Prescribing Rights for Psychologists

Maria Bradshaw
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Much has been written about the relationship between Psychiatry and the Pharmaceutical industry. The ways in which the two groups increase each other’s revenues, work together to influence public perception of the value of psychotropic drugs and the giving and receiving of gifts and incentives which influence professional practice to the detriment of patient safety.

Psychology on the other hand has been conceptualized as a discipline that rejects the medical model of emotional distress in favour of non-drug, holistic, patient centred care. The evidence however suggests that psychology’s links to both the mental illness and pharmaceutical industries are as strong as those of psychiatry and arguably more insidious given the extent to which they exist below the radar of those exposing mental health abuses.

It is well known that psychologists, like psychiatrists, use the DSM to label people with diagnoses that justify the prescribing of a psychotropic drug. According to the Society for Humanistic Psychology (Division 32 of APA),

“The DSM is a central component of the research, education, and practice of most licensed psychologists in the United States. Psychologists are not only consumers and utilizers of the manual, but we are also producers of seminal research on DSM-defined disorder categories and their empirical correlates. Practicing psychologists in both private and public service utilize the DSM to conceptualize, communicate, and support their clinical work[1]

Less well known perhaps is that psychology was as involved in the development of the ‘bible of psychiatry’ as psychiatry itself. The American Psychiatric Association tells us that the DSM-5 task force and work group members comprised nearly 100 psychiatrists and 47 psychologists.[2]

Psychology’s involvement in the development of the DSM-5 sits alongside its intense lobbying over the past 30 years for prescribing rights for psychologists (RxP). The APA states;

“APA supports the efforts of state and provincial psychological associations and individual psychologists as they pursue the right of appropriately trained psychologists to prescribe psychoactive medications.” [3]

Its position has secured prescribing rights for psychologists in a number of US States and is quoted by Psychology’s professional associations in other parts of the world who are preparing training curricula for their members on psychopharmacology and actively pursuing prescribing rights.

In its lobbying for prescribing rights, the American Psychological Association put forward arguments which centred on increasing access to treatment for communities underserved by psychiatrists, convenience for patients and the potential to increase revenues for the industry at a time when psychologists salaries were decreasing. [4]  It rejected claims that psychology would lose its focus on psychosocial approaches claiming that psychologists working within the biopsychosocial model could not ignore the biological dimension of mental illness and that psychologists would reduce their focus on therapy in favour of prescribing.

Nicholas Cummings, former president of the American Psychological Association however is less sure about this, asserting that when psychologists obtain prescribing rights “it remains to be seen . . . whether they abandon the hard work of psychotherapy for the expediency of the prescription pad.” [5]

There are a small number of prescribing psychologists worldwide and little research has been done on their practice and prescribing rates. As with any profession, from the limited information available, they appear to have adopted a range of approaches.

In an interview published by the American Psychological Association, James Quillin and Linda Upton, prescribing psychologists from Louisiana, report having 60% and 40% respectively of their patients on medication while E. Mario Marquez from Albuquerque has had prescribing rights for more than a year, but hasn’t issued a single new prescription and says the right to prescribe is also “the power to not prescribe, or to help wean patients off medications.” It is reported that “Marquez considers a range of psychosocial treatments before writing a prescription. In fact, he will only consider writing one after the child has already undergone comprehensive psychological evaluation and psychological tests; after he has interviewed the child’s parents or guardians; after he has observed the child in school; after the child’s teacher has rated the child’s behavior; and after he has the child’s medical, school and psychological history.” [6]

At the other end of the spectrum is Dr. Greenspan, a member of the American Society for the Advancement of Pharmacotherapy, a division of the American Psychological Association, who in a conference biography says she “adores the practice of psychopharmacology and believes that prescriptive authority is the key to psychology’s future” and is “devoted to RxP initiatives in the U.S and Canada. [7]

In 2003, psychologists were warning that “As professional psychology moves into a new era of prescription privileges, it will likely receive increasing direct financial and marketing attention from the pharmaceutical industry causing potential conflicts of interest that may affect the scientific database.” [8]

By 2004, they were reporting that this threat had been realized with psychologists being targeted with  “gifts, perks, and educational programs by big pharma.” [9]

Interestingly, psychologists seem to have convinced themselves that they will be able to resist pharmaceutical company attempts to influence their prescribing behavior in a way psychiatry has not. In an article about the need for psychology to erect a ‘firewall’ between itself and the pharmaceutical industry in an era of prescribing psychologists, prominent psychologists  address the issue by stating that

“One of the most important promises made by organized psychology in the pursuit of prescription privileges is that it will approach pharmacotherapy from the perspective of the scientist-practitioner . . . To back up this promise, we propose a high standard of scientific integrity and a clear boundary between science and advertising.” [8]

The Canadian Psychological Association comments that;

“It may be argued that it is naïve to assume that psychologists have a scientific moral superiority producing immunity from pharmacological marketing influences. It is equally naïve to argue that one should avoid delivering a potentially effective treatment because it exposes one to these marketing influences. Medicine has taken many steps in recent years to come to terms with this corporate influence, and psychology would have to take similar steps.”

To date however, psychology has not been particularly successful in avoiding becoming a tool of the industry. Training for drug company reps is based on “outcomes from well-designed research studies in the field of cognitive and educational psychology” [10], colour psychology is used to increase positive perceptions of drugs and medication adherence. Psychologists are employed by drug companies in a range of roles. Cognitive Psychologist Dr LaFountain developed the pharmaceutical industry’s only patented model predictive of drug adherence and has developed three US patents and one global patent for innovation in pharmaceutical marketing and analytics. [11]  Peter J. Snyder a neuropsychologist who works at Pfizer is employed to develop biomarkers of CNS disease progression and treatment response.

The development of psychological tools to assist pharma marketing may be a product of the fact that in contrast to the ethical principles developed by psychiatry, the American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct includes an exemption clause which allows psychologists to breach their code of ethics where the code is in conflict with their employers demands. [12]

Psychologists enjoy a very positive image with the public receiving a ‘very favorable’ or ‘somewhat favorable rating from 82% of Americans, [13]  while a Canadian study commented that “psychiatrists seem to have an image problem” and found that around 75% of respondents were hesitant to see a psychiatrist because they are too ready to prescribe drugs.[14]

They may be surprised that when a group of New Zealand psychologists were asked how useful medication would be in their practice 55% said “very or somewhat useful, 6% were unsure and  36% respondents said it would not be useful. Fifty-two percent of respondents listed at least one medication that would be of assistance with 91% of respondents to this question saying antidepressants and/or mood stabilisers would be useful. Medication for anxiety was thought to be useful by 61%, anti-psychotics by 27%, hypnotics by 24%, and stimulants by 19% of the group. [15]

I may have been living under a rock but I was shocked to find how many professions have prescribing rights around the world – opticians, dentists, midwives, nurses, chiropractors, osteopaths, pharmacists, podiatrists and physiotherapists. In fact, Dollars for Docs identifies a podiatrist as being the fourth on the list of the top earners from the pharmaceutical industry with a payment of over $650,000.

In reading the policy documents of these groups along with those of psychologists it is clear that for them, authority to prescribe symbolizes their legitimacy as scientists and physicians. Prescribing rights are accompanied by changes in job titles – medical chiropractors for example – which elevates them above colleagues without prescription pads. Prescribing has become a huge status symbol within the non-medical and alternative therapy fields.

I find this ironic given many chose their profession based on a rejection of the medical model. I find it even more ironic in relation to psychologists given the manufacturers of the drugs they prescribe talk about the ‘presumed mechanism of action’ as they are unable to provide any scientific evidence of their biological mechanism of action. As a symbol of scientific rigour, prescribing psychiatric drugs doesn’t seem the best choice.

I think the writing is on the wall that psychology will fill the gap left by the shortage of psychiatrists, that it will be cheaper, more accessible and less tarnished than psychiatry but deliver the same harms.  I think it will become the new target for pharmaceutical industry corruption as drugs are branded as part of a holistic approach to curing mental disorders rather than miracle neurobiological cures. I think the public who are increasingly wary of psychiatry will be lulled into a false sense of security that psychology will have equal emphasis on psychosocial as biological approaches and feel safer and more comfortable engaging with psychologists to their detriment.  I think those of us who promote alternatives to psychiatry need to be careful that we are not sending people from the frying pan to the fire.


 

References:

[1] https://www.google.co.nz/#q=american+psychological+association+DSM

[3] APA website, the American Psychological Association’s official position (adopted in 1995),

[4] Andrew M Pomerantz (Editor)2008 Clinical Psychology: Science, Practice, and Culture / Edition 2 Chapter3 Current Controversies in Clinical Psychology

[5] Cummings, N. A. (2007). Treatment and assessment take place in an economic setting, always. In S. O. Lilienfeld &W. T. O’Donohue (Eds.), The great ideas of clinical science (pp. 163–184). New York: Routledge (Taylor and Francis Group).

[6] Stambor, Zak. Psychology’s Prescribing Pioneers: Medical and Prescribing Psychologists in Louisiana and New Mexico Claim Added Patient Benefits. Monitor Staff July/August 2006. (37)7 American Psychological Association.

[7] Ontario Psychological Association The Prescriptive Authority (RxP) Initiative in Ontario

[8] David O. Antonuccio and William G. Danton. Psychology in the Prescription Era Building a Firewall Between Marketing and Science. American Psychologist 58(12), 1028–1043

[9] Reist, David; VandeCreek, Leon The Pharmaceutical Industry’s Use of Gifts and Educational Events to Influence Prescription Practices: Ethical Dilemmas and Implications for Psychologists. Professional Psychology: Research and Practice, Vol 35(4), Aug 2004, 329-335

[12] James B. Gottstein Ethical and Moral Obligations Arising From Revelations of Pharmaceutical Company Dissembling Ethical Human Psychology and Psychiatry. 2010, 12(1)

[13] Mills, K. Getting beyond the couch How does the general public view the science of psychology?Monitor Staff. 2009, 40(3)

[14] Sanua, V., Ph.D.; Perceptions of Psychologists and Psychiatrists The Psychotherapy Patient. 9(3-4).  Published online: 26 Oct 2008

 [15] Fitzgerald, J.,  Galyer, K.; Collaborative Prescribing Rights for Psychologists: New Zealand Perspective. New Zealand Journal of Psychology. Nov, 2008 37 (3)

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Maria Bradshaw
DelusionNZ: Maria Bradshaw lost her only child to SSRI induced suicide in 2008. Co-founder and CEO of CASPER (Community Action on Suicide Prevention Education & Research), Maria promotes a social model of suicide prevention focused on strengthening community cohesion, addressing the social drivers of suicide and providing communities with the knowledge and tools required to reclaim suicide prevention from mental health professionals. Maria has an MBA from Auckland University and particular interests in sociological and indigenous models of suicide prevention, prescription drug induced suicide, pharmacovigilance and alternatives to psychiatric interventions for emotional distress. Maria has researched and written a number of papers challenging the medical model of suicide prevention.

13 COMMENTS

  1. As an English clinical psychologist, I find this article unhelpful and inaccurate. It appears to be written in a way which is deliberately designed to provoke. As a practicing clinical psychologist for the past 25 years, I would like to raise my objections and state that this article seriously misrepresents my profession.

    The situation is not as the author claims and it is a pity she did not do more research before making inaccurate sweeping statements which many will find unhelpful and even offensive.

    The author may or may not be aware that UK clinical psychologists called for an abandonment of psychiatric diagnosis and the “disease model” last year. Please see this link for more information:

    https://www.madinamerica.com/2013/05/uk-clinical-psychologists-call-for-the-abandonment-of-psychiatric-diagnosis-and-the-disease-model/

    An issue of The Psychologist magazine here in the UK discussed prescribing rights in 2003:

    http://www.thepsychologist.org.uk/archive/archive_home.cfm/volumeID_16-editionID_93-ArticleID_538-getfile_getPDF/thepsychologist%5Capr03resnick.pdf

    Most British psychologists do not want to prescribe. I concur completely with the points made by Lucy Johnstone in the first and second links. Other relevant issues are raised by Jim Orford. See also the letter from Mary Boyle here:

    http://www.thepsychologist.org.uk/archive/archive_home.cfm/volumeID_16-editionID_95-ArticleID_562-getfile_getPDF/thepsychologist%5C0603lett.pdf

    Contrary to the general message which is portrayed by the author, the number of prescribing psychologists are few and links between psychology and Big Pharma are also not significant.

    I have to question the motivation of the author in writing this article. Was she deliberately trying to stir up controversy? Does she have a grudge against psychologists, an axe to grind or a vested interest to serve? Was she writing for the sake of getting published? I could offer other possible explanations, but will stop there.

    To summarise: the author has seriously misrepresented my profession, clinical psychologists here in the UK do not work within the psychiatric “disease model” and the DSM, we work with psychological formulation, which is a more holistic collaborative recovery oriented model, and most of us do not want to prescribe psychiatric medication.

    Therefore, for us, this is a non-story, as well as being a serious and unhelpful misrepresentation of our profession.

    • This article is so full of holes, fabrications, and outright falsehoods it must come from the Trump campaign. Psychologists who have prescriptive authority are now prescribing in 4 states and the military without any complaints: not one. Moreover, psychiatry themselves ranked military prescribing psychologists as good to excellent. Psychiatry is running scared because they gave up therapy to prescribe and certainly do not have the knowledge base in psychology that clinical psychologists take for granted. Face it: prescribing psychologists will do a better job and will soon be doing it in every state. If you can’t help, then get of the new road…

  2. Fantastic article, Maria! Reading and reflecting on this, I feel that you are beaming through some hard core illusions with your crystal-like analysis.

    I’m breaking down your last (truly wonderful) paragraph, below, just to add my two cents here. Thank you so much for this well-thought piece. It’s totally synchronistic with what is in my field of vision, as well.

    “I think the writing is on the wall that psychology will fill the gap left by the shortage of psychiatrists, that it will be cheaper, more accessible and less tarnished than psychiatry but deliver the same harms.”

    Yes, the myths and misinformation are deeply entrenched and habitually practiced beliefs!

    “I think it will become the new target for pharmaceutical industry corruption as drugs are branded as part of a holistic approach to curing mental disorders rather than miracle neurobiological cures.”

    Of course, they’ll say anything to make sales, playing off of these beliefs–from one manipulator to another, passing it on…

    “I think the public who are increasingly wary of psychiatry will be lulled into a false sense of security that psychology will have equal emphasis on psychosocial as biological approaches and feel safer and more comfortable engaging with psychologists to their detriment.”

    It’s become of game of persuasion for profit, forget honesty, integrity, Hippocrates, not to mention self-reflection. (Just to feel some balance here, and not overly cynical, I do understand that some may think they’re being helpful, but that would be a matter of 1) misguided education, and 2) not listening).

    “I think those of us who promote alternatives to psychiatry need to be careful that we are not sending people from the frying pan to the fire.”

    Extremely well put.

  3. Just a small addition to this very pointed, and from my perspective, right on the money, blogpost: The American Psychological Association was the only professional association that declined to issue a statement distancing itself from the Bush administration’s policy of sanctioning the use of torture in interviewing suspected terrorists. Both the psychiatrists’ APA and the social workers’ NASW readily joined the AMA in rejecting such practices. These interrogations were conducted under the observation/supervision of medical professionals including psychologists working for the military, who in turn were coerced by post-9/11 military policy to ignore professional ethical standards (like “do no harm”!).
    And Helen, please don’t feel offended. This article was surely not written to piss off allies in the struggle against the medical-industrial complex. The real danger is getting distracted from our collective efforts by quibbling amongst ourselves.

  4. Maria,

    Thank you for a very insightful article. I agree. In fact, I would go deeper. There are many angles from which to cover what I am thinking in response to your article. But I will say this. I am alarmed that my profession (psychology) is seemingly drifting towards the hard sciences for an explanation of human behaviour. Each year, if conferences are any indication, there seems to be a new found love for neuroscience. At least, this has been my observation.

    Why this drift towards neuroscience as an explanation for human behaviour? I believe it is precisely so psychology can play catch up with psychiatry in terms of pseudo-power; to make a bid on the massive revenue allocated by drug companies, which are largely funding research and mental illness education etc these days. As we know, revenue from drug makers will find its way into whatever pockets that can produce any reason for making drugs. [All we have to do is look at what Biederman did for child bi-polar. See http://www.alternet.org/story/88333/exposed%3A_harvard_shrink_gets_rich_labeling_kids_bipolar)]

    According to psychologist Martin Seligman (2002) psychology had three missions before World War II. These were i) curing mental illness; ii) ensuring people’s lives were productive and meaningful; and iii) recognizing and nurturing their natural abilities. However, psychiatry rather than psychology has emerged as the dominant authority in the mental health field, especially since the introduction of thorazine in the 1950’s, investing its focus on psychology’s first mission, curing mental illness; at the cost of the second and third missions.

    Thankfully concerned clinical psychologists are still out there, as Helen demonstrated in her response to you. I was encouraged that she challenged your article, not because you were wrong in anything you wrote; but because it indicated that psychology’s rejection of the biomedical model is doing well. I felt there IS hope for psychology to remain true to its ethos and original mission with comments such as hers.

    It is NOW as important as ever to protect and to serve these second and third missions, and as ethical. Psychology has absolutely NO scientific or valid reason to drift towards neuroscience (or to have ever rested in the biomedical explanation for human behaviour for that matter).

    I try to believe most psychologists still believe in the value of the original three missions of psychology before WWII. But I am more likely to believe that absolute power corrupts absolutely. In this context, drug companies are like an insidious illness, invading every possible opening they can find. They are making their way to psychology, and nursing, and soon probably sports. Why not. This is why I believe it is seriously urgent that psychologists work ethically by foregoing the temptation of corruption and remain true to that original mission, and to join millions of consumers who have already walked away from psychiatry and have returned to the holistic, existential meaning and exploration of life.

    In the face of increasing psychiatric drug deaths by suicide, homicide, cardiac arrest, etc., which leave families irrevocably in ruin, this perspective does not seem much on the surface, but I think it is. More and more people are “thinking globally, acting locally” to change the multi-faceted paradigm of chemical, neurological junk science approaches to so called mental health. For example, I am encouraged at the number of Open Dialogue type approaches that seem to be taking root now, and I hope that it continues to flourish. A good thing always does.

    It is also through dedicated unstoppable prolific writers such as you and many others, that change is taking place….albeit very slowly. And tragically too slowly for too many good lives, such as your young innocent son. However, it is still change that is taking place. So good on you Maria, for raising the ethical questions that need to be raised. Good on you for being a part of the solution towards ending the deadly problem of adverse drug reactions.

  5. Maria, I have great respect for you and enjoy your thoughtful and intelligent posts on this site. This post is no exception, but it hit me like a punch in the gut because you are calling out my profession. And you are right to do so. I think you mostly hit the nail on the head here, and the fact that psychology is moving in this direction is a cause for great concern to me. I’d like to note that I am not alone in my concern about the American Psychological Association’s push for Rx privileges. The APA has alienated thousands of its (former) members, many of whom have left the organization because of its pro-prescribing agenda, much of which has been carried out behind closed doors. A considerable percentage of psychologists are vehemently opposed to RxP, myself included, and are actively working to oppose the APA’s efforts on this front. I am optimistic about our chances. I plan on forwarding your post to some of my colleagues, who might be interested to know the black eye this situation gives our profession.

    My only note of criticism is in regard to your statement: “The evidence however suggests that psychology’s links to both the mental illness and pharmaceutical industries are as strong as those of psychiatry…” Most psychologists (like most mental health professionals in all fields) use the DSM, but I’m sure you realize that it is absurd to believe that psychology is as strongly linked to the pharmaceutical industry as psychiatry. Here’s hoping this notion stays absurd in perpetuity.

    I think Helen correctly notes that organized psychology in the UK is actively moving away from the biomedical model. The APA is moving in the opposite direction.

    Barrab noted, “There would be no difference between a clinical psychologist and a psychiatrist if they both prescribed drugs.” I think this observation perfectly summarizes the threat posed to psychiatry by APA’s RxP zeal, and accounts for the APA’s limited success to date in its state-by-state strategy for securing RxP for psychologists. The American Psychiatric Association and American Medical Association have no intention of allowing prescribing psychologists to make psychiatrists irrelevant in the health care marketplace.

    • Guess it could work if they use something like this to increase their charging rates.

      People might want to see the “real deal”, or there might need to be a certain amount of “real deal” to supervise the new recruits. Thus justifying a more profitable model.

      Might even work if they limit the amount of psychiatrists out there or if there’s less of them coming through the universities. More scarcity, more demand.

  6. It’s true that most clinical psychologists duck and dive as much as possible from prescribing drugs to their analysands but in the UK at least there is also a general reluctance in the profession to work with the “lost causes”, the people with the classic major psychiatric illnesses, who, ironically, if they do get to have a sit down and a chat, are more likely to be given the opportunity if they have already been ‘stabilised’ on psychiatric drugs. Prescribed by someone else of course.

    As someone of an existential bent I base near enough all my reality assessments on subjective experience and intution, like any self-respecting existential psychologist. Who are,by the way, as common around these parts as the woolly mammoth.

    Another observation worth gently stroking until it purrs is this: psychology as a profession is thin-skinned. It doesn’t take kindly to criticism. I think this has to be at least in part because it has been somewhat tarnished by the modern bullshit called “positive thinking”.

    Also, some of the most fundamental psychology studies are actually studies in abuse, and as such, psychology stands on the shoulders of abusers. Never forget that Jung was the pioneer of breaking sexual boundaries with female clients…