Prescriptive Authority for Clinical Psychologists

Prescriptive authority for psychologists has been hotly debated for decades, with literature identifying various stakeholder opinions, but minimal scholarship addressing training or outcomes (Heiby, 2010; Muse & McGrath, 2010; Robiner et al., 2003).  Robiner, Tompkins, and Hathaway summarize training programs of various health professions that prescribe for mental health patients.

Their study compares the training for psychologists to prescribe to that of physicians (M.D./D.O.), nurse practitioners (NP/DNP) and physicians’ assistants (PA). All prescribing professions, other than psychology, require undergraduate scientific coursework including biology, and organic and inorganic chemistry. Undergraduate basic science prerequisites are not required for psychology doctoral training programs, nor for the programs designated by APA to provide psychopharmacology training to prepare  psychologists to prescribe.

Similarly, all graduate professional programs, except psychology’s, include additional coursework in biology, anatomy/physiology and pathophysiology, and most require microbiology and organic chemistry/biochemistry. This coursework is supplemented by a range of 1,500 (NPs, DNPs) to 9,000 (MD, DO) hours of supervised clinical training that involves assessment, diagnosis, treatment planning and treatment. Practica and internship for doctoral psychologists also entail considerable clinical experience; however, the additional clinical hours required for the clinical psychopharmacology training programs are relatively minimal compared to other professions.

Whereas psychologists generally receive excellent training in assessment and diagnosis of mental health patients (more extensive than most medically-trained colleagues and other types of mental health professionals), their education and training in physical health conditions (e.g., organ function, pathophysiology) and biological bases and effects of medication usage throughout the human body is minimal. Psychopharmacology programs training psychologists to prescribe are largely on-line and provide abbreviated didactic and clinical training compared to other prescribers.

Relatively abbreviated training to prescribe raises public health concerns about how gaps in psychologists’ learning and supervised experience may limit or adversely affect the quality of care delivered. Discounting the importance of medical and scientific training is concerning given the complex issues that can arise from adverse drug effects, medication interactions, co-morbidities, and improper physical diagnosis. Those at greatest risk for medication mismanagement are likely the youngest, oldest, and sickest patients with complex conditions, numerous risk factors, and complicated medication regimens. In light of the relatively limited training, it is not surprising that prescribing psychologists have been the subject of lawsuits and actions by Louisiana’s board that regulates them.

Stuart and Heiby (2007) lamented the lack of data evaluating the risks and benefits of prescribing psychologists’ performance, arguing that psychology was in an “awkward position of being a scientifically based profession…seeking to expand its scope based on a small pilot program (e.g., the PDP) that reaches well beyond the parameters of available data”.  The RxP movement seems to reflect two core attitudes and beliefs that are odds with evidence-based practice (Lilienfeld, Ritschel, Lynn, Cautin, & Latzman, 2013): (a) naïve realism, i.e., relying on one’s own limited observations to judge safety and efficacy, and (b)the ad ignorantium fallacy, i.e., the “error of concluding that because a claim has not been proven wrong, it must be correct or at least possess substantial merit”.  If RxP proponents continue to advocate for psychologists to prescribe despite their limited training relative to other prescribers, objective, well-designed, adequately powered, and methodically executed studies are needed. In the absence of such studies there is currently noconvincing evidence that short-cuts in training programs produce psychologists who are ascompetent and safeas prescribers in other disciplines who undergo more extensive training. It would be wise for the future of the profession to resist the temptation to promote pharmacological approaches by less scientifically trained professionals over empirically supported psychotherapies that psychologists are remarkably well-prepared to deliver.

Reference Article

Robiner, W. N., Tompkins, T, L., & Hathaway, K. M. (December 2019). Prescriptive Authority:  Psychologists’ Abridged Training Relative to Other Professions’ Training. Clinical Psychology: Science & Practice.   https://doi.org/10.1111/cpsp.12309

Discussion Questions

  • Training programs for prescribing disciplines share fairly uniform scientific prerequisites across disciplines, except for psychology. Despite the similarities in prerequisite coursework, for other prescribing disciplines, data-based evidence would be useful to identify levels of prerequisite scientific knowledge and breadth of clinical training to ensure the safety and quality of care for patients who are prescribed psychoactive medications. Who would fund such research and who would be responsible for collecting such data?If such data were available, who would set standards and monitor outcomes across (not only within) disciplines to ensure quality care?
  • Meanwhile, in the absence of empirical evidence for setting training thresholds, prescribing psychologists are outliers among all prescribers in terms of having less scientific and medically oriented training. How can patients, psychologists, and other stakeholders be assured that psychologists graduating from APA-designated psychopharmacology training programs are prepared to manage medications as competently and safely as other prescribers?
  • RxP proponents assert that psychologists can be trained to safely prescribe without medical school training like other non-physician providers do. This assertion critically ignores the difference that all other prescriberscomplete core scientific and biologically based courseworkbefore entering training programs. They bring a broader and more biologically based perspective to pharmacological treatment. How might whatever is left out from the relatively abbreviated curriculum for psychologists’ prescribing (e.g., diverse functions of the human body, morbidities, and about other types of medications) affect clinical care and outcomes?
  • What ethical concerns arise for psychologist prescribers (e.g., recognizing own bounds of competence; providing informed consent to patients and transparency to other health professionals, policy makers and legislators about the relative limitations of psychologists’ training to prescribe; influence of pharmaceutical influence on prescribing behavior)?
  • Psychology requires doctoral programs to undergo rigorous accreditationreview, as do training programs for all other health professionals. However, APA’s training model for prescribing is based on a less rigorous standard, designationrather than accreditation.  Given the substantial risks to patients of errors in medication management, how appropriate is it to rely on relatively minimal training standards for prescribing?  Why isn’t accreditation necessary for psychologists to prescribe if it is for psychologists’ other psychological services and for all other disciplines’ prescribing?  Is it prudent for the profession for psychologists to be the onlyprescribers who have not undergone accredited training to prescribe?

Author Bios

Kate Hathaway, Ph.D. is Teaching Faculty in the University of Minnesota Academic Health Center, and also teaches in a graduate program at St. Catherine University.  She received her M.A. and Ph.D. in Clinical Psychology at Northern Illinois University and her B.A. in Psychology and Education from Macalester College in St. Paul, MN.  Her clinical and research interests focus on understanding the relationships between physiology and cognitive/emotional functioning.

Tanya Tompkins, Ph.D. is a Professor of Psychology at Linfield College. She received her M. A. and Ph. D. in Clinical Psychology at the University of California, Los Angeles and her B. A. in Psychology from the University of Colorado at Boulder. Her research focuses on understanding attitudes toward a range of professional issues (RxP, stigma toward those with mental illness and the transgender community) and evidence-based prevention in the areas of suicide and reducing eating disorder risk. She is on the Board of Advisors of Psychologists Opposed to Prescription Privileges for Psychologists (www.poppp.org).

William N. Robiner, Ph.D., ABPP is Professor in the Departments of Medicine and Pediatrics at the University of Minnesota Medical School where he is the Director of Health Psychology and the Psychology Internship.  He received his M.A. and Ph.D. at Washington University and his B.A. at the University of Rochester.  His research addresses diverse topics in education and training in psychology, health psychology, adherence in clinical research and practice, professional development, supervision, mentoring, the mental health workforce, interprofessional education, and professional affairs.  He served on the Education and Training for Credentialing Committee of the Association of State and Provincial Psychology Boards that authored Guidelines for Prescriptive Authority in 2001. He is on the Board of Advisors of Psychologists Opposed to Prescription Privileges for Psychologists.

References Cited

Heiby, E. M. (2010). Concerns about substandard training for prescription privileges for psychologists. Journal of Clinical Psychology, 66, 104-111. doi:10.1002/jclp.20650

Lilienfeld, S. O., Ritschel, L. A., Lynn, S. J., Cautin, R. L., & Latzman, R. D. (2013). Why many clinical psychologists are resistant to evidence-based practice: Root causes and constructive remedies. Clinical Psychology Review, 33, 883–900. https://doi.org/10.1016/j.cpr.2012.09.008

Muse, M., & McGrath, R. E. (2010). Training comparison among three professions prescribing psychoactive medications: Psychiatric nurse practitioners, physicians, and pharmacology trained psychologists. Journal of Clinical Psychology, 66, 96-103.  doi:10.1002/jclp.20623

Robiner, W. N., Bearman, D. L., Berman, M., Grove, W. M., Colón, E., Armstrong, J., Mareck, S., & Tanenbaum, R. L. (2003). Prescriptive authority for psychologists: Despite deficits in education and knowledge? Journal of Clinical Psychology in Medical Settings, 10, 211-221. doi:10.1023/A:1025419114038

Stuart, R. B., & Heiby, E. E. (2007).  To prescribe or not to prescribe: Eleven exploratory questions.  The Scientific Review of Mental Health Practice: Objective Investigations of Controversial and Unorthodox Claims in Clinical Psychology, Psychiatry, and Social Work, 5, 4-32.

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