by Saul Lindenbaum, Ph.D. and Morgan Sammons, Ph.D.
[February 1996; Vol. 23 No. 1]
Dr. Lindenbaum is President of the Maryland Psychological Association. Dr. Sammons is a member of MPA and a graduate of the Department of Defense Psychopharmacology Demonstration Project. The opinions expressed by him in this article represent his views as a private citizen.
This article will focus on three main points. First, the idea is presented that prescriptive authority is an important step in the evolution of the profession of psychology. Second, an overview of other non-physician groups that prescrib is presented. Third, a case is made for a continuation of a respectful dialogue on the issues involved, based on the many areas of common interest and successful collaboration shared by psychiatry and psychology.
It has been about 125 years since the discipline of psychology began to differentiate itself from the field of philosophy, in whose departments it was housed in a number of European universities. This new experimental science soon moved across the ocean to the United States, and the American Psychological Association was formed just over 100 years ago by a small group of academicians. Over the next 50 years psychologists began to broaden their scope, moving out of their laboratories and into industry, child guidance centers and other settings. Psychological testing became a major occupation for many, and a brave few took the radical step of beginning to do psychotherapy.
The Second World War wrought great change in America, and psychologists were not immune to these changes. Thus, about 50 years ago the ideal of the psychologist as a scientist-practitioner was born, and the profession made a dramatic turn toward psychotherapy. About 40 years ago, psychologists began to be certified by the state of Maryland, and the Maryland Psychological Association was formed. Almost 25 years ago, the state recognized psychologists as independent practitioners, and about 15 years ago, certification changed to licensing.
Clearly, this is a profession that has been evolving for more than a century, and is continuing to evolve. To take another relevant example, a psychopharmacology subspecialty has existed within psychology for many years. At this time it is a research and teaching specialty, in which psychologists study the effects of psychoactive drugs, and teach others, including medical students, about them. Many believe that an important next step in the evolution of psychology is the right to prescribe psychoactive medications, as well.
History is clear that when qualified non-physician providers seek the right to independently provide pharmacotherapy, state legislatures have allowed them to do so. Dentists and podiatrists prescribe in all 50 states. The recent successful efforts of optometrists to obtain prescriptive authority is another such example. In all 50 states optometrists have the ability to prescribe diagnostic agents, and they now prescribe therapeutic agents in 46 states. Another example is the increasing discretion given to advanced practice nurses. Nurse practitioners have prescriptive authority in 47 states. In at least four states, psychiatric advanced practice nurses prescribe without physician oversight. Certified registered nurse anesthetists and nurse midwives prescribe in many states with extremely limited oversight, and physician assistants (often with less than a Bachelor's degree) have prescriptive authority in 40 states, with varying levels of physician oversight.
Understanding the successful efforts of other non-physician prescribers should help psychiatrists and psychologists reframe what some have called a turf war between the two professions. We need to keep in mind that the piece of turf in question is relatively small. If we engage in a fierce battle over this small piece of territory, any victories are likely to be Pyrrhic, in that both professions will be damaged and other groups will be more than willing to seek control over the same terrain. Would it not be better to work collaboratively to ensure that those psychologists who do gain prescriptive authority possess the proper training?
We are encouraged by recent developments in California, which illustrate the benefits of cooperation between two previously antagonistic groups, optometrists and ophthalmologists. Optometrists in California have been seeking therapeutic drug prescription authority, and had been engaged in a long, expensive battle with ophthalmologists. Our understanding is that legislators there grew tired of the incessant lobbying from both groups, and asked not to be bothered by members of either group. As a result, optometrists and ophthalmologists sat down together, and jointly drafted a bill which will be supported by both professions during the next legislative session. The bill allows for therapeutic drug prescribing by optometrists, but contains requirements for training sufficient to reassure the ophthalmologists.
We wish to assure our psychiatric colleagues that the decision to seek prescriptive authority is being made only after lengthy debate and with meticulous attention to proper training models. Training for prescriptive authority will be available only to doctorally trained, licensed psychologists. Training will be rigorous and thorough and will encompass studies in the relevant basic and applied sciences, as well as a medically supervised clinical training period. Passage of a standardized examination will be mandated before a psychologist is certified to prescribe psychoactive medications. Most psychologists probably will not seek prescriptive authority. We envision prescribing as a fellowship specialty in psychology with a limited number of practitioners, similar to other subspecialties such as neuropsychology or forensic psychology.
Finally, we must never lose sight of the vision common to both our professions: Ready access to continuity of high quality, affordable mental health services for all those who are in need of it. In private offices, in hospitals, in universities and in research facilities across the country, psychologists and psychiatrists work together every day in a respectful collaboration that is beneficial to both our professions and to the public. In a similar manner, we have worked together on complex legislative issues. It is our hope that the spirit of professionalism that has served us well in these contexts, will continue to guide us in the matter at hand.