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Privileges: An Opportunity
Stanley Moldawsky, Ph.D.
support our efforts to seek prescriptive authority.
I entered this debate years ago on the side of maintaining our identity as psychologists and psychotherapists, rejecting the notion that psychology should pursue obtaining the legal authority to prescribe. I have slowly changed my mind. I’d like to tell you about this soul searching journey and at the same time remind us that it isn’t as simple as it sounds.
It is hard to stand up against your colleagues whom you respect who are hellbent on going for prescription privileges. My many good friends were strongly in favor of it and I certainly wasn’t very convincing in changing their minds. I attributed wrong motives to them. They wanted power. They wanted more money. They weren’t “real” therapists like me. Well, I’m open to their ideas and I listened to graduates of the Department of Defense program. I found them really concerned that they sometimes needed something more for their patients than psychotherapy. They were well trained. They were better trained than any medical person because they spent two years studying the physiology and the impact of drugs on the body. But I was cautious about getting on the bandwagon. I knew that when I began work with a patient it was always the relationship first and foremost that needed to be established. I know that the relationship is the primary healing force in therapy, not the cognitive interpretations. I believe the interpretations are valuable and important as we convey our understanding to our patients, but it is the caring, the trying to understand, the listening, the nonjudgmental interaction with another person that is such a rare occurrence. It happens in other relationships as well, but it is the consistent, reliable, working alliance, that allows a feeling of safety in our patient to develop which leads to slowly removing defenses to feeling and knowing about oneself. So when do I reach out to a psychiatrist for drugs? When the relationship alone doesn’t reduce any anxiety but increases it, when the relationship alone doesn’t lift any depression but continues it. Then I ask for help and ask for drugs. The patient and I continue our work together and as the improvement begins to occur (feelings emerge that had been repressed, greater freedom of assertive action occurs, relationships begin to improve, self-esteem improves, physiological deviations are reduced) the patient gets weaned off the drugs, with collegial discussions with the psychiatrist. So what is to be gained by my prescribing the drugs?
If I can maintain my focus, a lot is to be gained. I can take my patient off the drugs for one thing. I recall a patient who was referred to me by a psychologist who had been my patient. My former patient was Jane’s friend and knew she had been seeing a psychiatrist for the past few years and was on meds that were uppers and downers. Up for the day, down for the night. She saw her psychiatrist weekly and there were at least two telephone calls per week asking for advice about her children, etc. My former patient encouraged her friend to see me because she felt an analytic approach would be helpful. I saw Jane for three sessions a week. She called me on the phone at first, with the same kind of dependent behavior. I would always take her calls but would generally suggest we talk about whatever it was in our next session. When the session began I’d ask her what was going on that made her call me. I brought the phone calls into the session. Within two or three weeks she stopped calling and that continued for the remainder of our work. After a year, she stopped taking her medications without any word from me and was med-free for the rest of our work. If you asked her what helped her in her therapy (as I did when she visited me a year after we finished our work), she would say, “He helped me realize I was a grown up and could take care of myself.” Her dependency had turned to self-reliance by the way I behaved and by what we discovered about her life. In this case, she had become infantilized by her previous therapist and the drugs played a large part in maintaining that. Now, were I in a position to prescribe, I would have suggested she stop taking the uppers and downers. Would I have prescribed those for her in the first place? I don’t know. I certainly would have waited to observe how she was making use of our relationship and whether the relationship was sufficient to contain her anxiety. I don’t have any plans to get the additional training so I will always need a relationship with a supportive medicator. But I saw that being able to prescribe could be a good thing so long as the psychologist worked from a position of psychotherapy first medication as necessary.
The drug companies spend $5 billion dollars a year on advertising their products. Our culture has been saturated with the idea that there is “magic” in the pill and we are led to think that whatever ails us, a pill can cure it. This goes for problems in marriage, relationships, sleeplessness, potency, and general well being. There is a medicine for whatever ails you. We are told that mental illnesses are all caused by chemical imbalances and SSRI’s or other anxiolytics can rebalance us. A psychiatrist told me that the pill in a particular case works 40% of the time. My understanding is that psychotherapy has a better success rate and psychotherapy with drugs is also successful.
Just think! What if Psychology had $5 billion dollars to advertise our product? Imagine ads about the importance of relationship in healing? We could turn the mental health world around and the people would buy our product — psychotherapy. Advertising is powerful and more powerful than the effects of the drugs. People have come to expect that drugs will cure everything because of the advertising not the research.
So why am I in favor of psychologists prescribing? Because they are trained first in the methods of psychotherapy both long and short term. They approach a patient from the vantage point that psychological processes are responsible for much of the person’s difficulties. When you add the additional psychopharmacological training, you have added a valuable extra. This is very different from medical training, where you learn that biology is basic and what is taught is from a disease model. As a result, psychiatrists treat every symptom as a chemical imbalance and drugs therefore are the treatment of choice. I trust that psychologists would see whether a therapeutic relationship can be established with the patient before resorting to biological methods.
My concern has always been that we do not follow psychiatry into the world of biology but remain psychological. I think we can do this.
journey from an opponent to a supporter has taken three years. The next
generation of psychologists will be more open to these developments and
we can educate them to remain true to their roots. So, on to the future!
Moldawsky serves on the Division 42 Psychopharmacology Committee; he is
a Past President of the New Jersey Psychological Association and of
Division 42 and a Member of the APA Board of Directors.
This article originally appeared in the Fall 2000 Issue of the Independent Practitioner, the official publication of Psychologists In Independent Practice, Division 42 of the American Psychological Association, and is reprinted with permission.