Therapy Matters

Reflections of a young clinician

Why Medication Should be Left to Psychiatrists

If you want to prescribe medication, 
what’s wrong with going to medical school?

For the past decade there has been a debate raging within the American Psychological Association (APA) as to whether psychologists should be allowed to prescribe medication.  I say "debate," but in reality there hasn't been much in the way of genuine discussion on the topic.  The APA has been vocal in supporting prescription authority (RxP) for its members and in doing so it has been suggested that there is widespread support throughout the Association.  In fact, when it comes to RxP, I can tell you that the APA does not represent my interests.

Supporters of the RxP movement have advanced a number of arguments in support of their cause.  These arguments have included the following:

  • Allowing psychologists prescription authority would enable them to provide better and more comprehensive services to their patients. 
  • RxP is a natural and desirable extension of the practice of clinical psychology.
  • Since psychiatrists are legally permitted to offer psychotherapy (with little training), why shouldn't psychologists be allowed to provide the full spectrum of efficacious treatment, including medication?
  • Training psychologists to prescribe medication would be comparable to that of medically trained psychiatrists. 
  • Since most people already go to their primary care physician (PCP) for psychotropic medications, why not allow psychologists, who are trained in the treatment of mental illness, to provide similar services?  Furthermore, given the dearth of psychiatrists in certain areas of the country (particularly in rural areas), why not allow psychologist to fill the gap?
  • Psychologists in private practice cannot survive in today's competitive managed-care system without RxP because of the onslaught of social workers, licensed counselors, and psychiatric nurses offering cheaper therapeutic services.

While these arguments may seem reasonable on the surface, many do not hold up to closer scrutiny.  Furthermore, I believe that many of the underlying assumptions behind these arguments are dubious.  There are several reasons from my perspective why the APA is misguided in supporting RxP for psychologists.

If psychologists are granted RxP, I'm concerned it will come at the cost of diminished expertise in other important clinical areas.  RxP will change the practice landscape for psychologists and in ways that may not be in our shared long-term interests.  Those who believe psychologists can somehow avoid the fate that has befallen psychiatrists are deluding themselves.  Most psychiatrists begrudgingly acknowledge that managed care has forced them to adopt more "cost effective" approaches to treatment that have sacrificed patient-centered psychotherapy for pharmaceuticals.  This development has been reported widely in the media, most recently in places like The New York Times ("Talk Doesn't Pay, So Psychiatry Turns Instead to Drug Therapy").

Aside from such pedagogical arguments, the practicality of training psychologists to prescribe brings up many legal and ethical challenges that the APA has failed to adequately address.  According to Psychologists Opposed to Prescription Privileges for Psychologists (POPPP), RxP for psychologists would not adequately address the shortage of qualified psychiatrists in various parts of the country.  Furthermore, the idea that psychologists would be willing to fill this gap is questionable, as the field's geographic distribution already closely mirrors that of psychiatry.  While I could be wrong, I suspect the majority of psychologists who are fighting for RxP have no intension of leaving their affluent communities to practice in more rural parts of the country.  What incentive does a psychologist have to relocate elsewhere when there is more than enough demand for pharmaceuticals in areas where psychologists are already practicing?  Might this be part of the reason why consumer advocacy groups such as the National Association of Mental Illness (NAMI) have not chosen to take up this particular APA cause?

In addition to these economic considerations, there are also important safety concerns that the APA has failed to fully address.  While the Association has argued their proposed training would be as rigorous as that of psychiatry, the reality is far less convincing.  The program currently being advanced by the APA would entail 400 classroom hours of scientific training and a one year supervised practicum.  This would translate to approximately 2 years of full-time clinical work, a number that falls well short of the four years of medical school and (minimum) four years of residency required of board certified psychiatrists. 

And, let us not forget the considerable financial costs that all psychologists would bear should RxP be granted.  I have yet to hear the APA acknowledge, much less address, the impact RxP would have on professional malpractice insurance.  It's one thing for individual members to assume the legal and financial risks involved in RxP, it's quite another to ask the entire profession to supplement the insurance of a select few.  There is little question that psychologists prescribing medication would be assuming greater liability due to the risks involved in psychotropics, which can be toxic in combination with other medications and lethal when consumed in large doses.

I say to those psychologists who feel they need RxP to adequately serve their patients, you already have two available options.  There is nothing stopping a psychologist from becoming a nurse practitioners (NP).  In fact, this seems an ideal solution as it is both cost-effective and specifically designed to train clinicians in the biochemistry of medication and its management.  Likewise, what is stopping a psychologist who really wants to prescribe medication from going to medical school?  If the APA is truly interested in members having RxP, why are they not making more effort to encourage members to pursue nursing or medical training?  If you can answer that question, than you probably have a better understanding of the true agenda behind APA's push for prescription authority.

 

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Tyger Latham, Psy.D. is a licensed clinical psychologist practicing in Washington, DC.  He counsels individuals and couples and has a particular interest in sexual traumagender development, and LGBT concerns.  His blog, Therapy Matters, explores the art and science of psychotherapy.

Dr. Tyger Latham is a clinical psychologist practicing in Washington, D.C., where he specializes in men's issues, trauma, and LGBT concerns.

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