SSCP Task Force Statement
on Prescribing Privileges (RxP)
Prepared and submitted by
John Winston Bush, Ph.D.
Task Force Chairman
Advocates for prescribing authority for psychologists (RxP) have advanced the following major arguments:
A. Psychotropic medications have become a major class of interventions that can help psychologists' clients. There is, to be sure, considerable controversy over the actual degree of efficacy and over the biological and psychological mechanisms responsible for their apparent effects. Nevertheless, it is an undeniable fact that they seem to benefit a substantial percentage of their target populations. This includes people who lack access to psychosocial treatments, or who have refused or cannot be counted on to respond adequately to them.
B. Prescribing authority is a natural, desirable, and attainable extension of the practice of clinical and counseling psychology. Psychological science has long recognized the role of biological factors in psychological and behavioral functioning. Graduate programs in clinical psychology already offer at least some instruction in psychophysiology, behavior genetics, and psychopharmacology. Research psychologists routinely work side-by-side with biomedical professionals hi studying interactions among anatomy, physiology, psychological processes and behavior. We are no strangers to neurons and their workings.
C. While most psychiatrists no longer offer psychotherapy or behavior therapy to their patients, they are legally permitted to do so. There is no good reason why, given appropriate training, applied psychologists cannot and should not join their psychiatric colleagues in providing the full spectrum of efficacious treatments, at least to the extent of prescribing psychotropic medications.
D. Adequate training in drug prescribing can be accomplished in a time frame and at a financial cost accessible to many, if not most psychologists. There is a precedent for such supplemental training in the field of optometry. APA's model program (at Level 3; see below) sets forth the parameters for such training as it would apply to psychologists.
E. Many people in this country lack access to psychiatrists and must look to under-trained general practitioners for psychotropic medications. RxP would go far to full this gap. In addition, prescribing psychologists' clients would have a more complete array of treatment options available to them through a licensed practitioner without the complications of interprofessional collaboration.
F. Applied psychologists as a group cannot survive in today's competitive, oversupplied, care-managed mental health field. Lacking prescribing authority, we are progressively being driven from the arena. RxP is a matter of economic survival for our profession.
We understand the above points (A-F) to represent the case for RxP, as it is commonly made. It is the consensus of the leadership of SSCP that these arguments do not hold tip to careful examination.
In addition to the specific points set forth below, a further and more comprehensive objection is that RxP would dilute the existing scope of clinical psychology practice with the addition of RxP responsibilities. In an historical context, it is our belief that such a shift is short-sighted:
In the long run, it will be at the expense of the broader areas in which psychologists contribute knowledge.
In the short run, it will skew the clinical contributions made by psychologists away from those areas from which they have consistently arid historically made unique contributions (i.e., assessment, behavioral programming and analysis, and psychotherapy).
While the foregoing philosophical positions underlie this statement, the resolutions below are chiefly based on the practical ways that RxP is not viable. These resolutions grow out of the following objections:
There has never been a full debate on RxP that was open to all interested members of APA. The only consideration of RxP that has taken place has been within smaller groups of individuals within APA that cannot be assumed to represent the membership at large.
Council has received pro-RxP presentations and passed enabling resolutions without the input or even the physical presence of APA members and contingents who oppose or question it.
The APA central office has been aggressively pushing RxP without adequate consideration of the broader membership of APA and without using well-established procedures such as peer review. Over $800,000 from the APA budget has been spent advancing the RxP campaign during the past five years, despite widespread opposition in the ranks.
During the 2000 APA Annual Convention Program, APA headquarters sponsored a "mini-convention" devoted to RxP. The views presented there were strongly biased in favor of RxP, and they had not been subjected to peer review by the broader APA membership.
The RxP proposal may be the most radical proposal the APA organization has ever faced. Without a semblance of informed consent from the membership, we are gravely concerned that a fundamental change of great historical impact will be enacted in the field of psychology without fully considering the reasons and implications.
SSCP accordingly resolves:
- That beginning immediately, there be a moratorium on all expenditures and advocacy by APA on behalf of RxP until the following resolutions have been carried out in full.
- That the 2001 convention feature a second mini-convention on a scale with the last one—but this time with equal planning access and "airtime" for RxP opponents.
- That a complete, evenhanded report of the proceedings of the mini-convention be published in the October 2001 editions of the Monitor and American Psychologist, with full opportunity for prepublication editorial oversight by representatives of both viewpoints.
- That by January 2002, an objective and comprehensive survey of members' knowledge, experience, attitudes and intentions regarding RxP and prescribing-related issues, developed with full participation by both sides, be put into the field.
- That the results of this survey, again with bipartisan prepublication review, be published in the May 2002 editions of the Monitor and American Psychologist.
- That by July 2002, a binding membership referendum be completed on this or a closely similar proposition, "Shall APA continue or not continue to advocate for prescribing privileges within the profession and in the state legislatures?"
- That APA immediately reserve funds sufficient to put resolutions 2-6 into effect, including all out-of-pocket costs plus stipends and travel allowances for a reasonable number of members from both sides who contribute materially to carrying out these resolutions.
The position taken herein by SSCP, including the above seven resolutions, are based on the following evidence and reasoning:
What is wrong with RxP
1. RxP would not fill unmet needs for service as claimed by proponents.
(a) The psychiatrically underserved population is not very large. Even in the aggregate, it is smaller than RxP advocates in APA's central office wish us to believe.
(b) The geographic distribution of psychologists largely follows that of psychiatrists. Thus, little net gain in coverage is even possible.
(c) Few psychologists have chosen to practice in places like rural Montana or the South Bronx. There is no reason to think that RxP would make an appreciable difference.
(d) Organizations of consumers of mental health services (e.g., NAMI) have not come forth to endorse RxP. At the last RxP bill hearing in the Hawaii legislature, several consumers testified against RxP but none in favor.
2. No satisfactory precedents exist, either for designing suitable training programs or for predicting psychologists' performance as prescribers.
(a) The definition of what would constitute adequate training remains highly speculative and controversial. APA's model program is far from being a final or even an authoritative statement of what would be needed.
(b) The Department of Defense program, with 10 graduates, was about twice as intensive as that envisioned by the APA model program. It cannot be reproduced on a broad scale. It is therefore not a meaningful precedent.
(c) Guam—small, remote, and atypical in other respects —requires medical oversight of its handful of prescribing psychologists. It is not a precedent for RxP in the form espoused by APA.
(d) APA's training model specifies three sequential levels. Current RxP training programs offer Level III (see section 3 below), but omit the prerequisite Levels I and II. They also omit the undergraduate prerequisites in biology (12-15 semester hours), chemistry (9-12 hours) and algebra (3 semester hours).
(e) Some programs claiming to meet APA standards are conducted via distance learning—quite unlike the Defense Department program or those offered to optometrists.
(f) In short, there is no existing program that meets even APA's scaled-down criteria.
3. Few existing psychologists would be able to complete any acceptable training program.
(a) The APA Level III model, skimpy as many believe it to be, entails 28 semester hours of didactic work, plus one year of closely supervised practicum experience involving at least 100 patients. This is equal to approximately two years of full-time work.
(b) This time requirement does not include prerequisite undergraduate-level work (see section 2[d} above), some or all of which most prospective candidates would need.
(c) The cost of APA-model training =- even when no undergraduate work is needed—is estimated at $5,000 to $20,000 per student if received in a university or professional school setting. This does not include up to two years' worth of job or practice income sacrificed in order to make time available for RxP training.
4. Graduate education in basic psychological science and psychosocial treatments would be severely diminished and distorted unless most or all biomedical coursework were at the postdoctoral level.
(a) Many currently practicing psychologists are already undertrained in psychological science and empirically supported treatments. Displacing traditional curriculum content in graduate schools with RxP-focused coursework would render this deficiency still worse.
(b) Making RxP training wholly postdoctoral would add two years and $20,000 to $30,000—plus the cost of any undergraduate prerequisites needed and the years of earning ability forever lost—just as it would for existing psychologists.
(c) By changing the prerequisites for doctoral programs, RxP would attract a different population of applicants and further diminish the emphasis on psychosocial/behavioral treatments.
5. In addition to the direct costs of RxP training, there are a number of externalities—so far, not widely recognized—that argue strongly against RxP.
(a) Malpractice premiums would go up for those who elect to prescribe, and possibly for all licensed psychologists, whether they prescribe or not.
(b) Should even a few malpractice suits against prescribing psychologists based on claims of inadequate medical training be successful, insurance coverage would become prohibitively expensive or disappear altogether. Legislatures that had previously authorized RxP would face an onslaught of pressures to rescind it, and those that had not yet authorized it would reject RxP bills out of hand. The damage that would be done to psychologists and to the profession is incalculable—much worse than the damage done to physicians and medicine when they are sued.
(c) Student loan debt would increase sharply as a result of additional borrowings and years of delay in commencing repayment.
(d) Adding faculty to departments of psychology to teach the RxP curriculum would cost an estimated $800,000 to $1,000,000 annually. Only schools wholly supported by tuition could hope to recover these outlays. Universities relying on state funds and endowments would have to absorb a large share of additional faculty costs without recourse.
(e) RxP would widen the existing gap between university and professional-school programs, and in effect create two divergent spinoffs of clinical psychology. It would be only mildly facetious to say that we would come to be seen, at least by outsiders, as either underpaid psychiatrists or overpriced social workers. In the process, the cross-fertilization between psychological science and practice—psychology's trump card in the mental health field would have been severed.
(f) If psychologists obtain RxP, master's-level social workers and counselors will almost certainly try to follow. (Pat DeLeon has in fact written in support of social workers seeking RxP.) Should they succeed, the market will be flooded with Rx-eligible personnel, and the competitive advantage sought by psychology's RxP advocates would quickly vanish.
6. Psychologists would be exposed to patients' demands for 'pill fixes" and the blandishments of the pharmaceutical industry, just as psychiatric and other medical professionals already are.
(a) It is naïve to assume that psychologists' background in psychosocial treatments would significantly "inoculate" them against such powerful pressures.
(b) By de-specializing psychologists in psychosocial treatments and their scientific underpinnings, their commitment and competence in this area is likely to be further eroded.
7. Contrary to claims made by key people in APA's central office, psychology is not united behind RxP. A series of surveys over the past 10 years has shown sentiment to be about equally divided.
(a) APA's much-cited 1995 data, which showed a majority in favor of RxP, relied upon a single, highly biased questionnaire item in the context of an omnibus survey on membership issues. More adequate studies suggest that a majority is actually opposed to RxP.
(b) Recent survey evidence suggests that many psychologists nominally classified as "favorable" to RxP are willing to endorse RxP simply out of an altruistic desire to help colleagues —while having little or no interest in pursuing such training themselves.
(c) There is reason to believe that few psychologists -even those who find the RxP idea attractive - are aware of and have given careful thought to the length and cost of any plausible training requirements. What their attitudes would be if they were fully informed remains unknown.
8. Organized psychiatry and medicine can be counted upon to oppose RxP in state legislatures far more vigorously and effectively than they have opposed previous expansions in our scope of practice.
(a) They have the financial and political ability to turn the RxP campaign into a rout for psychology and are fully prepared to do so if necessary.
(b) Faced with RxP bills in the legislatures, they are likely to seize the opportunity to roll back gains in our scope of practice that have been painstakingly eked out over decades.
(c) There is evidence from New York that medicine's sabotage of scope-of-practice legislation sought by NYSPA was intended as a shot through our rigging to head off RxP.
(d) Fruitful collaboration between psychologists and medical professionals would be undermined—and possibly damaged quite seriously—by the battle over RxP.
(e) APA has spent over $800,000 pressing its RxP agenda, and has recently escalated its efforts still further. Yet all that it will take to defeat RxP bills in state legislatures is for psychologists opposed to RxP to expose its lack of solid support among psychologists. (This has already happened in Hawaii.)
9. RxP opponents fully recognize the need for psychologists to have education and experience relevant to biomedical treatments. But this does not imply a need for prescribing authority. Good alternatives exist that have few or none of the drawbacks cited above.
(a) For psychologists who want to prescribe drugs on their own, nurse practitioner (NP) training would prepare them far better than any RxP program that has been seriously proposed. It would provoke less opposition from the medical establishment. No new legislation—costly, time-consuming and dangerous to pursue—would be required. And it would probably be supported by the nursing profession, which as matters now stand is likely to join organized medicine in opposing RxP.
(b) For psychologists who do not want to prescribe, or who cannot afford the time and money to obtain the requisite training, well designed CE offerings would enable them to participate collegially and knowledgeably in collaboration with medical professionals. A large percentage of psychologists are already so equipped, and they collaborate routinely and effectively with their medical colleagues.
(c) Training is particularly needed for collaboration with primary care physicians—who write about 75% of the prescriptions for psychoactive medications in this country, yet often have skimpy knowledge of the proper use of such drugs, and are even less well acquainted with the advantages of psychological treatments. Such collaboration would also do more than RxP to meet the needs of underserved areas and populations.
(d) APA can play a vigorous and constructive role in enhancing psychological practice via these alternatives. It can take the lead in arranging NP training at an affordable cost, and it can develop and promote CE modules to advance interprofessional collaboration. These things can be done at much less cost and risk than pursuing the present quixotic campaign for RxP—and they would do away with the divisive atmosphere that APA's unilateral promotion of RxP has needlessly brought upon our profession.
In July 2001, the SSCP membership approved the statement in the form of a resolution by a vote of 98 to 6. The timetable is being revised to reflect the need for more time to implement its provisions.This article was posted on April 15, 2002.