From the President

Etta G. Saxe, Ph.D.  

I would like to begin my first column of this new year with a new year’s greeting. I hope that each of you will find ways to create interesting and satisfying experiences in living in this more than usually difficult and uncertain time.

One of the challenges for me of being “ for Psychoanalytic Psychology” is choosing and prioritizing among a rather ever-changing landscape of topics for the president’s columns. More and more I have noticed that in deciding on topics, my mind reluctantly focuses on those related to the socio-political-cultural contexts in which we do our psychoanalytic thinking, theorizing, educating and practicing. These contexts, and the issues arising within them, seem to me to have great potential to shrink the space available to educate, practice, theorize and think freely, and they lessen the degrees of freedom for individual discretion and diversity for our discipline and practice.

Recently, my attention has been called to prescription privileges for psychologists as one such socio-political-cultural and economic issue. I noted in a National Psychologist for instance, that the push for prescription privileges for psychologists is taking place in considerably more states than it was a year ago. In another publication, the Michigan Psychologist, there is mention of a task force within the MPA on prescription privileges for psychologists in Michigan.

About the same time, an article from the New York Times of January 14, 2003 was posted on the MPA listserv. Entitled,” Study Finds Jump In Children Taking Psychiatric Drugs,” it mentioned a number of ideas which seemed relevant to the future of psychology and psychoanalytic psychology/psychoanalysis. Among the things I particularly responded to was a quote in paragraph 4: "On the other hand, little research exists to indicate whether psychiatric drugs are being responsibly prescribed or whether they are over prescribed, in part because health insurers are reluctant to pay for "talk" therapies and other non medication treatments." A later quote (paragraph 9) from Dr. Leckman of the Yale Medical School: "We're doing these experiments more or less with our own children" also stood out for me. I was also struck by the information about the over abundance of Medicaid payer children being placed on drugs, especially antipsychotics and mood stabilizers, and the considerably higher rates of stimulant medications used with children whose care is through HMO’s or Medicaid. 

The information on Medicaid funded patients is particularly frightening in that it brings to my mind the so called ‘research’ on the course of untreated syphilis done on the indigent Black men many years ago which came to light a few years ago with much hair pulling, chest pounding mea culpas, and talk about such experiments not happening again in our more enlightened times. These men, too, were experimental subjects, although they did not know it or give consent, with the silent approval of a society and professionals who allowed them to be misused.
   With all this input, I cannot avoid thinking that it is time or even past time for beginning to think about the many relevant issues and potential impacts of the development of prescription privileges for psychologists on psychoanalytic psychology/psychoanalysis as discipline, practice and education, as well as on psychology as discipline and practice. We need to do this thinking now while it remains an issue about which the profession can debate, and before it becomes further interconnected with governmental regulation through law and with the pharmaceutical and insurance industries.  We need also to involve ourselves in this decision now, because how and upon whose behalf we decide to practice as professionals and the ethics that underlies and is manifest in this decision, will be defining of our professional identity and how we are perceived by those who seek our services now and in the future. For these reasons I determined that in being for psychoanalytic psychology I had a responsibility to begin such a discussion in this president’s column.

There has been very little discussion of prescription privileges for psychologists and psychoanalytic psychology/psychoanalysis to my knowledge and within my ear shot at national meetings which I have recently attended. There has been a mini convention at the August 2002 APA meeting which included at least one debate panel about the wisdom of moving forward with this initiative. It is nevertheless my understanding that APA is doing so. I have heard almost no discussion of this matter at Division 39 meetings with the exception of a panel chaired by Patrick Kavanaugh, Ph.D., with papers by Bertram Karon, Ph.D., and Johanna Krout Tabin, Ph.D., tapes to which we might want to listen together and then discuss. (Copies available through Division 39 tape service.)

To date, most of the discussion I have heard has lacked depth and breadth. Mostly I have heard the argument that no one would be forced to become a prescribing psychologist or mandated to take the special training. Therefore, the argument goes, those who want it should be able to have it within psychology and that their doing so would not impact the rest of us and therefore should not matter to the rest of us. It seems to me that this argument insufficiently considers the many ways in which the granting of prescription privileges to psychologists and perhaps more importantly, the presence of prescribing psychologists within the population of psychological practitioners and within the discipline of psychology (and psychoanalytic psychology as part of psychology) might impact and change practice and ethics, as well as change the ways of thinking about people and their mental life away from those ways which have traditionally been psychological. As I am drawn to the philosophy of “live and let live” I might wish the “live and let live” argument spelled out above, were convincing to me. However, whatever my wishes, I cannot avoid recognizing the need for deeper and more wide ranging discussion before a decision is made, especially in the current times as described in the article cited above from the New York Times.

It would seem from the information in the N.Y. Times article that in, the current healthcare climate and zeitgeist, suitable professional training does not prevent professionals, quietly and perhaps without awareness, from slipping into offering care based on economics and what is demanded by and for the good of healthcare organizations like HMO's, government funded programs and drug companies, and consequently neglecting to offer patient-oriented/individualized care in whatever service setting they find themselves, as our ethics seem to me to imply we must.

There is some writing on the subject of psychoanalytic work and medication scattered throughout the literature of the last half-century. I am sure that each of you can think of readings, panels and papers you are familiar with which come to mind as relevant to this matter. It would be wise for us to search the literature in this regard and consult the issues raised, the debates, discussions, theorizing and clinical presentations in this literature to enrich our thinking as we consider the potential impact on our work in a context wherein psychologists are prescribers working with biology rather than talkers working with mind and/or mind’s manifestation in behavior. 

In Dr. Tabin’s paper mentioned earlier she, for example, reviews work she did in the past where she referred for medication and offers the conclusion that this particular referral (and likely those made by others) was driven more by the analyst’s anxiety than the analysand’s need and that the referral gave the analysand the clear message that the analyst had doubts about the analytic method. Should psychologists gain prescription privileges there is real danger in our socio-political-cultural and economic climate that permission to prescribe will shortly turn into duty to prescribe and will then make one more “duty” that makes psychoanalytic listening and thinking more difficult and so-called “outdated.” 

However slowly or quickly permission (license) becomes duty, we can know from past and current experience with the many forms of managed care, both private and governmental/public, that such settings will be eager to even further substitute pills for talk, and invasive chemical behavior management for opportunities to think about how one lives one’s life. In no time flat we can expect that a psychologist will be expected to practice as a less expensive prescribing professional akin to a PA or nurse practitioner, whose specifically psychological ways of working will be substantially curtailed by being  relegated to the “unnecessary” category of medical necessity and cease thus to be permitted. These psychological ways will become even further equated with “community/support groups” as non-professional interventions, as so frequently is already the case. With this strong possibility I think we need to think seriously about this potential so we do not contribute through “live and let live” to shrinking the space for psychoanalytic psychology (and psychology of other persuasions as well).  

There is also a good deal of information we might do well to review within the oral tradition of our profession. Many of us who have worked closely with medically licensed psychoanalytic thinkers and practitioners have heard how lucky we are not to have to consider such matters as it enables us to listen associatively with less interruption emanating from our own anxiety about our role. Even before psychoanalytic work ceased to be a medical monopoly in the US there was oral tradition about innovation and “new directions” coming from the challenge of not being able to prescribe. Models like the one developed at Chestnut Lodge for work with very troubled individuals purposely relieved even the physician analysts of this interruption in listening and working analytically by having others deal with housing and managing the analysands in residence. And if we need a lesson about the impact of the socio-political-cultural context including its economic and legal aspects on practice choices, we need only consult the recent history of the demise of this interesting place. This demise resulted from a successful law suit against it for not prescribing medication, although full disclosure of the lack of reliance on medication was offered as part of the voluntary procedure for admission to the program.   

In addition to practice implications, prescription privileges for psychologists have implications for education as well. Graduate education in psychoanalytic psychology, including internships and fellowships for practice experience, are already barely available, although there remains a considerable call for this kind of graduate education. This is in fact an area of concern for Division 39. Making room in graduate education (and undergrad prerequisites) for the knowledge and experience to produce prescribing psychologists will only further erode the space for education in psychoanalytic psychology, as it also pushes out psychological science and psychosocial interventions of other persuasions. (SSCP Task Force Statement On Prescribing Privileges at http://pantheon.yale.edu/~tat22/rxp_statement.htm)

APA is pushing for prescription privileges and doing so although there is question as to whether this is a direction the majority of its members wish to pursue. APA also accredits graduate programs, internships and post-doctoral programs. Past experience with such accrediting activities would therefore strongly suggest that psychoanalytic psychology will not fare well when accrediting standards include education and training in prescribing, as they most likely will.

Finally there are also some practical-economic issues which we would do well to look into and consider in our decision making process about prescription privileges. How will talking psychologists be different from prescribing ones, when it comes to malpractice insurance rates? A look at the New Mexico law raises issues about our maintaining our status as independent practitioners with the presence of prescribing psychologists in our ranks. Medical input can quickly become medical oversight and oversight, medical supervision/control. We would be wise to look carefully at the law and administrative procedures developing in New Mexico as well as at the “model” training programs APA has developed as we think about this matter.

As is obvious in this writing I believe we need to begin thinking about this important issue of prescription privileges for psychologists on many fronts simultaneously and in a variety of formats. I urge each person to use the study groups in which they already participate to focus on papers or associative process material in some way relevant to the issue. I further urge people to get together and listen to tapes and read papers, including position papers, model laws, etc., for the purpose of thinking together on this subject. I urge people to come to the May meeting of MSPP, which will be a scholarly discussion of cultural issues and psychiatric “wonder” drugs. I urge people to write papers of their own for presentation in written and/or oral forms as debate opportunities become available, and to attend presentations and debates when they occur. I strongly urge everyone to visit http://pantheon.yale.edu/~tat22/rxp_statement.htm and read the position statement of SSCP, a Section of Division 12 of APA. Many important pros and cons are contained in this document and a course of action within APA to increase discussion and debate over the adoption of prescription privileges is therein contained. Reading this document and meeting with colleagues to discuss it would be something we all can do. We should not overlook our other-than psychologist members in these discussions, many of whom are experiencing the pressures in various work settings to focus their work on medication compliance rather than furthering the self understanding of those with whom they work.  

It would be my hope that in raising the issue for thinking and discussion in our Local Chapter newsletter which is distributed to other local chapters and through our local chapters representative to Section IV that not only would we begin to think about this matter pro-actively but that our interest might stimulate greater interest within the Division of Psychoanalysis of the American Psychological Association. Currently this issue remains a professional issue and one over which the profession can debate and make a decision before it becomes, as it has in New Mexico, any further interconnected with government, the insurance and the pharmaceutical industries.