In the last edition of The National Psychologist, David S. Doane, Ph.D., expressed his opinion that prescription privileges (RxP) would undermine the profession of psychology. We, the undersigned, all of whom participate on the statewide Prescription Privileges Committee of the Florida Psychological Association (FPA), would like to reply with our very different perspective.
Doane begins by saying, “Prescriptive authority … will be harmful for the practice of psychotherapy …. For those practices, prescription authority will be a game changer, turning them into being primarily drug prescribers ….”
When we look to those environments where RxP is already in operation, Doane’s fear appears to be unsupported by the facts. Accounts of prescribing psychologists in the Department of Defense and the states of Louisiana and New Mexico, indicate that their delivery of psychotherapy services go on as actively as before, and that the ability to prescribe is simply another form of treatment in their repertoire.
Doane then writes, “Psychological intervention and drug intervention are two different orientations, two different modalities, two different postures toward healing. They each have their value but they don’t mix any better than oil and water.”
A wealth of clinical experience and research decidedly disagrees. For example, patients suffering from bipolar disorder, obsessive-compulsive disorder, schizophrenia and major depressive disorder rarely go treated without medication, especially early in the course of treatment. It is a well-known finding, supported by numerous studies, that major depressive disorder is most effectively treated by the combination of psychotherapy and medication and obsessive compulsive disorder is most effectively treated with a combination of cognitive behavioral therapy and medication.
We find it difficult to imagine attempting to treat patients with acute mood disorders, including bipolar I and bipolar II disorders, without the use of mood stabilizers – not only would it be clinically inadvisable but also inhumane and contrary to most research findings.
Still, all of us agree that most patients receiving psychotropics profit tremendously from psychotherapeutic interventions aimed at helping them better understand their symptoms and how to cope better in the world. It is a fallacy to think of medication and psychotherapy as opposing, unrelated treatments. Modern science demonstrates that the mind and body are not a duality.
Psychotherapy changes how the brain and body operate, just as medications can, but through different pathways. Prescribing psychologists are also trained to identify medical conditions and medication side effects that may be contributing to mental health problems. Failure to understand the biological bases of behavior can lead to misdiagnosis and mistreatment by psychotherapists.
Doane later states, “Psychotherapy is re-empowering. Psychotropic drug prescription is disempowering.”
We believe he is correct that psychotherapy is empowering, and we agree that drug prescription can be very disempowering. However, we believe that medication has tremendous potential for empowering patients as well, particularly early in treatment when they are suffering most acutely and are feeling most weak – it is then that medication can provide the extra strength and hope for a patient to sustain effort and make better use of psychotherapy.
He continues, “I believe a professional can provide either psychotherapy or drug prescription but … not effectively provide both to the same patient…. If psychotropics are going to be prescribed, I believe it works best for one professional to provide the psychotherapy and another to be the drug prescriber.”
We most decidedly disagree. A common dissatisfaction among providers is when, in our judgment, a medication consultation is advisable, treatment must then be divided and the patient sent elsewhere, at considerable additional time and cost. Even with the most collegial relationships with physicians, psychiatric or not, the psychologist or the patient may disagree with the outcome of the consultation, resulting in a rift in the treatment plan or a decision by the patient to give up on psychiatric services altogether.
Doane sums up by stating, “My concern is that with prescriptive authority, psychologist psychotherapists will put their time and effort into drug prescription instead of plumbing the depths of psychotherapy and of themselves as psychotherapists…. Chemicals don’t heal psychological problems, they cover them, and they’re often used to do that for the rest of the person’s life. Psychotherapy heals.”
There are many patients whose lives have been dramatically improved through psychotropic medications who, we suspect, would disagree with this assertion. Certainly, for psychologists to stop using their psychotherapeutic skills in favor of medication alone would be most unfortunate. After 20 years of RxP experience, that concern has not been realized. Remember that prescribing psychologists are specialists within psychology; they receive the same training as all psychologists plus additional training specific to psychopharmacology. They are trained to integrate medications into their existing knowledge base, not replace it. If others place pressures on prescribing psychologists to only prescribe, it is the responsibility of the psychologist to resist and insist on providing quality, comprehensive patient care.
The fears Doane expresses are nothing new; they have been reiterated over decades. But they are the fears of the uninformed and contrary to the reality of actual practice. RxP continues to gain momentum and supporters from among our most experienced, respected colleagues precisely because the known benefits outweigh the possible risks. In Florida, where some of us practice, RxP is overwhelmingly supported by our state association membership. RxP leads to more comprehensive mental health services. We can do better than psychiatry, and we will do better.
Signed by Thomas Bonner, Ph.D.; Anthony Ragusea, Psy.D., MSCP,; Elaine LeVine, Ph.D.; Glenn Ally, Ph.D., MP; Robert McGrath, Ph.D., and Stephen Ragusea, Psy.D.
References available from authors
Thomas O. Bonner, Ph.D., ABPP, is a licensed psychologist in private practice in Miami, Fla. He was president of the Miami-Dade-Monroe Chapter of the Florida Psychological Association in 1989 and in 2013-14. Anthony S. Ragusea, Psy.D., MSCP, ABPP, is a licensed psychologist in private practice in Key West, Fla. He received his Master’s Degree in Clinical Psychopharmacology in 2015 and serves as chair of the Prescriptive Authority Committee for the Florida Psychological Association. He also was recently elected secretary of APA’s Division 55. He may be reached at dr.tony@.ragusea.com