There is one thing virtually everyone in the field of mental health can agree on: The issue of giving psychologists prescribing privileges is very controversial, even among psycho- logists themselves.
This issue has surfaced a number of times in the past few years, and although some bills proposing this measure have been shot down, the controversy continues and about half a dozen states are still considering this question.

First of all, what benefit is there to having psychologists licensed to prescribe drugs? A movement in California backed a proposed bill because of the "underserved" population of the mentally ill in areas where psychiatrists were outnumbered by psychologists. The logic was that, if it became more convenient for people to be treated by a psychologist, who could not only prescribe but also monitor their drug-taking, patients would be more likely to comply with their treatment plan. Rural
areas, such as in Montana, Wyoming and Alaska, are other places where this is being proposed to better serve people in remote locations where there may only be a mental health center staffed by psychologists.

But proponents of authorizing psychologists to prescribe also believe “it's a natural evolution” of their practice, clinical psychologist and adjunct faculty member Robert J. Resnick, PhD, of Randolph-Macon College in Ashland, Virginia, tells Professional Counselor. Psychologists are better distributed geographically than psychiatrists, allowing more people access to mental health-care. Also, fewer physicians are going into psychiatry today. Plus, having one person monitor your care is “cheaper and more efficient for the patient also, if only because there is only one co-payment or claim form,” says Resnick.

“When it comes to family physicians prescribing psychotropic drugs (and almost 80 percent of these prescriptions today are written by nonspecialists, two recent studies show), they don't have much behavioral training or education in these powerful medicines,” Resnick continues. This can cause them to miss certain “mental health aspects of physical illness,” leading to misdiagnosis and/or the prescribing of inappropriate drugs.

“Conversely, licensing authority is also ‘license not to prescribe,’ which is important when it comes to taking someone off a prescription that may be inappropriate, or in cases of ‘polypharmacy,’ where someone is taking numerous prescriptions that may conflict or be unnecessary,” notes Resnick, who also has a private practice at Dominion Behavioral Healthcare in Richmond. “For example, I had a three-year-old girl brought to me who was on Prozac. I couldn't tell her mother not to give it to her; I had to tell her to see the prescribing physician and discuss it.”

The first step

“The first proposal for licensing psychologists to prescribe grew from the U.S. military, where they were having trouble recruiting psychiatrists in the mid seventies,” explains clinical psychologist Allan Barclay, PhD, who has a private practice and is also an adjunct professor in psychology and psychiatry at St. Louis University.

“I wrote the original proposal for the Department of Defense (DOD) demonstration project, which was ultimately done at Walter Reed Hospital in Bethesda, Maryland. The idea was to develop a training program for military psychologists to prescribe psychotropic medications at the bases where they were assigned. Naturally, this was a political hot potato with psychiatrists.”
“Twelve men were enrolled in the study and allowed to prescribe, and the Government Accounting Office (GAO) recently evaluated the effectiveness of the program. They found that yes, it was effective, but the expense relative to the cost of training and the fact that neither field (psychology or psychiatry) enhances ‘military readiness’ (the standard by which programs in the DOD are judged) made them drop it. There were no problems with the psychologists who did the prescribing; they were well received,” but, Barclay adds, “today fewer than a dozen are practicing as psychologists and writing prescriptions within the military.”

“There are philosophical differences between psychology and psychiatry,” he continues, with the latter vigorously opposing the sharing of prescription privileges. Basically the dispute over prescription authority is an economic turf issue, with much lobbying at the organizational level for both sides and a good bit of friction. Recent efforts to pass legislation enabling psychologists to prescribe got a favorable response in the Missouri Senate,” says Barclay, “but the bill didn't get through the House. In Alaska, Wyoming and Montana, lobbying continues because the small number of psychiatrists in those states remote regions make a case for rural mental health centers staffed by psychologists."

Barclay notes that the present system “interpolates a third person (with referrals to psychiatrists) into the process and adds cost. Being able to prescribe psychotropic medications is a logical extension of the scope of training in mental health and behavioral psychology. In any event, psychologists should know a lot about those medications because many of the family physicians who are prescribing them are doing so without much knowledge of behavioral conditions.”
Michael Markovitz, PhD, is chairman and founder of the American Schools of Psychology, which now has 10 campuses across the United States and is one of the largest providers of doctorate-level psychologists (PsyD degrees) in the country. Students at two campuses have been offered the option of taking a post-doctoral, two-year program on psychopharmacology. Although completion of the course earns students an endorsement, at present there is no certification exam, nor any states where psychologists are licensed to write prescriptions.

Markovitz is impassioned in his beliefs that psychologists should — and someday will — write prescriptions: “Our post-doctoral program closely follows the DOD curriculum and is endorsed as a model of training by the APA,” he explains. “Psychologists are trained to treat a whole variety of mental and nervous disorders, and it makes no sense for them to be able to use 25 different types of therapies as treatment, and have this one form of treatment — medication — not available to them. It's like a dentist being prevented from using Novocaine. They don't have to be able to prescribe the entire panoply of medication, but need to work with medicine relative to their practice.”

Over the last seventy years, according to Markovitz, “The American Medical Association has tried to prevent every single profession from trying to practice, including dentists, optometrists, podiatrists, nurse practitioners. With them it's strictly a matter of economics. But why shouldn't the number of different helping professions be fully and completely able to practice their profession?”
But no one is suggesting this step be taken lightly. “Psychologists need to be able to work with the pharmaceutical compounds, they need serious education to learn to effectively prescribe psychoactive medications.” As with any other profession, “Psychologists need to understand when different medications are appropriate and also know when they need to consult with another expert professional, just as family physicians must consult with other specialists. This is just the responsible thing to do. The DOD has shown that you don't need to attend medical school in order to learn how to prescribe.”

The American medical establishment from the AMA and its associated societies to the American Psychiatric Association continues to lobby against prescription privileges for psychologists. Ronald Shellow, MD, is a psychiatrist in private practice in Coconut Grove, Florida, who is also a voluntary professor of psychiatry at the University of Miami School of Medicine. He has considered this issue for the American Psychiatric Association and has published papers on his position against psychologists having prescription privileges.

“Basically, there are too many adverse drug events with medical prescriptions," he tells Professional Counselor. "If anything, physicians need more training to prescribe medicines safely. It defies logic that practitioners with less medical education can do it better. Furthermore, psychologists have a different orientation altogether because their education is not medically oriented; it does not deal in a systematic way with medical issues. Serotonin, for example, has implications far beyond the brain, affecting the liver among other systems. Since patients’ lives and welfare are at stake, the standard of care should be the highest possible.”

The AMA's published policy is to oppose the prescribing of medication by psychologists and to join with other medical societies “to defeat initiatives that authorize” this, warning that “psychologists in Alaska, California, Florida, Georgia, Hawaii, Louisiana, Missouri and Tennessee are either currently seeking or considering seeking prescribing authority.”

A turf war

Many psychologists in favor of the authority to dispense medications see the AMA's and American Psychiatric Association's positions against it as “a turf war” or a “threat” to their practices. But the AMA's stance is extensive and clear, as stated in their Report of the Council on Medical Service on the topic of Non-Physician Prescribing (Resolution 511, A-98): “Physicians' unique training, experience, broad knowledge base, standards of care, and ability and expertise make them best suited to determine the drug of choice for individual patients. Moreover the extensive training of physicians — four years each of undergraduate and medical education, three to six years of residency training, and two or more years of additional training in a subspecialty for some physicians — allows doctors to make judicious decisions regarding the care of patients, including knowing when medical intervention is and is not appropriate. Furthermore, given the limited scope of practice of many non-physicians, it is argued that they are ill-prepared to address adverse reactions and other complications.”

As far as the DOD experimental project, Shellow notes: “The GAO did two reports this year as follow-ups and determined there was no need for psychologists in the military to be authorized to prescribe, that they were not able to prescribe independently, and that the training was very expensive.”

Currently in the United States, there are several groups of nonphysicians who can prescribe, although no specific non-physician group has prescription privileges in every single state. These include: optometrists, dentists, podiatrists, nurse practitioners and advanced practice nurses, physicians’ assistants, naturopathic physicians, homeopaths, midwives and pharmacists. In many states there are restrictions on the types of drugs that may be prescribed, often limited to the particular specialty, and restricting controlled substances or narcotics. And some of these nonphysicians, such as physicians’ assistants and nurse practitioners, are allowed to prescribe only under the supervision of a physician.

Psychologists have been licensed to prescribe in Guam, only after the legislature unanimously overrode the governor's veto. To be allowed to prescribe, psychologists there must have a collaborative agreement with a physician in the same specialty, just as physicians’ assistants must.

Patrick DeLeon, president of the American Psychological Association, hopes that “this first step will be modified over time, eventually providing for complete professional autonomy” for psychologists on the island, which is a U.S. territory.
Will psychologists go the extra mile?

How many psychologists will commit to the extra training required to write prescriptions?
According to Barclay, 70 percent of psychologists surveyed in Missouri were interested. Others, in established, older practices, may not be. “How much could I learn in the span of one course about various medical conditions that could interact with prescription medications psychologists might be likely to prescribe,” asks one Connecticut psychologist, who is also worried about the issue of liability.

Thomas Ansbro, PhD, clinical psychologist and supervisor of a mental health center in North Carolina, asks, “How much training would you actually need?” to prescribe. He feels clinicians should have a “good, solid medical underpinning” for writing prescriptions. Although he says that combining pharmacology and psychotherapy can be a powerful tool, Ansbro adds that some family physicians, mindful of the gaps in their training in terms of mental health studies, are “a little leery” of prescribing, particularly given the wide range of antidepressants and anti-anxiety medicines available. And he recalls his clinical training in Texas, where he drove 75 miles one way to a community of 7,000 to work at the mental health center, which had a psychiatrist available only once a week.

But this issue is not just a case of psychologists versus psychiatrists, or PhDs or PsyDs versus MDs. Arthur Kovacs, PhD of Pacific Palisades, California, teaches clinical and health psychology at the California Schools of Professional Psychology in Los Angeles and is founding dean emeritus there. He says he has been “desperately and endlessly involved” in this issue. And, although he is actively involved in working with the APA to implement a post-doctoral training program for prescribing, he feels this could lead to a change in the scope of the practice of psychology. He doesn't support psychologists prescribing, not because he feels they would lack the medical background (“It doesn't take a tremendous IQ to learn to prescribe, this is something we could learn to do competently”). Rather, he wonders, why do we (psychologists) want to do this?
Shrinks to be extinct?

Kovacs is adamantly opposed to the practice of prescribing away troubles, no matter who is wielding the prescription pad and pen. “It's part of a cultural trend I decry. We should be teaching people how to balance their lives without chemicals. Our culture is marching toward a mindset of using chemicals to relieve disease. Sometimes people need pain to motivate themselves to change their lives. Do we want to help them adapt to being miserable, by medicating them? Studies have shown that psychotherapy is as or more effective than antidepressants or anti-anxiety medications. If the aim is permanent relief, patients who merely take prescriptions won't find it if they haven't done the work.”

Psychologists, he feels, will go the way of psychiatrists once they have similar authority, and his vision of the future for psychiatry is dim. “Already psychiatric residencies go begging, and it's a low-paying, low-prestige profession today,” Kovacs says. “If psychologists get to the point of being paid for 10 minutes of monitoring meds, rather than 45 to 50 minutes of helping patients, then we're not any more noble than psychiatrists.”

Kovacs says the APA's market research shows that people don't want drugs or hospitalization as treatment, rather, they seek a “wise, tribal elder” with useful information. Besides, psychiatric treatment is stigmatizing, and he fears having psychologists with prescription privileges will cause patients to lump both professionals together, thus keeping some from seeking help. “We're doing a terrible thing to our profession and to the public's perception of our profession,” he warns. “Practically speaking,” he adds, “Psychologists are giving away their market” by joining psychiatrists.

Kovacs is a member of the legislative body of the APA and notes that he was among the 20 out of 123 members voting against legislating for prescription privileges, although “Californians continue to march up to Sacramento” in attempts to get legislation granting privileges passed. He concludes that, even if the inevitable happens, “Just because we can do it doesn't mean we should. I believe psychologists should become knowledgeable about the medications available and collaborate with those who can prescribe.”

What's next?

Resnick feels the challenge facing psychologists seeking prescription privileges is twofold: “First, we have to get our membership [in the APA] to understand the benefits through continuing education. Then we have to take it to the legislatures, state by state.”
Today, according to Kovacs, there are only two places where some psychologists have full prescription privileges: in the American Indian Service and in the military (the latter is limited to the 10 or so who completed the DOD's program).

In the meantime, proponents of licensure are continuing the fight to get legislation passed in each state and in the District of Columbia. Psychologists who want to be ready can take the post-doctoral psychopharmacology program through the American Schools of Psychology Hawaii campus (the program is being phased out on the Chicago campus); also at the California Schools of Professional Psychology (Los Angeles campus). There are also several distance-learning center sites in Texas, and the University of Florida in Gainesville also has a distance-learning program in the works.

Efforts in 1998 by an American Psychological Association committee to develop a national accreditation exam in the event that prescription privileges are legislated in some states are ongoing; the psychologists we spoke with anticipate completion within a few months of this writing.
Even if every state and the District of Columbia individually allow psychologists to prescribe, which some feel is inevitable, it would most likely be an option for them. They could take the post-doctoral training required and buy the additional liability insurance coverage that would be necessary — or not. Group practices, for example, might function with only one professional prescribing for all the therapists' patients who need drugs. Plus, psychologists with prescription privileges might train others, as long as a required curriculum is established and a certifying examination taken.
If nothing else, the controversy serves as a trigger for psychologists and other counselors to re-examine their philosophies regarding care and treatment of patients, comparing and evaluating the differences between behavioral models and medical models.

Mary Ellen Hettinger is a freelance writer in Coral Springs, Florida.

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