OJHAS Vol. 6, Issue
1: (2007 Jan-Mar)
Prescribing Privileges for Psychologists:
A Public Service or Hazard?
Shaheen E. Lakhan
Global Neuroscience Initiative Foundation, Los Angeles, CA, USA
Shaheen E. Lakhan
Address For Correspondence
Global Neuroscience Initiative Foundation,
Los Angeles, CA, USA
Lakhan SE. Prescribing Privileges for Psychologists:
A Public Service or Hazard?
Online J Health Allied Scs. 2007;1:1
Submitted Nov 17, 2006; Suggested
review Mar 15, 2007; Resubmitted: Mar 28, 2007 Accepted:
June 17, 2007; Published: July 17, 2007
The privilege to prescribe pharmacotherapeutics
has been granted in limited areas to psychologists. The psychologist's
role in society may be approaching a great evolution that can dramatically
impact the state of mental healthcare and the discipline of psychiatry. Opponents argue drug company funding and cheaper non-PhD psychological
professionals fuel the movement for prescription rights for PhD level
psychologists. However, proponents claim that this right would
equip psychologists with greater psychotherapeutic modalities
and the capability of having richer doctor-patient relationships to diagnose
and treat underserved populations. Nonetheless, the paucity of
prescribing psychologist studies cannot allow the biopsychosocial community
to make firm opinions, let alone a decision on this debate. This
article reviews the history of clinical psychology and highlights the
potential divergence into collaborative clinical and health psychologists
and autonomous prescribing psychologists.
Prescriptions, Psychologist, Psychiatrist,
Pharmacology, Privileges, Collaboration
difference between psychologists and psychiatrists – at least how
most of the public perceives it – may soon disappear. In the
last two decades, psychologists and their representative associations
have made a serious attempt to gain prescribing privileges for psychotropic
agents. Managed health care changes and the amplified output of
non-PhD psychotherapists have jeopardized the autonomy of clinical psychologists.
The profession of clinical psychology has only recently matured, yet
organized psychology is campaigning for privileges that physicians and
many psychologists oppose. The central debate is positioned
around the public health impact of prescribing psychologists. Psychology and medicine are two professions that function on empirically
based standards of practice for the benefit of the patient. The
prescription discussion is argued on vague and limited published studies
and demonstrations. As it stands, perusing privileges may fracture
relations between psychologists and physicians and thereby affect quality
this article, a brief history of clinical psychology
and the emergence of the modern theory of illness shared by many psychologists
and physicians is first outlined. Secondly, the collaboration between psychology
and medicine, which has contributed to development of the biopsychosocial
model of health is discussed. Third, arguments for and against prescription
privileges in the debate, including the monetary and survival mechanisms
that are motivating psychologists to seek change are reviewed. Fourth, the
implications for curriculum change and training of existing psychologists, and
the impact this may have on existing care are reviewed. Finally, how legislation
may impact clinical psychology as a profession is described. The central claim
is that although prescription privileges are likely to occur, the psychosocial values that founded clinical psychology should not
A Brief History of Clinical Psychology
psychology, at least the term, originated in 1896 from the American
academic psychologist Lightner Witmer of the University of Pennsylvania.(1) Witmer urged psychologists to collaborate with
physicians in the clinical environment. However, he did not favor
psychotherapy (or psychotherapeutics as it was called) and some
scholars say he even detested the practice.(1) He
believed the primary activity of most psychologists to be administering
tests and conducting research. The subject remained largely an
academic discipline until World War II, when there was a significant
demand and financial incentive to provide mental health services.(2)
Veterans Administration (VA) expanded the operations of psychologist
and shaped the professional psychology of today. In 1949, the
American Psychological Association (APA) developed a directional and
curriculum focus for clinical psychologist following a "scientist-practitioner"
model where the clinical psychologist was defined as both a scientist
and a professional clinician.(3) The
VA adopted the APA guidelines and a list of universities offering approved
doctoral-level schooling as the premise for practicing in the VA program
for psychological professionals. When the APA held scientist research
as the paramount practice for psychologists and psychotherapy as their
secondary function, psychiatry held that clinical psychologists lacked
the proper training focus in psychotherapy. Psychologists eventually
escaped the supervision of psychiatry, marked psychotherapy as their
given therapeutic tool, and became a professional guild in the 1950s.(4)
for their psychotherapy authority, clinical psychologists ironically dismissed
the opportunity to secure prescribing privileges for psychopharmacology agents
during the 1950s. The psychologists felt that psychotherapy would treat
the underlying psychological disturbance and rejected the biomedical disease
model of mental illness.(5) After a great battle, the two
professions kept their distance, but not for long.
as a profession has rapidly changed since a half-century ago.
Psychologists and other medical professionals are increasingly adopting
the biopsychosocial model, a theory that states biological, psychological,
and social processes are inherently, integrally, and interactively involved
in physical health and illness.(6) A new
breed of psychologists, health psychologists, currently performs
basic and applied research attempting to uncover how psychosocial and
biological factors influence the etiology and progression of disease. For instance, health psychologists have demonstrated the positive therapeutic
benefits of employing behavioral and coping strategies with prostate
cancer patients.(7) Psychologists are increasingly recognizing
the therapeutic benefit of psychotropic medications, particularly in
combination with psychotherapy.(8)
and health psychologists are now extensively collaborating in the medical
setting and have found a genuine locus in clinical care. Psychologists
and physicians, both psychiatrists and general medical providers, collaboratively
perform extensive case-sharing, cross-referrals, patient education,
and public policy for mental health.(9) The physician
normally prescribes medication, evaluates responses, and performs follow-up
clinical management, whereas the psychologist provides psychosocial
interventions and often monitors and reports medical compliance and
side effect profiles to the physician. Furthermore, psychologists
are discussing psychoactive agents to their patients as an ethical discretion
before securing informed consent for treatment.(10) Health psychologists prepare patients for anxiety triggering
procedures (i.e. with mental imagery), offer stress coping techniques,
and aid in the rehabilitation of chronic pain patients. Whether
operating in the same clinical environment or different private offices,
psychologists and their medical partners value their respective knowledge
and therapeutic potentials.
||Arguments in favour of prescription
1.The profession cannot survive
without prescription privileges
key argument is favour of prescription privileges, is that clinical
psychology cannot survive as a profession without them. In 1989, the
APA highly prioritized the need for psychologically managed psychopharmacological
intervention.(11) They claim psychologists cannot
function as independent professionals without the legal right to prescribe.
Prescription authority may help revive clinical psychologists who may
be struggling to survive without a research or teaching portfolio. In
a recent survey, APA members believed that prescribing was a logical
extension of current practice, necessary for survival of the profession.(12) Psychologists increasingly find themselves in
competition for counseling and psychotherapy services traditionally
reserved for clinical psychologists. Managed health care organizations
are creating "standards of care" that favor time-restrictive
and symptom targeted therapeutic options that lean toward pharmacological
Doctor of Philosophy (PhD) in Psychology has remained a research degree
with extensive didactic and clinical research methods and applications. A new doctoral program, the Doctor of Psychology (PsyD), is catering
solely to the practitioner model. Within freestanding professional
schools, PsyD are graduating and practicing psychotherapy in record
numbers. The psychotherapeutic role of the PhD-level psychologist
is increasingly being taken over by other mental health professionals,
including PsyD and masters-level psychologists, social workers, marriage
and family therapists, and occupational therapists.(5) For example, in the institutional treatment setting, social workers
cost less and generate just as much revenue for the organization.(14)
2. Pharmaceutical companies
pharmaceutical firms are funding training grants and conferences, promoting
psychological research with heavy emphasis on psychopharmacology.(15) With appropriate guidelines in place, additional
funding may support training and research. Antonuccio, Danton, and McClanahan
(16) recommend guidelines that boundary the drug industry from psychological
science. They advocate safeguards in various issues to be adopted
by professional psychology organizations and psychology training programs,
including conflicts of interest, journal advertising, continuing education,
training programs, gifts, clinical consultations, and research.
3. The current medical system
does not detect and treat the true prevalence of mental illness
exists a great underserved population throughout the US. There
are major national shortages of psychiatrists leaving many patients
un- or misdiagnosed and treated, or treated by non-psychiatric physicians
who have little or no training in psychological medicine. In fact,
primary care physicians are often the first contact for patients suffering
from psychological problems and they prescribe more than 60% of the
total psychotropic medication prescriptions.(17) Psychologists
argue they can better assess the patient's mental health status and
offer a well-rounded treatment plan, especially if given the authority
4. Psychotropic medications influence behavior
Psychologists should be well-placed to evaluate the
behavioral effects of psychotropic medications. Since psychotropic medications
influence behavior, many psychologists claim that prescribing authority should
be encompassed in their psychological practice.(18) Behavior is, after all, the domain of the psychologist.
5. Prescribing is the ‘last outpost’ in the psychologist’s professional
psychological testing and psychotherapy, prescription authority is the
‘last outpost’. That is, authority to prescribe is the last destination
on the psychologist's journey toward becoming an independent and autonomous
practitioner. A complete toolkit would allow a psychologist to offer
a complete treatment package. The patient could establish a solid repertoire
with the prescribing psychologist, make a single appointment for multi-modal
treatment, and be actively monitored for medical compliance and side
effects. In addition, prescribing psychologists could expand their
practice to settings traditionally dominated by physicians and select
non-physicians with prescribing authority, including nursing homes and
hospital inpatient services.(19)
||Arguments against prescription privileges
1. Market forces and pharmaceutical
have a vested business interest in psychologists. Not only will
prescribing psychologists expand drug use, but there will be a major
group of new prescribers that can be heavily influenced by marketing
campaigns and gifts. Drug companies publicise and support a model
of mental illness in which the brain is the chief determinant. Some
psychologists argue that we should focus on the social determinants
of mental illness, including poverty and injustice.(20) Others
note that since the precise causes of most mental disorders are not
known, the brain cannot be shown to be a ‘cause’. For this reason,
‘we are unable to design medications that target specific conditions’.(21,
2. Patient safety
psychiatrists, are naturally threatened and concerned about the
encroachment of psychologists on their territory. They may fear their
control over inpatient and hospital services is in jeopardy, question
the medical competence of prescribing psychologists, and discount any
claims that advocate prescribing psychologists will lower the overall
cost of psychopharmacologic treatment.(22) Opponents question the
medical competency of psychologists who have not undergone traditional
medical school curricula and label prescribing psychologists a public
health hazard. Currently, the vast majority of psychology graduate
programs do not have the pre-medical/basic-science courses in their
mandatory or even recommended admissions policies.(23) Most training programs are ill prepared and consequently
clinical psychologists do not have proper training in neuroscience,
physiology, organic chemistry, and biochemistry. Several commentators
simply argue that prescribing is unnecessary. Under the task force recommendations,
only a small number of psychologists would qualify for prescribing privileges.
For this reason, Moyer (24, p. 589) asked, ‘why develop
curriculum at all? Would this group of practitioners be better trained
3. Professional territory
debate on the psychologists' right to prescribe rests for most persons
on a key public health concern: Can prescribing psychologists properly
serve the mentally ill with psychotropic agents? The American
Psychiatric Association argues that they cannot, because prescribing
psychologists would put patients in harm's way. Organized psychiatry
claim psychologists have not undergone the extensive didactic and clinical
programs to measure the varied medical effects of psychoactive medications.
Conversely, psychologists might claim that psychiatrists have not undergone
sufficient training in the psychological, social and behavioral consequences
of psychotropic medication.
4. Psychologists already have
mechanisms to gain prescription authority
already have current mechanisms to gain prescriptive authority, by
earning a medical or nurse practitioner degree.(25,26) Psychologists
have legally and seemingly successfully prescribed within the Department
of Defense Psychopharmacology Demonstration Project (PDP), the VA (27), and the Indian Health Service.(28) The PDP program graduated ten psychologists
after a two-year course divided into pharmacology study and clinical
training. Additionally, New Mexico has allowed prescriptive authority
to psychologists from 2002. The existing mechanisms are discussed in
more detail below. However, it is important to note that nursing has
not become a ‘back alley’ to prescribing for most. In a recent survey,
95% of respondents with qualifications in both nursing and psychology
did not include prescribing as part of their practice.(29) The central issue here is not the current mechanisms
in place, but the development of ‘new
legislation that would allow psychologists to complete a specified
amount of additional psychopharmacological and biological training
in clinical psychology and then to become eligible for a license
to prescribe medications as psychologists’.(25, p. 667)
5. Insufficient research
I share the view that
this debate can only be settled by research. The decision of who
should and how to treat mental health should be due to rational
and empirical considerations. There are some studies demonstrating
that psychologists are competent to prescribe (i.e. the DoD-PDP and
HIS programs). However, they are underpowered with small sample sizes.
Psychologists and physicians cannot risk their inter-professional collaboration
on incomplete pilot studies. The capacity to work with physicians on
effective clinical management of mental disorders was determined by
empirical research over the last four decades, and so it should be for
prescribing capacity. Ultimately, data from the new prescribing psychologists
in New Mexico will determine the fate of widespread prescription authority
for – and the profession of – psychology. These data will need to
focus on the risks and implications for patient care. However, a move
toward prescribing seems likely, reflecting McGrath’s view that ‘there
is nothing more to be gained from treating these risks as reasons not
to move forward’.(30, p. 162). In the next section,
I review the implications for curriculum change and care.
||Implications for curriculum change
1. Changing the
One set of implications
for the curriculum concerns the training of new psychologists. Indeed,
it is the younger psychologists who show most interest in obtaining
prescriptive authority, when compared with those already in possession
of PhD and those in mid- to late-career. Psychologists early in their
training are ‘likely to have a considerable impact on the profession
as these individuals move into positions of responsibility and influence
in academia, public agencies, and state/provincial associations’.(31, p. 109) An ad hoc task force convened by the APA generated
guidelines specific to the training for prescription privileges.(32) They proposed three levels of psychopharmacology
training for doctoral-level licensed psychologists:
Level 1 (Basic Psychopharmacology
Education) – a single one semester course in psychopharmacology
with a course in physiological psychology/behavior as a prerequisite.
Level 2 (Collaborative
Practice) – study into seven "topics" (not necessarily
semester based courses), including psychodiagnostics, pathophysiology,
physical function tests, and psychopharmacologic research. Also,
incorporate simultaneous active collaboration with licenses prescribers
but not independent authority for the psychologist.
Level 3 (Prescription Privileges)
– training with a "limited" scope of practice akin to dentists,
optometrists, podiatrists, and nurse practitioners.
The task force vaguely proposed
a graduate curriculum of 26 semester units and later introduced a
national examination in psychopharmacology. Given the little or no basic science
requirements for admissions to clinical psychology doctoral programs, such
programs must significantly restructure their requirements to accommodate
students in track for the psychopharmacology subspecialty. Otherwise, the
concentration of psychology courses in the doctoral program would be replaced
with Level 1 and 2 studies, thereby nullifying the essential characteristics
that enable psychologists to successfully treat mental health.
1988, psychologists in the Indian Health Service, an agency within the
Department of Health and Human Services, have been prescribing under
physician supervision. But, the limited pilot projects and demonstrations
are inconclusive, though, often exploited for and against prescription
privileges. The DoD spent more money in the PDP program than the traditional
model of psychiatrists and psychologist, and labeled the program cost-ineffective.
Also, psychologists in the program earned substandard and failing grades
in conventional medical and pharmacology courses reflecting their poor
basic science background.(33) Though, perhaps more importantly, there has yet to
be a single quality-of-care complaint (34) and most (58%)
of the treatment beneficiaries favored training for clinical psychologist.(35) Many of the psychopharmacologists now serve in high-level positions and actively
advocate nationwide prescription authority for psychologists. The DOD
PDP programs illustrates that psychologists can be trained to
prescribe drugs, but does not address whether they should prescribe
or whether it is clinically productive. Nor does it speak to optimal
length and rigor of training for preparing psychologists to prescribe.
Nonetheless, the APA proactively engaged in training recommendations.
2002, New Mexico became the first state to enact a law allowing psychotropic
prescription privileges for psychologists.(36) Based on the APA guidelines, after completing coursework, supervised
training, and passing the national Psychopharmacology Examination for
Psychologists, state-licensed psychologists may gain two-years of physician
supervised prescription privileges. After the two-years, the prescribing
psychologist may achieve independent prescription authority if approved
by the supervisor and is encouraged to maintain a collaborative relationship
with the patient's primary care provider. In New Mexico, there is a
server shortage of psychiatrists; however, psychologists are well numbered
throughout the state.(37). Most residents live in
rural populations serviced by only 18 psychiatrists (calculated at 14,400
patients per psychiatrist). There are 176 psychologists for this
population, increasing potential medical service providers nearly 10
fold. Other states have pending legislation, including Georgia,
Illinois, Hawaii, and Tennessee. Guam held limited prescriptive
authority since 1998 under supervision of licensed physicians on the
similar ground – lack of physicians to address mental health.
The required curriculum
changes are substantial. Authors of the clinical psychology curriculum
would have to ‘reexamine
and reevaluate their program brochures and recruitment materials, their
selection criteria and procedures, their curricula and pedagogical methods,
their mentoring and evaluations systems, and their training outcomes
and placement records—all with an eye toward improving the effectiveness
of training in clinical science’.(25, p. 674) Nonetheless, many schools are now offering
psychopharmacology training programs, generally a combination of didactic
and clinical practice. Current licensed psychotherapists can complete
most of their studies are completed at a distance (i.e. via the internet,
videotapes, and DVDs) and/or attending a few weekends on campus.
The model curriculum meets or exceeds New Mexico laws requiring 450
hours of instruction. Some schools offer a master degree at program
completion (i.e. Alliant International University and Fairleigh Dickinson
University), while others officially transcript courses (i.e. New Mexico
As additional states
adopt prescription privilege laws for psychologists, there will undoubtedly
be an increase in psychopharmacology training programs. The postdoctoral
master's degree format seems to be most efficient model to gain privileges
in New Mexico. However, as other states ratify laws, so too will
required course-work change. Most postdoctoral psychotherapy programs
can be completed in one to two years part-time, far less training than
attending medical, nursing, optometry, dentistry, physician assistant,
or pharmacy school. Harvard Medical School psychologist Steven Kingbury obtained prescribing rights by becoming a psychiatrist. He feels that average psychologists can competently prescribe without
engaging in the full eight years of additional training that he undertook
(38Kingsbury, 1992). However, the paucity of prescribing psychologist
studies cannot allow the biopsychosocial community to make firm opinions,
let alone a decision on this debate.
2. Training for existing
A second set of implications
for the curriculum concerns the retraining of existing psychologists.
Clearly, ongoing education and reading would be required. However, training
in prescribing is likely to be expensive. Those most in favor of seeking
prescription privileges, the young, ‘are also those who can least
afford the financial burden of a postdoctoral prescriptive authority
training program.(31, p. 110) Fagan et al. (31) argue
that modifications might better be made across undergraduate, graduate
and postdoctoral levels, for new psychologists, as described above.
Psychologists spend relatively little time reading about pharmacology. Robiner et al. (39, p. 218) argue that ‘continuing education requirements
would be warranted to keep psychologists up-to-date with the burgeoning
formulary of psychotropic and nonpsychotropic medications (with which
they may interact) and to assist them in overcoming gaps associated
with their condensed training’. While 42 states require psychologists
to participate in continuing education, only the state of Georgia currently
requires psychologists to receive regular training in psychotropic medications.
If prescription authority was expanded, this obligation would need to
expand with it.(30) Robiner et al. (39) even doubt
the capacity to surmount these gaps at all, even with APA-recommended
criteria. In their view, pharmacologic knowledge would have to be increased
‘up to the level of other prescribers or substantially close to it’.
Otherwise, it ‘should not be presumed to be equivalent to that provided
by other prescribers, especially psychiatrists’. Psychologists obtain
less scientific and clinical training directly relevant to prescribing
than do other disciplines that prescribe.(39, p. 216)
Length of training is not the only issue, but also its focus. The deficiencies
in ‘doctoral-level psychologists’ knowledge and proficiency in key
scientific and clinical areas directly related to prescribing are legitimate
concerns’ to psychiatrists and other mental health professionals.(39, p. 217)
3. Impact on care
will inevitably have an impact on patient care. Psychologists are already
asked to provide advice on appropriate biological treatments, ‘frequently accompanied by an admission that psychologists
feel uncomfortable with this role given their limited training in psychopharmacology
but that the exigencies of the situation force the role on them’.(30, p. 161). If our colleagues and patients learn of the expansion
in prescribing rights, might this pressure increase? Patients might
find it difficult to distinguish between psychologists with the authority
to prescribe, from psychologists who have not yet undertaken the requirements.
We may see the development of a two-tiered system - consisting of those
who can prescribe, and those who cannot. Such inequalities could impact
psychology reacts, but also contributes to, changes in social and health
care. All professions seek to expand their special skills to new treatment
settings, with the ultimate aim of autonomy. As psychologists increasingly
follow the biopsychosocial model, psychopharmacology is the ‘last
outpost’ to create an independent clinical psychologist. Other professions
have been successful. Optometrists now have prescription privileges
in 55 states, a change which took their profession three decades of
work. This parallel example ‘offers an interesting and exemplary model
of the kind of change in scope of practice that can be – and likely
will be – achieved by psychology in the 21st century’.(40, p. 328) However, psychology is founded
on a biopsychosocial model, which I argue should not be forgotten. Psychologists
must maintain inter-professional collaborations with physicians and
continue to address the psychosocial aspects of medical problems. I
concur with McGrath (30, p. 159) that changes in the curriculum should
not ‘occur at the expense of an education in the psychosocial fundamentals
that continue to define our field’. A real dilemma may therefore face
psychologists. A narrow focus on prescribing privileges and discounting
the roots of clinical psychology risk replacing the biopsychosocial
model with a 'bio-bio-bio' model of mental health.(41) According
to Wiggins (42), if psychology is to preserve itself as a discipline,
it must provide services based on its own science... It must exchange
ideas and treatments with other disciplines such as biological, social,
and psychological domains and help educate the public about the unique
differences among these disciplines’ (24, p. 589) To remain
distinct from psychiatry, the focus should be on helping patients cope
with psychological distress and preventing illness through psychological
knowledge. The prescription debate is a politico-economic and public
health issue that will ultimately be decided in state legislature. Hopefully, in the journey to a fully biopsychosocial discipline, with
prescribing privileges as the last outpost; we will not forget the origin
of psychology as a behavioral discipline on the way.
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