This is a response from Barry Dauphin, Ph.D. to the position paper in favor of prescription privileges put forth by the Michigan Psychological Association.  MPA offered a period of comments on its position paper. Dr. Dauphin offered comments as a member of MPA.  This response solely represents the opinions of Dr. Dauphin and should not be construed in any way to represent or be viewed as the official position of MSPP.  Dr. Dauphin offers this feedback to MSPP and the Academy for the Study of the Psychoanalytic Arts in the spirit of furthering education and discussion on these issues.

 Feedback for MPA Position Paper on Prescription Privileges

I would like to thank the board of the MPA for soliciting input from the members on the very important issue of prescription privileges for psychologists.  I believe that such dialogue with the membership is important on all such issues involving potential legislative action.  MPA is to be commended for asking for this input.  I apologize in advance for the length of my feedback.  

It is in the spirit MPA is promoting by seeking feedback that I would like to make my first suggestion on this issue.  Although I have seen references to polls concerning the proportion of psychologists in favor of prescription privileges, conspicuous by its absence is the most important polling place for democratic organizations, namely the voting booth or equivalent.  I suggest that MPA put this issue to a vote of the membership before the organization embarks upon any legislative action.  It is a rare occurrence when organized psychology seeks to change its scope of practice in such a way.  This is a controversial issue.  The MPA is a democratic organization and can set an example that the APA could follow rather than vice versa. An election seems called for.  

I understand that it can be expensive to do, but issues of this magnitude arise perhaps once in a generation, if that often. In order to minimize expenses, I suggest that MPA simply put the issue on the ballot of the next regularly scheduled MPA election.  I am aware that is some months away, but the pursuit of prescription privileges is not an emergency issue. Psychologists have been without them since the beginning, so we should understand there to be no compelling need to unduly expedite this process.  

If MPA will not put this to a vote, it should at least survey the membership. If the leadership of MPA is unwilling to do that, then it should at least provide the references to the entire membership of previous polls frequently mentioned on the listserv so that the members can judge for themselves the results and quality of the surveys. Nonetheless I believe that an issue such as this should not be handled only through the usual means, i.e., by means of elected officers. This is not intended as a slight of the elected representatives but rather a statement about the importance of this issue and the infrequency of occurrence of such an issue. I do not believe that professional organizations either can or should put every decision to a vote of the members.  That would defeat the purpose of having elected officers and an organizational infrastructure and make for self defeating inefficiencies. However, because of the special circumstances involved and the unusual nature of significantly changing the profession’s scope of practice permanently, and possibly irrevocably, such a vote would not suggest a precedent for each and every issue facing the organization.   

In the event that MPA pursues prescription privileges absent a vote, then I have a request. Since expenses will be incurred by MPA in the lobbying process for prescription privileges and in the liaison process with Division 55 and the Practice Directorate, I request that an estimate and full disclosure of those expenses be made available to the membership as soon as is practicable, as well as a guarantee that the dues of MPA members will not be increased in relation to the pursuit or acquisition of prescription privileges. This seems only fair, as proponents of prescription privileges have repeatedly offered assurances that prescription privileges will in no way adversely affect those who choose not to obtain them. I assume this to include things such as membership dues to professional psychological organizations.  If MPA pursues prescription privileges and incurs increased expenses in the process, I expect that the organization will not pass on such expenses to the whole membership but will require that those who wish to pursue such privileges or those supportive of such a pursuit entirely bear the additional costs of the effort via some type of special assessment to dues. In light of these repeated reassurances, those who have strong reservations about prescription privileges should not have to carry water for the proponents.  

I believe that seeking prescription privileges represents a fundamentally mistaken policy for psychologists whether it is in the form of the policy from the APA or the position paper from the MPA. Although I personally espouse a rather libertarian political philosophy and would like to take the position to allow others to do as they wish, I believe that prescription privileges will adversely affect those psychologists who choose not to obtain them, will harm the field of psychology and will do more harm than good for the public.  Moreover, those who wish to obtain prescription privileges have other avenues available to obtain them.  The fact that those avenues are difficult (e.g., medical school, nurse practitioner status, etc.) is no reason to argue in favor of changing the field of psychology.  If such privileges are so valuable, then psychologists who desire them should undertake such efforts and not attempt to alter the field of professional psychology, affecting clinical psychology and those psychologists who wish no part in this undertaking.  

Prescription privileges are NOT psychology.  Unlike other arenas that were shut off from psychology, such as entry into psychoanalytic institutes, the act of and expertise around prescribing does not involve the field of psychology itself unless one expands psychology in a manner that leads to the absence of any logical limits being placed upon the definition of what should fall within our scope. Just because the medical profession erred in trying to prevent psychologists entry into psychoanalytic institutes in the past does not axiomatically mean that they are clearly so wrong about safety issues today, unless we start living by the proposition that once wrong, then always wrong.  If so, then we’re all in trouble. Without belaboring this point too much, even Freud himself wrote that he considered psychoanalysis to be a part of psychology and not just Medical Psychology, and his very own daughter was a psychoanalyst without a medical degree. This is a different kind of issue.  I wouldn’t be surprised to learn that many physicians fought to keep psychologists out of analytic institutes as part of a legal strategy aimed at broader safety concerns.  In effect they might have said to themselves: we better keep psychologists out of psychoanalytic institutes or the next thing you know, they’ll want to prescribe medicine without going to medical school.    

Prescription privileges represent an extension of our scope of practice into an area related to but nonetheless outside of psychology itself.  There is no logical rationale to limit the practice of prescribing psychology to an arbitrarily determined, limited formulary. Any physical disease could be said to have a psychological impact on any human being, but MPA does not appear to be advocating that psychologists obtain all medical privileges. Once psychologists are prescribing medicine to treat some medical diagnoses, what is the rationale to limit itself to any particular diagnostic subset, why not anything that could conceivably contribute to such diagnoses?  What exactly prevents a slippery slope rationale from developing?  

I have read on the MPA listserv recently that professional psychologists have desired access to an unlimited formulary but accept a limited formulary as a compromise.  The fact that some professional psychologists seek access to an unlimited formulary should strike most of us as highly irresponsible, even if it were only used as a bargaining tactic aimed at securing a compromise.  Such a fundamental position seems, quite frankly, ridiculous and speaks to the potential slipperiness of this position.  Some might argue that psychotropic medications affect one’s emotional state and are used to treat emotional concerns. But there is no logical reason to stop there. Other medications do too, and other medical conditions affect emotional functioning to a substantial degree.  Still, we do not include anything that affects a person’s psychology under our domain of expertise, or psychologists would seek to become qualified to undertake nearly all of the activities of other professions.  Surely many people become depressed and anxious in association to financial difficulties, but neither MPA nor APA are advocating accounting privileges for psychologists.  

Some might argue that prescription privileges represent “progress” for psychology.  But in no way will it represent progress for psychology if it inevitably discourages the psychologist from thinking psychologically and instead encourages thinking of human beings primarily in terms of symptom clusters or as merely walking receptacles of neurotransmitters or chiefly calculating how to use a chemical agent to effect a change in behavior without sufficiently exploring and understanding the psychology of the person displaying the symptoms.  Organized psychology has already engaged in efforts to become junior psychiatrists by not maintaining a critical enough stance toward medical nomenclature, such as the DSM series.  For example, how many graduate programs in psychology teach the DSM as authoritative without ever addressing evidence about its less than stellar level of reliability?  Why am I reading the statistics behind the mediocre inter-rater reliability levels for the DSM diagnoses in a Social Work journal?  This is exactly the type of analyses and tough-minded questioning that ought to be second nature to the field of psychology.  Too few of us in psychology have exerted enough effort to bring psychological knowledge to bear on issues pertaining to the possible overmedicalization of our work.  The medical model has influenced organized psychology too much already.  Injecting more of it into Clinical Psychology is not a good prescription for the welfare of psychology as a discipline of study.  

I contend that prescription privileges will do for psychology what they have done for psychiatry, namely diminish the role of psychological knowledge for the field. It is interesting that psychologists so often bemoan the biological emphasis in psychiatry and are now attempting to obtain these very same privileges.  Our usual, and often well founded, complaints about the biologization of psychiatry should be leading us to advocate more strongly for psychotherapy and the continued development of psychological understandings and interventions as opposed to emulating psychiatry. It is quite self deceiving for psychologists to think that we will not be prone to adopt the same biological-centric perspective of psychiatry and also be immune to temptations for quick medical solutions to psychological problems. One could argue that the very lack of medical training could make too many psychologists more susceptible to the biased information from pharmaceutical company representatives. Once upon a time people used to go to psychiatrists to talk about their emotional difficulties. That is a rarity these days.  Why will large numbers of prescribing psychologists ultimately be any different?  

Some will say that our training is different. Although that is true enough, psychiatrists were also trained differently once upon a time.  Training and training programs are not set in stone and adjust in light of many factors, such as new research.  They also change as a function of the marketplace as well as to factors that have little to do with the development of psychology as a discipline.  I believe that prescription privileges will not remain some postdoctoral acquisition but will come to be strongly prepared for, if not outright taught, in graduate school and would then fundamentally and adversely affect graduate and undergraduate education in psychology. I know that many suggest this will always remain a postgraduate form of training and would likely accuse me of being overly pessimistic. However, there are no guarantees that preparation for prescription privileges will remain exclusively postdoctoral, and I contend that many of the same arguments for expansion of the scope of practice will be used to argue in favor of altering graduate education itself. I suggest that graduate programs will feel the need to begin preparing students as soon as possible in their careers for this option and will even suggest that it’s the only ethical thing to do.  In fact it is already beginning to happen in some places.  

Because it is undesirable for graduate training to last 7-9 years at a minimum, graduate programs would have to be altered to accommodate prescription privileges training.  This would likely mean the reduction and elimination of many courses in assessment, psychology and psychotherapy.  That would further erode the practice of psychology itself as well as the development of skills and expertise so useful for understanding people in a psychological manner. Such an occurrence would undermine the development of expertise for the talking work that is at the core of our profession’s ability to be of assistance to people struggling with various emotional difficulties. In other words while the APA, the MPA and others suggest that psychologists should be allowed training for prescription privileges, I contend that this will ultimately undermine the broad based understanding of emotional issues that is currently one of the major selling points for psychologists obtaining prescription privileges in the first place.  I am concerned that prescription privileges will eventually kill the goose that lays the golden eggs.  

In the short run I am certain that many experienced clinicians can obtain prescription privileges and perform their pre-privilege functions as psychologists at an acceptable degree for a period of time and perhaps indefinitely depending upon their pre-prescription level of expertise. They might even continue to bring a psychological perspective to their work.  However, I do not see this as a recipe for the field of psychology over time.  More psychologists will obtain prescription privileges with shorter intervals postdoctorally and limit their psychological knowledge. Although one’s postdoctoral training should be a function of the individual’s professional discretion and responsibility, I fear that already some who advocate in favor of prescription privileges are developing an unrealistic set of expectations.  

I have frequently seen sentiments expressed reflecting the idea that the prescribing psychologist will be able to do it all.  Although there will be some exceptional individuals that can manage a sort of Renaissance-man set of skills, being a do-it-all is more problematic than advertised for the large majority of people that seek to obtain these skills.  Maintaining one’s expertise for prescribing will be time consuming. That is not a special problem in itself but can only happen in a couple of ways. Either the individual will diminish his/her studies of other areas of psychology or he/she will diminish his/her amount of leisure time (or some combination of both).  The former leads to a lessoned knowledge base in psychology, while the latter risks various personal difficulties that most people will understandably not wish to bear.  Either should be up to the individual, but I get the impression that too many who favor prescription privileges believe that they can add such privileges and nothing will be subtracted. But even after prescription privileges are obtained, they will still be faced with having 24 hrs. to a day.  In other words there are likely to be sacrifices to the continued study of psychology by most prescribing psychologists. I wonder whether enough individuals recognize this and whether the field of psychology is cognizant of this.  The sacrifices to psychology could be even greater if, or perhaps when, preparation for prescription training or the training itself migrates to graduate and undergraduate education. This would have implications for the study of psychology and for the allocation of resources.  

To consider just one type of impact, bringing new faculty into state universities to train psychologists to prescribe incurs large financial costs, in terms of recruitment, salaries, benefits, insurance costs to the university and expenses for student training. This can be undertaken in two basic ways. One would be to raise taxes. If organized psychology is advocating that, then these organizations should go on record publicly and explain why Michigan and other state taxpayers need a tax increase to pay for this. The other way would be to cut other expenses. Most bureaucrats will suggest cutting other parts of psychology departments (such as faculty positions for some areas of psychology, courses, funds, research space, etc.) to keep budget levels intact, instead of unfairly cutting programs of other areas. That would inevitably undermine the contention that prescription privileges will not hurt other areas of psychology.  It seems unusual that organized psychology would pursue a policy that risks increased state expenditures at a time when the state has persistent difficulty balancing its budget.  

If prescription privileges pass and the APA and MPA are shown to be wrong about the facts that prescription privileges won’t hurt other areas of psychology or isn’t good for the public, what will they be prepared to do about it? I’m about to ask for the impossible as a way of illustrating a point. In the event that the APA, MPA and others are wrong to suggest that prescription privileges won’t adversely affect those psychologists who choose not to prescribe or the field of psychology, will organized psychology ask to repeal these laws?  If too many prescribing psychologists become a safety issue, the various state legislatures will probably take care of the issue themselves. I am concerned that it is too easy for organized psychology and prescription privilege proponents to offer reassurances to skeptical psychologists now because there is no action that would be taken to rectify a problem later.  In other words we skeptics are being asked to buy a pig in a poke. If the pig is contaminated, who will buy it back?  

The MPA position paper states: “There is currently a serious shortage of psychiatrists, particularly child and adolescent psychiatrists, particularly in rural areas, and projected estimates of future members suggest this pattern will continue or worsen in the future.” What is the evidence for such a shortage; what is the definition of “shortage” or “serious” for that matter?  This suggests that the MPA believes that too few people are being medicated and that more should be. Although I have frequently encountered the contention from prescription privilege supporters that prescribing psychologists can take people off medication, this motto seems to only represent a truism and has not given me confidence that it represents a guiding principle.  Psychiatrists can also take people off medication. It appears to me that such sentiments are only uttered to convince the skeptics that psychologists won’t overmedicate people.  Time and again I have encountered the argument, devised in different forms, that somehow psychologists won’t be like psychiatrists, as if human nature were somehow altered by the degree one obtains and somehow the prescriptive powers themselves don’t contribute to the behavior of too many psychiatrists that psychologists have complained about (i.e., overmedicating people and treating painful emotions as diseases).  I am not anti-medicine, but I can discern no compelling reasons to drastically increase the numbers of psychotropic prescription writers in the state or in the country.  

If the rural are of such great concern, why don’t the APA, the MPA and other psychological organizations begin a partnership with the AMA and other state and national medical associations in a spirit of collegiality? We could offer education on emotional issues for rural family practitioners, internists and other relevant medical specialists in exchange for education in basic medical issues, such as diabetes, coronary disease, ulcers, diseases of the thyroid, etc. that affect the quality of life of various psychotherapy patients. This way the physicians who work with these patients will provide better care and the psychologists who work with these patients will understand the role of the body better.  This could lead to interdisciplinary cooperation and collaboration instead of the competition and turf issues that psychologists’ prescription privileges entail.  It is ironic that so many psychologists get concerned about Licensed Professional Counselors trying to do psychological testing (our turf) while the organizations that are spearheading the prescription privilege movement appear so insensitive to the turf reactions of the medical profession.  

If the rural are of such special concern, why enact such a sweeping change in regulations? Wouldn’t a targeted approach in cooperation with our medical colleagues be a more effective response, one that is less costly and one that does not call for more government intervention in and regulation of our profession?  Surely all those people I saw at the APA Convention a few years ago virtually standing in line to pay lots of money to learn more about how to prescribe are not heading for the U.P.  It is disingenuous to fail to acknowledge that many are hoping to reap big paydays in already well served urban and suburban areas. In fact such clinicians may constitute the overwhelming majority who are actively seeking such privileges.  They will become less expensive psychiatrists and become attractive to HMOs and PPOs seeking to cut costs while earning more money than their old therapy practice did.  

The MPA position paper states: “Most psychotropic medications are prescribed by non-psychiatric physicians, many of whom are not specifically trained to diagnose and comprehensively treat mental disorders.”  This is true but not because there are so few rural psychiatrists. This is true in urban and suburban areas because of the embarrassment and anxiety that many people feel about going to a mental health professional, as well as the convenience of having their family doctor or internist acting as a generalist. Nothing about the psychologist prescription movement is likely to alter this dynamic. Prescribing psychologists can be painted with the same “stigma” brush that our psychiatrist colleagues are painted with. Working with our physician colleagues stands a greater chance of improving service delivery than trying to replace psychiatry with prescribing psychologists.   

The MPA position paper states: “The current public mental health system in Michigan is seriously flawed and under-funded and thus there is a need for alternative services. Currently, the public mental health system is mandated to provide services only to the seriously mentally ill, thereby leaving the uninsured with less severe symptoms without treatment options.”  It is unclear how prescribing psychologists will substantially improve their options.  If they are not already seeing psychologists now, why will they go because psychologists have prescription privileges?  If they are seeing psychologists now, aren’t psychologists already capable of referring the patient to his/her physician or to a psychiatrist if that is considered appropriate?  Is MPA trying to state publicly that internists and family doctors are unqualified or incompetent to be prescribing psychotropics?  If MPA is not trying to say this, what is it trying to say?  

Shortly thereafter the MPA position paper states: ”Available evidence indicates that many persons with mental illness are not adequately served by the provision of psychotherapy alone, particularly those persons with more severe forms of illness” But the position paper had just stated that the state is mandated to provide services for those with more severe forms of illness.  How is the state failing at this and why will prescription privileges improve this? Aren’t psychologists already referring those individuals with “severe forms of illness” for medication under the state mandated care for such individuals the position paper had just explicitly referenced?  If not, why doesn’t the MPA begin an education program to address that issue rather than wield the blunt instrument of prescription privileges.  

The MPA position paper states: “Non-prescribing psychologists and their clients are likely to benefit from having prescribing psychologist colleagues with whom to consult on medication issues since significant percentages of clients of psychologists in practice today are already taking psychotropic medications and collegial consultation will lead to improved care.”  I could argue the language of this statement suggests that physicians aren’t seen as our colleagues.  Why would it be better to talk with a prescribing psychologist about medicine rather than a psychiatrist or other physician? Prescribing psychologists will have a very limited knowledge about medicine and cannot educate us about the human body with anywhere near the expertise of a physician. Moreover, it can create new problems, such as a prescribing psychologist not respecting the boundaries of therapy since he/she will claim to “know” therapy already or the prescribing psychologist treating the non-prescribing psychologist as less than instead of as equal.  We rightly feel affronted if a medical colleague treats us as junior or less than, but imagine when a fellow psychologist does so.  

The very language used, “non-prescribing psychologist,” surely is telling in this regard.  After all these years of fighting for respectability, credibility and esteem and fighting the pernicious definition of a psychologists as “not a psychiatrist”, now many psychologists can come to be seen as a non-something by their “colleagues.”  How soon before “non-prescribing psychologist” becomes junior partner?  This is especially important because since the very beginning of this movement back in the 1970s those who desire prescription privileges have argued vociferously that they don’t want to take anything away from those who wish to follow their current paths.  If this turns out not to be true, will the APA and MPA lead the charge to repeal these laws?  Prescription privileges risk creating a two-tiered system in psychology, which has all the potential of becoming a caste system.  Instead of advocating more forcefully for the importance of psychological testing, assessment and psychotherapy and promoting new avenues for the development of psychological knowledge, the large psychological organizations are positioning themselves for an eventual sellout of psychotherapy and other ways of working based on psychological understandings of people, such as coaching, systems of behavior modification, self monitoring techniques, etc.  The fact that the APA has spent so much money on this issue despite having faced years of large budget deficits speaks to having its priorities mixed up and serving to undercut psychology as science and practice even before any civilian psychologists prescribe.  

The entire movement rests on the premise that the public needs more medication and not more therapy and assessment.  Prescribing psychologists, as a group, will only make money if there are more and more prescriptions being written and people in need of ten-to-fifteen minute follow up appointments.  Taking people off medications is not a recipe for large numbers of practitioners to pay the mortgage.   Although particular psychologists might endeavor to help substantial numbers of patients reduce their over-reliance on using medicine as a solution to painful or distressing emotional experiences, I believe that this does not explain heightened level of interest this issue generates among many members of the psychological community.   

Although we have been told of the success of the military program, I have found discussion of this one of giving with one hand and taking with the other.  While citing the evidence in support of quality of care and safety concerns, some discussing in favor of prescription privileges then seem to turn around and tell others who desire these privileges that the training used in the states won’t be nearly as rigorous or demanding as the training and supervision the military psychologists underwent.  In other words, don’t worry it won’t take you too long before you obtain these privileges. The military evidence is used to say ‘see we can do it well’.  Yet none of the states thus far have passed anywhere near as stringent requirements as that of the military psychologists. So what exactly does that evidence mean?  

This seems far too close to bait and switch.  It suggests that those advocating for prescription privileges for psychologists are overemphasizing expediency as if the country were in a state of psychiatric emergency akin to a need to recruit anyone and everyone for the army in WWI & II.  Furthermore, the “success” of the military experience can hardly be seen as transforming itself seamlessly into civilian life.  The military is a highly hierarchical system with a regimented chain of command and severe penalties for failing to operate within the command structure. Civilian private practice is nothing like this.  So why are some advocating for less stringent requirements for civilian psychologists where there will be less control and oversight than in the military?  This seems quite misguided.  

The point here involves using the evidence from the military experience as if it will apply neatly to civilian life.  Any psychologist with even a cursory knowledge of statistics and design will suggest that the military example provides extremely limited evidence for the safety of prescribing psychologists since the training and practice environment will be substantially different for civilians.  Even the evidence I have seen informally presented, namely that the military psychologists use medicine less frequently than the psychiatrists is not without problems.  The participants in the military trial run are certainly at as great a risk of the Hawthorne Effect (or subject-expectancy effects) as I could imagine. The entire APA hierarchy has wanted this to come out “right.” The military trial run also provides no basis from which to consider how one’s behavior may change in the face of a different pattern of financial incentives in civilian life from those in the military.  

Advocates of prescription privileges, such as Morgan Sammons (PDP grad) suggest that those who are concerned about safety issues are ideologically opposed to prescription privileges and basically ignorant of the issues.  However, the AMA, the APA (Psychiatric Association) and other medical groups are very concerned about safety issues and the level of training needed for prescribing.  How can we be sure they are so wrong?  Are we going to say they are wrong because protecting their turf overly influences their reasoning?  However, psychologists such as Dr Sammons are not influenced out of a desire to acquire turf?  I am concerned that psychologists such as Dr. Sammons can be so glib about safety issues. I recognize that he has gotten prescription privileges, but the entire medical establishment appears concerned about safety issues. Organized psychology appears invested in winning the fight but not in actually addressing the concerns. I suspect that too many in favor of prescription privileges will say that organized medicine is opposed to this simply because it is afraid of the loss of power and income for physicians. The problem with such ad hominem arguments is that the same kind of reasoning could then just as easily be used in the reverse direction.  

The supporters of prescription privileges regularly refer to their opponents as ideological.  Yet, supporting prescription privileges is every bit as ideological.  Yes, this is ultimately about the philosophy of psychology, even if the safety concerns were fully satisfied.  This ultimately boils down to what psychologists wish professional psychology to be. If that isn’t worth the vote of the members of the organization, then I’m not sure anything is.  

I understand that the MPA Board is primarily concerned about prescription privileges as an issue for psychologists. I ask that the MPA address whether it is also in favor of such training for social workers that attain ACSW status or Licensed Professional Counselors (LPC). In other words whatever the position of the Executive Board is, could it articulate whether and why it is for or against similar status for ACSWs and LPCs.  

Once again, I wish to commend the executive board of MPA for soliciting feedback on its position paper and look forward to the results of this process.  

Sincerely,    

Barry Dauphin, Ph.D.