Prescriptive Authority (RxP) Will Benefit All California Psychologists and the Patients We Serve

John L. Reeves II, PhD, MSCP, ABPP, Sallie A. Hildebrandt, Ph.D., Doreen A. Samelson, EdD, MSCP, Rob Roy Woodman, PhD, MSCP, Jarline A. Ketola, RN, PhD, MSCP, David Silverman, PhD, FICPP, Stan Bunce, PhD, ABPP

Prescriptive authority for psychologists (RxP) is now a reality in two states, New Mexico and Louisiana where over 10,000 prescriptions have been written by psychologists without a single adverse event. Moreover, psychologists have been independently prescribing in the military for over 10 years with a stellar safety record. Many more states are now on the verge of passing RxP legislation. RxP is happening! There is no doubt that RxP is a critical step in the advancement of professional psychology and it is also the final step in providing comprehensive psychological treatment for the patients we serve. The American Psychological Association (APA) and The California Psychological Association (CPA) are both committed to advancing the RxP agenda. The CPA membership also understands the significance of RxP as evidenced by the recent overwhelmingly approval of the formation of the new Division of Clinical Psychopharmacology (Division V) in the September election. RxP will benefit the profession of psychology and all psychologists, not just those seeking advanced post-doctoral training in clinical psychopharmacology. More importantly it will benefit the patients we serve. The following discussion highlights some of the important benefits of RxP.

RxP Will Be a Positive Step towards Achieving Parity between Psychologists and Psychiatrists

RxP will ultimately result in parity for psychologists in terms of reimbursement and professional opportunity. There now exits a significant gap in terms of insurance reimbursement and pay schedules in Federal, State and university settings between psychiatrists and psychologists for doing similar work. The ability to prescribe and certainly not competence is at the crux of this inequality. RxP will improve access to many important leadership positions in hospitals and mental health care and research settings that have been the exclusive domain of psychiatrists. RxP would lessen the perceived competency gap that continually plagues California psychologists’ quest to practice to the full scope of our training. For example, in most California hospitals psychologists are not allowed to write orders on their own patients, nor can psychologists in many circumstances have meaningful input into the care of their patients once they are hospitalized without the approval of an attending physician. Most hospitals do not allow psychologists to be members of the medical staff with voting privileges. As token gesture psychologists are instead relegated to Allied Health Professional membership status without voting privileges or the ability to meaningfully participate on committees, even though State law mandates that we are entitled to full medical staff privileges to practice within our full scope of training (CAPP v Rank). Another example of the lack of understanding of psychologists as independent primary care providers is Senator Shelia Kuehl’s proposed single payer insurance for Californians which will require all referrals to psychologists to come from a physician or psychiatrist. Think of the serious and deleterious consequence if this should pass for patient access to mental health care. Yet another example of the disparity in perceived competency is the recent attempt by the California Medical Association (AB 1720) to introduce legislation that would limit the positions of hospital director, hospital administrator and clinical director in State Hospitals and mental health facilities to physicians only, even though there are many instances where non-physicians including psychologists have been successfully fulfilling these roles for over 20 years! Psychologists, though having made great strides, are still not viewed as primary care providers, but rather we are seen as Allied Healthcare Providers. It is time for psychologists to assert themselves and be seen as independent primary care givers in all settings. Gaining RxP would do just that. RxP would lessen the perceived competency gap for all psychologists.

Maintaining Our Professional Identity

Prescriptive authority will strengthen our professional identity. It will make a clear distinction between our doctoral training and that of Master’s level psychotherapists. Unlike master’s level psychotherapists whose training focuses narrowly on counseling, RxP will highlight that psychologists have advance training in diagnosis and treatment of mental disorders and that our training spans a wide range of psychological treatments, not just “psychotherapy and counseling.” Psychology is the only mental health care profession where our training uniquely qualifies us to utilize the broad range of psychodiagnostics and psychological treatments, including pharmacotherapy if we choose to pursue post-doctoral curricula in clinical psychopharmacology. At no other time in California has it been more important to make a clear distinction between the in-depth training that psychologists obtain from the narrow focus of training of Masters level psychotherapists in counseling. It is clear that many fail to see the unique and varied competencies and specialties that psychology as a profession brings to the table. A striking example of this is Governor Schwarzenegger’s ill advised attempt to integrate the Board of Psychology with the Board of Behavioral Sciences, the latter is charged with regulating the activities of LCSWs and MFTs. In this plan only one psychologist would sit on the new Board of Mental Health along with a MFT, LCSW and five consumer advocates, each having an equal say in terms of our scope of practice even though they have absolutely no training in the broad areas that define our diverse doctoral level profession. Although this issue has been tabled for two years due to CPAs incredible efforts, make no mistake, this fight is not at all over. Should the Governor integrate our boards the change will dramatically affect our professional identify and allow those with much less training and competence to broaden their scopes of practice to include areas that they are not competent to practice in. There will effectively be no perceived difference between psychologists, MFTs and LCSWs. Is this in the best interests of Californians seeking mental health care? Adding prescriptive authority to our armamentarium will highlight the fact that our expertise is unique and advanced amongst mental health professionals and enhance our role as primary care professionals.

Enhanced Collaboration Between Colleagues

The prescribing psychologist will not be a “mini-psychiatrist.” Psychologists have a very different perspective than psychiatrists and other non-psychiatric prescribers. Psychiatrists and non-psychiatric prescribers see mental disorders as primarily biologically based, and thus they view psychological treatments which include but are not limited to psychotherapy as an adjunct to pharmacotherapy. By stark contrast psychologists see mental disorders from a biopsychosocial perspective. As such, pharmacotherapy is viewed as another of many tools in our armamentarium of psychological treatments. The prescribing psychologist’s emphasis on the importance of the broad range of psychological treatments over the sole focus on pharmacotherapy will only enhance collaboration between psychologists and other psychotherapists seeking a psychopharmacology consultation. For example, the prescribing psychologist will be sensitive to the importance of the on-going psychotherapeutic relationship between the referring psychologist/psychotherapist and their patient and the prescribing psychologist will have a clear understanding of therapeutic boundaries. Prescribing psychologists will collaborate with the referring psychologist/psychotherapist on how best to integrate pharmacotherapy with their psychological treatments. The prescribing psychologist will not explicitly or implicitly misinform the patient that the medications are the most important aspect of their treatment. The prescribing practices of psychologists in the military indicate that they are much more conservative than psychiatrists in their prescriptive practices. One record review showed that psychologists prescribed 13% of the time, opting instead for other psychological treatments while psychiatrists prescribed over 80% of the time for the same patient populations. It is important to understand that the ability to prescribe, for the prescribing psychologist, is also the ability not to prescribe or to “un-prescribe” inappropriate medications when indicated. It is therefore in the patient’s best interest for the clinical psychologist and psychotherapist to collaborate with a prescribing psychologist who will appreciate the importance of the psychotherapeutic process and who is knowledgeable in the broad range of psychological treatments. Adding prescriptive authority to our armamentarium will highlight the fact that our expertise is unique and advanced amongst mental health professionals and enhance our role as primary care professionals. Unlike the biologically oriented psychiatrist, the prescribing psychologist would bring not only pharmacotherapy options to the patient but the range of psychological treatments as well.

Improved Accessibility to Pharmacotherapy

The issue of accessibility to pharmacotherapy has been a key factor in the success of prescriptive authority in New Mexico, Louisiana and Guam. Accessibility is also a critical issue in California. California has a paucity of psychiatrists in rural and poorer urban areas as well as nursing homes, prisons and public mental health clinics. In California, even though the majority of the 4,000+ psychiatrists practice in the largest cities one typically still has a long wait for a psychopharmacological consultation. As a result, it is the frightening reality is that an estimated 80 plus percent of all psychotropic medications are now being prescribed by non-psychiatric physicians with little to no training in the diagnosis and treatment of mental illness or the use of psychotropic medications. Moreover, the number of psychiatrists is dwindling at an alarming rate with significant drops in enrollment in psychiatric residency programs over the past 10 years. The AMA reports that the supply of U.S. psychiatrists shrank 27 percent between 1990 and 2002. Meanwhile, physician staffing industry data indicate that demand increased by 16 percent over that same time period. At the same time, the aging of the psychiatrist population is decreasing access: Almost half (46%) of the more than 40,000 U.S. psychiatrists are 55 years or older, compared to approximately 35% of all U.S. physicians, according to the AMA. The reality is that soon there will not be enough well trained psychiatrists to fill the exploding needs of those with mental health problems. There is a crisis brewing and RxP is the solution to the problem of accessibility to quality comprehensive mental health care. The bottom line is that all Californians will have greater access to safe and cost-effective psychopharmacological care when psychologists gain prescriptive authority. There is simply no doubt that psychologists can be trained to safely prescribe despite the same old and tired cries of “blood on the streets” that psychiatry has been lodging against psychology for over 50 years every time we try increase our scope of practice. Simply look at the safety record of those prescribing in the military, Louisiana and New Mexico. The facts speak for themselves.

Increased Access to Psychopharmacological Education

Our patients want to know about psychopharmacological options. They are flooded by “Big Pharma” and the media telling them that medications are the easy solution to their complex problems. Moreover, many patients referred to psychologists by physicians and other healthcare providers are already taking psychotropic medications. Due to limited access to psychiatrists, many physicians are now requesting help from psychologists in deciding which psychotropic medications to prescribe as well as help monitoring the effects of the psychotropic medications prescribed. In addition, many psychologists now informally prescribe in hospitals, psychiatric units, nursing homes and many other health care settings. The reality is that psychologists are now frequently included in the medication decision making process in many professional settings. It is therefore imperative that psychologists be knowledgeable regarding basic psychopharmacology. In addition, The California Board of Psychology states that psychologists should be knowledgeable in and able to discuss psychotropic medications as a treatment option with their patients and has increased our scope of practice to do just that (California Business and Professional Code 2914.3). In some circumstances failure to do so can be construed as mal-practice. RxP will improve access to psychopharmacological training for all California psychologists as the number of courses and training opportunities will undoubtedly increase.

Get involved in learning about clinical psychopharmacology. Become a member of the new CPA Division of Clinical Psychopharmacology (Division V) and be part of advancing our field and improving comprehensive psychological care for all Californians. Please feel free to contact any of the following members of the Division V Interim Board of Directors if you would like more information regarding RxP.

Doreen Samelson, EdD, MSCP, Chair samelson55@comcast.net
Jarline A. Ketola, RN, PhD, MSCP, Secretary Jketola228@aol.com;
John L. Reeves II, PhD, MSCP, ABPP, Treasurer reeves@ucla.edu
Sallie E. Hildebrandt, PhD, CPA Representative sehphd@cox.net
Rob Roy Woodman, PhD, MSCP, Member at Large rwoodman@sbcglobal.net
David Silverman, PhD, FICPP, Member at Larger d.silverman@comcast.net
Stan Bunce, PhD, ABPP, Member at large sbunce@pacbell.net