Monday, November 28, 2022

Comments by kfoag

Showing 1 of 1 comments.

  • Greetings Dr. Schroeder

    I greatly appreciate the balanced tone of your post; it contrasts substantially with some of the rhetoric I have seen over the years. Just to provide a bit of context. I am a clinical psychologist in Illinois, where RxP just became a reality, after almost 15 years of fighting. I also teach at a professional psychology school, and one of the courses I have taught for almost 10 years is intro to clinical pharmacology.

    I’ll just make a few comments that I hope are more refreshing than the usual “psychologists don’t have the training” “if you want to prescribe, go to med school,” “psychologists are going to kill people,” “psychologists are going to become junior psychologists…” etc. yawn.

    First, despite my interest in the subject and support for RxP over the years, I have become more ambivalent as the years have gone by, in large part because of pharma malfeasance. I introduce my class every year this way. Here’s one thing to consider: in case you haven’t noticed, pharma is not investing $ in psych disorders any more. This means that most meds are generic and therefore we don’t see the same marketing push as we did in the past. Thus, the “history” that MDs faced no longer applies from that standpoint. This also means that prescribing practice and research will finally start to clear out the garbage. And, prescribers are returning to the “tried and true.”

    Second, a mantra often brought out in legislative battles, and sometimes in online arguments, is that “the authority to prescribe is the authority to unprescribe” This should not be taken lightly. How many psychologists have been hamstrung when working with clients on meds that are clearly wrong, but powerless to act? Every year, I hear horror stories from my students at various training sites. When NM and LA got privileges, psychologist prescribers were removing meds from clients right and left. This is related to the next point.

    Three, as much as we would like to think that we can talk and listen all clients into mental health/wellness, there are simply some cases where meds are needed. One of the common threads of these cases is that the symptoms are interfering with the client’s capacity to engage in therapy. One cannot engage in systematic desensitization, cognitive behavioral therapy, or psychoanalytic engagement if the client is too anxious to stay in their own skin, or too severely depressed to get out of bed, or too manic to function. The key point here, and which is too often not seen in MD treatment plans or philosophy, is that meds are not meant to be a permanent fixture. This is a key difference between the biomedical model and biopsychosocialspiritual model. I have spoken to several prescribing psychologists about how they blend meds and talk: It’s just another art form, really, that changes with each client.

    Fourth, there is no way that prescription privileges will overtake the profession, such that all psychologists will have to manage another angle in a crowded and challenging caseload. I don’t know about you but the bulk of psychologists I know have no interest, but more importantly no strength in science to pursue it. This is not a continuing education program that you listen to and answer a few questions to get credit. Nor is it a standard masters degree. This is TOUGH, especially if you are not comfortable with bio-related material. A post-doctoral masters assumes a level of clinical and academic knowledge that far surpasses what is expected for a first year medical student. And those people who think that psychologists are doing this for the money? All I can say is, there are PLENTY of ways to make money that don’t require the level of commitment that this training demands. Easy street this is not.

    Fifth, always consider that there is no black-white here, as far as “is this good/is this bad.” It, like every other human issue in our world, is complex, ambiguous, and uncertain. Unfortunately, this had to play out in the legislative arena, which demands YES/NO, THUMBS-UP/THUMBS-DOWN, thinking. It brought out the worst in people. It dumbed many people down. At the end of the day, though, we can only rely on our own judgment and ethical stance to make a good-faith effort and do the right thing by our clients. There will most certainly be psychologists who “behave badly,” although it might take a few years. That is inevitable but should not be baby-bathwatered.

    Last, we don’t know what the near-future mental health landscape will look like, but it is definitely going to be different over the next 10 years. We need to look at the bigger picture. Prescriptive authority is not just about being able to use a script pad. It is more symbolic of being take more seriously in a multidisciplinary environment. Psychologists who prescribe in NM and LA are key players in hospitals and community mental health centers, whether they actually prescribe or not. I really hope that aspect does not get lost.

    SO. Yes, meds are potentially dangerous, and some clearly more than others. Yes, oh yes, there have been many evils committed by pharma in the name of big profits. Yes, we need to see clients in a wider lens than just symptoms to be medicated. Yes, there will be some mistakes from this, some ongoing doubts, some ethical dilemmas. These are challenges to be faced. BUT none beyond our scope or capacity to manage complexity. In fact, I would argue that clinical psychologists face some of the most complex phenomena on the planet, and yet seem to approach them in a deceptively simple manner. It won’t be far in the future, I believe, that we will look back and wonder, “why was this such a big deal?”

    Thanks for listening
    Ken Fogel, Psy.D.