In Opposition To Prescription Privileges By Psychologists

Articles by Ed Lundeed, Ph.D. and Jeffrey Schaler, Ph.D.

Posted by permission of author. Appeared in Independent Practitioner summer 2007, 117-118. Newsletter of Division of Psychologists in Independent Practice of the American Psychological Association. Posted by permission of author.

 

Rx Privileges: A Final Rejoinder

By Ed Lundeed, Ph.D.

Let me begin by saying that I was unsure if I should publish this column. Not because I doubt its content or sit concerned with retort. No, it was because of Glenn Ally I wasn’t sure. Glenn is a spearhead of the Psychologist Rx movement and was instrumental in seeing this enacted in Louisiana. He is a fine human being and he nearly changed my opinion on this issue. Nearly. And he made one really fine point that swayed me. He hoped that opponents to the Psychologist Rx issue would not use our own writings against us when opposing our efforts in the legislatures. I honestly hope so too, though even if it appears duplicitous I am still going to say what I believe below. But if you ever meet Glenn, shake his hand because he’s earned it.

Re. Rx privileges and why I still think we as psychologists should not seek them. And my hope is that I am elucidating for others what they may have considered as well on this subject. Even though this replicates some of what I published a few years ago, I believe it bears repeating and further explication.

Psychiatrists started out doing therapy too. They were well-intended and did what they could with what they had. They have fallen prey to the glitter and promise of medication, just like most of the public and many of our own colleagues. If they are indeed corrupted it is because corruption is endemic to systems that operate on the principles medication does — quick fix, no pain, easy money.

WHY OH WHY do we insist on believing that WE are nobler than that. That in 30 years (less, more?) we won’t be the same thing as psychiatrists. Why are we better, more ethical than they are/were? “We’ll do it better!” Why can we not see that as simply institutional narcissism that will fall by the wayside? Again, not everyone will fall, as all psychiatrists have not given way to the ease of medication – recall there remain many analysts who are purely psychiatrists. Please, if we’re going to use the emotional plea of “we’ll still listen” let’s check ourselves and ask if we can really promise that we are above it all. “We’re the good revolutionaries — power won’t corrupt us”. Cripes folks, just look at history and the thousands of groups who have said just the same. The revolutionaries are always going to change things, and then turn out like their original oppressors. Power motives are built into human being — to try to pretend that psychologists are above evolutionary epigenetic principles is, well, bad psychology.

There are lots of other ways to achieve the end we want, without picking up an Rx pad. But those few seem rarely discussed. What other options do we have regarding Rx for patients? That is IF we assume that it is important to see to it that our patients get access to Rx’s for their psychological problems. Because the precursor point is that maybe it is NOT important for us to get more patients on medication. Perhaps medications claims are fully overblown, their efficacy much more questionable than television would tell us, their status as “the medical solution” perhaps a serious mistake. Must we indeed prescribe at all or be concerned that others can? Must we jump on the medication bandwagon? No, I’m not suggesting that medication has not been useful for some — it has proven tremendously useful in many cases. But we are not forced to accept it is absolutely necessary for us as profession to see to it that we improve patient access to medication. Chiropractors e.g. are completely ANTI-drug and their profession is thriving and growing. But IF we assume that it is important for psychologists and APA to get behind seeing to it that as many patients as possible have access to psychoactive medication, there remain at least 3 other very viable ways to see to or aid this process. These are my alternative proposals — the list is hardly exhaustive, but is the limit of my cogitation thus far.

1) Psychologists can make a nationally organized push to coordinate with primary care physicians to see to it that these physicians offer patients who are deemed in need the right sort of psychoactive meds. We can make as our largest priority to collaborate with medical practitioners. In this regard we can train ourselves to be knowledgeable and we can collaborate. I can go on about this one, but I just want to make the point, not sell it for now.

2) Psychologists who wish Rx privileges, and the APA in assistance to this, can seek their Rx’ing licenses in other medical fields. Psychologists can become Nurse Practitioners or Physician’s Assistants. They can add this skill to their clinical repertoire as independent of their psychology license — related but separate. This has been done, with great success (e.g. by Mike Enright in Montana). The training is surely no longer than that which we propose for our own profession to be certified and simply side-steps the whole question of “should our profession do this?” I would fully support APA in assisting my colleagues interested in this endeavor. Be aware that such a tactic nearly completely avoids the battleground of psychiatry and medicine and even the likes of me and the others who agree that psychologists should NOT seek Rx privileges. If we don’t encroach on turf directly, the battle is never started.

3) APA and individual psychologists who are interested in seeking increased access to medications for patients can investigate other methods for dispensing such medications. E.g. in Brazil, medications are largely dispensed by a pharmacist — the patient tells the pharmacist what they are being troubled by, the pharmacist makes a suggestion for what might offer relief and the PATIENT CHOOSES WHAT THEY MAY OR MAY NOT TAKE. There is no parental regulation of what patient’s take to ease their ailment.

Note, the above example is only one, and others may immediately condemn it as stupid or dangerous. I simply note it as illustrative that if APA and psychologists are so gravely concerned about seeing to it that patients receive medicine, then why haven’t we considered reforming the whole system of how medication is dispensed. To my knowledge this has never been discussed. Complex issue? Of course. But if we are claiming such humanitarian status that we can’t watch patients suffer, then why aren’t we taking every avenue to help them.

To those who say we are trained differently and THAT is why we will do it better. If we join the ranks of medical professionals pro forma, why is it we WON’T simply more and more morph into what they think? If the argument is that we are “different” (and this argument is always forwarded), then how do we maintain that difference once we become part of the medical model. Again, this smacks of a kind of professional narcissism that says “we won’t be corrupted because we’re different”.

Another point. I encounter many patients who are divorcing or in the legal system. As do most of us. And often, I find that their lawyers do a less than superior job of representing their needs in the legal system. And I think I could probably do a better job if I had the privilege to do so. Thus, it would be legitimate for me to argue and expect my colleagues to seriously consider that I wish to add the working privileges of attorneys to the practice of psychology. After all, we’re very smart, we could come at the law from a different angle and we could do it much better. This is tantamount to the same argument as Rx privileges I suggest. Don’t dismiss it — logically these do not represent different positions. Shall we now pursue privileges with the all the State and Provincial Bars? 

Robert Resnick, ex-APA president, to whom I offer great respect, once opined re. Rx. privileges “It should never be the case where I don’t want them so you can’t have them.” My retort however respectful is “Like fun it shouldn’t be”! This is MY profession as much as those who are pro-Rx privileges. I’ve just told everyone at least 3 possible ways they can have what they want WITHOUT forcing me to go along for the professional ride — you see, if you take MY profession and give IT Rx privileges, that means ALL of us. My money goes to the effort just like yours, and the public lumps my name into the debate alongside yours. I say again, we are changing the fundamental nature of our design to do this.

I’ve heard the “there have always been dissenters to change” argument several times too. So what? Because something may or may not have worked for the best of our profession in the past, does not make all current progress intelligent. That is simply not a philosophically or debate based point that is interesting. It appeals to emotional pleas, and subtly attempts to paint dissent as “anti-progress”. There is nothing Phillistinic about not wanting certain things to change in certain ways — not all progress is the right choice.

Like it or not, believe in transference or not, prescribing medications for patients will forever change our profession in negative ways. Try on this scenario. “No Mr/Mrs. Jones, I don’t want you to take Prozac because it will dull your affective reactions and I believe will impede your ability to work through your emotional pain that you don’t yet understand”. Mr/Mrs Jones may have a large number of reactions, but, in my opinion many of them will be negative and will hurt the therapeutic process. It’s one thing to encourage Mrs. Jones NOT to take meds, but to be able to give them and withhold them will be seen as sadistic. On many occasions, Mr/Mrs. Jones will simply leave and go to Dr. X (the “Prescribing Psychologist” in town) who will surely give her what she wants, even if he says she still needs to work through her pain in therapy. And if not Dr. X., Dr Y. will. Or Dr. Z. In an infinite regress.

We’re not morally superior people. We have a bell curve of morality in our profession like any other. And there will be those practitioners who WILL give patients whatever they want, and they will formulate pressure for others in their profession to comply as well. There will be outliers, like me, but we will fade. It’s simple folks. Power corrupts. The power to NOT do something is a fallacy that never works. If one CAN do something they generally come to do it.

At present, this is a States rights issue; however APA has continued to place money into these endeavors at the State level which to me continues to make this a national issue. As always, perhaps even more on this issue than any other, the IP welcomes replies to this column, especially those designed to refute the above views. This is an issue on which complete education for all psychologists seems critical, and Division 42 is an excellent source for pursuing this end.
 

Commentary On Sanua’s “Prescription Privileges”

By Jeffrey A. Schaler, Ph.D.

From The Journal of Universal Peer Review [on-line], May 4, 1998, St. John’s University, Jamaica, New York. Invited response to “Prescription Privileges” versus Psychologists’ Authority: Psychologists Do Better Without Drugs by Victor D. Sanua, Ph.D. at http://rdz.stjohns.edu/jupr.

Posted by permission. Retrieved from http://www.schaler.net/sanuacomment.html. Copyright by Dr. Schaler

Professor Victor Sanua argues against state licensure of psychologists to prescribe drugs for behavioral disorders. He asserts that prescribing drugs by psychologists is a “category error.” Dr. Sanua cites evidence of the harmful physiological side-effects of drugs used to control behavior. He describes political maneuverings of influential persons in the American Psychological Association to secure prescription privileges for psychologists. He predicts that the licensure of psychologists to prescribe psychoactive drugs will harm those seeking help from psychologists, as well as the profession of psychology itself.

I will limit my comments on Dr. Sanua’s article to three areas: The first concerns the “category error” — the confusion of behavior and disease. The second concerns the admission of ineffectiveness by psychologists who are psychotherapists and wish to be licensed to prescribe drugs. The third concerns the right to prescription drugs as property.

THE CATEGORY ERROR
I agree with Dr. Sanua’s assertion that psychologists should not prescribe drugs for clients because the focus of study and practice for psychologists is behavior, not disease. Psychologists should neither diagnose or treat persons for disease. Physicians are the properly trained professionals for this activity. If psychologists wish to develop expertise in the diagnosis and treatment of disease they should also become physicians.

By definition, psychologists (_psyche_, soul, mind and _logos_, study) observe behaviors. In contrast, pathologists (_pathos_, suffering, disease and logos, study) examine the nature of diseases. There are reasons for behaviors. Diseases are caused. Psychotherapists (including psychiatrists, psychologists, social workers, nurse practitioners, pastoral counselors, lay counselors, etc.) analyze what their patients or clients say and do and converse with them to influence their conduct. Rhetoric is the tool of their trade. Physicians (including neurologists, cardiologists, dermatologists, ophthalmologists, urologists, endocrinologists, gastroenterologists, etc.) study what people say (symptoms) and the signs of disease (ascertained through objective tests) and dispense drugs to patients to influence their physical bodies. Drugs are the tools of their trade.

Psychologists and psychotherapists focus on what persons do – their attention is on “mind” and ethics — the moral choices people make in relationship with others. Pathologists and physicians focus on what persons have — their attention is on the body and physical health — their goal is optimal physiological function free of disease. Psychotherapists and physicians may focus on the relationship between behavior and disease, however, the primary focus and expertise of each is different.

When psychotherapists focus their attention on physiological processes, i.e. the “realm” of physicians, and vice versa, they commit a “category error” or mistake. When psychotherapists practice beyond the boundaries of their profession, they perceive mental activity as physical. Behavior ceases to be the central focus of the psychologist. The person as moral agent is disregarded, and responsibility for behavior is “removed.” Likewise, when physicians act like psychotherapists, they attribute physical processes with moral agency. Responsibility for disease is “assigned.”

Behavior refers to the activity of a moral agent. Behaviors are described through symptoms, or subjective signs. Behavior involves choice. Disease refers to the presence of physiological lesions — something strictly physical. Epilepsy, for example, is not behavior. Diseases are described through signs, or objective symptoms. Disease do not “choose” to invade the body. Something causes a physiological change.

Psychotherapists act like physicians when they say they are diagnosing and treating disease — the basis upon which they claim the right to prescribe psychopharmaceuticals. Physicians act like psychotherapists when they make moral judgments and influence behavior — a basis upon which some “holistic” physicians operate. Since drugs are the tool of physicians, psychotherapists who wish to use drugs, wish to act as physicians. Since rhetoric is the tool of psychotherapists, physicians who wish to talk to patients (instead of dispensing drugs), wish to act as psychotherapists.

THE FAILURE OF PSYCHOTHERAPISTS
When psychotherapists wish to prescribe psychopharmacological agents,they tacitly admit that they are failures in their own profession (1). Psychiatrists have painted themselves into a corner. Those arguing that behavioral disorders are caused by neurological dysfunctions have made poor professional investments. Instead of training in neurology, they have trained in psychiatry. Now they seem to regret their choice of professions. In the guise of neurologists, they have convinced insurance companies that behavior is rooted in biology. As a result, they can’t make a living conversing with people anymore. They are neither fish nor fowl, neurologists nor psychotherapists. Understandably they try to protect the professional “turf” they still enjoy — thus fighting against prescription privileges for psychologists (while retaining these privileges for themselves).

Psychologists arguing for the right to prescribe drugs are painting themselves into a similar professional corner. Aspiring to be psychiatrists, they are trying to convince insurance companies and state legislators that behavior has biological causes, not reasons. Perhaps this is also because they too can’t make a living talking to people anymore. In other words, if they could help people by talking to them, they would not be interested in prescribing drugs. Their desire to prescribe drugs for behavior is an admission of failure.

How have they failed as psychotherapists? I suspect the fact that they have confused behaviors with diseases has had a lot to do with this. Psychologists who wish to prescribe drugs to control behaviors probably subscribe to the myth of mental illness (whether they believe in it or not). They fail to differentiate between metaphorical and literal disease. Since metaphorical disease cannot be treated literally, they’ve created an impossible situation for themselves. By describing metaphorical diseases as literal ones, psychologists have rendered themselves impotent and incompetent.

ANYONE SHOULD BE FREE TO PRESCRIBE AND PURCHASE ANY DRUG
Although I agree with Dr. Sauna about the discrete functions of the professions, I disagree with him about the _right_ of psychologists to prescribe drugs. I believe anyone should have the right to prescribe or purchase any drug — not just physicians and now psychologists. Licensure of physicians and psychologists to prescribe drugs is an attempt to protect the economic interests of both trade professions under the guise of protecting the public welfare.

Should psychologists be able to write prescriptions for drugs? Of course. Should they be licensed by the state to prescribe drugs? Absolutely not. Are physicians more qualified to prescribe drugs for physical illness? Most likely. Should they be licensed by the state to prescribe drugs? Absolutely not. People should be free to purchase and consume any drug they wish to without being coerced by a trade profession or the state to consult with anyone in particular.

The sanctioning of prescription privileges by the state for any trade profession establishes monopoly. People should be able to purchase any substance they wish, e.g. antibiotics, select serotonin re-uptake inhibitors (SSRI) and even heroin if they want to. They would probably benefit a great deal by seeing a physician for guidance in taking drugs. However, if they decline to visit a physician, they should still be free to purchase and ingest drugs as they choose. And if they prefer to see someone who is not a physician for guidance in how to use drugs, they should be free to do so as well. Heroin users prefer not to see a physician.

Many people in countries where antibiotics are available without a prescription purchase these drugs without the advice of a physician. Moreover, according to a study appearing in a recent issue of _Journal of the American Medical Association_, (April 15, 1998, Volume 279, No. 15, pp. 1200-1205) “[m]ore than 2 million Americans become seriously ill every year because of toxic reactions to _correctly_ [emphasis added] prescribed medicines taken properly, and 106,000 die from those reactions…That surprisingly high number makes drug side effects at least the sixth, and perhaps even the fourth, most common cause of death in this country” (2).

And this is Dr. Sanua’s scotoma: If psychologists prescribe drugs inappropriately, consumers will cease to go to them for prescriptions or will hold them accountable for harm they cause by prescribing drugs. If psychologists prescribe drugs, a new area of liability may emerge as a result of their negligence and malpractice. The economic curb on inappropriate dispension of drugs by psychologists will be the threat of malpractice litigation. Consumers harmed by psychologists, as well as their lawyers, will make lots of money in malpractice suits.

If prescription laws protecting the psychiatric profession are repealed, consumers will have free access to “Prozac,” for example, as an over-the-counter drug. Pharmaceutical companies will benefit by eliminating the middle man, i.e. the psychiatrist or psychologist. They will sell greater quantities of Prozac at lower prices because insurance companies won’t have to pay exorbitant fees to psychiatrists and prescribing psychologists. Insurance rates will drop as a result because consumers won’t have to go to psychiatrists or psychologists in order to acquire drugs. People who don’t wish to ingest Prozac will benefit because their insurance premiums will drop as well. If psychologists fail to give consumers what they want, consumers will simply stop going to them. If psychologists give consumers what they want, consumers will continue to go to them — licensure has nothing to do with it.

Psychologists have a right to prescribe drugs if they wish to, just as psychiatrists do. However, non-psychologists and non-psychiatrists also have a right to ingest (and prescribe) any drug they wish. At the same time, they alone will be responsible for the consequences of their actions. There is a difference between rights and responsibilities. The right to choose does not guarantee that choices will be made wisely.

The consumer’s right to drugs as “property” is completely overlooked by Dr. Sanua and other psychologists arguing against prescription privileges. By arguing that psychopharmaceuticals are “dangerous,” and that psychologists aren’t “qualified” to prescribe them, he argues that people need to be protected from their own choices. That’s the same kind of “reasoning” drug warriors use. In other words, Dr. Sanua and those psychologists arguing against prescription privileges are supporting a form of paternalism. And paternalism sanctioned by government is far more destructive to liberty than any drug (or psychologist) could ever be. (3)

NOTES
(1) The idea of admission of failure is from Amos M. Gunsberg.
(2) Weiss, R. (1998). Correctly prescribed drugs take heavy toll._The Washington Post_, A1, April 15.
(3) See “Is Depression A Disease?,” Show #235, with Thomas S. Szasz,M.D., Donald F. Klein, M.D., Jeffrey A. Schaler, Ph.D., Frederick K. Goodwin, M.D. Ron Leifer, M.D., and Peter Kramer, M.D.; and “Do We Need Prescription Drugs?,” Show #238, with Thomas S. Szasz, M.D., Charles A. Sanders, M.D., Jeffrey A. Schaler, Ph.D., Ron Leifer, M.D., and Tia Powell, M.D., both shows taped March 31, 1998, from debates, Warren Steibel Producer, http://www.debatesdebates.com. (Videotapes available for $35.00 each, includes shipping and handling, at (212) 849-2851.

Jeffrey A. Schaler, Ph.D., teaches psychology at Johns Hopkins University and is an adjunct professor of justice, law, and society at American University’s School of Public Affairs. jschale@american.eduMay 4, 1998