The greatest challenge to RxP is opposition by physician groups, based on the perceived encroachment of professional psychology on psychiatry. Psychiatry has all but abandoned talk therapy, largely over reimbursement. The criterion issue remaining that separates psychiatry from psychology is prescription authority.
Pursuit of prescriptive privilege validates the perception that professional psychology is encroaching on psychiatry. It deepens the rift between us and physicians. This seems especially unwise in the context of shrinking resources and growing pressures for integrated care.
The facts and figures of experts show that professional psychology can only contribute a tiny fraction of what medical groups contribute to lobbying efforts. This further adds to concern that going to war with the medical profession over prescriptive privilege is unlikely to be successful. From political and practical standpoints, pursuing prescriptive privilege seems unwise.
From a medical safety standpoint, it may also be unwise.
Unlike many psychologists, I have a substantial basic science training background. I took biochemistry, organic chemistry, zoology, physiology, physiological psychology, did research in physiological psychology and taught graduate psychology courses in physiological psychology. I have worked full time in a hospital, have been on hospital staffs for 30 years and have chaired a hospital department. I have been in and around medical settings for most of my 35 years in the field of psychology.
I have had thousands of patients on psychoactive medications and would venture to say that I know a fair amount about them, their chemical structures, mechanisms of action, common and uncommon side-effects. I would even say that I have a passing familiarity with many non-psychoactive prescriptive medications, including beta blockers, cholesterol medications, diabetes medications, pain medications and heart medications.
I know exactly enough to know that the major and minor effects of prescriptive medications are not fully understood or entirely reliable, nor are their interactions with other prescriptive or OTC drugs or medical conditions which may or may not appear relevant.
Medical science is already functioning on the bare edge of its comprehension of the human body and its functions. For psychologists with a couple of years of ancillary training to prescribe medications of any kind seems to be getting in way over our heads. The potential medical-legal liability issues are enormous.
According to the logical principles employed by attorneys and legislators, the argument that general practitioners, physician assistants, nurse practitioners and even some psychiatrists know as little or less than psychologists do about psychoactive medications (“they do a lousy job, so we are likely to do no worse”) derives from an indefensible position. Psychologists – as ‘non-medical’ professionals – are likely to be held to a higher standard by licensing bodies.
There is also a psychotherapeutic concern about the difference in relationship dynamics between psychotherapist and prescriber. Many of the discussions we have with patients on Rx medication have to do with their ambivalence about Rx’s, their compliance or noncompliance with the Rx and general feelings about being on medication. We encourage them to share these concerns with the prescriber, but it is notable that they first bring such concerns to someone else (the non-prescribing psychologist).
I am not an opponent of RxP, but I do see potential difficulties with the agenda and believe that it might be premature to rush headlong into political efforts to win prescriptive privilege. Just because we can do something does not mean that we should do it.
In my state, California, much attention is being given to the pursuit of RxP. The California Psychological Association (CPA) supports this effort. I am told by our county psych association representatives to CPA that the greatest challenge to the psychologist license in California is, of course, the California Medical Association (CMA).
They say CMA has launched repeated campaigns in the state legislature to eliminate the psychology license, limit the scope of the license, lump our license in with MFTs by collapsing the Board of Psychology into the Board of Behavioral Science Examiners (BBSE, which licenses MFTs and LCSWs) which almost succeeded and keep psychologists from practicing in hospitals (despite CAPP v Rank).
On the other hand, desperation is in the air. Professional psychology is scrambling for a foothold in an ever meaner economic environment. Due in large part to our failure to join with other professions with whom we share common interests – the CMA and the California Association of Marriage and Family Therapists – our influence in the state legislature (much less the Congress) is marginal.
We are an easy target. Our reimbursement continues to dwindle, and more unreimbursable documentation is required of us each year. Psychologists are casting about for a way to make a living. Coaching? Mindfulness workshops? Maybe yoga instruction.
So it may come as no surprise – if psychologists ever are awarded prescriptive privilege in California – that I am one first in line to get such a credential. After all, a person has to pay the bills.
Charles M. Lepkowsky, Ph.D., is in private practice in Solvang, Calif. He is a past president of the Santa Barbara County Psychological Association. He taught graduate psychology courses for 14 years. He may be reached at: firstname.lastname@example.org.
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