“Insanity is doing the same thing over and over again but expecting different results.”
~ Rita Mae Brown
Ya have to admire psychologists who endlessly lobby state legislatures for the right to extend prescription privileges to their profession (with a little additional training). They won’t take repeated defeat as a sign that perhaps their efforts are… insane?
Illinois is the latest state to hand psychologists seeking prescription privileges a defeat, with NAMI Illinois siding on the side of not supporting the bills in front of the Illinois legislature. After intense lobbying by both sides of this issue, they concluded, “NAMI Illinois opposes SB 2187 and HB 3074 in its current form to expand prescriptions privileges to psychologists.”
When will psychologists learn?
The movement that is supported by some psychologists to gain prescription privileges is called RxP. The rationale behind the movement is that, in some communities in the U.S., psychiatrists are few and far between. With too few psychiatrists, patients often have little choice but to wait weeks or months for an appointment, or travel long distances to see another psychiatrist. Psychologists argue that their existing training prepares them to take an additional set of courses (which can be taken exclusively online) and training (supervision under a physician) that results in them being high-quality prescribers — equivalent to a medical doctor.
NAMI Illinois’ statement is worth a read, so we’ve posted a copy of it here. But here’s a highlight:
If we don’t fully address integrated health care needs, mental health needs become moot if people continue to die so early from physical causes. NAMI Illinois cannot advocate for the creation of more silos that hinder full integration of physical and mental health care needs.
Exactly. Instead of working with the profession of psychiatry to help address the shortage of psychiatrists, psychologists seek to circumvent that profession entirely by pushing for professionals with little medical background or knowledge to become medical prescribers.
This is a misguided, failure-ridden effort that has been going on now for more than three decades — with very little success to show for it. The bills are introduced into a number of state legislatures each and every year. Each and every year, they get defeated or never get voted out of committee.
And Illinois is not alone. Ohio’s legislators appear disinclined to keep reintroducing the same bills that keep failing, year after year, according to an update sent out by Janet Shaw, MBA, the executive director of the Ohio Psychiatric Physicians Association:
It appears Senators Burke and Seitz are no longer inclined to reintroduce last year’s bill in its current form.
Instead, Senator Burke suggested, and Senator Seitz agreed, that psychologists in Ohio who want to prescribe medications go the route of becoming a physician assistant since the training is similar and duration the same (approximately two years), to the psychopharmacology programs for psychologists, and since the scope of practice for a physician assistant already allows them to prescribe in Ohio.
I agree. Psychologists — like all mental health professionals who don’t hold a medical degree — already have a path to gaining prescription privileges. It’s called “go to medical school” and become a medical doctor, a registered nurse practitioner, or physician’s assistant. There is virtually nothing unique or special about a doctoral degree in philosophy (the Ph.D., which most psychologists hold) that gives them a leg up on the medical training necessary to prescribe.
Psychologists should be working with psychiatrists to understand how best to address the dearth of psychiatrists in certain geographical areas in the U.S., instead of trying to steal their profession away from them.
Psych Central remains steadfastly against psychologists gaining prescription privileges. It is a waste of psychologists’ time and efforts, and minimizes their specialized expertise and training in being uniquely qualified in the understanding of human behavior.
38 comments
Great article John. I totally agree with your position on this matter. Our expertise lies in psychosocial behavioral treatments for mental health that are much more needed than drug treatments.
For a person who was trained in the scientist practitioner model, this article is not even remotely scientific.
Here is what the data shows: Psychologists have written over 50,000 prescriptions for our soldiers, for Native Americans on Indian reservations, and in New Mexico and Louisiana. There has not been one reported adverse incident or any complaints filed against a prescribing psychologist. Zero out of 50,000 is a very good track record. Wait times to see a prescriber are upwards of 2-3 months even in urban areas. Thus, although some psychologists will be prescribing in urban areas, these areas are still underserved. However, if one looks at the distribution of prescribing psychologists in New Mexico (available on the New Mexico Psychological Asoscation’s website under the “RxP News” link), quite a few psychologists are in very rural areas with no mental health prescribers. Ask these people receiving the medications they need in these areas if they are happy that psychologists are prescribing; do not rely on a psychologist who is far removed from these underserved areas and has no idea of their suffering.
Psychiatrists have been promising to expand access for 20+ years but the problem is only growing. There are fewer and fewer psychiatrists and the wait times are growing to see them. If psychologists do not step in, then who will?
Do you honestly believe that market forces somehow wouldn’t be in effect if prescription privileges were available to psychologists in all 50 states? How long before those lesser-paid rural psychologists moved into the nearest big city to double or triple their income??
Psychologists have identified a need (rural prescribing), but haven’t spent time thinking of the logical ramifications if they were to actually succeed.
Remember way bay yonder when psychiatrists were actually the primary provider of psychotherapy? Why did they stop doing that?
Why are psychologists oblivious to the fact that, given the same chance, they would follow the same road psychiatrists have?
So IL passed the bill and now ready for signature by the governor. Here are some thoughts:
So 12 months for an accelerated BSN, 24 months to become a nurse practitioner, and prescribe in a collaborative agreement with physician for any medication. Yet how many courses did they have in diagnostic and treatment interventions for mental disorders?
8-10 years of education/practica/internship/dissertation research for a doctorate degree specializing in mental health conditions, post-doctoral supervision 2 years, an additional 2 years for a MS in clinical psychopharmacology, internship under the supervision of a physician/psychiatrist, and then able to prescribe psychotropic medication from schedule III-V, for adults between the ages of 18-65 without medical issues/developmental disorders, and only if there is an agreement with the patient’s physician (not just any physician).
Yet, people are concerned about psychologists prescribing psychotropic medications? Who would you want? The person that sees you for 15-30 minutes every month to 3 months or the one that sees you weekly for an hour addressing your psychosocial stressors, exploring alternative ways of coping, monitoring overall health, consulting with your physician, and prescribing medication only as a last resort? This is not about comparing psychologists to physicians or psychiatrists- there is no comparison MDs are the supervisors of medical healthcare. This is about access to care and collaboration between mental health and physical health. Articles tend to slant the discussion toward comparing doctors of psychology with doctors of medicine, rather it should be: can a doctor of psychology with additional medical training prescribe like a nurse practitioner or physician assistant so as long as there is a collaborative agreement/supervision from the patient’s physician?
FYI, I am a rural psychologist and will forever be a rural psychologist. I know what is going on here and hear all the frustrations from our local physicians/RNs/PA-Cs who prescribe psychotropics. We have only 1 adult psychiatrist every 2 weeks and 1 child psychiatrist once a month for an entire county’s mental health services. They are always asking for input from me (sometimes as specific as to what dose).
Unfortuantely, Dr. Ancona, your statistics are not relevant. First, what complaint or adverse reaction do you think would be reported to the licensing board…assuming somebody can even find the board to report something. What is more relevant is whether the doctor doing the prescribing has accurately diagnosed the condition and prescribe the right medication. Your supposed statistics do not track that.
I totally agree. I go to a psychopharmacologist for medication – they have the in-depth knowledge from the physician’s perspective. I see a psychologist for counseling – they specialize in talk therapy and have spent years perfecting their craft. These folks are doing what they know best, and that’s what I want them for.
That’s a good suggestion to become a physician’s assistant. I’ve seen some very good physician’s assistants. I wonder if there is any sort of psychopharmacology track or extra specific training for physician’s assistants who want to specialize in psychiatric issues.
Nicely said here, Dr G.
And how shrill and exhausting in their cries would psychologists be if Social Workers demanded the right to do psychological testing?
Do as I say, not as I do.
Oh, the campaign slogan for reelections of incumbents across this country for next year!
Joel
If Social Workers undergo the required training in psychological assessment, they would be be allowed to do psychological testing.
On a similar note… these Social Workers will not have to undergo training in ALL aspects of psychology to be able to perform psychological testing. In that same way, clinical psychologists gaining (limited) prescriptive authority would not have to go to medical school/become nurse practitioners/clinical associates to understand physical conditions relating to psychiatric/psychological problems. They would NOT treat ALL physical conditions, only psychiatric disorders, holistically. Why would you want to re-train a specialist in Mental Health/Illness as a general practitioner where more appropriate, focused but comprehensive training would be more sensible.
So… if Social Workers want to do psychological assessment, they don’t have to go to graduate school for this – there are many 1 year courses that they can do in a specific field of assessment that will allow for them to use these tests.
If clinical psychologists are to prescribe, they need comprehensive training indeed, but not general training, rather specific, tailor-made programmes developed by psychiatrists, pharmacologists and prescribing psychologists relating to all the physical aspects of Mental Illness (and Health).
Sincerely
Actually, your first sentence is largely untrue for general psychological assessment. Social workers can’t do psychological assessment if they were just to get the same training as psychologists. Because, psychologists — like every professional guild — have protected “psychological assessment” in nearly each of the 50 state laws. Yes, there are special carve outs for certain kinds of testing, but in general, psychologists have nicely fenced off a skillset that (a) they do very little of themselves (instead farming out the actual test-taking to trainees or lesser-paid professionals) and (b) rely on computer programs to do most of the scoring and even summarization.
You can’t argue with Dr. Grohol. If you notice, he constantly makes points without any evidence Please give me a citation saying that psychologists do “little psychological testing” and simply copy computerized summaries in many cases…
Also, the article makes it sound like the bill in Illinois has been defeated but it hasn’t. Passage actually looks possible this year!
Dear John
Further afield the question about whether clinical psychologists gain prescription rights are more a need than a want.
I work in rural South Africa as a clinical psychologist. We serve a population of 500 psychiatric patients per month. We have access to a Psychiatrist (via Teleconference) for 3 hours per month. This means that only about 1% of our population are in contact with a psychiatrist per month.
This means that 99% of psychiatric medications in our population are prescribed by junior doctors and clinical nurse practitioners not well trained in psychiatric case formulation, and not at all trained in psychological formulation. This leads to inaccurate diagnoses and unfortunately sub-optimal care with regards to psychopharmacology.
In cases such as this I cannot, just sit and “do psychoanalysis/CBT/group therapy/community awareness” and not be directly involved in patients psychopharmacological care.
In areas such as these prescription rights become a need, rather than a want.
Task shifting has worked very well to alleviate professional shortages in other fields of medicine, and I think that with the proper additional training, clinical psychologists, being dedicated mental health care proferssionals, can contribute meaningfulyl to holistic (BPS) patient care.
I agree with NAMI, but this article is very poorly written, misinformed, and biased. Furthermore, mental health care is in a state of crisis in America and the prescription movement is an effort to correct that, not “steal” from another professon. Just as you say psychologists should not prescribe, I say that PsyD’s should not write articles.
Wow, I am saddened by this entry. There are so many things off/misguided/misunderstood/just plain wrong that a complete response cannot fit in a comment space. Just some examples:
“They won’t take repeated defeat as a sign that perhaps their efforts are… insane?”
EXCEPT IN LEGISLATIVE POLICY-MAKING
It’s a good thing psychologists didn’t listen to you when we were trying to gain equal reimbursement from insurance, or heck, even the “privilege” of offering psychotherapy! Medical professionals said we were going to kill people if we were allowed. Sound familiar?
“…integrated health care needs…
…people continue to die so early from physical causes…
…the creation of more silos that hinder full integration of physical and mental health care needs…”
This seems somewhat backwards to me in several ways. First, physical and mental needs are not quite so unidirectional in importance or in causation, as we are discovering more every week or so. The biomedical model has been sorely lacking in accounting for mental illness/mental health. Second, RxP is about integration! Hello! Talk to some psychologists who are ACTUALLY PRESCRIBING about this before making assumptions.
“This is a misguided, failure-ridden effort that has been going on now for more than three decades — with very little success to show for it.”
Unfortunately, this is a political process NOT rational or empirical thinking. Thus, it is ruled by black & white thinking and action by fear, in addition to money (and of course not necessarily in that order). The number of failures says nothing about whether the idea is worthy. In fact, if people–like you especially–focused a little more on the successes, the fear would shrivel away like mold from soap. How about the FACT that there has yet to be one single aversive event to be reported? Don’t you think that if something bad had happened by now, 30 years later, anti-RxPers would be all over it?!
One of the repeated concerns revolves around safety, and how psychologists are going to kill people (again). Well, I think at this point, the onus is on you and yours to prove that.
“go to medical school†and become a medical doctor, a registered nurse practitioner, or physician’s assistant.”
Two things: First, those professions have to study THOUSANDS of meds, not just psychotropics. To compare them is grossly unfair. Second, psychologists want to remain psychologists; not NPs or PAs. Funny how the con-side brings up the identity of the profession and then recommends altering it…
“nothing unique or special about a … Ph.D., …that gives them a leg up on the medical training necessary to prescribe.”
All I can say is this is one of the most preposterous things I have read about the doctorate in clinical psychology.
“instead of trying to steal their profession away from them.”
So how many psychologist prescribers do you think there will be? Do you honestly think that a majority of psychologists are going to pursue an additional masters degree plus hundreds of hours of extra practicum training, in a very difficult program, studying material that most psychologists don’t feel comfortable with, let alone mastering?
“Psych Central remains steadfastly against psychologists gaining prescription privileges. It is a waste of psychologists’ time and efforts, and minimizes their specialized expertise and training in being uniquely qualified in the understanding of human behavior.”
Truly, truly unfortunate and sad. You are a VERY influential force, and your opinion carries much weight among laypersons/patients/clients. Certainly, the “steadfast” part is alarming, since it suggests rigidity of thinking. In any case, prescription privileges or RxP EMPHASIZES and AMPLIFIES our expertise!!
Sincerely and sadly,
Ken Fogel, Psy.D.
Hi Ken,
I haven’t said a thing about safety or “killing people,” so you’re arguing a point not made in this article.
Do you honestly believe that market forces somehow wouldn’t be in effect if prescription privileges were available to psychologists in all 50 states? How long before those lesser-paid rural psychologists moved into the nearest big city to double or triple their income?? (There was a just an article in the NYT about this, except in regard to lawyers in rural areas — no one wants to practice much in rural areas, because the big money is in urban or suburban areas.)
Psychologists have identified a need (rural prescribing), but haven’t spent time thinking of the logical ramifications if they were to actually succeed.
It’s called simple market economics, and it’s the reason there are shortages of prescribers in some areas in the U.S.
Remember way bay yonder when psychiatrists were actually the primary provider of psychotherapy? Why did they stop doing that?
Why are psychologists oblivious to the fact that, given the same chance, they would likely follow the same road psychiatrists have?
This is nothing more than trying to expand a guild into another guild’s area of expertise. It’s like a plumber saying, “Well, I can do some electrical work while I’m down there. After all, I haven’t killed anyone yet and even some homeowners do their own electrical work…”
John
Firsty,
Effectively comparing clinical psychologists’ prescriptive efforts to insanity, when a need for it has clearly been identified is unfortunately less than expected from a highly regarded, opinion-forming editor like yourself.
Secondly, it is difficult to fully comprehend why you would use the comparison of the plumber and the electrician: clinical psychologists spend all of their pregrad and post-grad training on understanding and studying the human mind. After this their internships are focused on one area: understanding the mind (mostly in psychiatric contexts) After this, they enter into tough extra training (not a short course, an extra Masters’ Degree, followed by practicals and a national examination) to understand the biological underpinnings of the mind and the effects that pharmacological treatment has on it. Only then are they able to effectively prescribe and treat patients safely.
Keeping this in mind I think prescribing psychologists are owed a little more respect than comparing them to plumbers who can also do a little bit of unsafe electrical work (psychiatric prescriptions).
Please don’t denigrate the amount of knowledge and training of professions other than your own. Plumbers and electricians are honorable and time-tested professions that provide valuable services to our world. A psychologist should be honored to be compared to one.
As for the use of the word insane, I gave a definition, then compared it to what a small group of psychologists have been trying to do for over 3 decades, with little change to show for their efforts. I might call it an apt comparison, but you’re welcomed to disagree (sometimes writers exaggerate a bit to make a point).
I didn’t spend a lot of time in my graduate program studying “the human mind.” What I did spend an enormous amount of time was understanding research, good research methods, statistics, human behavior, psychological assessment, and the myriad of psychological theories underpinning these things. I had more courses than I care to remember on the process of psychotherapy, the clinical interview, etc. Yes, I had a course or two in neurology and neuropsychology, but they were a small part of my overall graduate program training in psychology. I certainly wouldn’t say I had much of a leg up in medicine just because of this training.
And again, the overall point that NAMI, Psych Central, and many others are trying to make — if you have a problem with the marketplace, fix the underlying problem — not the symptom of the problem. Here, psychologists are trying to patch up a symptom (lack of access in rural areas) that simply won’t work once adopted on a 50-state scale (the market forces will just favor psychologists going to markets where they will make the highest salary for their new prescription privileges).
NAMI is asking two professional guilds to come together and try and address the underlying problem — how do we best serve those in rural locations who have mental health needs?
One possible solution that has been floated in the past is a new degree program, equivalent to an MD but with a much heavier grounding in PhD psychotherapy and research training. This was tried once in the past, with little success (many years ago).
Throwing less-trained professionals at the problem hardly seems like a good long-term approach.
First, I greatly appreciate the personal response given the value of your time (although part of it is cut-pasted, with the same typo, as a previous response).
Second, I sincerely apologize for the “killing people” comments. You did not make any mention of that, I infused my comment with statements made by other opponents of RxP. I understand that misattributing statements, especially online, can be very harmful to one’s career.
That being said, I don’t think you said anything in your reply that counters my points. You emphasized the monetary consequences of this movement, “market forces,” and the path taken by psychiatry. Some of this is certainly valid, and definitely a risk. Outside of the legislative setting, when it is safe to express the “gray” of an issue, I remain concerned about the ethics of some psychologists.
However, consider this. I could be wrong, but it seems to me that there are many more ways for psychologists to make more money than to go through the required training to learn to safely prescribe. Most psychologists aren’t in the profession for the money (if they are, they should have been dissuaded in grad school).
Furthermore, while it is possible that psychologists could “follow the money” laid out by Big Pharma, sell their souls, and (prescription) pad their nests, the social context is quite different than it was 10-15 years ago, when pharma wool was pulled over our eyes. It is MUCH harder for pharma companies to play the same games now.
The argument about psychologists willing to move to rural areas to help out there is valid. I personally don’t rely on that particular argument in RxP discussion. However, you don’t have to go out to farm country to see unmet needs. Just look at the low SES, inner city/currently-minority population to see the frustration faced by people without access to needed psychiatric meds. Again, I can refer to someone ACTUALLY IN this situation to back this up. This particular psychologist moved to Louisiana to be able to use his skills, learned while in Illinois.
Finally, I agree with JHDK’s statement about your use of the plumber analogy. Not to say anything about plumbers in particular, but this type of loosely spoken, fear-mongering, inaccurate rhetoric is what leads to defeat in legislative efforts.
I appreciate that you are against RxP, and certainly support your right to express your thoughts (especially on your own blog, duh!). But as I said at the beginning of this rambling reply, you didn’t really address my points in the original. I don’t expect you to now–you have probably filed this in the “too much effort to respond personally anymore” category–but I felt the need to add more to mine.
Thanks for the opportunity to dialogue.
Ken
Here, here, Dr. Fogel.
Something that individuals often fail to recognize is that psychologists are not “just therapists”.
Many are in the field in order to assess and diagnose mental illness. They are also typically the ones that correct a misdiagnosis, narrow down diagnoses for individuals who have too many, and
recommend (or provide) treatments that will most likely benefit that individual and help alleviate
the symptoms of their diagnosis. They also catch symptoms that are often missed by other practitioners. The following scenarios are examples of what psychologists deal with often.
Misdiagnosis:
Because it is the diagnosis that informs the treatment, a misdiagnosis often leads to inappropriate (and potentially harmful) treatment. Take the example of someone who is given a dx of ADHD when, in fact, they are in the midst of a manic episode of a bipolar disorder. Prescribing ADHD medication would harm this individual a great deal.
Over diagnosis:
Or how about the person who is over diagnosed? Maybe someone leaves their doc’s office
diagnosed with an anxiety disorder w/panic, a depressive disorder and insomnia, when, in fact, they are going through a financial hardship or have just suffered a loss? Because they are over diagnosed, they end up being prescribed two addicting substances (the anxiolytic and a sleeping pill) and an antidepressant. This can harm the
individual in many ways (financially, functionally) and could even hinder their recovery rather
than help it. A psychologist would know better than to start labeling this person with disorders.
They would educate the patient about their condition (which is understandably awful but
temporary) vs. what is experienced in a chronic mental illness. They would provide individuals
with options of treatment (including the option of medications) that are better in the short term
until their life circumstances change. They would educate them on how to monitor their own symptoms in case they develop into something worse.
Missed diagnosis:
Finally, symptoms of a potentially harmful mental health issue can be overlooked. Psychologists
have the advantage of getting specific training in how to thoroughly assess someone’s risk of harm to self and/or others. What happens if a person who is at high risk for suicide is not assessed thoroughly, and ends up walking
out of their doc’s office with a handful of pills for a diagnosis for insomnia? Sure they have
insomnia, but now they have the means to harm themselves as well.
I can imagine a psychologist with prescribing rights (after training) would serve the public well in these instances. Because it is the diagnosis that guides the treatment. Wouldn’t it be nice if we had a provider who got it right from the beginning?
If prescribing is so easy, then why do most people who get the “privilege” have to go through such a rigorous training program to earn it? Really, are people who do not have a self serving agenda here comfortable with people basically bypassing the training prerequisites and wanting to see a provider who claims an equal expertise to a physician and accept prescriptions? As was said earlier, why not just get a PA or NP degree and have more legitimacy to prescribe? Oh, takes longer than those alleged a couple hundred hours of “courses”. Wow, has the quick fix model permeated every aspect of American culture these days!!!
And also, there have been no consequences with psychology prescribing since it first started about 15 years ago with the federal government first? Are we really to believe that EVERYONE who has prescribing habits and is not an MD has an immaculate record with treatment? Maybe people need to step back and think why there are no problems whatsoever reported with psychology prescribing.
Yeah, people don’t need to know the truth, as the truth does not pay the bills for a good portion of providers in health care these days, eh?
Dear John
I most certainly do not “denigrate the amount of knowledge and training of professions other than (my) your own”. I have absolutely no objections that psychologists are being compared to plumbers and electricians who “are honorable and time-tested professions that provide valuable services to our world”.
What I do object to is “loosely spoken, fear-mongering, inaccurate rhetoric is what leads to defeat in legislative efforts”, as Ken said…
I believe it is unfair to compare a prescribing clinical psychologist to a plumber “that also does a bit of electrical work” and then in essence to some home owners who does electrical work themselves.
There is a much greater difference between a plumber, an electrician and a layman, than between a prescribing clinical psychologist and another mental health prescriber.
Thank you for your input regarding your training. Psychology, could perhaps do more to study the biological underpinnings of the human soul and mind on pre -and postgrad level. Perhaps even before being considered for a Post-Doc Masters in clinical psychopharm, a certain amount of “medically arientated” courses (Biochem, Anatomy, Physiology, Pharmacol etc.)should be met.
Joel,
What I fail to understand is the appropriateness to re-train a mental health specialist as a general practitioner. Will it not be more appropriate to train the prescribing clinical psychologsist only (but comprehensively) in disorders relating to psychiatric conditions/general medical conditions presenting as psych? I agree with you that comprehensive training is required, but should this not be “focused” in-depth training rather? Let me know what you think.
Thanks for this platform for exchanging ideas John.
Joel wrote
“Really, are people who do not have a self serving agenda here comfortable with people basically bypassing the training prerequisites and wanting to see a provider who claims an equal expertise to a physician and accept prescriptions?”
When you compare the amount of training in mental health/illness AND psychopharm received by physicians with that of prescribing clinical psychologists, I would much rather send a family member (or myself for that matter) to a prescribing clinical psychologist if and when a need for psychopharmacology exists.
JHDK wrote above:
” I would much rather send a family member (or myself for that matter) to a prescribing clinical psychologist if and when a need for psychopharmacology exists.”
I get called on coming off as self serving as a psychiatrist, well, isn’t that the same thing here?
No one points out problems with psychologists prescribing, so I guess we are to assume the training makes psychologists infallible, eh?
Really does come back to my point earlier about other disciplines providing psychological testing. You as a profession may dismiss it because if the prescribing matter has more traction, then this will substitute for what is unfortunate woeful low billing for a valuable service like psych testing, but what if prescribing privileges don’t go far, yet testing rights are accessible to others.
Bet psychologists howl as loud as psychiatrists!
Dear Dr. Joel Hassman,
Prescribing privileges does not make psychologists infallible but definitely prescribing psychologists make it better, because they use psychotropic medication as part of a treatment, and not as the main treatment. There is a change in here, and that is why people gets so anxious before RxP. We do not care for the power of a pen on a paper but we care for the patient or client in front of us.
In Norway, psychologists do not have a prescriptive authority but they not only are officially recognized as physicians but also got the right to see the patient before the MD, when it concerns to mild to moderate anxiety and/or depression, as well as, work leaves. This is bigger than RxP, because that means patient or client comes first.
Also, RxP offers diversity to mental health, that’s to say, there are more people thinking and working on it. Talking about diversity, some fellow neuropsychologist in the U.S. do not take a bachelor’s degree on Psychology but go to Pre-Med, and then re-define their career on Master and Doctorate Degrees.
Concerning qualification to prescribe, Neuropsychology programs offer classes to provide knowledge on global body functioning to make sure neuropsychologists understand the integration between body, brain and mind. Also, APA (the Psychology APA) determines a minimum of 5,000 hours (I am not sure) of clinical training, and a test before given the prescriptive authority.
Yours Sincerely,
Rodrigo Pissarra.
Dear Joel
Off course no one is unfallible. Not prescribing psychologists, not physicians, not NPs or associates.
Facts are just that only psychiatrists receive more training in psychopharm (clinical) than prescribing psychologists.given their background in mental health… Chances are much better that the prescribing psychologist (rather than the physician, NP) will be able to make the correct psychiatric Dx / psychological formulation (or actually understanding of the patient’s current difficulties). This will enable them to effectively decide whether pharmacological treatment is a requirement/not and to develop an appropriate treatment plan
Again… when it comes to holistic mental health, i will happily advise any family member to rather go to a prescribing psychologist than a general physician (I am not going to go into depth about physicians’ lack of training in psychopharm, let alone psychotherapy, but they are allowed to practice both).
For very complex pharmacological cases the prescribing psychologist will alwyas be able to consult with a psychiatrist/pharmacologist (standard ethical treatment)
This is not about stealing a profession. The majority of psychiatric scripts are written by general physicians and NPs, not psyhiatrists. Psychiatrists remain the specialists in this field of psychopharmacological intervention, but they cannot meet society’s needs at this point in time, nor could they for the last couple of decades.
“Without an agenda”… I wonder how many people in the medical profession and psych services (psychologists, social workers, doctors) who do not have access to a psychiatrist would rather go to a general physician/NP than to a prescribing psychologist (knowing about the differences in training/expertise)?
When it comes to psych testing…
I know of many Masters Level social workers who are very competent in performing a variety of psychological tests. They use these tests effectively and incorporate it into their skillful psychotherapy (Im talking about social workers who have been trained in performing psych tests and providing psychotherapy).
I have to admit, sitting in on some supervision sessions and watching video recordings, some of these social workers will give any PhD or PsyD a run for their money when it comes to psychotherapy.
So you’re making a good point here — that a master’s level degree is all you need in order to do the vast majority of work psychologists (who have a doctoral level degree) do. Unless you want to go and do research, all you need is a master’s degree in order to be an effective therapist (and even assessment provider, apparently).
Given that the cost of many doctoral programs are now equivalent with a medical training track, there’s zero reason to enter a doctoral program in psychology if you want to prescribe. Get an MD, become a psychiatrist who is old-school and does as much psychotherapy as she or he wants.
If I look at the psychiatry residents and consultatnts, I see very few of them actually doing medical examinations themeselves (Normally they want to have ALL medical conditions to have been excluded prior to accepting a patient. Sure they have plenty of knowledge with regards to the human physiology, pharmacology and neuroscience, but I wonder how many of them would, if there were no agenda, agree that they require med-school to practice psychiatry on a day to day basis. I know that this statement might sound controversial, but many of my psychiatrist colleagues have expressed these feelings.
So, again, I wonder about the appropriateness of training mental health practitioners as general physicians if they are only going to be working with “the mind”?
John, you said:
“One possible solution that has been floated in the past is a new degree program, equivalent to an MD but with a much heavier grounding in PhD psychotherapy and research training. This was tried once in the past, with little success (many years ago).” Could you perhaps expand on this/post a link so that we can see this.
If this type physician could be trained, one that will work exclusively in Mental Health it will surely address the need of access to psychopharm care. If this were the case, prescribing psychologists would not be required to step in. As for now, unfortunately, this is not happening.
Currently, many clinical psychologists (yes, esp. those working in rural areas) find it very difficult to just “sit back, provide psychotherapy and assessments”, and let general physicians and NP’s prescribe psychiatric medication without a proper psychological formulation of what is going on with the patient.
Dear Dr. John M. Grohol,
Why go back to an old-school, whether we can have a new-school besides the old-school? Diversity is the word here, and I have to say merit and competence are mandatory to any professional. Also, psychologists can be sued if they go on mal-practice.
Oh, before writing anything that comes to your mind in an article, check over on the information about the topic you are about to write. APA has a policy to Prescriptive Authority, which emphasizes clinical training and a testing before authorizing the psychologist to prescribe.
Yours Sincerely,
Rodrigo Pissarra.
Life is made of diversity, that´s why a new school of thinking is always welcomed, since it enlarges possibilities, competition, etc.
John…
The Masters’ Level Social Workers, as far as I know, did not receive training in the neurosciences or neuropharmacology, nor did they enter into internships working hand-in hand with psychiatrists, learning about clinical, practical psychopharmacology. This all, again as far as I know, only happens at the PhD/PsyD level for clinical psychologists (excluding those who studied natural sciences at pre-grad level).
These social workers do not provide psychological assessment for patients with neuro/cognitive disorders or vehicle accidents, because they were not trained in it(They were trained mostly in personality assessment and projective tests). Fact remain that they are competent in what they were TRAINED in.
So no, I do not make the point that a Master’s level degree is appropriate for a Post-doc in clinical psychopharmacology.
What troubles me most is the arbitrary classifications of knowledge base based solely on academic degree attained.
I attended two years of medical school before having to withdraw due to a severe illness I have since recovered from. I was the top candidate for the top psychiatric program in Canada, after my first year. A week long invitation of a handful of medical students and by the end, I was demonstrating CBT to residents.
I’m quite proficient at reading EEG’s, EKG’s, at a non-specialist level. I’m often shocked at the lack of nuance my preceptors had insight to, within receptor reciprocal regulation, parasynaptic signalling via neuro-glial cells. The innumerable biological tests for numerous mental illnesses. The poor understanding of medications not used locally (SSRE’s, reboxatine… adrafinil, moclobemide (the only reversible maoi inhibitor… lowers cortisol, ups gh, low risk for 5HT syndrome, decreases cortisol, important interleukins, which have downstream effects, downregulates beta-3 and beta-2 pns receptors… increased sexual function, relief of inattentive ADHD (which is often confused with PTSD caused depersonalization… with stress induced enkephalins) so the latter or former, I’m betting on latter due to the substantial effects on the endocrine system… in fact, yes, I can spot Antipsch induced ketoacidosis… which eventually leads to post ketoacidotic acidosis… because the na+/k+/glucose transporter doesn’t function without glucose… meaning that H+/K+ antiporter in your nephrons… yeah, I can name ever transporter, will cause hyperkalemia, and well, the hyperpolarization of your SA node will cause your heart to stop, fun. Yeah, pharmacokinetics… I read every patent of every psych/neuro drug that comes out… lamotrogine… NA+ blocker, glutamate antagonist… and over 200 mg, mild 5ht agonist… antimanic and antidepressive, whoa… now, wait, that’s a first since lithium, a cofactor in the breakdown of IP3, IP5… downstream… what about 5ht2a doanregulation seen in certain comt mutations which produce 5htaa breakdown products from catecholamine precursors… ever wonder how abilify works, lol… oh, what else, levitiracetam… impaired kidney function req dialysis…. gfr under 20, right… oh shoot increased alpha waves versus high beta cause internal versus pns like anxiety… ace inhibitors in black men… first line right… well, no, they have less renin, and chinese women often develop a cough… oh, and of course flumanezil, inverse agonist for all subunit sites on the BZD allosteric modulator of GABA-A… now half lives… lorazepam… abouth 3-5 hours, depending on liver and kidney function… alpha1 and 5 heavy… basically, sadative/hypnotic… and highly addictive… cool thing is alpha 5 inverse agonists… which will bring benzo’s back into the mainstream… and psychiatrists wouldn’t have to read 1 page monologues to yell finally… no more z-drugs… except, most… are fairly non-selective anyways… minus zopilidem… yeah, zopiclone… lol, abuse potential… just as high as xanax plus 3 hours on the half life…. anyhoo ill leave it at that… remember proponal inhibit’s beta 2, avoid in those asthmatics… better go with something selective, like metrpolol… yeah, so me with a phd in neuropsych… lol, i ask myself, can i just challenge the prescription exam, practice usmle 2’s in psychiatry arent especially challenging… i doubt the psychopharm will be, so… do all people fit in an educational box, their knowledgebase determined by title… lol
MD2PHD;
How arrogant. To suggest you can somehow skip the training and residency of another profession to practice the same. A non specialist or amateur interpretation of ECG and EEGs is not what patients deserve.
With regard to you saying that peoples knowledge base is based on titles, no it isn’t. But a title implies a certain level of training, it suggests a certain level of competency within a subject. An MD has gone (as you will know) through hundreds of hours of basic and clinical pharmacology. And you defeat your own point, as your pharm knowledge is more likely to have come from your medical background than your psych one.
With regards to your non specialist interpretation of ECGs and EEGs, basically then an amateur interpretation of them yes? Do you not think patients deserve better? I just don’t understand why people go into professions with the desire to actually practice medicine. I don’t know whether its just job envy or arrogance to suggest that they can do the job of another without the training or experience.
It is the dumbing down that various intrusions are doing throughout health care, starting with PPACA of late. As long as at least two things happen, people without the real training and experience sell themselves as professionals equivalent to others with said training, and, patients either naively or cluelessly accept the sales pitch of said under trained professional, acceptance of treatment without debate or demand of proof of expertise will happen.
Frankly, what is pathetic is how there has been fairly much NO press to the psychologists who have caused consequences, and wait for the apologists and defenders of psychology getting prescription privileges reveal the gall to say there have been no examples of consequences.
Makes you wonder what they are hiding/suppressing.
I’m glad psych. testing was mentioned here, as it illustrates the real issue, which is that medicine (which also encompasses behavioral health) is a power based hierarchy. Regardless of the true needs of the patients, physicians do not want to lose their abilities to be the gate keeper. As the gate keeper, they can ensure higher reimbursements. I encourage folks here to scour the online medical student and psychiatry resident forums to get a flavor for how important financial success is relative to patient care. it’s sad, really.
Back to psych. testing, I’ve observed myriad physicians, including neurologists and psychiatrists administer psych. tests, including computerized assessment without prior training. In fact, I am often direct witness to them making a Dx and prescribing medication (the same medications that Dr. Grohol and his contigency state are dangerous in the wrong hands) based on their findings, which are often based on misinterpretation of test data and are thus erroneous. This can put the public at great risk, yet phsycians are not regulated in their use of these tests and I have seen not one article written to the dangers of this practice.
Dr. Grohol, perhaps you might consider protecting your field by speaking intelligently about testing issues as they pertain to the potential for patient harm, rather than sycophantically genuflecting to your psychiatrist bedfellows? You cheapen the field of psychology and impead progress.
P.s. I anxiously await your reply to MD2PhDwRx’s post.
Dr Grohol,
When you state that Psychologists will “steal” Psychiatrists’ professions by also prescribing, are you insinuating that Psychiatrists have no other skills than to engage in the wooly art of prescribing psychotropic medication? Further that they have absolutely no clinical expertise in human behaviour and/or psychotherapy?
Are you suggesting that they are nothing more than glorified pharmacists?
This bill has been defeated this year, yet again.
With many highly medically complex patients that are seen and the potential interactions of many psychotropic medications with cardiovascular, hepatic and renal systems in the body, it becomes imperative for the psychologists to obtain general medical training as well. Unfortunately, this bill fails to mandate this training, thus potentially creating a dangerous situation for our patients.
Also, many psychotropic medications can interact with other medications used to treat medical problems, such as immunosuppresants, cancer chemotherpeutic agents, antibiotics, etc. Allowing psychologists to prescribe without proper general medical training will seriously endanger the general public.
Correction, actually the bill was defeated last year. Again, I want to emphasize that there should be NO short cuts when it comes to patient safety.
If do not agree with RxP that´s ok but you should check the requirements to be a prescribing psychologist before you say a PhD is not necessary. According to APA, the psychologist who wishes to prescribe must go to master and doctorate degrees, preferably, in Neuropsychology which offers a global comprehension of the neural system and the body altogether, then, go to a post-doctorate program in Psychopharmacology, confirm that (s)he has 5,000 hours of clinical training, and take a test on the local psychology council before being allowed to prescribe psychotropics.
You should also know that only New Mexico and Lousiana allows RxP but on the U.S. Armed Forces opens this possibility to psychologist all over the U.S. territory. Plus, The Netherlands recently passed the bill authorizing psychologists to prescribe under the APA basis, that´s to say, Post-doctorate + 5,000h clinical training + test.