotherapy. It is another intervention that is needed to help some patients with mental disorders improve, sometimes very significantly.
2) There is a dearth of prescribers of psychotropics. Many studies have shown that 80+ % of prescriptions for psychotropics are written in primary care. Most primary care practitioners admit that they’d prefer not to write these prescriptions but they do so because they know their patients otherwise will likely go without.
3) Psychiatry is on the decline – studies have shown that increasingly fewer physicians choose psychiatry as their specialty.
4) For all the talk about other prescribers (nurse practitioners, PA,s etc.), they really have not appreciably changed the overall degree to which those in need of psychiatric meds go untreated, especially in rural areas of the US.
5) Where psychologists prescribe, it has been shown they do so safely – in fact, more so than other prescribers. What prescribing profession do you know that has had zero evidence of major problems in 30 years?
6) Prescribing psychologists have been doing their jobs more cost effectively than other prescribers.
7) Where psychologists prescribe, it has been shown they are more likely to do so in rural and underserved areas than other prescribers.
8) Prescribing psychologists are the only professionals trained to utilize formal psychological assessment, psychotherapy and psychotropic prescriptions as tools of their practice. Other mental health professionals are mostly trained to use one or two of these tools, at the most.
9) Surveys of prescribing psychologists have shown that they remain psychologists and continue to use all three of those tools, rather than relying on only one or two, as most other mental health professional do in their usual practice. Isn’t this what the goal is – to utilize psychotropic meds in addition to (rather than instead of) other interventions? What other prescribers do so?
10) RxP opponents have tried to make a big deal out of the “millions” that APA has spent on RxP. So, time for a reality check. RxP expenditure has constituted a tiny percentage of APA’s budget. Where APA has not been successful (like fighting insurance companies), it has been outspent multifold by the opponents. Adding the APA’s RxP funds to APA’s spending on these efforts would likely make little difference, as it would not make up the overwhelming deficits APA has in comparison to the deep pockets of managed care. Let’s get real.
In the end, reading the thoughts of the opponents of RxP, an old proverb comes to mind: “If the only tool you have is a hammer, every problem looks to you like a nail.” That’s what opponents of RxP tend to do – desperately hang on to only that which they know. I am hoping readers of this debate are able to look beyond such myopic attitudes. It’s time to look forward, not remain stuck in the past.
I appreciate the dialogue but your admonishment that some of the justifications offered by those who question the wisdom, competence and safety of RxP are not factual or are only partial truths also holds true for those who support RxP.
It is accurate and truthful to describe the MS Clinical Psychopharmacology programs as both designated (vs. accredited) and “truncated”.
First, with regard to designation: It is false to claim that post-doctoral training programs are not accredited. As one example here is an accredited post-doctoral residency training program in neuropsychology: http://apps.apa.org/accredsearch/?_ga=1.106829251.1532574462.1486534256
Designations are provided by review of 6 people with submission of paperwork (and fee) by the program about how they meet the standards (which themselves represent a devolution from original DoD training standards). To my knowledge, this is a far cry from the self-study and site visits that go along with the more rigorous accreditation process (with the CoA having no fewer than 32 members).
http://www.apa.org/ed/accreditation/about/coa/index.aspx
The point, thus, is both technically correct and substantively true (designation by a 6 person committee is a much less stringent evaluation/regulatory standard).
Second, with regard to “truncated”: given that MS in Clinical Psychopharmacology programs require NO basic science background, nor impose any other criteria (entrance exam, transcript review) that would ensure that all incoming students have a solid foundation in the sciences upon which to build it is truncated. Compared to the DoD training model on which it is modeled it is also truncated. Why, given that the original APA task force (1992), argued that “retraining of practicing psychologists for prescription privileges would need to carefully consider selection criteria, focusing on those psychologists with the necessary science background” (p., 66) does every bill leave this out (except for Illinois which I know was met with mixed results from RxP supporters)?
Speaking to the issues raised by several other comments which seem to suggest that psychologists either all support RxP or they SHOULD: 1) studies that survey representative samples (vs. small convenience samples) of psychologists suggest more division than those typically cited by proponents. For example, in my large sample of Oregon psychologists, while a large minority was in favor (10.9% unconditionally in favor; 32.1% generally in favor), nearly one-third of the sample was opposed (6.4% unconditionally opposed; 25.2% generally opposed) and one-quarter were undecided. Even though older studies have found that about 60-65 percent of those polled agree to nominal support for prescription privileges, questions have not typically addressed the extent of training that would be required (Walters, 2001; Baird, 2007). Thus, these data may include psychologists who envision post-doctoral training that varies from self-study and passing an exam to receiving training equivalent to a medical degree (and likely everything in between). I was surprised at how little psychologists knew about RxP (e.g., less than 20% indicated any familiarity with the RxP training model of DoD training model, only 4.3% were knowledgeable of the three prerequisites to enter an APA psychopharmacology program; just over 6% could name the states/territories where psychologists can prescribe). It puts responses to a simple question about support for RxP into a new light. 2) What is also clear is that few express an interest in pursuing such training themselves. Given so few are interested why don’t we put in place more rigorous requirements for training to ensure that those who will pursue the pathway to prescribe are skilled and capable of attaining and maintaining competence in the science of clinical psychology AND psychopharmacology (science prerequisites, “pass rate” on a multiple-choice exam that seems to vary by state with data suggested an average of a low C on these exams and some states allowing students to take it multiple times). 3) The APA adopted the policy to pursue prescription privileges by suspending parliamentary rules, so the issue was not debated by the rank-and-file of the APA (DeNelsky, 2001). When the SSCP published a white paper calling for a moratorium on prescribing bills in the early 2000’s until we had data to evaluate safety and prescribing patterns it was demanded that they take it down or risk being kicked out of APA. Proponents often malign POPPP members as “cranks” or “fringe” and yet having attended to present my work at the APA and sitting in on RxP symposia I was struck by what a small group of fervent supporters were present and how it felt more like political strategizing than a professional conference as no data were presented.
Proponents claim that the lack of a reported death or serious harm by prescribing psychologists somehow provides evidence of safety. It does not! It only provides evidence that any harm done by these psychologists was not identified and reported by the psychologists themselves or their patients (or errors are caught by supervising physicians). A lack of evaluation of safety, and the absence of any credible, comprehensive system to identify problems, does not constitute evidence for safety. The ability to un-prescribe depends on one’s license. If one can’t make decisions about scripts without physician approval this argument is also a partial truth.
Furthermore, claims of no adverse events are simply not true. Recent data from the Part D Prescriber Public Use File (PUF) from the Centers for Medicare and Medicaid Service (CMS) suggests that some medical psychologists from Louisiana and prescribing psychologists from New Mexico have been prescribing beyond the legislative bounds of their licenses. For example, not only have they been prescribing powerful psychotropic medications (e.g., antipsychotics), but also anti-Parkinsonian agents like benztropine mesylate, likely to help control extrapyramidal disorders associated with anti-psychotic use. In addition, several classes of drugs used to treat cardiovascular disease (e.g., Hytrin, Plavix) and other systems (e.g., muscle relaxants) reflect prescribing practices well beyond the competence of training (and in some cases the statutory limits of the prescribing license). Given that these data are only available for two years (2013, 2014) and only include prescriptions provided to approximately 70% of all Medicare beneficiaries it is unclear to what degree these instances of inappropriate prescribing may reflect more widespread problems with prescribing psychologists prescribing outside their bounds of competence. Recent disciplinary action in Louisiana suggests some prescribers’ inappropriate prescribing are being detected. Lawsuits filed in Louisiana suggest that patients of medical psychologists HAVE suffered serious harm at the hands of these prescribers (e.g., life-threatening reaction to fibromyalgia drug Savella; acute myocardial infarction stemming from Pristiq and Ritalin when it was not safe or medically advisable to prescribe; overdose of Tenex in a 4-year-old with prior history of myoclonic seizures which required hospitalization and worsened his seizure disorder). Other cases have been sealed by the court. Again, saying that there have been no adverse events is factually inaccurate.
Several of you point to data to suggest that prescribing psychologists are safe and competent prescribers who prescribe less than others. Research touting evidence of “safety” and “competence” are limited in their extremely small samples prone to response bias (Levine et al., 2011 – n = 17 which was less than 30% of all prescribing psychologists; Linda & McGrath, 2017 – n = 24 which was less than 15% of all prescribing psychologists) and their reliance on self-reported behaviors (rather than actual prescribing practices). While Shearer et al. (2012) surveyed 47 primary care prescribers and residents about their views of prescribing psychologists and concluded that his research provided evidence that prescribing psychologists “practice safely and effectively” (p. 428), the study participants were reporting about their experience with ONE prescribing psychologist in a primary care setting in the Army. It would be generous to suggest there is anything but a weak evidentiary basis supporting competency across all current prescribing psychologists. Additionally, there is no evidence to suggest the prescribing psychologists won’t succumb to the same pressures to prescribe, rather than provide evidence-based psychotherapies given that it is more lucrative to do so (the reference to the Reeves study referenced by Barnett appears to be unpublished “data” and the link is broken). In fact, two-thirds of Linda & McGrath’s sample of prescribing psychologist reported increased income and if systemic factors that favor reimbursement of meds over therapy do not shift it is naïve to assume that any professional-based bias toward therapy won’t fade over time.
Finally, many of highlight in your responses the need for personal knowledge, anecdote as proof and a “seeing is believing” ethos that frankly is concerning given the wealth of data we have regarding treatment outcome evaluation and the role that social cognitive biases play in clinical decision making (and perceptions of efficacy). I would hope your solid grounding in the discipline would cause you all to be a bit more skeptical and demanding of rigor (both in training and evaluation).
Tanya,
You offer a mixed, albeit fair on some points, rebuttal; however, I think audiences will find your closing argument on “anecdotes” juxtaposed with your position. Is not your experience of attending (arguably with a biased attitude) a RxP symposia of fervent, politically-minded RxP supporters anecdotal in and of itself? I find it hard to believe that said colloquium offered no meaningful data to assimilate and accommodate into your schema of progressive and holistic care.
I would suggest that skeptics enroll in any of the fine RxP Training programs and, at the bare minimum, achieve Level 1 status on psychopharmacology education so that they might better offer a more informed over anecdotal opinion.
It’s unfortunate there must be so much filibuster within our ranks. With wavering partisan dialogue aiming to sidetrack a natural evolution of great scientist-practitioners who may choose to pursue qualifications that could reduce health disparities in our nation. For example, the Gentleman with the first comment entry here has a readily available online ppt. (slide 29) where he educates the general population that the great States of NM and LA are apparently only good, comparatively, for legalizing Cock Fighting and psychologists with Prescriptive Authority.
We could do so much more with unity.
Respectfully,
Casey
I would really like a copy of your dissertation….how do I go about that? Thanks for the article. I’m extremely interested in prescription privileges. There’s a reason I didn’t go into psychiatry…I WANT to be a practicing psychologist. That doesn’t mean that I 1. wouldn’t like some more $$$, and 2. There’s a very serious place for the integration of medication into practice.
Thanks!