Prescription privileges: an iatrogenic disease for psychology

February 27, 2008

In an arguable effort to weaken – not strengthen – the profession of Psychology, the California Pychological Association (CPA) has propelled the obtaining of prescription privileges to the top of its legislative agenda for 1995. This at a time that the profession falls victim to unprecedented attacks. The insurance companies strive to severely limit patients’ access to mental health services; the medical establishment often views psychological services as “medically unnecessary”; the drug companies sell psychotropic medication as being more cost-effective and efficient. And the American public, possessed by the spirit of fast-food, all too often bows to these forces. All this after psychology finally emerged, in the last few decades, as a strong, distinct, independent discipline.

Rather than protect professional psychology’s strengths, the CPA seems to increasingly capitulate to these political and economic forces. The CPA has repeatedly co-sponsored programs with managed care companies that promote exclusively short-term, crisis intervention psychotherapy. They have provided training in gaining access to provider panels and, more disturbingly, in how to “sell” one’s clinical experience so as to be palatable to managed care companies. Many other CPA programs and articles preach compliance to these dangerous trends that threaten confidentiality and restrict access to treatment. Now, the CPA strives to earn the ability to prescribe psychotropic medication, also in accordance with the prevailing opinion that such interventions are more efficient, cost-effective, and necessary for the survival of the profession.

Not only are such conclusions an unnecessary surrender, but the timing of their promulgation could not be worse. The current competencies of psychologist have to be supported and strengthened, especially in the public view. Instead, organized psychology appears to be accommodating to the view of the insurance companies. Both the rallying point and the metaphor for this struggle has become the push for prescription privileges.

Those in favor of such privileges suggest that psychologists could use another competency with which to compete with other healing professions. They believe that prescription privileges would make psychologists more competitive in the mental health marketplace. They argue it would allow psychologists with certain specialized training, such as those in medical psychology or in the neurosciences, to more directly apply their clinical skills. Finally, they propose that it would allow psychologists to help more people in more diverse locations. With the possible exception of this last point, these conclusions are easily dismantled.

First, psychologists hardly need another competency. Their capacity for conducting psychotherapy and related treatments, performing psychological assessments and doing research has not nearly been developed to its fullest. Doctoral training programs and internships already lack sufficient time for training in these areas. One could devote one’s entire career to the study of psychotherapy and not master the technique. The same goes for psychological assessment or research.

Second, regarding the idea that prescription priVileges would make psychologists more competitive, this, if valid at all, would be countered by the increased diffusion that would occur in the field of psychology. The American Psychological Association is already so split by factionalism that the addition of another major clinical area may well destroy it, most definitely resulting in a loss of professional power. The public is already confused about what psychologists do. What competitive edge would be gained by adding another clinical skill when many psychologists lack mastery of the skills they are already licensed to provide?

Furthermore, prescription privileges could make psychologists less competitive. At its best, the privileges would be limited in scope. At its worst, they would be granted only under the direct supervision of a physician. In either event, rather than strengthening the independent practice scope of psychology, the move would only serve to further the perception of psychology as somehow being “beneath” the medical profession. Whatever prescription training psychologists obtain would be second rate compared with complete medical training. Prescription-pad wielding psychologists would still be ill-prepared to deal with complicated medical/psychological issues, such as providing an anti-depressant medication to a diabetic or to a person with heart disease.

Third, regarding the ability for psychologists trained in the neurosciences or related areas to apply their skills, those psychologists who wish to expand their scope of practice should do so fully. Among the first set of individuals chosen to go through the Department of Defense . training in prescription privileges for psychologists, a number of them ended up applying for and being accepted to medical school. Obviously, many who are interested in obtaining prescription privileges desire to practice medicine. If the neuropsychologist or health psychologist desires prescription privileges to more directly help patients, they would be better served by formal medical training.

Fourth and last, it is a compelling argument that a need exists for provision of psychotropic medication to members of the population lacking sufficient access to physicians. But this issue would be better addressed by providing incentives, and training in psychotropic medications, for family practitioners or internists.

To add prescription privileges to the psychologist’s tool box to fill this one need is inefficient and unnecessary. These under-served people would be consulting psychologists with second class prescribing power rather than physicians. And the question of easier access to psychologists has yet to be addressed. Providing incentives for psychologists to serve these people would be no easier than doing so for physicians.

Instead of bowing to competitive and economic forces by seeking prescription privileges, professional psychology would be better served by endorsing its strengths and acknowledging its limitations. If one is trained as a lawyer, should one be attempting to psychologically counsel distraught clients? Or should a surgeon attempt medical management of a chronic diabetic? Both professions could perform these services, but should they? Legislative efforts would be much more effectively directed towards promoting psychology’s provision of excellent psychotherapy, assessment, and research, thereby filling the vacuum left by psychiatry and by masters level psychologists.

With economic changes affecting the income that physicians make, and other social changes, admission to medical school is easier than it was in past decades. For many young psychologists, it would not be too late to enter a medical training program. Rather than weaken the profession of psychology, and provide a service that is second-class to our medical colleagues, it would be wiser for psychologists interested in prescription privileges to seek formal medical training. Psychology needs to stand strong as a peer among other fields in the healing arts, not capitulate by mimicry or by attempted merger with medicine.

Published as:

Karbelnig, A. (1995). Prescription privileges: An iatrogenic disease for psychology. The California Psychologist, 28(8), 22-23.

(Dr. Karbelnig, a past Member of the CPA Board of Directors and current Chair of the Ethics Committee of the San Gabriel Valley Psychological Association, practices psychoanalytic psychotherapy and forensic psychology in South Pasadena, California.)

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