Beware psychiatrists bearing gifts.
If psychology wants to remain a science based upon the understanding of human behavior — both normal and abnormal — and helping those with the “abnormal” components, it would do well to avoid going down the road of prescription privileges. But perhaps it’s already too late.
We first noted this disturbing trend in 2006, how they were shot down 9 out of 9 times trying to gain prescription privileges in 2007, and why prescription privileges for psychologists will eventually drive psychiatrists out of a job. We also noted that one of the programs setup to help psychologists get prescription training wasn’t a “college” at all.
The fundamental problem with psychologists gaining prescription privileges is the inevitable decline over time in the use of psychotherapy by those same psychologists. This is precisely what happened to psychiatry — they went from the psychotherapy providers of choice, to the medication prescribers of choice. Now it’s hard to find a psychiatrist that even offers psychotherapy.
Psychologists claim that they are somehow “different,” and that their training makes it less likely they would simply go to an all-prescription practice over time. But those claims ring hollow to me.
By switching to a heavily prescription-based practice, a psychologist will be able to nearly double their salary. Can you imagine any other field where you can double your salary with an additional 2 years’ worth of training? Are proponents actually suggesting that money has little or no significant impact in helping a person make career decisions? (We only have a few decades’ worth of research to demonstrate how money does indeed influence our decision-making process.)
My good colleague Dr. Carlat has the first salvo — in anticipation of his upcoming book (which is a must-read when it’s published in May) — on his blog, Psychologists Prescribing: The Best Thing That Can Happen to Psychiatry. His argument in a nutshell:
[P]sychiatrists are not [yet] losing business [in the 3 states where psychologists can prescribe]. But as more and more states approve prescribing psychologists, this will probably change. I predict that patients will vote with their feet and preferentially see prescribing psychologists once they realize that such practitioners provide one-stop shopping — meds and therapy combined.
And herein lies the great opportunity for psychiatry. As psychologists gradually become serious competitors for our patients, we will have to re-evaluate how we practice and how we are trained. We will have to take a close look at our catastrophically inefficient medical school-based curriculum. We will have to decide which medical courses are truly necessary and which are not.
So what evidence does Dr. Carlat have that psychologists will continue to offer both psychotherapy and medications? Sure, the initial psychologists will stick close to home — psychotherapy — and use medications as a sometimes-adjunct to help therapy get its kickstart. That makes sense, as they’re likely to be a little older and well-established in the field.
But as more and more psychologists gain prescribing privileges, what’s to stop the profession from following in psychiatry’s footsteps? Why wouldn’t a large group of clinical psychologists — perhaps even a majority in a few decades’ time — just turn to the same “dark side” psychiatrists have turned to … What’s to stop them from going to the 3 or 4 medication check-in appointments per hour that most psychiatrists do?
I suspect proponents of psychologist prescription privileges believe that because of psychologists’ fundamental, significant training in psychological methods and behaviors, this makes them less likely to be influenced by pharma’s siren call. But without specific data one way or another, I’d defer to the evidence that we already have:
- Psychiatry went from primarily doing psychotherapy to primarily prescribing medications in the course of a few decades.
- A significant body of research demonstrates the influence of money on human decision-making
- Psychologists have not demonstrated why or how they would forgo the influence of money and follow psychiatry into the same pharma-focused model of treatment (psychotherapy is hard; medication is easier and people prefer ‘easy’)
For these reasons, psychologists shouldn’t prescribe — it’s likely to dilute psychology’s focus and function. They should remain the primary psychotherapy experts that their four years of didactic training — mixed in with direct clinical experience during most of that time plus the additional year of internship — have provided. To gain prescription privileges is to open the door to losing that expert position in the future.
61 comments
there is now considerable research indicating that psychotherapy and psychotropics work better together than apart – especially with regard to augmenting cognitive behavioral therapy. psychologists are best positioned to manage the potentially powerful effects of both combined. adding psychotropic privileges to psychotherapy privileges will only help me serve my clientele better. and isn’t THAT what it is all about, really?
To Jlrockdoc
Thank you for your post. I would be very interested to see the particular research you are referring to in your post…I am always on the lookout for valid,unbiased, and accurately executed research,especially if it can inform my current beliefs…unfortunately, most psychological research is so suspect and shoddily done that statements such as “considerable research indicating” remain empty phrases to me until I see the research in front of me…please post your references!
Thank you,
Alexander
P.S. I still maintain that even if medications can be seen as effective, they will always be dangerously toxic and their risks are completely unnecessary due to the existence of therapeutic methods which do not rely on their use and result in far more effective and long-lasting results.Plus, medications are only used due to blind belief in the medical model of mental illness, an outmoded theory which exists only to line the pockets of psychiatrists,insurance and pharmaceutical executives, and hospital chains.
Because I have never had a psychiatrist who would listen to me, I refuse to see one even if my pscholigist recomends it. If She and her coharts could prescribe, I could trust her/and her coharts to listen, not simply write more scripts. It is the pill pushing psychiatrists who have driven people away from them, by their own actions(non-actions) being intent in getting as many patents into their office as possible, yet refusing to see those on medicare/medicade becouse they get less. I do not see psychiatrist as caring Dr’s –just busness people who want money.
We already have a way of extending prescribing rights – psychiatric nurse practitioners. These individuals already have a medical background and work under supervision of psychiatrists. Psychologists will not have this option in most cases as then tend to have practices independent of psychiatrists.
I agree with the majority of the arguments of Dr Grohol and even more so with Dr Pies. We are not medically trained, we don’t even have the medical training of psychiatric nurses and going down that route without the proper training is simply dangerous. Of course the same argument holds for psychiatrists who go down the route of psychotherapy when they have a 10 year background in biomedical sciences.
I grew up professionally at the Institute of Psychiatry, in London and I was lucky to work alongside many great psychiatrists who did an excellent job practicing both psychopharmacology and medicine. They really valued our input and work on diagnostic assessments, psychotherapy and research and I don’t see what’s wrong with maintaing such important alliances in the care we provide to our patients.
We really need more medically trained psychiatrists and more psychologically trained psychologists working together.
I can not read your words without feeling like screaming. Why do people like you always ruin things for individuals who strive for change? I am certain they (psychiatry) will always run to you when they are attempting to strangle appropriately trained medical psychologists. Until we have ALL the privileges of “doctors”, we will continue to be treated like “beggars at the table.” Your words are fallacious and dangerous.
I suffered at the hands of a psychologist that thought that she was a psychiatrist. Her irresponsible recommendation of medication without the sufficient expertise to properly judge the appropriate treatment resulted in the worst possible choice of medication for my condition.
One cannot blame psychiatrists for practicing according to how they were trained. And that’s the problem, psychologists aren’t trained…yet…to prescribe medications. The notion, as the article suggests, that medication management is complex is accurate. However, the assumption that psychologists cannot be trained to take these complexities into mind is inaccurate. The author assumes that medical doctors of all brands simply “recall” significant swaths of pharmacological knowledge. Many of my medical doctor friends openly acknowledge depending on technology to help keep them out of hot water. EHR’s have built in contraindications, and I have personally witnessed doctors use apps on their phones to check for adverse side effects. Additionally, PCP’s, who are medically trained, acknowledge they are untrained to manage psychotropics.
Let’s consider the argument that psychologists will turn greedy (which is a truncated version of what the author suggests). This may be true. It’s hard to hedge against humanities flaws. But this isn’t a problem of competency, it’s a problem that is equally present in billing 60 minutes when only seeing patient for 45, conducting 30 minute intakes, hiring unqualified psychometricians to save money, or overcharging for assessments. On another note, financial incentive is a ethical motivator. What’s not ethical is allowing it to affect the quality of your service, as perhaps SOME psychiatrists have.
Inevitably, there is an underlying assumption that all one needs to know to prescribe meds is taught in medical school, and therefore because Clinical Psychologists do not attend medical school we are unqualified. I believe education standards, including as it currently stands a MASTERS in pharmacology, plus supervised training following something akin to either LA or NM, appears sufficient.
Finally, the author assumes the “inevitable decline of psychotherapy over time” without citing any evidence to this. One might argue that the frequency of individual sessions have increased over time…just not by Psychologists. It is ironic that proponents against prescriptive privilege for Psychologists make the same arguments against Masters level practitioners who want to assess! i.e. not qualified. Well. Let’s fix that and stop resisting the tides of change. Also, I, for one, would appreciate varying my work. Certainly, I may see a patient for 45 minutes and spend the last 15 doing a psych consult. Or, meet less regularly for therapy but more frequently for med management- thus increasing the overall contact time. Or, assess, treat, and manage all at once….fewer patients in the long run but more comprehensive care. I lament trying to manage 150+ patients, unable to remember pivotal key points to their life story, names of their family members, or even where we “left off”.
My hope for the future is a revamping of psychological care in this country where Psychologists must burn themselves out performing one mode of treatment day in and out, and Psychiatrists enter the relationship unprepared to cope with problems outside of biology. If we don’t do this, psychology as an industry is doomed.
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