Drug Wars: The Siren Call of Prescription Privilege
How and why do psychologists and psychiatrists work together in treatment?
Posted Apr 08, 2010
How do clinical psychologists competently and effectively treat patients in this era so heavily dominated by psychopharmacology? Traditionally, psychologists could only work closely and cooperatively with psychiatrists and other prescribing physicians to ensure their patients received appropriate phamacotherapy as needed. But in recent years, there is a growing momentum afoot to train and license clinical psychologists as psychopharmacologists. Fierce debates about this controversial movement are raging. (See, for example, PT blogger psychiatrist Steven Schlozman's legitimate medical concerns.) While it may seem strange to some readers, I (along with many of my colleagues) am not a big supporter of clinical psychologists obtaining prescription privileges. And here is why.
Just take a long, hard look at what has become of the profession of psychiatry. Today, approximately ninety-percent of psychiatrists no longer provide psychotherapy--once the mainstay of traditional psychiatric treatment--to their patients. Why is that? For a few reasons. First, psychiatrists and their patients were disillusioned and frustrated with psychotherapy, its expense, duration, and limitations, especially in the treatment of more severe mental disorders such as bipolar illness, schizophrenia and major depression. Hopeful advances in the development of more efficacious pharmacological therapies fueled the biological revolution in psychiatry. The seminal contributions of Freud, Adler, Rank and Jung to depth psychology have sadly lost favor among most psychiatrists today. And the dubious benefits of Ellis and Beck's cognitive-behavioral therapy, while more medically accepted, are rather condescendingly perceived by most as, at worst, innocuous, and at best, merely a minor adjunct to pharmacological treatment.
Second, it's a turf war: Prescribing psychotropic drugs places psychiatry in a unique, lucrative and powerful position. Right now, with the exceptions of Oregon, Guam, Louisiana, New Mexico, and pending legislation to grant clinical psychologists obtaining one to three years additional pharmacological training prescription privileges in several other states, psychiatrists are the only mental health professionals licensed to prescribe such medications in the U.S. The American Psychological Association has taken a stand supporting prescriptive authority for properly educated clinical psychologists. Organized psychiatry vehemently protests such a trend.
How, readers might wonder, with this professional and political tension between the American Psychiatric Association and American Psychological Association, do psychologists and psychiatrists currently work together in treatment? Most (but not all) clinical psychologists today are fairly well-versed about psychiatric medications, via both experience treating such patients and having taken at least one course in graduate school and/or post-doctorally in this area. In my own practice of clinical and forensic psychology, when I believe that one of my patients could likely benefit from psychiatric medication of some sort, I refer them for a medication consultation to one of several psychiatric colleagues with whom I have established a professional relationship over the years. While I may have some suggestions regarding the type of medication to be taken, the psychiatrist (many of whom today see themselves exclusively as "psychopharmacologists") makes the final decision on whether or not to medicate and what type of drug to prescribe at what dosage, based on his or her own independent evaluation of the patient. Psychotropic medication can be tricky, and, while any physician is legally permitted to prescribe them (and many do), psychiatrists have, by far, the most hands-on clinical experience and expertise in dealing with these potentially dangerous and sometimes life-saving drugs. But, unfortunately, both medical psychiatry and the general public tend to overestimate the power and importance of biochemistry, neurology and psychotropic drugs in mental health while minimizing the basic role of psychology in both causing and healing mental disorders.
Once patients have consulted with the psychopharmacologist, something that can occur at the start of treatment or at any point later on as needed, they typically continue to see me for psychotherapy. As part of their therapy, we discuss how the psychiatric consultation went, whether they intend to take the recommended medication as prescribed, and review what might be expected regarding their symptoms as a result of doing so or not doing so. Many patients are quite fearful of, reticent or resistant to taking any medications in general, let alone psychiatric medications, and require a sometimes prolonged opportunity in therapy to voice their concerns, doubts and anxieties before being willing to even consider a psychiatric consultation or trying medication. If they do decide to follow the prescribed drug regimen, patients require regular and consistent support in staying the course long enough to start feeling some benefit. This is especially true of the antidepressant medications, whose sometimes unpleasant side-effects (e.g., dry mouth, constipation and diarrhea) typically precede any therapeutic effects by several weeks. Part of psychotherapy in such cases involves encouraging the patient to continue taking the medication despite those side-effects long enough for it to fully kick in. Of course, it is primarily the prescribing physician's responsibility to address severe side-effects, to adjust dosing when needed, and to try different or additional drugs if the first aren't adequately alleviating the patient's symptoms. Consultation between the prescribing psychopharmacologist and psychologist can be essential in sharing information regarding the patient's progress or problems, especially since the treating psychologist typically has more regular contact with the patient, and can more closely monitor his or her mental status.
Currently, the California Board of Psychology's official public position is that clinical psychologists (a highly specialized type of training that not all generic psychologists share) are legally and ethically within their scope of practice when discussing psychiatric medications and their possible utilization with their patients and other health professionals: "Psychologists may discuss medications with a patient . . . , suggest to a physician a particular medication to be prescribed . . . , may engage in a collegial discussion with a patient's physician regarding the appropriateness of a medication for the condition being treated . . . , [and] has primary responsibility to monitor the patient‘s progress in psychotherapy, which includes assisting in monitoring the changes which may be attributable to the medication in the patient." This has become an important and routine part of the practice of clinical psychology, since so many patients either have previously taken, presently take, or could potentially benefit from psychiatric medications as part of their therapeutic treatment plan.
However, having said all that, my own position on this matter is that psychiatric medication is seldom, if ever, a substitute for psychotherapy. Psychotherapy is not (or shouldn't be) secondary to phamacotherapy, but rather the primary mode of treatment, with pharmacotherapy supporting psychotherapy, not vice-versa. In most cases, patients who take these medications should be in concurrent psychotherapy. (Yes, even patients suffering from psychotic disorders.) For one thing, they need to be carefully monitored as to serious side-effects such as suicidality, homicidality, psychosis, mania, agitation or other untoward tendencies, something that prescribing psychiatrists or general practitioners typically do these days only on a very limited, sporadic basis, and at significantly longer intervals than once or twice-weekly therapy sessions. Indeed, most psychiatrists, psychopharmacologists and other physicians today work in tandem with psychologists and other mental health professionals, depending on the psychotherapist to see the patient more frequently and to spend more time doing so.
So most patients seen by psychologists and taking medication today have two separate providers: the psychiatrist/psychopharmacologist or non-psychiatric physician and the clinical psychologist or psychotherapist. At one time in the not too distant past, all psychiatrists were well-trained not only to provide psychopharmacological treatment, but to practice psychotherapy too. In this case, the patient only needed to see one clinician, who provided both psychotherapy and psychopharmacology--a seemingly more efficient and self-contained situation for both patient and doctor. But, despite the fact that there are still some psychiatrists (some of whom are Freudian or Jungian analysts) providing both therapy and psychopharmacology, those days are, for the most part, long gone. And, unless psychiatry does a dramatic about face--recognizing the true limitations of psychopharmacology and placing more emphasis and value once again on the practice of psychotherapy--they seem unlikely to return. Now the crucial question being raised is whether clinical psychology will attempt to step into that dual psychotherapist/psychopharmacologist role once historically occupied by psychiatry.
The potential problem with that scenario is demonstrated clearly by what has happened in and to the field of psychiatry over the past few decades. Psychotherapy receives increasingly less emphasis in psychiatric training and practice today as compared to decades ago. One reason for this has to do with the popularity of pharmacological treatments for mental disorders not only with the general public, but especially with insurance companies, who would much rather pay for relatively rapidly-acting, inexpensive pharmacological therapy than more expensive, prolonged psychotherapy. While this policy is rationalized and defended as being supported and indicated by evidence-based scientific research, the truth is that no studies to date have demonstrated psychopharmacology to be superior than psychotherapy in treating mental disorders, especially over time. In fact, studies tend to suggest that psychotherapy is superior in most cases to psychopharmacology alone, and that, for many disorders, a combination of psychotherapy and psychopharmacology is the most effective treatment. Indeed, as more longitudinal research emerges, the efficacy of psychopharmacological treatment for psychiatric disorders, and its benefits versus risks ratio is becoming increasingly questionable. The reality is that psychotherapy and pharmacotherapy do different things in exceedingly different ways. One cannot substitute for the other. Both have their rightful place in treatment when necessary. Unlike medications, real psychotherapy goes beyond mere symptom suppression. Some mental health consumers seem to intuitively understand this, choosing psychotherapy over pharmacotherapy, psychology over psychiatry. And we may even be seeing the beginnings of a consumer backlash against psychiatry and its lopsided biological treatment of mental disorders. Nonetheless, pharmaceutical companies and most biologically-oriented psychiatrists continue to mislead the public into believing these drugs are miraculous substances sufficiently efficacious as to render psychotherapy a comparatively archaic and virtually obsolete treatment approach.
This does a grave disservice to the community. Nothing could be farther from the truth. Most people suffering from emotional disturbance who receive at least several sessions of psychotherapy--any type of therapy--are far better off than untreated individuals. And, in at least one study (1998), 50 percent of patients noticeably improved after eight therapy sessions, while 75 percent of individuals in psychotherapy progressed by the end of six months. Research suggests that psychotherapy is frequently at least as effective as medication, and that the benefits are more enduring. While we are fortunate to have such potent pharmacological agents in our therapeutic armamentarium today, they are certainly no panacea, have profound limitations in what they can and cannot do, and carry potentially dangerous and disturbing short and long-term side-effects, including, in some cases, suicidality, homicidality, habituation, sexual dysfunction, major weight gain, and permanent neurological damage to mention but a few.
So why are psychologists so anxious to prescribe? Of course, the main argument is that we would be in a better position to serve our patients needs for both medication and psychotherapy. That there is a severe shortage of psychiatrists, especially in rural areas, and that prescribing psychologists would make medication more accessible to those who most need them. And perhaps more affordably. Maybe so. Would it be more convenient for me to prescribe psychiatric medications to my patients rather than referring them to a colleague to do so? Absolutely. Could I make more money by providing brief medication consultations and follow-up visits to patients instead of spending forty-five minutes with each patient doing psychotherapy? Of course. After all, there are only so many hours in a day. And, therefore, only a very limited number of psychotherapy patients one can see. (From a financial standpoint, because of the enormously increased risks of prescribing psychotropic drugs to patients, malpractice insurance would become considerably more expensive, possibly limiting these eagerly anticipated economic gains.) My main concern is that since writing prescriptions for a psychotropic drug is far easier and less time consuming than psychotherapy sessions, clinical psychologists will very quickly succumb to the demand for these drugs and to the powerful allure of making a much easier buck.
The tempting siren call of psychopharmacological treatment, which has already lured psychiatry to near wreckage on the rocks, now beckons seductively to clinical psychology. And it grows ever more appealing, almost irresistable, as the combination of public craving for quick and easy physiological fixes such as psychiatric drugs and poor public relations portray psychotherapy to be a less desirable and inferior type of treatment. Prescribing psychologists could compete equally in the market place with psychiatrists. And would no longer be limited to providing only psychological treatment. But is this a good thing? I don't think so. Clinical psychology would quickly deteriorate into something akin to what psychiatry has become. Psychotherapy would be all but abandoned by most, as it has been basically by psychiatry. And this would not be in the best interest of patients' well-being. They would be left in the lurch, forced to seek out lesser trained, less qualified, less sophisticated master's level clinicians to provide psychotherapy. Not that such non-doctoral clinicians cannot provide adequate psychotherapy. They can, and many are capable of far more than merely adequate therapy. But the consumer will have taken a hit in terms of the type of psychotherapists they could see. Indeed, this might exacerbate the already disastrous trend toward minimally trained, unlicensed, pseudo-therapists, psychics, life-coaches, exorcists, etc. filling this void. Now is not the time to abandon the healing (though admittedly still evolving) art of psychotherapy developed over the past hundred years. This would not be progress, but a fatal mistake and failure of courage and commitment on the part of clinical psychology to take up its banner and champion its worthy cause. And psychotherapy, already embattled, wounded and weakened, will have received yet another death blow, another fateful nail in its coffin. (See my prior post.) As Jesus of Nazareth some 2,000 years ago so insightfully observed, it is devilishly difficult to faithfully serve two masters.