Therapy Matters

Reflections of a young clinician

Why Medication Should be Left to Psychiatrists

For psychologists who want prescription authority, 
what’s wrong with going to medical school? Read More

And psychological assessments should be left to psychologists

http://www.illawarramercury.com.au/news/local/news/general/wollongong-ho...

A girl with a brain tumour was told she was "stressed", sent home with paracetemol....

I agree that that specialists should be respected. It's a pity that not everyone is a specialist....this girl was lucky enough that her mum questioned a specialist's recommendation that she took her daughter to another hospital!

Yes, but not quite.

I like my medication and my therapy to be two separate things, however at the same time I value my psychologist's queries and suggestions about medication. I value that he keeps a record of what I'm on, follows through on how it's helping or not helping, and guides me through discussing issues I have with medications and my psychiatrist. My psychiatrist focuses on symptoms, while my therapist unmasks the things I'm not telling my psychiatrist for whatever reason and helps me cope with the trial and error of finding a pill that works. I gave him and my psychiatrist rights to talk about me in full when they feel necessary. If I suddenly become exceedingly happy or sad, I can trust my psychologist to contact my psychiatrist, and my psychiatrist will book an immediate appointment. Unfortunately, my psychiatrist isn't so willing to contact my psychologist to let him know that I've undergone a major drug change that likely needs a therapy session dedicated to itself given my hatred for my psychiatrist and his pills.

While I don't agree with psychologists being given prescribing power, for all the reasons you mentioned and more, I do believe that psychologists can and should play a more active role. While you may be lucky enough to find a psychologist or psychiatrist willing to do this, more often than not there's a communication barrier that the client has to attempt to work around on their own. There's a middle ground that can be reached, and if both sides work together they would be much more beneficial to the client than their long-running tiff over titles is.

Response

Dear Anonymous,

You raise an excellent point and one I neglected to mention in my recent post.

I am not suggesting psychologists should be ignorant about biochemistry and pharmaceuticals. On the contrary, we in the profession have a clinical and ethical responsibility to keep ourselves informed about psychotropics, particularly those that pertain to our patients' clinical care. Often times, it is psychologists who are the first to become aware of behavioral changes due to drug side effects.

Sadly, few psychiatrist have the time or luxury to closely monitor their patients' weekly progress; therefore, it takes a team effort to makes sure everyone (including the patient) is well informed. Thanks for highlighting this important point.

Sincerely,

TL

As a med student, I feel that

As a med student, I feel that the comparison drawn here between the extra training psychologists would need to prescribe, vs. the 4 years of medical school education psychiatrists receive is a bit weak. The vast majority of that 4 year education is NOT related to mental health nor the medications commonly prescribed in the field. I am of the opinion that a comprehensive and condensed education containing only the most relevant information needed to gain the knowledge to prescribe these types of medications would be well comparable to the bits and pieces that medical students get during their 4 years.

That said, this was a very enjoyable and interesting read. Clearly well thought out.

Therapist trying to prescribe medications/why they shouldn't

As a Psychiatric Nurse Practitioner I struggle with the whole issue of therapist trying to pick medications for patients.

I had a patient come to me with a sticky note with the name of a medication that her therapist thought that she should be on. Unfortunately, therapist do spend more time with their patients and the patients trust them. Suggesting a medication to their patients sets up an expectation. IE: I trust my therapist therefore he/she must know what they are talking about.

When the patient arrives in my office with the expectation and the choice is not appropriate then it is a lose/lose situation.

If the therapist picks a med that works then when the pt can't sleep or is more depressed or whatever, the patient will talk to their therapist about their meds. Even with a fairly good knowledge base, the therapist will not pick the right med every time. And what if their choice doesn't work? Gee, do they get to pick again? And what happens when the patient gets a rash or the med doesn't work or he has a drug/drug interaction?? and the patient calls the therapist for help? The therapists only out would be to say "call the prescriber". While therapist may think they know what drug to pick, actual prescribing is MUCH different than THINKING that you can prescribe.

I had another patient come to me and say that his therapist thinks that he needs to be on cymbalta,clonazepam and adderall. Seriously?? Yes, let's start him out with a stimulant and a sedative. The pt was unrelenting in his request and totally believed in his therapists' choices. So, really, therapist out there...what's wrong with this picture??

My answer had to be NO. and the patient thought I was in the wrong. So, this is also a lose situation for the patient. In an attempt to help his patient this therapist just set him up as he wanders prescriber to prescriber trying to get what his THERAPIST thinks are the right medications.
Another issue is liability. Why would I let a therapist pick medication under my license? Why would therapist assume that they know better than the prescriber? Prescribing IS what we do ALL day. We have experience at it. In truth, if the therapist picks a medication, chances are, as the prescriber, I have already run that options through my mind.

I think the grass can sometimes LOOK greener. Just thinking "I can do that" Doesn't mean it is in the therapist scope of practice and that they should do it.

So from my perspective, a therapist suggesting medication is akin to me sending a sticky note with the patient to their therapist, and having the patient say, "My prescriber thinks that this is the type of therapy that you should do with me" (like CBT or EMDR or whatever). I don't try to pick your mode of therapy, please don't try to pick meds. It is called boundaries.

And try it is, because there is so much that goes into the decision of what to prescribe, the therapist does not know that component.

So, when therapists try to pick medications they are saying "I think this medication would be helpful, even though I have no license or authority to do this and not to mention no liability in what I have chosen. So, prescribe this because I know your job better than you do"

Really? Seriously? Why would I let a therapist do this? Answer: I wouldn't.

I am however open to talking the therapist about their patients and even their medication suggestions because then I can educate them as to why the med could be an option or why it is not appropriate.

Ok, enough said.

Therapist trying to prescribe medications/why they shouldn't

As a Psychiatric Nurse Practitioner I struggle with the whole issue of therapist trying to pick medications for patients.

I had a patient come to me with a sticky note with the name of a medication that her therapist thought that she should be on. Unfortunately, therapist do spend more time with their patients and the patients trust them. Suggesting a medication to their patients sets up an expectation. IE: I trust my therapist therefore he/she must know what they are talking about.

When the patient arrives in my office with the expectation and the choice is not appropriate then it is a lose/lose situation.

If the therapist picks a med that works then when the pt can't sleep or is more depressed or whatever, the patient will talk to their therapist about their meds. Even with a fairly good knowledge base, the therapist will not pick the right med every time. And what if their choice doesn't work? Gee, do they get to pick again? And what happens when the patient gets a rash or the med doesn't work or he has a drug/drug interaction?? and the patient calls the therapist for help? The therapists only out would be to say "call the prescriber". While therapist may think they know what drug to pick, actual prescribing is MUCH different than THINKING that you can prescribe.

I had another patient come to me and say that his therapist thinks that he needs to be on cymbalta,clonazepam and adderall. Seriously?? Yes, let's start him out with a stimulant and a sedative. The pt was unrelenting in his request and totally believed in his therapists' choices. So, really, therapist out there...what's wrong with this picture??

My answer had to be NO. and the patient thought I was in the wrong. So, this is also a lose situation for the patient. In an attempt to help his patient this therapist just set him up as he wanders prescriber to prescriber trying to get what his THERAPIST thinks are the right medications.
Another issue is liability. Why would I let a therapist pick medication under my license? Why would therapist assume that they know better than the prescriber? Prescribing IS what we do ALL day. We have experience at it. In truth, if the therapist picks a medication, chances are, as the prescriber, I have already run that options through my mind.

I think the grass can sometimes LOOK greener. Just thinking "I can do that" Doesn't mean it is in the therapist scope of practice and that they should do it.

So from my perspective, a therapist suggesting medication is akin to me sending a sticky note with the patient to their therapist, and having the patient say, "My prescriber thinks that this is the type of therapy that you should do with me" (like CBT or EMDR or whatever). I don't try to pick your mode of therapy, please don't try to pick meds. It is called boundaries.

And try it is, because there is so much that goes into the decision of what to prescribe, the therapist does not know that component.

So, when therapists try to pick medications they are saying "I think this medication would be helpful, even though I have no license or authority to do this and not to mention no liability in what I have chosen. So, prescribe this because I know your job better than you do"

Really? Seriously? Why would I let a therapist do this? Answer: I wouldn't.

I am however open to talking the therapist about their patients and even their medication suggestions because then I can educate them as to why the med could be an option or why it is not appropriate.

Ok, enough said.

Thank you for your post. My

Thank you for your post. My life was completely destroyed by a therapist that thought she was more knowledgeable about meds than she was really was. The hell that my life has become could have all been avoided if she would have been responsible enough to know her limitations.

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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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