Prescriptive Authority for Psychologists: A History and Guide

Prescriptive Authority for Psychologists A History and Guide Edited

by Sammons, Levants, and Paige

CONTENTS

Contributors

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Foreword: Reflections on Prescriptive Authority and the Evolution of Psychology in the 21st Century . . . . . . . . . . . . . . . . . . . . . Patrick H. DeLeon

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Chapter 1.

Chapter 2.

Introduction: The Politics and Pragmatics of Prescriptive Authority . . . . . . . . . . . . . . . . . . . . . . . . . . Morgan T. Sammons

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Early Efforts by Psychologists to Obtain Prescriptive Authority . . . . . . . . . . . . . . . . . . . . . . . . . . Ronald E. Fox

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Chapter 3.

Doubts About Prescribing . . . . . . . . . . . . . . . . . . . . . . . . Laura S. Brown

Chapter 4.

The Prescriptive Authority Agenda: Evolving Structures and Efforts in the American Psychological Association . . . . . . . . . . . . . . . Ruth Ullmann Paige and Elizabeth A. Robinson

Chapter 5.

The Department of Defense Experiment: The Psychopharmacology Demonstration Project . . . . . Gregory B. Laskow and Dennis J. Grill vii

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59

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Chapter 6.

Experiences of a Department of Defense Prescribing Psychologist: A Personal Account . . . . . . . . . . . . . . . . . 103 Debra Lina Dunivin

Chapter 7.

Training Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Ronald F. Levant, Judith E. N. Albino, Anita B. Brown, Samuel A. Feldman, Raymond A. Folen, Peggy Kaczmarek, Elaine S. LeVine, Robert E. McGrath, Gloria D. Pickar, A. Eugene Shapiro, Steven R. Tulkin, and Cal VanderPlate

Chapter 8.

The Struggle in the States . . . . . . . . . . . . . . . . . . . . . . . 141 Tommy T. Stigall, Charles A. Faltz, Raymond A. Folen, and Cal VanderPlate

Chapter 9.

Alliances With Consumer Groups and Other Associations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Linda F. Campbell and Pat Gardner

Chapter 10.

Psychopharmacology Examination for Psychologists Developed by the American Psychological Association Practice Organization’s College of Professional Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Patricia M. Bricklin and Janet Ciuccio

Chapter 11.

Prescribing Psychologists: The Future . . . . . . . . . . . . . . 191 Morgan T. Sammons, Ruth Ullmann Paige, and Ronald F. Levant

Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213 Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219 About the Editors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227

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CONTRIBUTORS

Judith E. N. Albino, Alliant International University, San Francisco, CA Patricia M. Bricklin, Committee for the Advancement of Professional Practice, American Psychological Association Practice Organization, Washington, DC Anita B. Brown, Department of Psychology, Hampton University, Hampton, VA Laura S. Brown, Argosy University Seattle–Washington School of Professional Psychology, Seattle Linda F. Campbell, Department of Counseling and Human Development, University of Georgia, Athens Janet Ciuccio, College of Professional Psychology, American Psychological Association Practice Organization, Washington, DC Patrick H. DeLeon, Former President, American Psychological Association, Washington, DC Debra Lina Dunivin, Department of Psychology, Walter Reed Army Medical Center, Washington, DC Charles A. Faltz, California Psychological Association, Sacramento Samuel A. Feldman, Prescribing Psychologist’s Register, North Miami Beach, FL Raymond A. Folen, Argosy University–Honolulu Campus, Honolulu, HI Ronald E. Fox, The Consulting Group: A Division of HRC, Chapel Hill; Department of Psychology, University of North Carolina, Chapel Hill Pat Gardner, Georgia Psychological Association, Atlanta Dennis J. Grill, Department of Behavioral Medicine, Brooke Army Medical Center, San Antonio, TX Peggy Kaczmarek, Department of Counseling and Educational Psychology, New Mexico State University, Las Cruces ix

Gregory B. Laskow, Center for Creative Leadership, Greensboro, NC Ronald F. Levant, Center for Psychological Studies, Nova Southeastern University, Ft. Lauderdale, FL Elaine S. LeVine, The Center Through the Looking Glass, Las Cruces, NM Robert E. McGrath, School of Psychology, Fairleigh Dickinson University, Teaneck, NJ Ruth Ullmann Paige, First Hill Psychological Associates, Seattle, WA Gloria D. Pickar, Compass Knowledge Group, Ocoee, FL Elizabeth A. Robinson, Robinson/Nedelman Psychological Associates, Everett, WA Morgan T. Sammons, Mental Health Department, Naval Medical Clinic, Annapolis, MD A. Eugene Shapiro, Center for Psychological Studies, Nova Southeastern University, Ft. Lauderdale, FL Tommy T. Stigall, The Psychology Group, Baton Rouge, LA Steven R. Tulkin, Postdoctoral Master of Science Program in Clinical Psychopharmacology, Alliant International University, Alameda, CA Cal VanderPlate, Peachtree Psychological Associates; Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA

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FOREWORD REFLECTIONS ON PRESCRIPTIVE AUTHORITY AND THE EVOLUTION OF PSYCHOLOGY IN THE 21ST CENTURY PATRICK H. DELEON

It has been tremendously rewarding to watch up close the maturation of psychology’s prescriptive authority agenda. Over the past 25 years, I have had the opportunity of being personally involved within the public policy (e.g., political) process. I also have been most fortunate to have been elected to a number of American Psychological Association (APA) governance positions. These positions have been very satisfying, both personally and professionally. I have worked with psychologist colleagues of the highest caliber who have repeatedly demonstrated that their primary dedication is not only to their profession but also to what is in the best interests of their patients. Psychology is among the pre-eminent learned professions and, as such, psychologists have much to offer society. Because of the fundamental importance to society of the profession’s endeavors in research, teaching, and the psychosocial aspects of health care, psychologists have a special responsibility to provide proactive vision and effective leadership. Psychologists must appreciate the transformations that are occurring within society and ensure that psychology’s considerable expertise is appropriately used. The 21st century will be an era of educated consumers; an explosion of technology in the xi

health care arena; and systematic utilization of objective, data-driven, clinical decision making. This is the essence of the prescriptive authority agenda.1

PRESCRIPTIVE AUTHORITY: PAST AND FUTURE A Historical Glimpse As described in several chapters in this volume, the prescriptive authority movement is evolutionary and received its first real impetus little more than 15 years ago, in Sen. Daniel K. Inouye’s (D–HI) November 1984 suggestion to the Hawaii Psychological Association that it adopt an entirely new legislative agenda, one that he felt would fit very nicely into that year’s programmatic theme: “Transcending Traditional Boundaries.” At that time, 39 states allowed optometrists to use diagnostic drugs (4 states had authorized the use of therapeutic drugs), and 18 states allowed nurse practitioners to prescribe, generally under some form of supervisory arrangement with a physician (DeLeon, Fox, & Graham, 1991). Today, the nonphysician landscape has drastically changed, with all states allowing these professions to effectively use medications and an increasing number authorizing physicians’ assistants, clinical pharmacists, physical therapists, and other health care providers previously viewed as ancillary service providers. The ascendancy of these health care professions to central roles in primary care service provision is one of the most remarkable changes in the health care constellation in the past few decades, as Morgan T. Sammons documents in chapter 1. Drug companies are now overtly advertising to the public at large, and this form of pharmaceutical advertising has grown far more rapidly than other forms of drug promotion (Rosenthal, Berndt, Donohue, Frank, & Epstein, 2002). Whether this represents a public benefit is subject to debate (see Wolfe, 2002), but the net result is that the consumer has more—if not better—information than ever before. This fact alone fundamentally alters the dynamics of the prescriber–patient relationship. During the year of my APA presidency, I was pleased that the national leaders of psychology and clinical pharmacy actively explored areas of common interest and concern—including prescriptive training and collaborative practice. As I traveled across the nation visiting state associations, I also sensed developing interest at the grassroots level in fostering collaborative practice opportunities and legislative endeavors.

1At

this point I would be remiss if I did not formally express my sincerest appreciation to former APA President Ron Fox, who has understood this nexus from the very outset of the move to acquire prescriptive authority. Without Fox’s effective leadership, psychologists would never have come this far, this fast; cf. DeLeon, Sammons, & Fox, 1995.

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A Vision of the Future The 21st century will be an era of the educated consumer and a time when the United States will experience an unprecedented impact of technology on its health care delivery and educational systems. For example, objective (e.g., data-driven) clinical protocols will become increasingly common; telehealth care and Web-based distance learning will make traditional time and distance considerations almost inconsequential; and the all-important behavioral, environmental, and cultural aspects of service delivery will finally be accorded their appropriate priority. At the same time, there is also every indication that unprecedented changes will be seen in the manner in which health care services are delivered. Economic concerns, including the costs inherent in ensuring that practitioners are able to access the most advanced scientific knowledge available, will strongly encourage interdisciplinary care and provide enhanced opportunities for psychology within primary health care systems. For some senior clinicians, the traditional fee-for-service practices will flourish. Future generations of psychologist clinicians, however, will undoubtedly experience a very different working environment. In my judgment, these expected changes go to the essence of psychological training and service delivery: Psychologists are, above all else, behavioral scientists. For psychologists to actively participate in shaping the nature of this monumental shift in focus within the U.S. health care system, it is critical that the profession’s national leadership proactively work to ensure that psychologists’ clinical and scientific skills are increasingly recognized and valued by society and by U.S. health policy experts. It is important that members of professional psychology never lose sight of the fact that the essence of the prescriptive authority agenda is fundamentally a social policy agenda, that is, ensuring that all Americans have access to the highest possible quality of care. It is my steadfast opinion that, by implementing a model wherein psychotropics are prescribed in the context of an overarching, psychologically based treatment paradigm, as opposed to current psychiatric models that have an almost exclusive biological orientation, the quality of mental health care will improve. It is equally important to appreciate that the prescriptive authority agenda is a psychology agenda (DeLeon, Sammons, & Sexton, 1995). The concerns that have been raised over the past 20 years by members of other professions are, in the larger scheme, irrelevant. The underlying policy discussion is, and always has been, about where the profession of psychology collectively wants to evolve to embrace these public service challenges. It is not about the future or preferences of any other profession. It is also important to note that this is an agenda that involves all of psychology, not just professional psychology. The prescriptive authority agenda is fundamentally an educational agenda—in spite of the fact that it was initiated by, and fostered by, the front-line practicing clinician community. But our educators, in truth, play the most FOREWORD

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important role in this process of change; they ensure that the core identity of the profession—psychologists’ understanding of the basic workings of the human psyche and the application of this understanding to ameliorate suffering and enhance performance—be strengthened, rather than diluted, by this new clinical skill. It is clear that at every stage in professional psychology’s development there have been individuals both within the profession and external to it who have actively resisted any change in the status quo (Resnick, 1997). This was the case when psychologists sought to provide psychotherapy; independently diagnose and treat patients; and receive reimbursement for services rendered, regardless of the location (e.g., inpatient care). Change is always unsettling, and there can be no question that the movement toward the professional degree (PsyD), in particular, represented a major shift in psychology’s fundamental identity and inherent value system. This is a shift that even today some more traditional psychologists continue to actively resist. It is impossible to predict with any sense of certainty where the future will take us. Accordingly, in my judgment it is absolutely critical that psychologists who genuinely care about the profession, and who are willing to be responsive to society’s pressing needs as well as being sensitive to the broader changes evolving within society, become intimately involved in shaping psychologists’ collective future. Focused Debate As is described in depth elsewhere in this impressive and most timely volume, the prescriptive authority agenda has now been thoroughly debated and discussed in the classroom, in professional journals, at state and national gatherings, in various state legislative venues, in the halls of Congress, and throughout the APA governance. At each step of the way, the underlying concept of appropriately trained psychologists obtaining independent prescriptive authority has always been endorsed, nearly unanimously, by psychology professionals (DeLeon & Sammons, 1998). In 1989, APA’s Board of Professional Affairs, under the chairship of Norma Simon, held a special retreat meeting on the issue in which members heard from a wide range of experts and perspectives. The board ultimately recommended that focused attention on the responsibility of preparing psychology to address current and future needs of the public for psychologically managed psychopharmacological interventions be made APA’s highest priority. In 1990, the APA Council of Representatives established an ad hoc Task Force on Psychopharmacology, with at most only two council members expressing opposition. Two years later, this task force, under the chairship of Michael Smyer, submitted its report to Council. In its judgment, practitioners with combined training in psychopharmacology and psychosocial treatments could be viewed as a new form of health care professional, one xiv

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who would be expected to bring to health care delivery the best of both psychological and pharmacological knowledge and who possesses the potential to dramatically improve patient care and make important new advances in treatment. As later developments demonstrated, the proactive vision of these earlier colleagues is most impressive. Over three consecutive convention meetings—1995, in New York; 1996, in Toronto; and 1997, in Chicago—APA’s highest elected body of governance, the Council of Representatives, voted overwhelmingly to make obtaining prescriptive authority APA policy, including endorsing a model legislative bill and training curriculum. Furthermore, the APA College of Professional Psychology was authorized to develop an appropriate national examination, suitable for use by the state and provincial licensing boards, which has now been taken by approximately 50 postdoctoral psychopharmacology graduates. During these deliberations within the APA’s governance, the Committee for the American Psychological Association of Graduate Students (APAGS) adopted a formal resolution of support for prescriptive authority. This is particularly significant, as APAGS is the future of the profession. As one reviews the chapters in this historic book, one gets a firsthand sense of how a steadily increasing number of dedicated and visionary psychologists have truly made a difference in the lives of many U.S. citizens, often behind the scenes and at great personal sacrifice. They have been willing to move the profession of psychology into uncharted waters. If one is honest with oneself and focuses on the unique needs of any subset of the U.S. population—whether this be children, elderly people, women, ethnic minorities, those residing in rural America, or those in need of chronic or long-term care—it is clear that such groups are not receiving the quality of care that every one of us would desire for our own loved ones. Furthermore, it readily becomes evident that the systematic and enhanced availability of psychological expertise will provide an increased benefit to many. In my judgment, any other conclusion would be simply intellectually dishonest. The underlying policy question remains whether professional psychology is willing to assume this clinical responsibility. Psychologists also must ask whether the field of psychology has matured sufficiently to become one of the country’s bona fide health care professions (DeLeon, Bennett, & Bricklin, 1997; DeLeon, Robinson-Kurpius, & Sexton, 2001).

PRESCRIPTIVE AUTHORITY IN THE CONTEXT OF NATIONAL HEALTH CARE POLICY For readers who have not taken a careful and candid look at the status of the current U.S. health care delivery system, I suggest reviewing several landmark reports by the Institute of Medicine (IOM). The IOM has served FOREWORD

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as a highly respected health policy think tank for Congress and various Presidential administrations since it was chartered in 1970 by the National Academy of Sciences, acting under the academy’s 1863 Congressional charter responsibility to be an advisor to the federal government. In 1999, the IOM released a highly controversial report indicating that each year between 44,000 and 98,000 Americans died in hospitals as a result of medical errors (Kohn, Corrigan, & Donaldson, 1999). The report noted that medications are the most frequent medical intervention. Encouraging interdisciplinary collaboration, the report further described how merely having clinical pharmacists participate during daily hospital rounds decreased significantly (66%) the rate of preventable adverse drug events relating to prescribing within major teaching facilities. I remind readers that these patients were under the clinical care of licensed physicians and were being treated in licensed health care facilities. Another far-reaching IOM report (IOM, 2001) addressed the extent to which the current American health care system lags significantly behind other segments of the economy in applying advances in relevant technology and in ensuring that scientific advances are used in a timely fashion. The American health care delivery system is in need of fundamental change. Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge, yet there is strong evidence that this frequently is not the case. The lag between the discovery of more efficacious forms of treatment and their incorporation into routine patient care is unnecessarily long, in the range of 15–20 years, and even then, adherence of clinical practice to the evidence is highly uneven. Accordingly, to profess (as some in organized medicine have done) that highly trained and dedicated clinicians will become “public health hazards” when they obtain the clinical responsibility to independently prescribe is simply absurd. This is an emotionally charged argument that for generations has been used against a wide range of nonphysician health care providers. It simply has no basis in fact and, not surprisingly, is overtly contradicted by objective study after study (see chapter 11 for a further review of this subject). In light of the absence of any data suggesting that nonphysicians as a group provide substandard care, it remains rather perplexing that this particular policy argument is still being advanced. The key to providing quality care is the ability to make an accurate clinical diagnosis. If any of the nonphysician disciplines were inherently dangerous, one would expect that those public institutions (e.g., state legislatures and regulatory and licensing boards) who have a long and distinguished track record of protecting the public would prohibit psychologists (for example) from being licensed to diagnose. Yet, since 1977, psychology has been licensed (or certified) in all states, and today psychology is recognized as an independent profession under every one of the federal government’s health care delivery and reimbursement programs. Essentially, the “public health hazard” argument has xvi

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long ago been deemed moot at best, and at worst irresponsible, in that it impedes portions of the U.S. citizenry from receiving the most appropriate health care. A related perspective is provided by academic psychologists involved in establishing quality psychopharmacology training modules. These professionals have described the extent to which organized psychiatry has systematically attempted to prevent their courses from even being offered. This brings to mind the worst of the anti-intellectual eras in U.S. history. As an individual who grew up in a family that highly valued education, I think the idea that any segment of society would affirmatively attempt to prevent anyone from bettering oneself through education is simply unconscionable. For the prescriptive authority agenda the relevant educational question is “What aspects of the current psychopharmacology didactic training programs (conducted by medicine, nursing, or pharmacy) should be incorporated into psychology’s already extensive knowledge base to improve the functioning of psychology’s clinicians?” The answer is not “One should go to medical school.” It is the underlying mission of the U.S. educational system to develop courses that are relevant to societal needs. By using up-to-date technological advances within education (e.g., virtual training modalities), these can be readily adapted to the unique circumstances of practicing clinicians, graduate students completing internships, and psychologists who are interested in respecializing. Given the intensity of the opposition, one can only conclude that psychologists must be making a difference. That is what members of a learned profession must strive to do. Quality education is the strength of psychology and of the United States. A Personal Aside Over the past several years, I have had the distinct honor of serving as the commencement speaker at three separate psychopharmacology graduating ceremonies. These have all been very special events. Some senior colleagues had agreed to go back to school, with all of the accompanying self-doubts, stressors, and anxieties. They survived and did very well. At graduation time, they were rightfully proud of their newest accomplishments. The graduates began to publicly share how much they had learned and how they now saw their patients from an entirely different perspective. Before enrolling in their psychopharmacology training, their peers all agreed that these colleagues were excellent therapists. Now they described themselves as bringing something qualitatively different to those patients for whom medication might be clinically useful: a fundamentally psychological approach to psychotropic interventions. They had become, in fact, an entirely new breed of clinician with a highly unique perspective, thereby fulfilling the vision of earlier governance policy reflections (DeLeon & Wiggins, 1996). Most important, society was being well served. FOREWORD

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It has been my observation in talking with colleagues across the nation over the past 30 years that the overwhelming majority of practicing psychologists originally went into the field because they wanted to be able to make a meaningful difference in the daily lives of the individuals they would eventually serve. During my APA presidential year, I reached out on a weekly basis to members who were not involved within the APA governance. These were very moving and inspiring discussions. There can be no question that the field of psychology possesses extraordinary talent and dedication. Countless colleagues are making contributions at the local level every day. Psychological principles are being effectively used in an increasingly wide range of forums—sports psychology, health psychology, psychology and the law, and so on. The professional future is limited only by psychologists’ collective vision and willingness to confront new challenges and opportunities. Those of us who have been fortunate to gravitate to positions of national psychology leadership must now fulfill our unique responsibility. Historically, psychology’s nationally elected officials seem to have not appreciated the policy importance of their positions. We must, for example, ensure that society becomes aware of, and can readily avail itself to, the most up-to-date psychological expertise. To cite but one example, it is clear that it never occurred to our graduate students when they entered the field that the U.S. health care delivery system would establish arbitrary barriers to making their services readily available to those in need, under the rubric of being a “medical care system.” We must work to change that. We must strive to ensure that the most up-to-date scientific knowledge (including that of the behavioral sciences) is effectively used throughout the health care delivery system. In seeking to accomplish this laudatory objective we will come to appreciate the importance of true interdisciplinary collaboration and training. Psychology is but one of the health professions. We must, for example, learn to become team players within the primary health care arena. Above all else, organized psychology requires proactive leadership at the national level in furtherance of these goals. Within universities, psychology continues to be one of the most popular, if not the most popular, undergraduate majors, and every year extraordinarily bright seniors apply for advanced training. When President Carter established his landmark Presidential Commission on Mental Health, there were approximately 59,900 members and affiliates of the APA. A decade later (1988), APAGS was established by the APA Council of Representatives. As the 21st century begins, the comparable APA membership numbers have grown to 155,000, including approximately 60,000 APAGS members. These are very impressive numbers, and they speak well for the future of the profession. I reiterate, however, that a promising future exists only if those of us in leadership positions fulfill our responsibilities. Collectively, we must possess a vision that is consistent with evolving national trends. In this light, it was with great personal pleasure that I was able to have the prescriptive auxviii

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thority agenda become one of my APA presidential initiatives and convention programmatic themes, admirably cochaired by Department of Defense (DoD) Psychopharmacology Fellow Anita Brown, Chuck Faltz, Ray Folen, and Sandy Rose. A Step Forward During the Congressional deliberations on the fiscal year 1989 appropriations bill for the DoD, the conferees directed the department to establish a demonstration pilot training project under which military psychologists would be trained and authorized to issue appropriate psychotropic medications under certain circumstances. On June 17, 1994, then APA President Bob Resnick and I attended the graduation ceremonies at the Walter Reed Army Medical Center of the first two DoD Psychopharmacology Fellows: U.S. Navy Commander John L. Sexton and Lt. Commander Morgan T. Sammons. This federal program caused considerable consternation (to put it mildly) within the psychiatric community and ultimately graduated 10 Fellows. Numerous external evaluations of the prescribing practices of the DoD Fellows have been laudatory in terms of the clinical expertise and practice of the graduates (Newman, Phelps, Sammons, Dunivin, & Cullen, 2000). These dedicated individuals have visually demonstrated to the public—and, perhaps more important, to their own peers—that professional psychologists can be successfully trained to safely and cost-effectively use psychotropic medications. Listening to their words, one realizes that they definitely have made a difference in the lives of their patients. From a more global perspective, a number of the Fellows have been intimately involved in the grassroots state-based legislative movement. Others have been on the cutting edge of developing psychology’s civilian postdoctoral psychopharmacology training modules. Most important, each of them has provided a living face to the previously purely abstract concept of psychology’s prescriptive authority agenda. Thus, the Psychopharmacology Demonstration Project succeeded on two fronts: (a) by preparing clinicians to incorporate pharmacological interventions into their treatment plans and (b) by providing leadership for psychologists seeking prescriptive authority in the future (DeLeon, Sammons, & Fox, 2000).

PRESCRIPTIVE AUTHORITY AND THE FUTURE OF THE PROFESSION Practitioners Obtaining in-depth knowledge about the rapid advances occurring within the field of pharmacy and the expanding appreciation of the biological basis of various mental health and emotional disorders is the fundamental FOREWORD

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key to improved quality of care. Prescriptive authority opens up entirely new marketplaces and provides the profession of psychology with the legal standing to insist on the recognition of the psychosocial aspects of mental health care. Psychologists who already prescribe (either within the federal jurisdiction or as “learned collaborators” with primary care physicians) clearly indicate that, from their personal experiences, ensuring that patients who are prescribed psychotropic medications receive the appropriate dosage is a high priority. Psychologists who are interested in serving individuals with chronic or severe mental disorders will find historical artificial programmatic barriers removed; those interested in working with nursing home populations will find ready access to patients and their families with significant psychological needs; and those interested in focusing on unique population subsets—for example, women or children—will again find that their fundamental psychological approach will provide a unique and welcomed perspective. The DoD Fellows have truly taught their psychologist colleagues that, above all else, the power to prescribe is also the power to unprescribe (or modify) inappropriate or excessive medication regimens. Scientists It is difficult to fathom any limit on the newest scientific problems to be systematically explored, particularly within the area of therapeutic effectiveness. What, for example, is the role of hormones in the production of depression in menopausal women, and how can pharmacological interventions be designed to ameliorate this condition? How should hyperactive children be assessed and treated? What about depression related to serious physical illnesses, such as cancer or renal failure? What are the long-term developmental effects of psychotropic medications? How can psychotropics and psychotherapy be combined to produce the best clinical outcomes? The history of clinical medicine’s training resources suggests that graduate departments of psychology and professional schools that are involved in these psychophysical investigations will do very well. Educators These should be extraordinarily energizing times, particularly for psychologists who are interested in interdisciplinary collaboration. Those who have been involved from the earliest days in the development of the prescriptive authority agenda have consistently agreed that for psychology to retain its fundamental behavioral science identity (and its psychological approach to using medications), it is important that psychopharmacology training be obtained at the postdoctoral level. This policy orientation is reflected in the requirements for taking the national College of Professional Psychology examination. Accordingly, one should expect a rapidly expandxx

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ing educational market, not only for formal training leading to an advanced psychopharmacology degree but also for the soon-to-be required (by licensing boards) continuing-education modules, hands-on training for individuals completing clinical internships, and for members of other professions (e.g., advanced-practice nurses, clinical pharmacists, and clinical social workers) who are interested in the broad behavioral health area. With increasing reliance on Web-based virtual teaching environments, I cannot see any limit to the development of future educational activities in this field. As nonphysician clinicians become more involved in serving diverse subpopulations (e.g., elderly people and children), there will be an ever-expanding need for quality educational modules targeting practicing clinicians. As a nation, the United States is experiencing a virtual explosion of scientific knowledge; even though information doubles every 5 years, it is projected to soon double every 17 days, with traffic on the World Wide Web already doubling every 100 days (Jerome et al., 2000).

THE MATURATION OF THE PROFESSION AS A PUBLIC POLICY FORCE Today, 31 state psychological associations possess prescriptive authority task forces. Enacting prescriptive authority legislation is a very high priority for the Committee for the Advancement of Professional Practice, which annually makes available discretionary financial support for these legislative activities. In the next several years, it is projected that over a quarter of the state legislatures will grapple with formal prescriptive authority bills. Relevant legislation has already been enacted into public law in Guam (1998) and Indiana (1993)—admittedly, perhaps not with the exact wording that professional psychology desires, but the underlying policy message is definitely there. The signing into law of a bill enabling psychologists in New Mexico to prescribe, in March 2002, clearly indicates that psychologists have come a very long way indeed since the introduction of the Hawaii prescriptive authority study resolution in 1985 (Burns, DeLeon, Chemtob, Welch, & Samuels, 1988; DeLeon, Folen, Jennings, Willis, & Wright, 1991). What has been particularly exciting from my public policy vantage point has been watching colleagues who support the prescriptive authority agenda become personally engaged, both within the governance of their own state psychological associations and their state legislatures. Considerable energy is oftentimes first spent educating fellow psychologists as to the value of the prescriptive authority movement. Soon a small, but definitely dedicated, group of like-minded colleagues surfaces. Survey after survey demonstrates that with concerted educative effort (and often a personal visit from one of the DoD psychopharmacology Fellows), approximately three quarters of the local state psychological association membership eventually FOREWORD

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becomes supportive (Sammons, Gorny, Allen, & Zinner, 2000). However, it remains those select dedicated few who will spend the necessary personal time with their individual state legislators and remaining reticent colleagues to ease their concerns. Frequently, these individuals have not previously been involved within their local psychological association governance; they now bring the necessary enthusiasm and energy for an entirely new agenda. Ultimately, they will make a real difference to a revitalized state psychological association. Not surprisingly, the external medical opposition within the legislative arena remains consistent; most often this is expressed in the form of spreading emotional “public health hazard” allegations. Members of organized psychiatry and medicine spend considerable financial resources and make emotional appeals to legislators and the public. On the other hand, efforts to work collaboratively with various potential stakeholders (e.g., clinical pharmacists, advanced nurse practitioners, consumer groups, educational institutions, and leaders of community health centers) often turn into fruitful interactions. The keys to legislative success are ultimately a belief in ourselves and persistence. I have no doubt that psychology’s prescriptive authority agenda is good for the future of professional psychology and good for the nation. Equally important, it is highly consistent with evolving national trends—both within the various health professions and in society in general. The number of Americans who use the Internet to retrieve health-related information is estimated to be 70 million–100 million annually. Currently over half of American homes possess computers. These numbers continue to increase. The highly educated consumers of the 21st century will value psychologists’ scientific and clinical expertise as long as psychologists themselves value their extensive training and clinical skills and if they ensure that society becomes increasingly aware of psychologists’ potential contributions. Extraordinarily bright students are seeking careers in psychology; they simply will not be held back by historical artifacts or barriers. From my vantage point, psychology’s prescriptive authority agenda is an agenda for the future and one of hope and optimism. As a profession, psychology is evolving out of nearly a decade of despair and frustration verbalized by practitioners as they began to come to grips with managed care and external demands for clinical accountability. The prescriptive authority agenda is a positive one; it provides a creative vehicle for constructive professional accomplishments. It is a policy agenda around which all aspects of psychology can productively coalesce. In my judgment, time is definitely on our side. Aloha. REFERENCES Burns, S. M., DeLeon, P. H., Chemtob, C. M., Welch, B. L., & Samuels, R. M. (1988). Psychotropic medication: A new technique for psychology? Psychotherapy: Theory, Research, Practice, and Training, 25, 508–515.

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DeLeon, P. H., Bennett, B. E., & Bricklin, P. M. (1997). Ethics and public policy formulation: A case example related to prescription privileges. Professional Psychology: Research and Practice, 28, 518–525. DeLeon, P. H., Folen, R. A., Jennings, F. L., Willis, D. J., & Wright, R. H. (1991). The case for prescription privileges: A logical evolution of professional practice. Journal of Clinical Child Psychology, 20, 254–267. DeLeon, P. H., Fox, R. E., & Graham, S. R. (1991). Prescription privileges: Psychology’s next frontier? American Psychologist, 46, 384–393. DeLeon, P. H., Robinson-Kurpius, S. E., & Sexton, J. L. (2001). Prescriptive authority for psychologists: Law, ethics, and public policy. In M. T. Sammons & N. B. Schmidt (Eds.), Combined treatments for mental disorders: A guide to psychological and pharmacological interventions (pp. 33–52). Washington, DC: American Psychological Association. DeLeon, P. H., & Sammons, M. T. (1998). Foreword. Prescription privileges for psychologists: An historical overview. In L. A. Pagliaro & A. M. Pagliaro (Eds.), The pharmacologic basis of psychotherapeutics (pp. xvii–xxiii). Washington, DC: Taylor & Francis. DeLeon, P. H., Sammons, M. T., & Fox, R. E. (1995). A commentary: Canada is not that far north. Canadian Psychology, 36, 320–326. DeLeon, P. H., Sammons, M. T., & Fox, R. E. (2000). Prescription privileges. In A. E. Kazdin (Ed.), Encyclopedia of psychology (Vol. 6, pp. 285–287). Washington, DC: American Psychological Association and Oxford University Press. DeLeon, P. H., Sammons, M. T., & Sexton, J. L. (1995). Focusing on society’s real needs: Responsibility and prescription privileges? American Psychologist, 50, 1022–1032. DeLeon, P. H., & Wiggins, J. G. (1996). Prescription privileges for psychologists. American Psychologist, 51, 225–229. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. Jerome, L. W., DeLeon, P. H., James, L. C., Folen, R., Earles, J., & Gedney, J. J. (2000). The coming of age of telecommunications in psychological research and practice. American Psychologist, 55, 407–421. Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (1999). To err is human: Building a safer health system. Washington, DC: National Academy Press. Newman, R., Phelps, R., Sammons, M. T., Dunivin, D. L., & Cullen, E. A. (2000). Evaluation of the Psychopharmacology Demonstration Project: A retrospective analysis. Professional Psychology: Research and Practice, 31, 598–603. Resnick, R. J. (1997). A brief history of practice—Expanded. American Psychologist, 52, 463–468. Rosenthal, M. B., Berndt, E. R., Donohue, J. M., Frank, R. G., & Epstein, A. M. (2002). Promotion of prescription drugs to consumers. New England Journal of Medicine, 346, 498–505. FOREWORD

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Sammons, M. T., Gorny, S., Allen, R., & Zinner, E. (2000). Prescriptive authority for psychologists: A consensus of support. Professional Psychology: Research and Practice, 31, 604–609. Wolfe, S. M. (2002). Direct-to-consumer advertising—Education or emotion production? New England Journal of Medicine, 346, 524–526.

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Prescriptive Authority for Psychologists

1 INTRODUCTION: THE POLITICS AND PRAGMATICS OF PRESCRIPTIVE AUTHORITY MORGAN T. SAMMONS

The impetus to acquire prescriptive authority for psychologists comes at a time of dramatic change in health care service provision in America. Many observers are inclined to attribute recent significant shifts in health care policy and practice to the ascendance of managed care entities as a force in American medicine, but a more fundamental and enduring change is simultaneously occurring that will ineradicably alter the face of health service provision in the future: the explosive expansion of the scope of practice of nonphysician health care providers (NPHCPs). How other health care professions have expanded their professional jurisdiction to include the ability to prescribe has much to inform psychologists who seek the same end. The first section of this chapter is, therefore, devoted to a brief historical synopsis of the acquisition of prescriptive authority by other health care professions, including physicians—lest we forget that physicians were not The opinions expressed in this chapter are solely those of the author and do not reflect any official opinion of the U.S. Navy or Department of Defense. Ruth Ullmann Paige and Ronald F. Levant also contributed to the development of this chapter.

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granted prescriptive authority by divine fiat but used legislative and political mechanisms to expand their early dominance of the U.S. health care system to include a virtual monopoly on prescriptive authority. At the same time that NPHCPs are increasing in number and expanding their scopes of practice, two other shifts of considerable importance for mental health service provision also have taken place that directly bear on the prescriptive authority movement for psychology. First, there has been a marked rise in the use of mental health services in general and an unprecedented growth in the prescription of psychotropic agents across all ages and patient populations. Between 1987 and 1996, the total number of ambulatory mental health visits (defined as acute psychiatric hospital treatment; community mental health center visits; or visits to physicians, psychologists, or counselors) increased 29%, and total spending on mental health services increased (in constant dollars) 46% (Zuvekas, 2001). It is not surprising that the lion’s share of this increase reflects a substantial escalation in spending for psychotropic drugs. Antidepressants are the most commonly prescribed psychotropic, and spending on this class of drug alone is estimated to have increased by 600%, to more than $6 billion, in the 1990s (Croghan, 2001). This is attributable not only to the higher cost of newer psychotropics (Zuvekas, 2001) but also to the increased consumption of such agents, which is due at least in part to their improved tolerability and safety. Zuvekas (2001) did not separately analyze visits to NPHCPs versus medical providers but noted that 39% of patients surveyed in 1996 reported receiving nothing other than drug treatment—indicating that drug treatment is the mainstay, if not the only treatment, for many patients seeking mental health services. Other often-cited references (Pincus et al., 1998; Zito et al., 2000) corroborate significant increases in use of psychotropic drugs, particularly antidepressants and stimulants, in patients as young as preschoolers. Both the rise in prescriptions and their increasing use as sole therapeutic modalities have provided impetus to the prescriptive authority movement, as psychologists maneuver not only to firmly establish themselves as first-line providers of mental health services but also to gain greater control over the types of therapeutic regimens offered their patients. An additional issue—one that represents an area of significant controversy for mental health providers—is closely related to the increase in use of psychotropics. This is the as-yet-unresolved question of the true efficacy of psychotropic drugs—in particular, the antidepressants. High rates of placebo (cf. Khan, Warner, & Brown, 2000) and nonspecific responses (cf. Kirsch & Sapirstein, 1998) have been reported for antidepressants and other classes of psychotropics (notably antipsychotics) in general. In response, some psychologist commentators (e.g., Antonuccio, Danton, & DeNelsky, 1995) have argued against the acquisition of prescriptive authority by psychologists on the basis that the true efficacy of antidepressant medication remains to be definitively established. 4

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Moncrieff (2001) summarized the extant literature on antidepressants and made a number of observations that should inform any debate regarding whether psychologists should seek to directly use these agents. First, Moncrieff observed that in spite of the exponential rise in use of antidepressants, the social burden of depression has not lessened—indeed, the rate of work absenteeism attributed to depression is increasing, rather than decreasing. Moncrieff also cited other data that revealed that patients taking antidepressants are no less likely to commit suicide than those receiving a placebo (Khan et al., 2000, as cited in Moncrieff, 2001). The long-term efficacy of antidepressants has yet to be unequivocally demonstrated, and even shortterm randomized trials are compromised by numerous methodological flaws, notably measurement difficulties, incomplete blinds, and equivocal ability to detect differences between antidepressants and active (vs. inert) placebos. Finally, Moncrieff summarized the literature on the nonspecificity of response to antidepressant medications, observing—like Valenstein (1998), Healy (1997), and others—that until a heretofore-lacking specific neurobiological mechanism of depression has been defined, all treatment responses are, de facto, nonspecific. Sufficient data have been accumulated such that it is safe to declare that a placebo or nonspecific response indisputably exists for antidepressants—when used in the treatment of depression. Similar, though less robust, findings are summarized for other psychotropics in later sections of this chapter. However, more central questions remain: Should psychologists and other mental health practitioners eschew the use of certain drugs simply because a high placebo response exists for them, and should this finding deter them from seeking prescriptive authority? In this chapter, then, I attempt to address a number of issues pertaining to the history of, and current controversies surrounding, the acquisition of prescriptive rights by psychologists. First, I summarize the history of prescribing for other health care professionals. I then examine some questions surrounding the placebo/nonspecificity debate. Finally, I focus on the issue of the proliferation of psychotropic drug prescriptions and what role prescribing psychologists can play not only in stemming this but also in enhancing the provision of mental health services in general.

A BRIEF HISTORY OF PRESCRIBING IN THE UNITED STATES How Physicians Gained Control of the Prescription Pad Some people may assume that the almost exclusive monopoly on the prescription pad that physicians have enjoyed in the past century is a natural function of the training and scope of practice of physicians. A closer examination of history does not support this view. Before the turn of the 20th INTRODUCTION

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century, nurses and pharmacists, among others, could order, compound, and dispense medications—indeed, citizens in most instances did not require the consultation of a medical professional to obtain pharmacological remedies. Harkless (1989) provided a valuable history of the accretion of prescriptive authority into the hands of physicians. She noted three central factors in the shifting of control of the prescription pad to physicians. First, the abuses and public dangers engendered by vendors of patent medicines attracted the attention of politicians and journalists at the turn of the century. Second, the growing political influence of the American Medical Association (AMA) led to its greater ability to pass laws limiting prescriptive authority to physicians. Also, drug manufacturers began to rely more heavily on physicians to promote their products, as physicians were increasingly seen as sources of expert information on drugs. The passage of successive versions of the Pure Food and Drug Acts further served to consolidate prescribing power with physicians. Harkless thus concluded that the near-monopoly on prescribing now enjoyed by physicians was less a function of a particular competence than a fortuitous combination of legislative, political, and social events cementing the ability to prescribe firmly in physicians’ hands. The roots of the AMA were those of a civic-minded organization that championed numerous progressive 19th-century causes designed to improve public health. Since the turn of the 20th century, however, a major thrust of the AMA and other branches of organized medicine has been, with varying degrees of explicitness, to limit the number of physicians and control competition from outside the profession (Duffy, 1979). This change has turned medicine into an increasingly conservative profession: “For the past half-century the organized profession has a record of opposing virtually every piece of progressive legislation” (Duffy, 1979, p. 306). This is not to presume that the success of physicians rested entirely on political astuteness. Much of the growing authority of the AMA came from the ability of the profession to establish credible, uniform training programs, as well as scientific advances in infectious disease and improvement in surgical techniques (cf. Duffy, 1979), that imbued the profession with public regard that had been previously lacking. Before the 1920s, medical education was essentially unregulated, requiring no preparatory work or even a baccalaureate degree. Numerous medical schools existed: a handful with national reputations and links to more advanced European training institutions, and some with a rudimentary 2-year curriculum, but none with full-time, salaried staff (Fischer, 1999). Many schools were run by only one or a small number of physicians with extraordinarily limited didactic training. Training was based almost entirely on an apprenticeship model; thus, graduates varied widely in their knowledge base and doctoring proficiencies. Medical practice reflected this haphazard training, and the profession was not held in high regard; many physicians worked primarily in other fields and practiced medicine “on the side” (Duffy, 1979). 6

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In the early part of the 20th century, a Kentucky pathologist, Simon Flexner, was appointed director of the Rockefeller Institute of Medical Research. John D. Rockefeller had a strong interest in improving the quality of medical service in the United States, and Flexner’s dedication to improving medical research, as well as his shrewd public relations skills, along with a huge influx of Rockefeller money, did much to establish standards for medical education in the United States. Coupled with this was the release, in 1910, of a report written by Simon Flexner’s brother, Abraham, that roundly condemned current medical training practices. The report recommended closing many substandard medical schools and proposed a standard curriculum with structured clinical experience and a minimum of 3 years of training. Most medical schools gradually adopted this approach, although not without resistance. Because of his association with the Rockefellers and the tremendous amount of research money coming from that source, Flexner and his report had an enduring effect on the American medical system, unifying an uncertain curriculum, limiting the number of medical schools and their graduates, and bringing a research base to the education of physicians (Chernow, 1998). The resulting improvement in medical practice was a fundamental factor leading to the increased prestige of physicians and the authority of the AMA. The Rise of NPHCPs Numerous other professions have, with varying degrees of success, challenged the dominance of physicians. Osteopathic physicians, dentists, podiatrists, optometrists—and, to smaller degrees, physical therapists and chiropractors—have all acquired some ability to prescribe medications. With the exception of osteopaths, who are licensed and regulated by the same state boards that regulate physicians, no other health care professional group has achieved the carte blanche that MDs enjoy in regard to prescribing. All other groups have various constraints placed on their ability to prescribe, either by means of formulary restrictions (e.g., physical therapists are confined to the prescription of nonsteroidal anti-inflammatory agents) or scope-of-practice restrictions (e.g., podiatrists are able to provide medications only to treat conditions of the lower extremity). Psychologist prescribers will represent a hybrid that is reflective of the diversity that now characterizes the profession: Many psychologists will, of course, choose not to seek prescriptive authority, and their licensure and scope of practice will remain unchanged. Those who do will retain their independent licensure to provide psychological services but will also be certified to provide medications from a restricted formulary. Formularies for prescribing psychologists will be limited to psychotropics, but may in addition include adjunctive agents (e.g., anticholinergics or anti-Parkinsonian drugs) that are used to treat side effects of commonly used psychotropic drugs. INTRODUCTION

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Nurse Practitioners NPHCPs, largely nurse practitioners (NPs) and physician assistants (PAs), have experienced an explosive increase in numbers over the past few years. Both professions have recent historical roots in the United States. Training for either did not begin on a large scale until the 1960s. Despite this recent entry into the health care marketplace, both professions have experienced not only a dramatic increase in numbers and scope of responsibility but also increasing prominence as major players in the provision of health care. NPs and advanced-practice nurses (APNs) continue to make significant strides in increasing of their scope of clinical responsibility, including major expansion of prescriptive rights. By the year 2000, APNs in all 50 states had legal authority to receive or dispense samples of drugs within their scope of practice (Pearson, 2001). Pearson’s (2001) comprehensive annual survey of legislation affecting NPs continues to demonstrate the legislative and regulatory successes of that profession in expanding its members’ scope of practice. Pearson’s survey reveals that, in 2000, NPs had sole authority over their scope of practice (i.e., no physician oversight) in 26 states, with varying degrees of physician oversight in the remaining states. NPs were able to prescribe medications (including controlled substances) completely independent of physician involvement in 11 states and the District of Columbia. Prescribing rights for all medications (including controlled substances) with some degree of physician involvement existed in 31 states, and physicianoverseen prescribing rights (except for controlled substances) existed in 8 states. Pearson also noted that, in 2000, another significant expansion in APNs’ scope of practice occurred when, despite strong lobbying by the AMA, the Health Care Financing Administration rescinded a regulation requiring nurse anesthetists to be supervised by a physician. As encumbrances to the scope of practice of APNs are lifted, their numbers continue to expand. Pearson estimated that 139,394 APNs were licensed in the United States in 2000, including NPs, clinical nurse specialists, certified nurse midwives, and certified registered nurse anesthetists. In 2005, the number of NPs is expected to equal the number of family physicians in practice (Cooper, Laud, & Dietrich, 1998). Physician Assistants Another profession that has experienced an explosive growth in numbers and scope of care is that of physician assistant (PA). Although its historical antecedents are varied, with roots as diverse as 17th-century Russian military medical paraprofessionals (feldshers) and the experience of “barefoot doctors” in 20th-century China (Ballweg, 1999), the American PA experience has some remarkable similarities to that of prescribing psychologists. As Ballweg (1999) described, former military corpsmen, highly trained 8

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in emergency medical intervention, were selected for further training to supplement physician shortages in civilian and merchant marine settings. A few former military corpsmen were trained in the 1930s, but the concept became dormant after the Second World War. In the mid-1960s it was recognized that corpsmen returning from Vietnam had received extensive and costly medical training through the government but had no avenues of employment in the civilian health care system, and they often returned to menial employment with no chance of capitalizing on their medical experience (Smith & Vath, 1971, as cited in Ballweg, 1999). Ballweg pointed out that programs founded during this period, such as those at Duke University and the University of Washington, “presented philosophical challenges to established concepts of medical education” (p. 3), inasmuch as PAs lacked both a premedical background or medical school training in basic biological sciences. Ballweg also enumerated some societal conditions existing during the nascency of the PA profession, such as increasing demand for medical services, dissatisfaction with health care delivery and costs, concerns about the supply and geographical and specialty distributions of physicians, and awareness of other physician extender models (Carter & Gifford, 1982, as cited in Ballweg, 1999) as spurring the development of that profession. It is clear that many of the same issues remain unresolved today, particularly in the field of mental health service provision, and serve as objective bases for the expansion of psychologists’ scope of practice. PAs have significantly expanded their scope of practice and presence as health care providers in the remarkably short period of 35 years. By 1997, there were 104 accredited PA programs, with a 120% increase in enrollments of students since 1989 (Hammond, 1999). Although PAs continue to practice under the supervision of physicians (however variable that may be), and although the profession does not have a stated goal of seeking independent practice (Ballweg, 1999), their scope of practice has nonetheless expanded significantly in the past few decades. This expansion in the scope of responsibility of both NPs and PAs has not gone unnoticed by one of the key players in the health care marketplace: the pharmaceutical industry. Physicians were able to establish a monopoly on prescribing in part because the pharmaceutical industry recognized them as potent agents in marketing their products (Harkless, 1989, as noted earlier). A similar process is under way today for nonphysician providers. In the first quarter of 2000, for example, NPs and PAs received 10% of all drug company representatives’ visits to medical practitioners; the numbers are estimated at 728,000 for NPs and 501,000 for PAs. Summary Nonphysicians and physicians have engaged in similar legislative and political processes to establish the right to prescribe. The long tradition of INTRODUCTION

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the medical profession; the absence of other credible competing health care providers; the establishment of rigorous, respected training programs; and a spirit of true altruism in attempting to protect the public from ineffective or dangerous remedies gave physicians an early monopoly on prescribing. The improved status of their profession gained by instituting standardized, science-based training programs, and the fact that they were the first profession to attempt to regulate allopathic therapies, resulted in a clear and early advantage in control of the political process regulating the prescription pad. In contrast, the efforts of other professions toward this same goal have been shaped by the opposition of the medical profession toward expansion of any clinical privileges, including prescribing, that might be seen as competition to physicians. In spite of the dominance of the medical profession, however, shortages of physicians and changing societal expectations allowed NPHCPs to increase their scope of practice to include prescribing. Although further expansion of nonphysician roles is currently being vociferously opposed by organized medicine (Greene, 2001), this opposition is not scientifically based: There is no evidence to suggest that nonphysicians have poorer outcomes or less patient satisfaction in any area (Catlin & McAuliffe, 1999; see also further discussion of this issue in chapter 11, this volume).

PRESCRIPTIVE AUTHORITY AND PLACEBOS: INFORMING THE DEBATE As noted in the beginning of this chapter, a number of opponents of prescriptive authority for psychologists have argued that the profession should not seek this ability because the effectiveness of psychopharmacological agents has not been incontrovertibly established. These opponents, many of whom are academic psychologists, focus in particular on the high placebo response rate to antidepressants that has been documented in a number of meta-analyses and other reviews. Because this argument often forms the core of their opposition to prescriptive authority, it is worth examining in some detail. Before proceeding further, however, it is important to emphasize two highly salient facts. First, no treatment—behavioral, psychological, or medical—is of undisputed efficacy. Variations in administration and response will always diminish the real-world efficacy of empirically validated treatments. Second, it is illogical in the extreme to oppose a treatment for mental distress on the grounds that its effects are nonspecific, because nonspecificity characterizes the overwhelming majority of responses to any intervention for psychological problems. These caveats, however, should not preclude a discussion of the placebo/nonspecificity issue, for here a psychological perspective can, I believe, advance an understanding of this phenomenon. In medicine, the placebo issue is commonly regarded as an irritant (Morris, 1997) and the 10

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clinical use of placebos as a form of quackery (Shapiro & Shapiro, 1997). Nevertheless, the placebo response is endemic in medicine, and discussion of the role of placebos in the treatment of mental distress is essential to good clinical use of psychopharmacological agents because of the repeatedly demonstrated, often substantial, placebo effect associated with them (Kirsch, 1997). The placebo effect is bound to an array of poorly understood factors, but characteristics of the patient, the clinician, and the disorder are all certainly involved. Patient expectancy undoubtedly plays a major role in determining the strength of a placebo response. This expectancy may be shaped by the patient’s pre-existing attitudes toward a type of intervention, but it has also been demonstrated to be responsive to the type of information provided about the treatment (Flaten, Simonsen, Waterloo, & Olsen, 1997). The placebo effect is not purely psychological but has biological substrates as well, as has been famously demonstrated in studies wherein a placebo-induced analgesic response has been reversed by the administration of the opiate antagonist naloxone (Levine & Gordon, 1984). Also, the nature of the disorder being treated is likely to influence placebo responding. Milder, less chronic forms of a disorder (especially one in which the primary symptoms are often subjective, such as depression) are probably more subject to placebo effects. It is true that placebo responses may be demonstrated in chronic and severe disorders, such as hypertension (Ader, 1997), but it is also clear that patients with certain disorders are more prone toward placebo influences than others. In this regard, it is crucial that clinicians understand differences in placebo responding among various psychological disorders. A high rate of placebo response to antidepressants when used to treat major depression has been convincingly and repeatedly demonstrated in meta-analyses and clinical studies (Frank, Karp, & Rush, 1993; Greenberg & Fisher, 1989; Kirsch & Sapirstein, 1998; Malt, Robak, Madsbu, Bakke, & Loeb, 1999). Antidepressant–placebo differences are in general more prominent when inert placebos are used. In part, this may result from the inability to maintain adequate experimental blinds. Blinds can be weakened or broken because groups receiving active compounds experience therapeutic and side effects of medications, and groups receiving inert compounds note the absence of these effects and correctly deduce that they are receiving a placebo. When active placebos (drugs that are pharmacologically inert as antidepressants but produce some physiological effect comparable to that of the antidepressant in question) are used, antidepressant–placebo differences may be smaller still. Kirsch and Sapirstein (1998) provided a meta-analysis of 19 studies of antidepressant medication and concluded that a very large proportion (approximately 75%) of the response to antidepressants is a placebo response. Furthermore, analysis of their data led them to believe that the nature of the remaining 25% of drug response was sufficiently vague that it could not be INTRODUCTION

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determined if this was an active drug effect or some form of active placebo response. Greenberg and Fisher (1989) noted that because the pharmacological effects of tricyclic antidepressants (TCAs) are readily apparent, and generally bothersome, studies comparing their efficacy to inert placebos were fundamentally flawed, as patients can easily detect when they are prescribed an active compound. Greenberg and Fisher surveyed a number of studies and concluded that active drug effects produced only a modest improvement over placebos and that the effect of the drug was diminished when it was compared against an active placebo. In a recent meta-analysis that compared TCAs with an active placebo (atropine or similar substances), only small, and generally nonsignificant, differences were revealed. Moncrieff, Wessely, and Hardy (1998) investigated the ability of active placebos to unintentionally “unblind” depression research protocols. They included seven studies that compared a TCA with an anticholinergic active placebo (atropine); analysis of results of these studies revealed a small, nonsignificant effect size of .21 favoring antidepressants over active placebos. It should be noted that this analysis was based on a very small number of studies and that none of them involved newer generation antidepressants. Also, in spite of the small effect sizes for antidepressants in this study, the authors noted that their data suggested that between 58% and 68% of patients on antidepressants would respond better than patients receiving a placebo. Nevertheless, the inability to detect a statistically significant effect of antidepressants is striking. On the basis of an earlier meta-analysis (Janicak, Davis, Preskorn, & Ayd, 1993), Preskorn (1996) observed that approximately 25% of the patients in the studies surveyed responded specifically to active antidepressant medication. He suggested that 30%–40% of the remaining participants would have responded to parallel placebo treatments and noted that “the ‘placebo’ response in antidepressant trials is arguably the most reproducible finding in psychiatry” (p. 232). He nevertheless continued to argue that to abandon antidepressant medications would represent a significant step backward in that they have been of tremendous value to patients who respond specifically to them, and he noted that “the pressing issue now is not whether antidepressants work, but what to do when the first antidepressant chosen does not work” (p. 232). Preskorn’s reasoning was identical to that espoused by Hollon (1996), who argued that “if psychotherapy works (that is, if it has causal agency), then it really does not matter if it works for specific or nonspecific reasons” (p. 1028). These meta-analyses are the subject of vociferous debate. Much controversy surrounds methodological issues in meta-analyses. Kirsch and Sapirstein’s (1998) study has been questioned for being overly exclusionary (only 20 of approximately 1,500 studies met criteria), for including studies in which subtherapeutic doses were used or studies that focused on drugs other than recognized antidepressants (Klein, 1998), and for the use of controversial statistical methods (Nathan & Seligman, 1998). Klein (1998) fur12

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ther argued that even if comparison were possible, differences in effect sizes of a meta-analysis can in no way be compared to actual clinical outcomes for individual patients. This criticism is reasonable, although it cannot be applied in particular to meta-analyses. Any study that reports group data is subject to similar limitations, and clinicians must always use caution in applying these results in patient care settings. High rates of placebo response to antidepressants are not unique to the treatment of depression; such responses have also been observed when antidepressants are used to treat other psychological disorders, such as binge eating disorder (Hudson et al., 1998) or anger attacks in depressed patients (Fava, Savron, Grandi, & Rafanelli, 1997). When antidepressant drugs are used to treat other disorders with definable target symptomatology, the response to placebo fades. In the treatment of obsessive–compulsive disorder (OCD), the placebo response rate to antidepressants drops remarkably, suggesting a specific, if yet unknown, pharmacological mechanism of action for the treatment of OCD (Janicak, Davis, Preskorn, & Ayd, 1997). Not only has the efficacy of antidepressant drugs vs. placebo been convincingly demonstrated for OCD, but also there are marked differences between classes of antidepressants. Agents that are more serotonin specific are considerably more efficacious than the TCAs in the treatment of OCD (Piggott, 1999). Thus it may be that, at least in the case of antidepressant agents when the specificity of the disorder or the target symptom is greater, the rate of placebo responding diminishes. Placebo responding might be expected to be high in mild to moderate depression, as it is idiosyncratically experienced and generally comprises a plethora of poorly defined symptoms. Diagnostic specificity, therefore, as well as response specificity, becomes central in analyzing placebo response. There are no reliable data indicating the accuracy of the diagnosis of most patients prescribed antidepressants in real-world clinical practice (Croghan, 2001). This leaves open not only the question of whether antidepressants are being appropriately prescribed for many patients who take them, but how well placebo findings derived from randomized controlled trials (RCTs) translate to everyday clinical settings. As noted previously, placebo responding is likely to be less of a clinical consideration when antidepressants are used strategically to treat highly specific phenomena, such as trichotillomania or other OCD-spectrum behaviors. A further complication to the placebo debate is the absence of a clear-cut dose–response curve for antidepressants. Various pharmacokinetic and pharmacodynamic issues (such as the existence of pharmacologically active metabolites for many antidepressants) cloud the dose–response picture for psychotropics (DeVane, 1998). Clinically, no dose–response relationship for most antidepressants has been demonstrated. For serotonin reuptake inhibitors, plasma drug levels have not been correlated with clinical response (Tollefson & Rosenbaum, 1998). Many patients gain maximum benefit from INTRODUCTION

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the usual starting dose of 50 mg for sertraline, and dose–response relationships for this drug are unclear (Gelenberg, 1997). Fluoxetine once weekly has been shown to be as effective in preventing relapse of depression as has fluoxetine 20 mg daily (Burke, Hendricks, McArthur-Campbell, Jacques, & Stull, 1996). The results of a meta-analysis of dose–effect relationships for antidepressants are instructive. Bollini, Pampallona, Tibaldi, Kupelnick, and Munizza (1999) examined rates of response to various doses of tricyclic, serotonergic, and other antidepressants. They standardized doses of medications given across all studies to an equivalent of 150 mg of imipramine, the recommended dose for this agent. Several significant findings emerged. First, a rather high rate of placebo responding (35%) was observed across all studies. Second, on aggregate, only 53% of patients treated with active antidepressants were judged to be clinically improved. No positive dose–effect relationships were shown for doses higher than the standard recommended dose. Third, although significantly fewer patients treated with lower than recommended doses (less than 100 mg of imipramine equivalents daily) were rated as improved, this difference was not large (46% vs. 53%). Bollini et al. concluded that the dose–response curve for antidepressants was fairly flat and noted that, had an active placebo been used in many of the studies they surveyed, the placebo response might well have been higher. Most analysis of the placebo response to psychotropics focuses on antidepressants. Less well-developed evidence also has demonstrated that the placebo response to other classes of psychotropics, including antipsychotics, can be robust. In a placebo-controlled study that compared the efficacy of haloperidol and risperidone in hospitalized patients with schizophrenia, a placebo response rate of over 50% was demonstrated at the end of the 8-week study (Marder & Meibach, 1994). Unfortunately, comparisons of this nature are difficult to encounter in the schizophrenia literature. Almost two thirds of 2,000 clinical trials in schizophrenia have been found to give inadequate consideration to issues such as placebo effects (Thornley & Adams, 1998). What are the consequences of the placebo debate for the practice of psychologists and other mental health providers? One possible conclusion is to entirely forgo the use of antidepressants, at least in cases of mild to moderate depression, and perhaps with all diagnoses for which a significant placebo response has been demonstrated. This is an extreme approach that has practical and logical flaws. In a practical sense, a clinician would be forced to abandon that portion of depressed patients who demonstrate a positive, non-placebo-mediated response to medication. Because this number hovers around 30% of patients with depression, pursuing this option would exclude a large number of potentially treatable individuals. Logically, it would be an error of considerable dimensions to base a decision regarding the use of antidepressants on the basis of the lack of specificity of their effects. Even if Kirsch and Sapirstein (1998) are correct that the response in this 25%–30% of patients is due to nonspecific effects, this should have little bearing on 14

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clinical decision making. The alternative would be to offer these patients psychotherapy, which, although it may be effective, is even more nonspecific in its effects, to the point that some have labeled it “the ultimate placebo” (Shapiro & Shapiro, 1997, p. 25). As should be clear, a nonspecific treatment is not necessarily a bad one, and the absence of specificity of a particular intervention is not a barrier to its effective clinical use. Another option is to take clinical advantage of the robust placebo response to antidepressants. Because a demonstrably high placebo response exists, it can be argued that placebos might be conceptualized as “weak antidepressants”; that is, they have a considerable ability in their own right to treat symptoms of depression, although pharmacologically active agents (which may be considered “strong antidepressants”) almost universally have more. Should antidepressants, then, be forsaken in most cases in favor of an initial trial of placebo, as this would be less costly and would not expose the patient to the risks of treatment with a biologically active compound? Under this condition placebos might be routinely used in clinical practice to treat mild to moderate forms of depression. This, unfortunately, provides a lessthan-optimal solution. The strongest arguments against the routine use of placebo in the clinical management of depression are grounded in common sense. It is true that at least 30% of all patients treated with placebo show a clinical response, but it is also true that approximately twice that number show a response to an active antidepressant. It is also true that active compounds are far more effective in preventing relapse than placebo (Keller & Boland, 1998). Also, as Preskorn (1996) pointed out, the use of a placebo agent is not without cost. Patients must still make clinic visits, and a medication must be compounded and supplied. Furthermore, patients exposed to pill placebos may develop unpleasant side effects similar to patients who are taking an active compound (cf. Flaten et al., 1997). The ethical ramifications of providing a patient with a deceptive treatment seem insurmountable on two sides. The provision of an ethical informed consent about placebo agents would likely abolish any positive expectancy the patient might harbor regarding the use of inert compounds, and it would be quite difficult to justify the use of a sham medication when effective, biologically active medications exist. In the final analysis, the appropriate use of placebos may be not deploying an inert agent but recognizing that the placebo response is an enduring component of clinician–patient interactions that can be used strategically to enhance outcome. Enhancing patients’ expectations of the potency of any treatment (drug or nondrug) will boost the response to that intervention. This is undoubtedly a component of what Howard, Lueger, Maling, and Martinovich (1993) described as the initial, “remoralization” phase of therapy. Educating patients as to the high placebo response associated with antidepressants may allow them to consider other, possibly more effective regimens. Educating patients as to the nonspecificity of psychotherapeutic INTRODUCTION

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responses may allow them to consider alternative treatments and to be active decisionmakers in the therapeutic process—which in turn may engender enhanced perceptions of independence and self-efficacy. The placebo issue continues to be contentious. Although researchers are making some progress in understanding this complex response, their knowledge remains too rudimentary to permit the strategic use of placebos in clinical practice. It can be said with certainty, however, that a significant proportion of the response to both allopathic and psychological interventions is either a placebo or nonspecific response. It can only be to the advantage of the field that psychologists continue to investigate placebo responding to all forms of mental health intervention. On the other hand, to use the placebo issue as a political argument against psychologist prescribing is both disingenuous and, as I hope the previous analysis demonstrates, specious.

HOW PRESCRIPTIVE AUTHORITY CAN ENHANCE PRACTICE: OVERCOMING GUILD BIASES AND DICHOTOMOUS THINKING TO DEVELOP BEST CLINICAL PRACTICES Diverging opinions regarding effectiveness of drug and nondrug treatments for depression are a clear example of how dichotomous thinking about the superiority of either drug or nondrug treatments negatively affects sound clinical practice. Investigator bias and research designs that are suboptimal for assessing the effects of combined treatments have also contributed to a lack of knowledge about them. If one accepts, however, the fact that in routine practice combined treatments are more common than not, it becomes apparent that the notion of the absolute superiority of one form of treatment over another is probably not shared by the majority of clinicians and their patients. In the ultimate analysis, a significant percentage of patients treated with either medications or psychotherapy fail to respond. The number varies across disorders, but failure rates for acute treatment of 50% or more are not uncommon, and, almost universally, rates of relapse in the long term are even higher. The addition of new agents to the psychotropic pharmacopoeia has not improved this situation; neither has the development of specific psychotherapies. It has been demonstrated that, in general, one form of credible, active psychotherapy is as efficacious as any other (Wampold et al., 1997).1 The following examples regarding the difficulty of implementing combined treatment strategies for two common forms of mental distress—depression and schizophrenia—should inform readers of both the 1This

is, of course, not universal. Highly specific cognitive and behavioral therapies have been devised for specific conditions, and these have been demonstrated to be superior to more nonspecific treatments. An excellent compendium of such treatments may be found in Nathan and Gorman (2002).

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lack of support for unimodal treatments and the difficulty in implementing effective, integrated treatments. High rates of placebo response to antidepressants, equivocal findings in large comparative-outcome trials, and some meta-analyses that have found superiority of nondrug over drug treatments have given rise to considerable controversy over the role of drugs in the treatment of affective illness. This picture is complicated by other studies that have failed to reveal any specific effect of a variety of psychotherapies devised to treat depression and by other studies demonstrating uniformly less than desirable outcomes at long-term follow-up regardless of the treatment used. Rush and Hollon (1991) determined that there was little evidence in the literature to support the superiority of either cognitive, pharmacological, or a combination of the two approaches in treating unipolar depression. Studies published in the intervening years have done little to refute this opinion. Readers should also understand that the rancorous divisions surrounding the treatment of mental disorders are also attributable to changing definitions and societal expectations regarding appropriate treatments. As Healy (1997) observed in the case of depression, the concept of depression that has sprung up since the beginning of the psychopharmacological era is far different from past notions. The modern definition of depression is far more inclusive than historically has been the case and owes much to the ability of antidepressant medications to treat the illness in outpatient settings. Healy noted that, until the late 1950s, significant depression was considered sufficiently unusual that there was considerable question regarding whether antidepressants could be profitably marketed: This is very difficult to understand now, when depression is seen as such a widespread illness—almost the common cold of psychiatry. But at that time many of those affected suffered in silence in the hope that the condition would remit, as it very often did. It was often only when sleep and appetite were completely lost or the individuals were suicidal that their relatives committed them to the asylum, when ECT, after its introduction, often turned them around. Subsequently in the 1960s, when the use of chlorpromazine, Librium, and imipramine had created outpatient psychiatry, primary care physicians began to detect depressive disorders earlier and refer them for appointments. (Healy, 1997, pp. 58–59)

In the case of schizophrenia, it has been assumed for the past several decades that only pharmacological treatments had any effectiveness in managing the disorder. This presumption has little validity, because remission rates for schizophrenia have not improved with the introduction of effective antipsychotics. Hegarty, Baldessarini, Tohen, Waternaux, and Oepen (1994) performed a meta-analysis of 320 outcome studies of individuals with schizophrenia dating back 100 years. According to their criteria for improvement, 40.2% of patients in all studies combined demonstrated a INTRODUCTION

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favorable outcome. Of those treated with antipsychotic medication, 45.6% were judged to have improved at follow-up, a greater percentage than those treated with other methods, such as convulsive treatment, nonspecific therapy, and lobotomy. Hegarty et al. also observed that aggregate numbers of patients considered “improved” increased substantially during the period from 1956 to 1985 (48.5%) but began to decline again, to a surprising low of 36.4% during 1986–1992. This figure, as the authors noted, is not statistically different from rates of improvement reported for the period 1895–1925. These data are subject to a number of interpretations. The authors hypothesized that introduction of antipsychotic agents in the 1950s contributed to the enhanced improvement rates between 1956 and 1985. They also argued that the application of narrow diagnostic criteria in later years might account for the lowered improvement rates seen recently. It may also be theorized that the ascendancy of drug treatment and an abandonment of psychosocial interventions has led to a decline in positive outcomes. The period of 1960–1980, when positive outcomes were highest, may have represented an era when psychosocial and pharmacological interventions were applied with equal vigor. Although appropriate long-term data are unavailable, it seems likely that Hegarty et al.’s results will be extended and that the use of atypical antipsychotic agents (risperidone, ziprasidone, olanzapine, quetiapine, and even clozapine) will not result in much change in overall rates of improvement. On the other hand, there is increasing evidence that combining either specific psychotherapies, such as cognitive–behavioral therapy, behavioral management techniques, or supportive interventions with medications may result in greater improvement than medication alone (for recent reviews, see Rector & Beck, 2001; Spaulding, Johnson, & Coursey, 2001). With the examples of schizophrenia and depression aside, there is a further illusory notion generated by dichotomous models of mental health intervention. This is the fallacy that purely biological or purely psychological therapies exist. So much has been made of this in recent years that little can be added to the discussion here. Nevertheless, the point should be emphasized, to provide some inoculation against simplistic clinical thinking. Purely psychological treatments can be applied in a reasonably pristine manner, at least in manualized treatment studies carried out in research settings. Fair approximations of purely psychological therapies probably exist in most outpatient settings, although the indefinable blend of social support, environmental manipulation, therapist and patient expectancies, and other elements contributing to the nonspecificity of outpatient verbal therapy makes this difficult to measure. On the other hand, pharmacotherapy of mental disorders is never carried out in a vacuum, so the notion that purely biological therapies exist is illusory. All but the most ardent of biological psychiatrists would likely concede that effective psychopharmacology cannot be conducted without prescriber/patient rapport. At a minimum, patients 18

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receive clinical management, wherein the patient’s symptoms are assessed, basic properties of the drug prescribed explained (however briefly), and symptoms reassessed at periodic follow-up visits. No formal psychotherapy is provided, but because active verbal interventions are used, clinical management cannot be assumed to be some type of attention placebo. The positive effect of a strong therapeutic alliance between psychotherapists and patients is well known. There is also evidence suggesting that alliance effects are present in drug-only experimental conditions and that this nonspecific factor may contribute substantially to pharmacological outcome (Krupnick et al., 1996). In everyday practice, it is likely that even the most biologically oriented practitioners provide some degree of verbal intervention that patients interpret as support; hence, measurement of “drug only” conditions, both within and outside of clinical trials, is quite problematic. Societal trends and expectations, evolving definitions of mental disorders, investigatory bias, and guild alliances have all contributed to a situation in which patients are often presented with a false choice between two competing treatments. Nonmedical psychotherapists may argue that psychotherapies are superior in long-term outcome, and—because they are drug free—represent some sort of morally superior treatment. Biologically oriented therapists, on the other hand, dismiss the effectiveness of psychotherapies for many disorders, pointing to superior short-term outcomes and high rates of relapse on withdrawal of an active drug treatment. Neither position is correct. Factors contributing to this dichotomization include both the declining importance of psychotherapy training in psychiatry and the inability of psychologists to use pharmacological interventions. Realistically, though, using both interventions may afford patients the best chance of lasting relief. When one or the other is used, the choice between medications or psychotherapy is pragmatic, not moral, and should be based on the best fit between patient and treatment, as well as the patient’s complete understanding of the options involved, rather than by guild biases or artificial limits to scope of practice.

THE OVERPRESCRIPTION DILEMMA Any discussion of the overuse of psychotropic medications must take place in the context of a dramatic rise in the use of all categories of prescription medications over the past decade. Having said this, it is true that sales of antidepressants were greater than those of any other category of drug in the past 2 years. Antidepressants represented $10.4 billion in sales in 2000, a 21% increase from the previous year. This is reflective of a larger trend of overall increased prescription of medications, as overall spending on drugs increased by amounts similar to that for antidepressants (“Spending on prescription drugs,” 2001). INTRODUCTION

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This represents an escalation of a previously existing trend. The number of prescriptions written by psychiatrists for antidepressants has vastly increased since the mid-1980s, around the time that fluoxetine, the first selective serotonin reuptake inhibitor (SSRI), became available. An analysis of findings of the National Ambulatory Medical Care Survey revealed that patients visiting psychiatrists in 1992 or 1994 were 2.3 times more likely to receive an antidepressant than they were in 1985 (Olfson et al., 1998). Perhaps more alarming is that individuals under 18 years of age were 6.1 times more likely to receive an antidepressant in 1993–1994. Olfson et al. (1998) noted that the rise in use of antidepressants in children was not supported by research. As I discussed previously, there are rather consistent findings that antidepressants in children do not improve outcome more than placebo. Olfson et al. also cited data suggesting far more abstemious use of antidepressants in other countries (England), indicating that this increase may be more or less an American phenomenon. Finally, their analysis suggested that antidepressants were being used for less severe forms of depression than in the past. The tremendous rise in psychotropic drug prescribing has not been limited to psychiatrists. Although the increases have been far smaller for primary care physicians (Pincus et al., 1998), psychotropic drug prescriptions for children and adolescents also significantly increased among these physicians. Much of this was accounted for by increases in visits for stimulant medication; such visits increased sevenfold between 1985 and 1993–1994. Psychotropic drugs have always been among the most commonly prescribed of pharmacological agents. Whether they are overprescribed is a highly contentious issue with few clear answers. On the one hand, there are areas of demonstrated need, where drugs may be less available or affordable and therefore underused. Impoverished rural communities or inner cities may represent sites of relative underusage of psychotropics. On the other hand, evidence that psychotropics are overused exists for a number of groups across the life span. Nowhere is this more apparent than with children and adolescents. In the past few years, trends in the prescription of stimulant medication have received national attention (National Institutes of Health, 1998). Rates of prescription of stimulants that far outstrip predicted rates of prevalence of attentional disorders are evidently common, at least in some areas and with certain groups. Lefever, Morrow, and Dawson (1999) examined the prevalence of attention deficit hyperactivity disorder medication use in two Virginia school districts and found rates of 8%–10% in general; in some groups (fifth-grade White schoolboys), rates of stimulant use were 18%–20%, which vastly exceed estimates of the prevalence of ADHD in these populations. The valuable work of Pincus et al. (1998), cited earlier, has documented significant rises in the prescription of psychotropic medications in the past 15 years. Use of all medications increased substantially, but increases were particularly noticeable for the prescription of stimulant 20

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medications to children and adolescents. In general adult populations, West, Zarin, and Pincus (1997) reported on a group of psychiatrists in a practice research network and discovered that over 90% of these psychiatrists’ patients were receiving psychotropic medications. In geriatric populations, high rates of prescription of psychotropics among institutionalized elderly individuals has received considerable attention (Beers et al., 1992; Schmidt, Claesson, Westerholm, Nilsson, & Svarstad, 1998). In a recent retrospective review of prescribing patterns in nursing homes, 69% of residents were taking at least one psychotropic. Antidepressants were the most commonly prescribed; 61% of residents were taking an antidepressant, and 53% were taking an SSRI. Thirty-two percent of residents were taking a benzodiazepine, and 42% were taking an antipsychotic (Lasser & Sunderland, 1998). This represented a fivefold increase in the use of antidepressants (from a range of 6.1%–16% prior to the introduction of SSRIs). Lasser and Sunderland (1998) speculated that side-effect profiles that are better tolerated by elderly patients had increased the use of these agents in nursing homes. Those authors welcomed this increase in light of cited statistics that between 15% and 25% of nondemented nursing home patients, and up to 57% of nursing home patients with Alzheimer’s disease, had symptoms of depression, thereby suggesting that previously untreated depressions were now being better managed. It is true that arguments that psychotropics are overused in the elderly must be balanced against the fact that certain disorders, such as late life depression, may be undertreated in other geriatric populations (Abou-Saleh, 1998). Undertreatment does not, however, imply that pharmacological intervention needs to become the mainstay treatment. Psychosocial intervention may be equally effective in many of these cases, and psychological or other psychosocial interventions are, in general, woefully unavailable in institutional settings. On the whole, it is likely that integrated psychological and pharmacological approaches that are based on well-researched combined treatment paradigms will lead to more abstemious use of psychotropic drugs. Using the example of depression, for which group outcome data indicate that drugs and psychotherapy are equipotent, it makes good theoretical sense to start with nonpharmacological alternatives. To adopt this practice requires fluency in both drug and nondrug interventions, and prescribing psychologists will be, by virtue of extensive training in both fields, well suited to do this. Over the past few years, some investigators have focused on developing best-practices guidelines for combining drug and nondrug treatments. Although well-developed treatment algorithms for combined interventions are lacking, some authors have provided guidance that is worth considering. On the basis of a review of numerous meta-analyses of treatment of depression, Antonuccio et al. (1995) formulated perhaps the most restrictive criteria to date governing the use of antidepressant medications. They suggested that (a) antidepressants be reserved only for patients who do not reINTRODUCTION

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spond to cognitive–behavioral psychotherapy (they found limited evidence supporting the use of insight-oriented therapy and cautioned against its use); (b) psychotherapy be included with all pharmacotherapy to lessen the risk of relapse; (c) only single medications be used until the efficacy and safety of combined pharmacotherapies have been better studied; (d) the lowest therapeutic dose of a medication be used; (e) antidepressants be used with great caution in medically ill hospitalized patients, especially the TCAs; (f) drugs be prescribed with great caution to suicidal patients because of risk of overdose; and (g) no antidepressant be prescribed to children or adolescents and only with great caution to elderly patients (pp. 581–582). These authors further suggested that 8–16 weeks of effective psychotherapy be used for the majority of patients prior to a trial of medication. Some of these suggestions have become less cogent with new developments in psychopharmacology. The safety-in-overdose issue has largely been eclipsed by the precipitous decline in the use of TCAs after the introduction of less lethal agents. Similarly, many newer antidepressants are far less cardiotoxic than earlier agents, reducing, but not erasing, concern about their use in medically ill or elderly patients.2 Other of these suggestions make good sense in the abstract but may not be clinically viable for many patients; for example, waiting 2–4 months to determine a response to psychotherapy will be intolerable for many patients who are depressed. To compound this with the additional delay of the time to onset of action of antidepressants would result in a delay in the provision of effective treatment of potentially more than 5 months. This obviously does not represent good practice. A more reasonable alternative would be to suggest the use of combined treatments if an initial response to psychotherapy is not observed within the first 3–6 weeks of treatment. These concerns aside, Antonuccio et al. are on solid empirical ground when they recommended that the pharmacological treatment of depression be avoided in children and adolescents (see Brown & Sammons, 2002, for a recent review of the literature on pediatric psychopharmacology), that pharmacotherapy not be supplied without psychotherapy, and that no medication be provided without psychotherapy because of the association between the provision of psychotherapy and prevention of relapse (e.g., Jarrett et al., 2001). Frank et al. (1993) reviewed numerous meta-analyses of drug treatment of depression. Their analysis revealed a 50%–60% response rate to antidepressant medication in short-term treatment, with no significant difference between the types of antidepressant agent used. For patients 2Although

the improved safety profiles of most newer psychotropics is undisputed, it is worthwhile here to emphasize the obvious: that safe medications can be used unsafely. For example, providing antidepressants to a patient with an unsuspected bipolar disorder can precipitate a manic episode. Because psychologists are more likely to detect more subtle presentations of mental disorders than are generally trained physicians, however, it seems likely that this represents another instance where psychologist prescribers can enhance the safe provision of psychotropics.

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with recurrent depressive episodes, treatment with medication was less efficacious in preventing relapse, unless medicine was administered at acute dose levels throughout the follow-up period. Frank et al.’s review led them to suggest that drug treatment would lead to a better outcome than placebo or psychotherapy in the presence of any or all of the following criteria: (a) when depression is severe; (b) when a psychotic component exists (in these cases, the addition of antipsychotics is required); (c) melancholic or atypical features exist; (d) the patient prefers medication; (e) competently performed, depression-specific psychotherapy is not available; (f) the patient has shown a prior response to medication; and (g) long-term maintenance prophylaxis is needed (pp. 457–458). In contrast, they suggested that the following conditions indicated the use of psychotherapy alone: (a) patient preference for psychotherapy, (b) patient commitment to psychotherapy, (c) nonpsychotic outpatients who cannot take antidepressants because of medical conditions, and (d) patients with prominent psychosocial difficulties or personality disorders (p. 466). As previously discussed, it seems that the severity criterion is unlikely to survive more intense research scrutiny. Also, at least some data indicate that long-term relapse is best avoided when psychotherapy is added to drug regimens. Thus, the indications for medication-only treatment conditions are probably less frequent than Frank et al. (1993) concluded. Without a doubt, though, there are numerous instances in which patients will prefer medication and, in the case of some chronic relapsing conditions, must rely on medication, with or without other intervention, for optimal functioning. If the use of medication in the treatment of unipolar depression is guided by the conservative but prudent recommendations suggested previously, it is unlikely that adopting combined treatments will lead to an increase in unnecessary prescribing. If psychologists, as single providers, are able to incorporate mood-stabilizing agents or antipsychotic agents into psychosocial regimens for the treatment of cycling mood disorders or psychosis, it is probable that patients will be afforded more than the standard drug-only treatments that are often recommended for such conditions and, if speculations about the superiority of combined treatments are correct, outcomes will improve.

CONCLUSION We live in an era of allopathic ascendancy. Prescriptions for all classes of drugs have increased markedly, but sales of antidepressants and other psychotropics have grown more rapidly than almost any other class of drug. It is apparent that for many forms of mental distress drugs are overprescribed, particularly among children and adolescents, and use of these compounds often lacks a sound scientific basis. Some psychologists fear that if psychologists achieve the ability to prescribe they will succumb to the temptations of INTRODUCTION

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easy fixes and their practices will devolve to the point where they are little more than pill-pushing automatons (cf. Adams & Bieliauskas, 1994). Others believe that, because data on combined treatment outcomes in schizophrenia and other serious mental illness indicate that patients do better with both psychological and medication treatments, the acquisition of prescriptive authority will serve as an impetus to develop and provide truly integrated treatments and will ultimately lead to a reduction in medication use. As I asserted earlier, the ability to combine well-developed methods of psychological analysis with expertise in both psychopharmacology and behavioral interventions is a skill almost exclusively limited to doctoral-level psychologists. Such psychologists’ ability to engage in the development of effective behavioral and psychological protocols for patients with mental distress will remain severely compromised if they limit their roles to those of consultants on multidisciplinary teams or advisors to primary care physicians. Only if psychologists directly involve themselves in the prescription of psychotropics can they hope to play a more forceful role in issues such as overreliance on psychotropics, inappropriate use of psychotropic agents in special populations (e.g., children, elderly people), and the neglect of effective behavioral interventions. It represents a surrender to the status quo if psychologists do not intervene and bring a fundamentally different orientation to the prescription of psychotropics—and there is much to suggest that the status quo is not very good. Despite the huge increase in antidepressant prescriptions, for example, there is ample evidence that most primary care patients are not adequately informed about their use and that the majority of these patients stop the medication prematurely, because of side effects or lack of expected benefit (National Depressive and Manic Depressive Association, 2000). Neither does it appear that the situation is much improved when specialty care is involved. Simon, von Korff, Rutter, and Peterson (2001) compared practice patterns between psychiatry and primary care in a Washington State health care organization and found that only 48% of primary care patients received adequate pharmacotherapy for 90 days, as compared with 49% of psychiatric patients. Outcomes as measured by patient completion of self-report scales were not significantly different between patients in psychiatric or primary care practices. Numerous patients did not meet the criterion for “adequate” follow-up care—defined as at least three visits in 90 days, with at least one of those to a prescriber. I believe that most psychologists would object to the notion that three visits in 90 days represents adequate treatment for depression. Simon et al. also stated their belief that it is not differences in expertise between generalists and specialists that is the issue but rather more systemic issues: We believe that shortcomings in primary care and psychiatry practice reflect systemic problems that are unlikely to be overcome by educational approaches alone. In a recent review of research on primary vs. specialty

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care for various chronic medical conditions, Donohoe [1998, cited in Simon et al., 2001] reached a similar conclusion: differences between primary care and specialty practice are less important than the gaps in long-term illness management common to all physicians. (p. 400)

Simon et al. (2001) studied patterns in a managed care organization, but data from the National Depressive and Manic Depressive Association (2000) suggest that these practices are not peculiar to managed care organizations. One is left with the conclusion that the treatment of depression using the medical model (high reliance on drugs, low reliance on behavioral or psychological intervention) is inherently suboptimal for the management of depression and other chronic mental disorders. One may conclude that only if psychologists choose to provide an alternative, by means of which a truly integrated pharmacological and psychological approach can be offered to patients, will they be able to effectively intervene and alter a system that does not provide appropriate treatment to most patients. History has demonstrated that acquisition of prescriptive authority has been a long and difficult political struggle—less so for physicians than for other health care providers, but a political process nonetheless. Dire warnings regarding endangerment of the health of the citizenry have generally accompanied efforts by other NPHCPs to gain prescriptive rights. In no case have these come to pass—indeed, prescriptive authority is often the capstone of a profession’s attempt to become a central player in the health care marketplace. The chapters that follow in this volume should serve to hearten proponents and reassure skeptics of prescriptive authority for psychologists that psychologists’ efforts have been carefully deliberated, their educational programs well designed, and their personal experiences as prescribers consistent with their vision of psychologists as primary providers of behavioral health care. The history presented in this chapter should also convince all involved that, without astute political action, psychologists’ high standards of training, rigorous examination procedures, and ideals for the future of mental health service provision will serve for little save to remind them of what might have been.

PLAN OF THE BOOK This volume is the first dedicated solely to a review of psychology’s history of and current attempts to obtain prescriptive authority, and as psychologists look to the future and recognize paths they must take, one fact is clear: Psychologists have every reason to persevere. Virtually every chapter in this volume identifies psychology’s strengths in the prescriptive authority movement. Ronald E. Fox (chapter 2) reminds readers of the courageous efforts shown by pioneering psychologists at every stage of the INTRODUCTION

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profession’s growth, development, and expansion and how those early efforts paved the way for psychologists’ current activities. Laura S. Brown (chapter 3), in reviewing early and current opposition, actually builds a strong case for psychologists’ prescribing. Readers should be alerted to one fact of great significance in reading this chapter: More commonly than not, the identical arguments enumerated in opposition to prescriptive authority have accompanied virtually every attempt made by psychologists to grow the profession and otherwise expand practice during the past century. Ruth Ullmann Paige and Elizabeth A. Robinson (chapter 4) describe the growing momentum within the American Psychological Association (APA), the world’s largest association of psychologists. Obtaining the right to prescribe is now a policy position of APA, and APA supports state legislative efforts with manpower, dollars, and strategy formation. Gregory B. Laskow and Dennis J. Grill (chapter 5) make clear the importance and the success of the U.S. Department of Defense program. The Department of Defense project left no doubt that psychologists can, and do, prescribe safely and effectively. Debra Lina Dunivin (chapter 6) eliminates all questions, once and for all, about whether a prescribing psychologist is still a psychologist. Such a psychologist is most definitely not a junior psychiatrist but is instead the person best trained to intervene with patients behaviorally and psychopharmacologically. Ronald F. Levant et al. (chapter 7) describe the emergence of several postdoctoral training programs. Their chapter reveals some variations from program to program, but a clear common element is that each thoroughly prepares psychologists to prescribe safely, effectively, and in a uniquely psychological manner. Tommy T. Stigall et al. (chapter 8) eloquently outline the courageous, tenacious, and bold efforts of some pioneering, leading-edge states to obtain prescriptive authority for psychologists. Linda F. Campbell and Pat Gardner (chapter 9) make eminently apparent that psychologists do not exist in a vacuum. They need to have, and they do have, consumer allies—patients who want psychologists to prescribe because patients believe they will benefit from psychologists’ services and from their new service delivery model founded in psychology. Patricia M. Bricklin and Janet Ciuccio (chapter 10), in outlining the thoughtful and comprehensive processes involved in the creation of the Psychopharmacology Examination for Psychologists, provide a worthy exemplar of the solidly grounded, carefully devised processes that typify many aspects of the movement itself. In chapter 11, the editors of this volume describe the evolution of the professional practice of psychology from psychologists’ initially narrow scope of practice in assessment and psychotherapy to the current expansion to a new role: as primary providers of behavioral health care. This new role acknowledges psychologists’ status as the premier providers of interventions designed not only to treat emotional and psychophysiological disorders but also to promote states of wellness and enhance psychological resilience. The editors also address the issue frequently raised by opponents of prescribing psychologists: that the acquisi26

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tion of prescriptive authority will harm patients. The chapter demonstrates that in no instance where NPHCPs have acquired prescriptive rights has patient safety been compromised. Thus, the chapters in this book provide a compelling illustration that psychologists can and should prescribe. We are demonstrably on our way.

REFERENCES Abou-Saleh, M. T. (1998). Pharmacological treatment of mood disorders in the elderly. Current Opinion in Psychiatry, 11, 441–445. Adams, K. M., & Bieliauskas, L. A. (1994). On perhaps becoming what you had previously despised: Psychologists as prescribers of medication. Journal of Clinical Psychology in Medical Settings, 1, 189–197. Ader, R. (1997). The role of conditioning in pharmacotherapy. In A. Harrington (Ed.), The placebo effect: An interdisciplinary exploration (pp. 138–165). Cambridge, MA: Harvard University Press. Antonuccio, D. O., Danton, W. G., & DeNelsky, G. Y. (1995). Psychotherapy versus medication for depression: Challenging the conventional wisdom with data. Professional Psychology: Research and Practice, 25, 574–585. Ballweg, R. (1999). History of the profession. In R. Ballweg, S. Stolberg, & E. M. Sullivan (Eds.), Physician assistant: A guide to clinical practice (pp. 1–24). Philadelphia: W. B. Saunders. Beers, M. H., Ouslander, J. G., Fingold, S. F., Morgenstern, H., Reuben, D. B., Rogers, et al. (1992). Inappropriate medication prescribing in skilled nursing facilities. Annals of Internal Medicine, 117, 684–689. Bollini, P., Pampallona, S., Tibaldi, G., Kupelnick, B., & Munizza, C. (1999). Effectiveness of antidepressants: Meta-analysis of dose–effect relationships in randomised clinical trials. British Journal of Psychiatry, 174, 297–303. Brown, R. T., & Sammons, M. T. (2002). Pediatric psychopharmacology: A review of new developments and recent research. Professional Psychology: Research and Practice, 33, 135–147. Burke, W. J., Hendricks, S. E., McArthur-Campbell, D., Jacques, D., & Stull, T. (1996). Fluoxetine and norfluoxetine serum concentrations and clinical response in weekly versus daily dosing. Psychopharmacology Bulletin, 32, 27–32. Carter, R. D., & Gifford, J. F. (1982). The emergence of the physician assistant profession. In H. B. Perry & B. Breitner (Eds.), Physician assistants: Their contribution to health care. New York: Human Sciences Press. Catlin, A. J., & McAuliffe, M. (1999). Proliferation of non-physician providers as reported in the Journal of the American Medical Association (JAMA), 1998. Image: Journal of Nursing Scholarship, 31, 175–177. Chernow, R. (1998). Titan: The life of John D. Rockefeller, Sr. New York: Random House. INTRODUCTION

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Cooper, R. A., Laud, P., & Dietrich, C. L. (1998). Current and projected workforce of nonphysician clinicians. Journal of the American Medical Association, 280, 788–794. Croghan, T. W. (2001). Increased spending for antidepressants. Health Affairs, 20, 129–135. DeVane, C. L. (1998). Principles of pharmacokinetics and pharmacodynamics. In A. F. Schatzberg & C. B. Nemeroff (Eds.), Textbook of psychopharmacology (2nd ed., pp. 155–170). Washington, DC: American Psychiatric Press. Duffy, J. (1979). The healers: A history of American medicine. Chicago: University of Illinois Press. Fava, G. A., Savron, G., Grandi, S., & Rafanelli, C. (1997). Cognitive–behavioral management of drug-resistant major depressive disorder. Journal of Clinical Psychiatry, 58, 278–282. Fischer, J. E. (1999). Flexner and the whole-time system: The second Flexner report and the whole-time system in American academic surgery. American Journal of Surgery, 178, 2–13. Flaten, M. A., Simonsen, T., Waterloo, K., & Olsen, H. (1997). Pharmacological classical conditioning in humans. Human Psychopharmacology: Clinical and Experimental, 12, 369–377. Frank, E., Karp, J. F., & Rush, A. J. (1993). Efficacy of treatments for major depression. Psychopharmacology Bulletin, 29, 457–475. Gelenberg, A. J. (1997). Introduction: The practice of pharmacotherapy. In A. J. Gelenberg & E. L. Bassuk (Eds.), The practitioner’s guide to psychoactive drugs (4th ed., pp. 3–19). New York: Plenum. Greenberg, R. P., & Fisher, S. (1989). Examining antidepressant effectiveness: Findings, ambiguities, and some vexing puzzles. In S. Fisher & R. P. Greenberg (Eds.), The limits of biological treatment for mental distress: Comparisons with psychotherapy and placebo (pp. 1–37). Hillsdale, NJ: Erlbaum. Greene, J. (2001, January 1–8). AMA backs limits on scope on nonphysician practice. American Medical News. Retrieved July 31, 2002, from http://www.ama.assn.org/sci-pubs/amnews/pick_01/prsb0101.htm Hammond, J. (1999). Education. In R. Ballweg, S. Stolberg, & E. M. Sullivan (Eds.), Physician assistant: A guide to clinical practice (pp. 24–36). Philadelphia: W. B. Saunders. Harkless, G. E. (1989). Prescriptive authority: Debunking common assumptions. Nurse Practitioner, 14, 57–61. Healy, D. (1997). The antidepressant era. Cambridge, MA: Harvard University Press. Hegarty, J. D., Baldessarini, R. J., Tohen, M., Waternaux, C., & Oepen, G. (1994). One hundred years of schizophrenia: A meta-analysis of the outcome literature. American Journal of Psychiatry, 151, 1409–1415. Hollon, S. D. (1996). The efficacy of effectiveness of psychotherapy relative to medications. American Psychologist, 51, 1025–1030.

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Howard, K. I., Lueger, R. J., Maling, M. S., & Martinovich, Z. (1993). A phase model of psychotherapy outcome: Causal mediation of change. Journal of Clinical and Consulting Psychology, 61, 678–685. Hudson, J. I., McElroy, S. L., Raymond, N. C., Crow, S., Keck, P. E., et al. (1998). Fluvoxamine in the treatment of binge-eating disorder. A multicenter placebocontrolled, double-blind trial. American Journal of Psychiatry, 155, 1756–1762. Janicak, P. G., Davis, J. M., Preskorn, S., & Ayd, F. J. (1993). Principles and practice of psychopharmacotherapy. Baltimore, MD: Williams & Wilkins. Janicak, P. G., Davis, J. M., Preskorn, S. J., & Ayd, F. J. (1997). Principles and practice of psychopharmacotherapy (2nd ed.). Baltimore, MD: Williams & Wilkins. Jarrett, R. B., Kraft, D., Doyle, J., Foster, B. M., Eaves, G., & Silver, P. C. (2001). Preventing recurrent depression using cognitive therapy with and without a continuation phase. Archives of General Psychiatry, 58, 381–388. Keller, M. B., & Boland, R. J. (1998). Implications of failing to achieve successful long-term maintenance treatment of recurrent unipolar major depression. Biological Psychiatry, 44, 348–360. Khan, A., Warner, H. A., & Brown, W. A. (2000). Symptom reduction and suicide risk in patients treated with placebo in antidepressant clinical trials: An analysis of the Food and Drug Administration database. Archives of General Psychiatry, 57, 311–317. Kirsch, I. (1997). Specifying nonspecifics: Psychological mechanisms of placebo effects. In A. Harrington (Ed.), The placebo effect: An interdisciplinary exploration (pp. 166–186). Cambridge, MA: Harvard University Press. Kirsch, I., & Sapirstein, G. (1998). Listening to Prozac but hearing placebo: A meta-analysis of antidepressant medication. Prevention and Treatment, 1, Article 0002a. Retrieved July 31, 2002, from http://www.apa.org Klein, D. F. (1998). Listening to meta-analysis but hearing bias. Prevention and Treatment, 1, Article 0006c. Retrieved July 31, 2002, from http://www.apa.org Krupnick, J. L., Sotsky, S. M., Simmens, S., Moyer, J., Elkin, I., Watkins, J., et al. (1996). The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: Findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology, 64, 532–539. Lasser, R. A., & Sunderland, T. (1998). Newer psychotropic medication use in nursing home residents. Journal of the American Geriatrics Society, 46, 202–207. Lefever, G. B., Morrow, A. L., & Dawson, K. V. (1999). High prevalence of drug therapy for attention-deficit hyperactivity disorder (ADHD) among children in public schools. American Journal of Public Health, 89, 1359–1364. Levine, J. D., & Gordon, N. C. (1984). The role of pain in placebo analgesia. Proceedings of the National Academy of Sciences, 76, 3528–3531. Malt, U. F., Robak, O. H., Madsbu, H. P., Bakke, O., & Loeb, M. (1999). The Norwegian Naturalistic Treatment Study of Depression in General Practice (NORDEP) I: Randomised double blind study. British Medical Journal, 318, 1180–1184. INTRODUCTION

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Marder, S. R., & Meibach, R. C. (1994). Risperidone in the treatment of schizophrenia. American Journal of Psychiatry, 151, 825–835. Moncrieff, J. (2001). Are antidepressants overrated? A review of methodological problems in antidepressant trials. Journal of Nervous and Mental Disease, 189, 285–295. Moncrieff, J., Wessely, S., & Hardy, R. (1998). Meta-analysis of trials comparing antidepressants with active placebos. British Journal of Psychiatry, 172, 227–231. Morris, D. B. (1997). Placebo, pain, and belief: A biocultural model. In A. Harrington (Ed.), The placebo effect: An interdisciplinary exploration (pp. 187–207). Cambridge, MA: Harvard University Press. Nathan, P. E., & Gorman, J. M. (2002). Treatments that work (2nd ed.). New York: Oxford University Press. Nathan, P. E., & Seligman, M. E. P. (1998). Editors’ note: Listening to Prozac but hearing placebo: A meta-analysis of antidepressant medication. Prevention and Treatment, 1, Article 0002a. Retrieved July 31, 2002, from http://www.apa.org National Depressive and Manic Depressive Association. (2000). Beyond diagnosis: Depression and treatment. Chicago: Author. National Institutes of Health. (1998). NIH Consensus Development Conference: Diagnosis and treatment of attention deficit hyperactivity disorder. Washington, DC: Author. Olfson, M., Marcus, S. C., Pincus, H. A., Zito, J. M., Thompson, J. W., & Zarin, D. A. (1998). Antidepressant prescribing practices of outpatient psychiatrists. Archives of General Psychiatry, 55, 310–316. Pearson, L. (2001). Annual legislative update: How each state stands on legislative issues affecting advanced nursing practice. Nurse Practitioner, 26, 7–57. Piggott, T. A. (1999). A review of the efficacy of selective serotonin reuptake inhibitors in obsessive–compulsive disorder. Journal of Clinical Psychiatry, 60, 101–106. Pincus, H. A., Tanielian, T. L., Marcus, S. C., Olfson, M., Zarin, D. A., Thompson, J., et al. (1998). Prescribing trends in psychotropic medications: Primary care, psychiatry, and other medical specialties. Journal of the American Medical Association, 279, 526–531. Preskorn, S. H. (1996). A dangerous idea. Journal of Practical Psychiatry and Behavioral Health, 1, 231–234. Rector, N. A., & Beck, A. T. (2001). Cognitive behavioral therapy for schizophrenia: An empirical review. Journal of Nervous and Mental Disease, 189, 278–287. Rush, A. J., & Hollon, S. D. (1991). Depression. In B. D. Beitman & G. L. Klerman (Eds.), Integrating pharmacotherapy and psychotherapy (pp. 121–142). Washington, DC: American Psychiatric Press. Schmidt, I., Claesson, C. B., Westerholm, B., Nilsson, L. G., & Svarstad, B. L. (1998). The impact of regular multidisciplinary team interventions on psychotropic prescribing in Swedish nursing homes. Journal of the American Geriatrics Society, 46, 77–82.

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Shapiro, A. K., & Shapiro, E. (1997). The placebo: Is it much ado about nothing? In A. Harrington (Ed.), The placebo effect: An interdisciplinary exploration (pp. 12–36). Cambridge, MA: Harvard University Press. Simon, G. E., von Korff, M., Rutter, C. M., & Peterson, D. A. (2001). Treatment process and outcomes for managed care patients receiving new antidepressant prescriptions from psychiatrists and primary care physicians. Archives of General Psychiatry, 58, 393–401. Smith, R. A., & Vath, R. E. (1971). A strategy for health manpower: Reflections on an experience called MEDEX. Journal of the American Medical Association, 217, 1365. Spaulding, W. D., Johnson, D. L., & Coursey, R. D. (2001). Combined treatments and rehabilitation of schizophrenia. In M. T. Sammons & N. B. Schmidt (Eds.), Combined treatments for mental disorders: A guide to psychological and pharmacological interventions (pp. 161–190). Washington, DC: American Psychological Association. Spending on prescription drugs increases by almost 19 percent. (2001, May 8). The New York Times. Retrieved July 31, 2002, from http://www.nytimes.com/2001/ 05/08/national/08DRUG.html Thornley, B., & Adams, C. (1998). Content and quality of 2000 controlled trials in schizophrenia over 50 years. British Medical Journal, 317, 1181–1184. Tollefson, G. D., & Rosenbaum, J. F. (1998). Selective serotonin reuptake inhibitors. In A. F. Schatzberg & C. B. Nemeroff (Eds.), Textbook of psychopharmacology (2nd ed., pp. 219–238). Washington, DC: American Psychiatric Press. Valenstein, E. S. (1998). Blaming the brain. New York: Free Press. Wampold, B. E., Mondin, G. W., Moody, M., Stich, F., Benson, K., & Ahn, H. (1997). A meta-analysis of outcome studies comparing bona-fide psychotherapies: Empirically, “all must have prizes.” Psychological Bulletin, 122, 203–215. West, J. C., Zarin, D. A., & Pincus, H. A. (1997). Treatment issues in clinical psychopharmacology: Clinical and psychopharmacological practice patterns of psychiatrists in routine practice. Psychopharmacology Bulletin, 33, 79–85. Zito, J. M., Safer, D. J., dosReis, S., Gardner, J. F., Boles, M., & Lynch, F. (2000). Trends in the prescribing of psychotropic medications to preschoolers. Journal of the American Medical Association, 283, 1025–1030. Zuvekas, S. H. (2001). Trends in mental health services use and spending, 1987– 1996. Health Affairs, 20, 215–224.

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2 EARLY EFFORTS BY PSYCHOLOGISTS TO OBTAIN PRESCRIPTIVE AUTHORITY RONALD E. FOX

The prescriptive authority movement grew out of two separate but closely related trends: (a) the growing professionalism of the field and (b) changes in the scope of psychological practice. The first trend began more than 60 years ago and is still continuing; the second began several decades later as an outgrowth or natural consequence of the first. In this chapter I summarize these trends, discuss where things currently stand, and then attempt to elucidate some lessons for the future.

THE GROWING PROFESSIONALISM OF PSYCHOLOGY Many psychologists believe that modern professional psychology grew out of the standardization of clinical psychology training programs by the American Psychological Association (APA) at the behest of the Department of Veterans Affairs and the National Institute of Mental Health after World War II. Indeed, the funds provided by the Department of Veterans 33

Affairs and National Institute of Mental Health to psychology departments for clinical training played a critical role in fostering the growth and development of modern professional psychology (Routh, 2000). However, the perceived need for highly trained and skilled professional practitioners had been anticipated several years earlier. The lead article in the first issue of the Journal of Consulting Psychology in 1938 was devoted to the topic of professional education in psychology and to the formation of the new American Association of Applied Psychology (Poffenberger, 1938). Psychologists who believed their interests were not well served by APA, which at that time was dominated by scientists and academicians, formed the new association. Supporters of the new organization advocated the creation of a new Doctor of Psychology (PsD) program that would place major emphasis on preparation for clinical service and less on conducting research. This same goal would appear and reappear in discussions and debates about optimal professional training over the next few decades until a purely professional degree and training model was approved by the APA Council of Representatives in 1973. It is ironic that what may be the greatest boost to the development of psychology as a practice profession came from a proposal made by a prominent psychiatrist, Lawrence Kubie (Kubie, 1954). Kubie proposed a new profession (called medical psychology) that combined the best elements of psychiatry, psychology, psychoanalysis, and social work into a new type of practitioner capable of truly integrating biological and behavioral aspects of mental health treatment. The interest and enthusiasm sparked by Kubie’s creative proposal eventually led to the establishment of a doctor of mental health (DMH) degree jointly offered by the University of California’s Berkeley and San Francisco campuses (Wallerstein, 1991). As Kubie had proposed, the new program combined behavioral, social science, and biological aspects of diagnosis and treatment to prepare graduates for practice in the community and—most controversially, as it turned out—to prescribe and administer psychotropic drugs autonomously. The first students were admitted in 1973 amidst great excitement. Unfortunately, this highly innovative program was closed after graduating the class of 1986, primarily because of the jockeying for leadership in the new community mental health movement among the mental health professions and the adamant opposition of organized medicine to the licensure of program graduates for independent practice that included the prescribing of medications. Another significant milestone in the professionalization of psychology came from a proposal developed by Paul Meehl, one of psychology’s most innovative and critical thinkers. At a retreat of the University of Minnesota Department of Psychology in 1964, Meehl (1971) first catalogued the deficiencies in the scientist–practitioner model of education, to which all accredited programs at that time were committed, and then proposed the 34

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creation of an alternate doctorate: a doctor of psychology (PsyD) in professional clinical psychology. The PsyD program would include some medical school courses but not as many as the DMH program based on Kubie’s ideas. Meehl called for an applied psychology training program explicitly designed for professional practice, not research, thus echoing the call issued by his psychology predecessors in 1938. The Minnesota faculty debated Meehl’s proposal at some length but never implemented it. However, the power of Meehl’s logic and persuasiveness captured the imagination of many colleagues in other parts of the country who were bothered by the lack of professionalism in many doctoral training programs at that time. Meehl gave voice to their dissatisfactions, provided direction on how to proceed, and spelled out the supporting arguments in a logical and thorough manner that was difficult to refute. Meehl’s was not the only voice critical of current training. The 1960s was a decade marked by a rising tide of criticisms of traditional educational models and calls for more emphasis on practice and professional issues. Practitioners were gaining more access to APA governance positions and were making their presence felt through calls for educational reforms that would better prepare graduates for practice. Many of their concerns were reflected in a 1964 report of APA’s Committee on Scientific and Professional Aims of Psychology (Pottharst, 1973). The committee underlined the shortcomings of graduate education, claiming that research training and the dissertation requirement were emphasized at the expense of preparing graduates as deliverers of services to people in distress. They recommended that training programs be housed in administrative structures different than departments of psychology (e.g., medical schools or schools of applied behavioral science), that they employ practitioners who practiced in the community, and that the PsyD degree be granted to graduates of the new programs. The recommendations were not adopted by APA, but they were influential, and they were highly similar to those made by Meehl to the Minnesota faculty. Barely 4 years after Meehl’s proposal, the first PsyD program in the United States was established, not at Minnesota but in the psychology department of the University of Illinois by Donald Peterson, a Minnesota PhD. Earlier, at a Chicago conference on the professional preparation of clinical psychologists (Hoch, Ross, & Winder, 1966), Peterson had gained qualified and somewhat grudging acceptance for a PsyD program as an experimental alternative to the PhD programs then in existence. This approval partially acknowledged the criticisms of current training promulgated by many young psychology practitioners who were calling for educational reforms (see, e.g., Newbrough & Barclay, 1964). Although the Chicago conference did not respond to all of the criticisms of professional training that were extant, it did contribute to the advancement of a professional model of training in two fundamental ways (Pottharst, 1973). First, it highlighted a number of critical issues associated EARLY EFFORTS BY PSYCHOLOGISTS

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with the professional model, including the definition of professional psychology, professional schools as preferred centers of professional education, and a specific degree (the PsyD) for professional practitioners. Second, the conference recommended modifications in the scientist–practitioner model that included greater involvement of experienced clinicians in training and accorded greater recognition for faculty members’ clinical practice and professional activities in addition to their research activity. In addition to the Chicago conference, 1966 also was the year that a group of psychologists advocating the establishment of professional schools and sweeping changes in existing programs founded the National Council on Graduate Education in Psychology (NCGEP; Pottharst, 1973). The new organization quickly drew widespread attention and the support of many APA practice divisions, state associations, and leaders in the practitioner community. Over the next few years, NCGEP became a significant lobbying group within APA for changes in practitioner education and training and a central repository for practitioner criticisms of current professional education. Largely in response to NCGEP, APA established the Ad Hoc Committee on Professional Training to consider several issues, including the identification of innovative training models or programs; the provision of consultation and assistance in their development, support, and evaluation; and sponsorship of a national training conference. For a variety of organizational and individual differences, the task force was able to complete only one of its major objectives: planning and implementing a national conference on professional education and training. The new conference met in Vail, Colorado, in 1973 (Korman, 1973). Among the diverse and sometimes-controversial agenda items addressed was one action that constituted a historic step for advocates of more explicit professional training for practitioners; it asserted that “the development of psychological science has sufficiently matured to justify creation of explicitly professional programs in addition to programs for training scientists and scientist–professionals” (Korman, 1973, p. 99). Furthermore, the conference addressed the long-standing debate over the appropriateness of a different degree for practitioners and recommended that completion of doctoral-level training in explicitly professional programs should be designated by the awarding of the Doctor of Psychology (Psy.D.) degree, and that completion of doctoral-level training in programs to train scientists or scientist–professionals be designated by the Doctor of Philosophy (Ph.D.) degree. (Korman, 1973, p. 101)

By the time the conference convened, several independent movements toward the professionalization of training had already occurred that were applauded in the practitioner community and provided a significant backdrop for the Vail conference. One such development was the California Psychological Association’s founding of the first state-chartered, degree-granting, 36

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freestanding professional school, which opened its doors on two campuses in 1970. The same year, a group was organized in New Jersey to begin plans for the establishment of a professional school in that state. The group succeeded in founding a new school of graduate and professional psychology at Rutgers University, which admitted its first class 4 years later. Other significant events that occurred in 1970 included the decision by administrators at Adelphi University to organize the university’s clinical training program as a professional school and the granting of provisional approval by APA’s Accreditation Committee to the PsyD program at the University of Illinois. The APA Council of Representatives finally recognized the legitimacy of explicitly professional training leading to a professional degree in 1976. Implementation of the new policy was placed in the hands of the Education and Training Board, which the council directed to revise its accreditation criteria in keeping with the recommendations of the Vail Conference. Although this action did not end the debates over the most appropriate training for practitioners, it did give legitimacy to those who wanted to pursue that alternative to the traditional model. Over the next decade, the National Council of Schools of Professional Psychology grew to include 22 full and 6 associate institutional members (Bent, 1987). In less than 40 years, the profession of clinical psychology grew from a relatively small number of practitioners who were mostly involved in test administration to more than 50,000 providers delivering a wide range of behavioral assessment and intervention services. The profession of psychology moved from having no common educational model to having two major models with strong accreditation criteria and an extensive accreditation process for doctoral programs and internships. In the beginning, there was little or no statutory or formal recognition as a profession. By the 1980s, there were psychology licensure laws in every state, the authority to diagnose and treat was recognized in federal and state laws and policies, eligibility for insurance reimbursement was universal, and psychologists had emerged as health service providers and the most highly educated of all the mental health professions. From 1940 to 1980, APA changed from a small, predominately scientific organization that held its national conferences on university campuses to a large, predominately professional society that was too large to meet in any but a handful of cities. With increased professionalism came changes in the scope of psychological practice that ranged from intellectual-testing technicians to autonomous providers of a wide range of assessment and intervention services with the ability to admit and treat hospital patients. Much of the expanded scope of practice—in particular, licensure as independent providers, the right to diagnose and treat, and the ability to provide psychotherapeutic services—was accomplished over the objections of organized medicine. The impetus for adding prescriptive authority to psychology’s scope of practice came from several sources, as I explicate in the following section. EARLY EFFORTS BY PSYCHOLOGISTS

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EXPANDING THE SCOPE OF PSYCHOLOGICAL PRACTICE As psychological principles and techniques were applied in an increasing array of situations and venues, questions arose about the legitimacy of psychologists’ use of techniques and procedures that went beyond “talk” to such activities as recommending a drug regimen (called pain cocktails) in chronic pain treatment programs, ordering physical restraints for hospital patients, diagnosing functional brain abnormalities, and the like. The APA Board of Professional Affairs appointed a task force to survey current practices and make recommendations. The final report (Board of Professional Affairs Task Force Report, 1981) cast a large net with respect to psychology’s scope of practice. The task force noted a large number of procedures developed and used by psychologists to treat such physical conditions as tracheotomy addiction, megacolon, and chronic pain, to name only a few. The task force defined the scope of psychological practice as the observation, assessment, or alteration of behavior and concomitant physiological functioning through behavioral procedures and concluded that the techniques available to effect such alterations included both physical as well as purely psychological interventions. By that definition, asserted the task force, psychologists using physical interventions are practicing within the scope of their profession if such use ■

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is in the domain of health care and designed to improve the quality of assessment or treatment; is within the scope of the practitioner’s competence by virtue of appropriate training, supervision, and experience; and is determined primarily by a decision based on consumer welfare.

To the surprise of many, the task force members did not limit themselves to examining those physical interventions under question; they also gave attention to prescriptive drugs, noting the substantial contributions psychologists had made to the field of chemotherapeutic intervention and concluding that it probably was unwise for psychology as a science and as a profession to accept an indefinite “proscription” of prescriptive interventions. The report was accepted by the Council of Representatives but was not formally incorporated into APA policy until 1995, when the council formally endorsed prescriptive authority as a legitimate part of psychological practice for appropriately trained, licensed psychologists. However, the seed had been firmly planted in the minds of many psychologists, who began to rethink their professional roles and how they defined themselves. More food for thought was provided the following year by additional evidence that nonphysician providers could be trained to dispense medications appropriately and responsibly without the necessity of acquiring a med38

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ical degree. The most extensive and relevant demonstration to date came from a project conducted under the auspices of the State of California, Office of Statewide Health Planning and Development, Division of Health Professions Development (1982), which used its health manpower demonstration authority to conduct 10 different training projects over a period of several years. The final report delivered to the California legislature recommended that clear authority be enacted for prescribing and dispensing drugs by appropriately trained physician assistants, pharmacists, and registered nurses. Noting the strenuous objections of the medical profession to its recommendations, the report writers wryly noted that none of their other projects had received such intense scrutiny. The report encompassed results with more than 1 million patients, 50% of whom had been prescribed drugs. Only 56% of the trainees had at least a bachelor’s degree. Fully 99.5% of patients were comfortable with the care they received; in fact, 84% said that they got more information from the trainees than from physicians, and the supervising project physicians agreed that the project was a success. The recommendations died in the legislature, but the point had been made: Contrary to the claims of professional medical organizations, medical education was not required for responsible prescribing. The results of this and similar studies helped pave the way for nonphysician providers to win prescriptive authority in more and more states in the latter part of the 20th century. With their growing status as health care providers, extensive experience in treating patients on medication in collaboration with physicians, and the demonstrable need for services by professionals who could combine behavioral and medicinal treatment, psychologists were poised for another expansion in their scope of practice. Over the next few years, calls for such an expansion came from several quarters. In a speech to the Hawaii Psychological Association in 1984, U.S. Sen. Daniel K. Inouye startled many psychologists by calling for the profession to seek prescriptive authority as a tangible way to improve the availability of comprehensive, quality mental health services. In the following year, the first psychology prescription bill was introduced in the Hawaii legislature, and APA’s Division of Independent Practice (42) established a committee to make recommendations regarding psychologists’ use of psychopharmacological drugs as a part of their practice and increased access to hospital care for their patients. By 1988, the expansion of psychologists’ scope of practice to include prescriptive authority seemed all but assured by the actions taken by two major divisions of APA. The Division of Clinical Psychology (12) adopted a policy statement urging training programs to develop curricula and training programs in psychopharmacology, and the Division of Psychopharmacology and Substance Abuse (28) established a committee to develop a curriculum for preparing psychologists to prescribe. Further support was provided EARLY EFFORTS BY PSYCHOLOGISTS

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by the first articles to appear in a refereed journal in support of prescribing by psychologists (Burns, DeLeon, Chemtob, Welch, & Samuels, 1988; Fox, 1988). Finally, the Committee for the Advancement of Professional Practice awarded $42,000 to the School of Professional Psychology at Wright State University (Buie, 1988) to conduct a feasibility study on training psychologists to prescribe—the first of many subsequent grants to state associations to help them expand the scope of psychological practice by advancing the prescriptive authority agenda. It was an exciting and exhilarating time for supporters of the change. Several states were preparing for legislative efforts, some training programs were beginning to think about how to integrate the additional training that would be required with the basic doctoral education, state organizing committees were coming into being, and support within the profession and in professional organizations was growing rapidly. Amid this excitement came reports of a psychologist, Floyd Jennings, who had been legally prescribing in the Indian Health Service (DeLeon, Folen, Jennings, Willis, & Wright, 1991) since mid-1988. The Indian Health Service’s Santa Fe Indian Hospital had granted the authority to prescribe to clinical or counseling psychologists with a doctoral degree who had completed an internship that included an inpatient component; 1 year of supervised postdoctoral experience; and relevant experience and training in psychopharmacology, including hands-on supervision with documented physician oversight. Such qualified psychologists were required to keep chart notes reflecting a review of contraindications, precautions, any side effects noted, and the patient’s response to treatment. Consultation with a physician was required when serious side effects were suspected, or contraindications noted, or when an organic disease with psychiatric symptoms was suspected. All orders for controlled substances required a physician’s countersignature. Patients receiving medications prescribed by a psychologist for more than 6 months were required to be evaluated by a physician. Finally, each month the hospital’s clinical director and supervisor of mental health randomly selected five inpatient charts for review. Jennings kept detailed records for 378 patients he treated in the first year. The drugs he had prescribed included amitriptyline, desipramine, doxepin, imipramine, trazodone, chlorpromazine, haloperidol, and trifluoperazine. No adverse experiences were encountered, and his most frequent clinical decision for these patients was to reduce or eliminate drugs previously prescribed by a physician. Because of the unprecedented nature of what he was doing, Jennings sought an opinion about his prescribing activities from the New Mexico Psychological Association’s Ethics Committee. After reviewing the relevant policies of the Indian Health Service and the nature of his practice, the committee ruled that he was practicing within relevant APA ethical principles in his employment by the Indian Health Service. 40

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Once the policy of the Indian Health Service became known, members of the psychiatric profession launched an intense campaign to have it nullified. The result was an eventual ruling requiring all psychologist-written prescriptive orders to be countersigned by a physician. This ruling was significant in that it meant that the focus of the policy debate had shifted from whether psychologists would continue to be allowed to prescribe to the conditions under which they would do so. Another significant event of 1989 probably tipped the balance in favor of including prescriptive authority within psychology’s scope of practice: APA’s Board of Professional Affairs strongly endorsed studying the feasibility of and the appropriate curricula in psychopharmacology so that psychologists might provide broader service to the public and more effectively meet the psychological and mental health needs of society. The board recommended that APA make its highest priority the responsibility of preparing members of the profession to address current and future needs of the public for psychologically managed psychopharmacological interventions. Although the expanded scope of practice was not formally endorsed by the Council of Representatives until 1995, it is clear in retrospect that after 1989 the debate was largely over within the leadership of the practice community: Both of APA’s primary oversight groups for practice (the Board of Professional Affairs and the Committee for the Advancement of Professional Practice) had endorsed the change, the three largest practitioner divisions (12, 29, and 42) had also endorsed it, prescriptive authority committees were active in a dozen states, model curricula were being written, and the Department of Defense (with the formal encouragement of the APA Board of Directors) was being directed by Congress to initiate a demonstration training program under which psychologists would be prepared to prescribe psychotropic medication (see chapters 5 and 6, this volume). There would be many more debates and struggles, just as the debates over earlier expansions had lingered for years, but for all practical purposes the matter was settled within APA as an organization by 1989. The final outcome still lay in the future, and major efforts to pass enabling legislation had not begun, but the issue of whether the field of psychology was committed to the new direction had been decided. It was all over but the shouting, as the saying goes. LESSONS LEARNED After reflecting on the early history of the prescriptive authority movement, several conclusions or lessons may be drawn for future endeavors of this nature: 1. Significant change takes significant time and energy. 2. If psychologists build a true profession, students and the public will come. EARLY EFFORTS BY PSYCHOLOGISTS

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3. Students and new graduates can change the profession. 4. Do not be afraid to make bold moves when they are needed; one cannot leap the Grand Canyon in a series of small steps.

Significant Change Requires Significant Time and Energy Major shifts in the credentialing and definition or scope of practice of a profession do not, as a rule, happen overnight. They require time, energy, resources, commitment, and persistence. From the first proposal for a specific doctoral degree for practitioners to approval of the PsyD degree by APA’s Council of Representatives required a total of 38 years. More than 40 years passed from Kubie’s first proposal to merge some aspects of the social and behavioral sciences of psychology with selected aspects of medicine to produce a new kind of practitioner before the Council of Representatives approved adding the prescribing knowledge and skills to psychology’s scope of practice. Almost 20 years passed after the Task Force on Physical Interventions recommended that psychologists seek prescriptive authority before New Mexico passed the first law in 2002 allowing appropriately trained psychologists to prescribe. The lesson seems clear: If the field of psychology intends to change and expand how it defines itself—which adding prescriptive authority certainly does—then psychologists must be prepared to take a long-range view. Major efforts must be planned and implemented in every state, daunting opposition must be overcome, significant resources must be assembled, and the profession’s support must be steadfast.

If We Build It, They Will Come At every critical juncture in the development of the profession, some colleagues always warn of dire consequences should a particular change or expansion be implemented. Despite the naysayers, increased professionalism and licensing laws did not detract from the discipline. Adding psychotherapy to the scope of practice did not make psychologists junior psychiatrists; neither did the opposition of members of the medical profession lead psychologists to ruin. Winning the right to insurance reimbursement did not medicalize the profession, as some had predicted. Despite the fears and warnings, what has happened is that the public has accepted psychology as another major profession. Laws and policies increasingly recognize psychologists’ expertise. Psychology became the largest undergraduate major in colleges and universities across the country, and graduate enrollments for professional programs have grown as the profession has expanded. Psychology has flourished both as a discipline and as a profession. As the profession was built, society and students embraced it. 42

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Students and Recent Graduates Can Change, and Have Changed, the Profession In the development of psychology as a profession, students and new graduates often have played a pivotal role. The Corresponding Committee of Fifty, consisting of recently graduated clinical psychologists, was formed by APA’s Division of Clinical Psychology in the 1960s to facilitate a dialogue on training and to make recommendations for change to APA (Newbrough & Barclay, 1964; Pottharst, 1973). A similar group of 40 recent graduates of the University of Michigan’s doctoral program also documented what they believed to be a diminishing commitment to improve professional training by APA. Concurrent with these efforts, the Los Angeles Society of Clinical Psychologists, which included a number of articulate, newly minted clinicians, weighed in with similar critiques of professional training (Pottharst, 1973). All of these efforts played a pivotal role in creating the demand for the Chicago conference and helped shape the nature of the deliberations that took place there. Barely 2 years after the report of the Chicago conference, the newly formed National Council on Graduate Education in Psychology, initially organized by two graduate students, was instrumental in shaping developments that led to the convening of the Vail conference, which validated, for the first time, a purely professional model of education leading to a professional degree (Korman, 1973). In psychology, students and new graduates have a history of speaking up, and the profession has demonstrably benefited from taking their criticisms seriously. As the profession moves into new practice venues, psychologists would do well to remember that history.

Do Not Be Afraid to Take Big Steps The report of the Task Force on Psychologists’ Use of Physical Interventions opened new professional territory when it boldly concluded that psychological practice included some physical interventions previously reserved for the medical profession. The task force based its conclusion on the evolution of current practice and a logical extension of that evolution into the future. It looked at the profession as it actually was rather than at what it was supposed to be. Psychologists had developed or used (or both) a number of physical interventions, and they were significantly involved with prescriptive medications in patient care, despite the fact that theirs had not been seen as a hands-on profession. In the future, psychologists should not be afraid to take big steps when big steps are needed. One cannot leap the Grand Canyon in a series of small steps. In the natural evolution of professions, new applications and new arenas for practice are a regular order of business. Professions grow, expand, EARLY EFFORTS BY PSYCHOLOGISTS

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and develop. Sooner or later, such growth inevitably leads to overlaps and conflicts with the boundaries of other professions. Dentistry, nursing, optometry, social work, and pharmacy, for example, all have had to contend with objections from the field of medicine and from one another as each profession expanded its scope of practice. Such conflicts help professions define themselves more clearly and should not be a reason for avoiding growth and expansion. Of course, such conflicts can be daunting when one profession is much more powerful than the other. During the internal debates regarding prescriptive authority, some psychologists have fretted over the certain opposition of the medical profession and how difficult and expensive it will be to counter that opposition. Psychologists cannot shrink from conflicts in which another profession attempts to impose its definition of who psychologists are and what they do. A profession that does not insist on defining its own boundaries will either be extinguished or relegated to technical roles that other professions do not wish to provide themselves. When psychological knowledge, attitudes, and skills lead into new areas of practice, one must not hesitate to follow. This is how professions grow.

REFERENCES Bent, R. J. (1987). Foreword. In E. Bourg, R. Bent, J. Callan, N. Jones, J. McHolland, & G. Stricker (Eds.), Standards and evaluation in the education and training of professional psychologists (pp. vii–ix). Norman, OK: National Council of Schools of Professional Psychology. Board of Professional Affairs Task Force Report. (1981). Psychologists’ use of physical interventions. Washington, DC: American Psychological Association. Buie, J. (1988). Practice priorities: Medicare amendments, hospital privileges, HMO reforms, prescription privileges? APA Monitor, pp. 1, 14–15. Burns, S. M., DeLeon, P. H., Chemtob, C. M., Welch, B. L., & Samuels, R. M. (1988). Psychotropic medication: A new technique for psychology? Psychotherapy, 25, 508–515. DeLeon, P. H., Folen, R. A., Jennings, F. L., Willis, D. J., & Wright, R. H. (1991). The case for prescription privileges: A logical evolution of professional practice. Journal of Clinical Child Practice, 20, 254–267. Fox, R. E. (1988). Prescription privileges: Their implications for the practice of psychology. Psychotherapy, 25, 501–507. Hoch, E. L., Ross, A. O., & Winder, C. L. (Eds.). (1966). Professional preparation of clinical psychologists. Washington, DC: American Psychological Association. Korman, M. (Ed.). (1973). Levels and patterns of professional training in psychology. Washington, DC: American Psychological Association. Kubie, L. S. (1954). The pros and cons of a new profession: A doctorate in medical psychology. Texas Reports on Biology and Medicine, 12, 692–737.

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Meehl, P. R. (1971). A scientific, scholarly, nonresearch doctorate for clinical practitioners: Arguments pro and con. In R. R. Holt (Ed.), New horizons for psychotherapy (pp. 37–81). New York: International Universities Press. Newbrough, J. R., & Barclay, A. G. (1964). Training in clinical psychology: A report of the Corresponding Committee of Fifty. Washington, DC: American Psychological Association, Division of Clinical Psychology. Poffenberger, A. T. (1938). The training of a clinical psychologist. Journal of Consulting Psychology, 1, 1–6. Pottharst, K. E. (1973). A brief history of the professional model of training. In M. Korman (Ed.), Levels and patterns of professional training in psychology (pp. 33–40). Washington, DC: American Psychological Association. Routh, D. K. (2000). Clinical psychology: History of the field. In A. E. Kazdin (Ed.), Encyclopedia of psychology (pp. 113–118). New York: Oxford University Press and American Psychological Association. State of California, Office of Statewide Health Planning and Development, Division of Health Professions Development. (1982). Prescribing and dispensing pilot projects. Sacramento, CA: Author. Wallerstein, R. S. (Ed.). (1991). The doctorate in mental health. Lanham, MD: University Press of America.

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3 DOUBTS ABOUT PRESCRIBING LAURA S. BROWN

Since the question of psychologists as providers of medications emerged at the end of the 1980s, the debate over whether prescribing is an appropriate role for psychologists has been engaged in a number of forums. As of this writing, the leadership of organized professional psychology, through the American Psychological Association (APA) Council of Representatives and the Committee for the Advancement of Professional Practice, has thoroughly adopted the value of such actions by psychologists. However, unanimity does not exist among practicing psychologists regarding this stance. Some practicing psychologists are enthusiastic in their pursuit of training in the use of psychotropic medications. Others are conscientious nonobjectors, preferring never to prescribe medications themselves but willing to allow, if not support, prescriptive authority for colleagues who want them. Still other psychologists are engaged in active, organized opposition, including the introduction of antiprivileges testimony in legislative venues where the inclusion of psychologists as prescribers is being considered. Thus, the debate over the integration of prescribing medications into the array of skills used by practicing psychologists is not over. Whether a somatic intervention can be helpful to many suffering people is less debated at this juncture. Psychologists are increasingly influenced by and trained in 47

a biopsychosocial model of behavior in which the concept of a mind–body split is seen as counter to effective interventions. Although there may be argument over which somatic interventions to offer (e.g., psychotropic drugs vs. herbal remedies, exercise, yoga, or the like), the integration of soma and psyche is now known to be complete. Even those disorders whose causation is routinely seen as psychosocial, such as posttraumatic stress disorder, can be shown to have a biological component resulting from exposure to traumatic stressors. Consequently, in this chapter I do not review the issue of whether psychologists should engage in somatic interventions. Psychologists already perform many somatic interventions aside from the prescribing of psychotropic medications, as part of their treatment of clients. In this chapter I specifically review arguments against psychologists as prescribers of psychotropic medications. A subtext to this discussion is the question of the value of psychotropic medications as the somatic intervention of choice. Because that question is inextricably woven into many of the arguments advanced against psychologists’ prescriptive authority, I also briefly review that issue here. The arguments against psychologists as prescribers of psychotropic medications can be outlined as follows: ■

■

■

the question of threats to the identity of professional psychology principled issues of opposition from within the field of psychology principled and other issues of opposition from outside the field of psychology.

For purposes of disclaimer, I have consistently taken a position against the use of psychotropic medications by psychologists. This perspective and bias inform the discussion in this chapter, just as do the perspectives and biases of those in support of prescribing.

THE OPPOSITION: THREATS TO THE IDENTITY OF PROFESSIONAL PSYCHOLOGY Professional psychologists are commonly those trained in clinical, counseling, and school psychology. Each of these specialties has a unique heritage and boundaries to its identity. In practice, all three kinds of psychologists, when engaged in psychological practice, frequently manifest the same sorts of behaviors, including psychological assessment; the diagnosis of and intervention to ameliorate human distress in its various forms; and working with other members of clients’ social and support networks, including family, physical health care providers, spiritual resources, and community, to assist clients in obtaining and retaining good functioning. 48

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The identities of professional psychologists are founded, historically, in several sources. The science base of practice is a paramount identity issue. The professional practice of psychology, especially the practice of psychotherapy by psychologists, emerged late in psychology’s first century, in the aftermath of World War II. The core identity of all psychology is thus based in psychological science and the scientific study of human behavior, emotion, and cognition (Routh, 1994). Psychology is a science that was, until very recently, informed by Cartesian notions of a mind–body split. As a result, the study of the biological bases of behavior and of the influence of behavior on biology were latecomers to psychologists’ professional identity. This separation of the biology that both underlies and arises from behavioral, affective, or cognitive distress (or some combination of these) has fueled the feeling on the part of some psychologists that prescribing medications is alien to the identity of the profession and its members. In addition, most American psychologists now living have developed, personally and professionally, in the era of allopathic medicine’s hegemony over access to pharmacological resources. The illusion, as a consequence, is that this was always so. In fact, as psychotherapy, which is now a core component of the profession of psychology, was a relative latecomer to psychologists’ identity, so too was the control over pharmacology by allopathic physicians also relatively late on the scene of health care. The field of American medicine has, until very recently, accomplished an effective campaign of public relations regarding the mystery and dangers of prescribed medications (Breggin & Cohen, 1999). But prior to the early 1900s, most medications—including those that are now scheduled narcotics, such as opiate derivatives—were available over the counter, as they continue to be in many other parts of the world. In the past few decades, a number of drugs have made the leap back over the line, from being available by prescription only to over the counter, for example, diphenhydramine (Benadryl) and ibuprofen (Advil). These drugs did not become any more safe, or less dangerous, when their status and modes of availability changed, which raises questions about the importance of a physician’s participation in patient access to any and all medicines. Today, drug companies actively advertise prescription medications through all sorts of media, demystifying medications for the general public. The public is bombarded with television ads for Zoloft, Prozac, and Serafem. Also, although this practice is usually illegal, some prescription drugs, including well-known selective serotonin reuptake inhibitors, can be obtained without prescriptions through Internet sites operating from outside of the United States (Yeoman, 2001). A consequence of these two factors (i.e., the earlier impact on training and practice patterns of the belief in the mind–body split and medicine’s seeming ownership of anything pharmacological) has been that many psyDOUBTS ABOUT PRESCRIBING

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chologists have seen the prescription of medication as lying outside the boundaries of their science and knowledge base. Were these the only factors seen by some as threatening psychology’s identity, they might be rendered moot by current knowledge and conditions. The field of psychology now definitely includes the body; psychoneuroimmunology, psychopharmacology, and other fields of scientific inquiry lie directly within the boundaries of psychology’s identity. Clinical, counseling, and some school psychologists take coursework in these topics and may also have practicum experiences that directly reflect on mind–body connections. As both professionals and consumers, psychologists are aware that psychotropic medications are not mysterious. However, many psychologists see a further identity issue: whether psychologists ought to add an equally strong somatic tool to their armamentarium of interventions or whether they should remain staunchly and strongly identified as practitioners of emotional, interpersonal, and behavioral interventions only. This group of psychologists argues that the factor that distinguishes psychology from psychiatry is that psychologists are the only doctorally prepared mental health professionals whose entire expertise is in interpersonal and behavioral interventions; that through the use of psychometrics, in which psychologists alone receive advanced training, they are prepared uniquely to assess not simply a person’s Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) diagnosis but also the interpersonal dynamics and social problems that will emerge from that list of symptoms. The question that remains is whether professional psychologists can incorporate the prescription of medications into their identity. Will the boundaries flex, as they did after World War II, when psychotherapy and professional practice were added to the identity of psychology, or prior to that, when testing and guidance were added to the science-only parameters of the earliest field? Or, in flexing, will the boundaries break? Will psychologists integrate prescribing into a uniquely psychological perspective, as is reported to be the case in their practices by psychologists who now prescribe? These questions of identity diffusion versus identity expansion lead to the principled opposition to prescriptive authority that has arisen, and continues to function, within psychology itself.

WHY PSYCHOLOGISTS SHOULD NOT PRESCRIBE: VOICES FROM WITHIN THE PROFESSION No One Should Be Prescribing, or Medication as a Dangerous Thing Even within psychiatry there is not unanimity on the value of prescribing medication for distress. Chief among those arguing against the use of 50

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psychotropic medications has been Peter Breggin (1983, 1991; Breggin & Cohen, 1999), who reviews the literature on the dangers and side effects of many of the commonly prescribed psychotropic medications and concludes that in many, if not most, cases such medications are either not efficacious or may be dangerous. Other psychiatric commentators, while not taking a stance as radical as Breggin’s, have raised concerns about possible overprescription of medication, particularly for conditions such as attention deficit hyperactivity disorder. Even apparent proponents of medication use, such as Peter Kramer (1993), address the question of whether, when it is possible to prescribe, a psychiatrist may pull out the prescription pad for subsyndromal levels of anxiety or depression simply to reduce the time and work required to achieve the same outcomes that a number of empirically supported therapies would also achieve. Other commentators have raised concerns that medications are overprescribed for certain vulnerable groups of people. Hamilton and Jensvold (1995) noted that almost none of the psychotropic medications currently on the market were field trial tested on women (as is true for most medications, psychotropic or otherwise; Blumenfeld & Wood, 1997). Yet women are more than twice as likely as men to receive a diagnosis of depression and thus twice as likely to be given a prescription for these medications. African Americans may metabolize psychotropic medications at rates different from those of Caucasians, posing risks of side effects or more dangerous adverse reactions. It is possible that unconscious racist biases on the part of a treating professional might lead to overprescription of medications to African Americans or other ethnic minorities rather than active engagement in a psychotherapy process. Poor people, particularly those who are dependent on Medicaid, may be able to gain access only to medications, not to psychotherapy, because of limitations on providers funded by the program; consequently, they may be overprescribed medications at the expense of psychological therapies. Some psychologists may fear that, in the absence of remediation of this system, the ability to prescribe will lead to psychologists’ participation in already inequitable treatment processes. For psychologists who view their interventions with people as a strategy for social change and the achievement of greater social justice (Brown, 1997), the inclusion of medications in the skill set of psychologists may be particularly problematic. What would it mean for psychologists to use agents that may be seen as calming or palliative to individuals and groups who struggle to promote greater social justice? The Mind Is Part of the Body, or What About Adverse Medication Reactions? Psychotherapy clients frequently have physical as well as emotional problems. Studies from large health maintenance organizations have shown DOUBTS ABOUT PRESCRIBING

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that patients with a history of severe childhood maltreatment, who are at the highest risk of emotional distress and need for psychological services, are also extremely high users of medical services (Walker et al., 1988; Walker, Katon, Roy-Byrne, Jemelka, & Russo, 1993). The same psychosocial factors that are associated with the risk of development of depression, anxiety disorders, posttraumatic stress disorder, and dissociative disorders are also associated with the risk of developing autoimmune disorders, chronic pain, and irritable bowel syndrome. As a result of problematic behaviors such as cigarette smoking, consumption of high-fat diets, and lack of aerobic exercise, many people who are depressed also struggle with cardiovascular disease, Type II diabetes, and cancer. There are, in addition, medical problems whose initial symptoms appear to be entirely psychological in nature. Hypo- and hyperthyroidism, as well as thyroid tumors, are among the best known, with conditions that may closely resemble depression or mania. Early symptoms of undiagnosed multiple sclerosis may be mislabeled as somatization or depression. Tumors of the brain can initially manifest with behavioral changes. All of these realities lead some psychologists to fear the risks to clients’ health if psychologists, who are not trained in the rest of medicine, undertake to prescribe psychotropic medications. Even though life- and health-threatening adverse reactions to medications are rare, they do occur. If a psychologist is able to prescribe medication, will she or he skip the now-necessary step of sending a depressed-appearing client to a medically trained person, either a physician or a nurse practitioner, who will, in the screening process, determine that the symptoms are actually caused by hypothyroidism and that the medication of choice is, consequently, not a selective serotonin reuptake inhibitor but synthetic thyroid hormones? This last question is quite serious. Chronic, untreated hypothyroid problems can lead to permanent losses of cognitive function and eventually to organ failure or death.¹ If psychologists can prescribe medication, will they fill their ethical obligations to screen patients carefully for health concerns and continue the partnerships that many now have formed with family practice and other primary care health providers? Because the bulk of psychotropic medications are prescribed in those health care settings, not in the offices of psychiatrists, the current situation creates a treatment team for patients in which the combined, albeit different, expertises of medicine and psychology can be made available. Will this be less available if psychologists can prescribe medication for their own clients? Or, as was reported in one case (Dunivin & Foust, 1999), will a highly conscientious prescribing psychologist catch a physical diagnosis that was missed by a physician? ¹Editor’s note: This concern actually applies to all of psychological practice. Missing medical diagnoses is not dependent on the prescribing status of the psychologist. There is no evidence to suggest that nonmedically trained therapists “miss” medical diagnoses more frequently than do physicians.

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“No Room in the RAM,” or We Have Too Much to Learn Already Psychology doctoral students today have ever-increasing amounts of material to master. The science of psychology has grown exponentially in the past few decades, with cognitive science and neuroscience leading the way. Also, approaches to treatment, particularly empirically supported efficacious treatments, have increased in number as treatment research has become more targeted and sophisticated. Advances in psychodynamic perspectives have added depth, and time, to psychoanalytic training. Multicultural issues and the recognition of dimensions of human diversity require additional courses of study. Graduate education in psychology, which once took 3 or 4 years and an internship, now routinely takes 6 and 7 years and an internship. Students now graduate having acquired far more information than their predecessors. The human “hard drive” gets more and more full. If prescribing psychotropics is added to normal professional practice for psychologists, then it will become necessary to add what may amount to an additional year’s worth of coursework to the doctoral professional psychology curriculum. How can one ask this of the next generations? If psychologists attempt to control the amount of time required to earn a degree, what equally necessary materials will be deleted from the curricula? Also, if materials are deleted to create space, will professional psychologists be adequately informed on other topics? The Ultimate Victory of Managed Care Health Delivery Systems Managed care health delivery systems, in their zeal to manage costs, tend to overuse psychotropic medication. A patient is seen for an initial visit and then no more than 15 minutes monthly after that: no muss, no fuss, no paying for psychotherapy or paying of claims managers to deal with therapists requesting more sessions. In the early days of managed care health delivery systems some prophets within psychology predicted the demise of the doctoral psychotherapist within the decade of the 1990s. This prediction has not come to pass. Nonetheless, many psychologists who are troubled by prescriptive authority see this as an engine driven by managed care health delivery systems. If psychologists can prescribe drugs, goes this reasoning, psychologists will be kept on managed care panels rather than being tossed off in favor of lesser trained and less expensive master’s-level psychotherapists. Psychologists who have a principled opposition to mental health care delivered through managed care systems thus frequently see the addition of prescribing as a bow to that medical–industrial complex. The redefinition of psychotherapy—a caring, science-based art—into behavioral health, measured out in managed doses, based on symptoms and syndromes, sits poorly DOUBTS ABOUT PRESCRIBING

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with many psychotherapists in psychology, especially those trained psychodynamically and humanistically. Many of these psychotherapists acknowledge the mind–body connection and have been, in the case of humanistic practitioners, at the forefront of integrating nondrug somatic interventions into psychology. To these psychologists, the bow to managed care health delivery systems and the hegemony of psychotropic medications appears to be a betrayal of psychology’s legacy of fighting for client and practitioner autonomy. Summary All of these forms of objection and concern remain extant in the minds of some professional psychologists. For psychologists who, given the chance, would choose never to use prescriptive authority, but who are willing to cede that choice to their colleagues, the acceptance of prescriptive authority does not mean the end of their concerns. At this juncture, none of these hypotheses about the problems with prescriptive authority for psychologists have been subjected to empirical test. Neither, I should add, have the hopeful hypotheses of those who strongly support prescriptive authority been adequately tested. The Department of Defense experiment, which involved only a small number of psychologists and was limited in terms of context, may or may not generalize to larger samples of psychologists and more diverse patient populations (see chapters 5 and 6, this volume). Consequently, what the current state of concern may reflect is a tension between more or less risk- and change-averse groups of psychologists. Support for prescriptive authority should not become a loyalty test for the leaders of the profession, as now appears to be the case. Although the presentation of a united front in the face of external opposition may be politically wise in the context of state legislatures, for example, the imposition of a virtual gag rule on the continued dialogue about the value of prescriptive authority has had, as of this writing, unfortunate, polarizing consequences. Clinical psychologists, in particular those affiliated with science-based doctoral programs, have been especially vocal in their opposition, and the debate has fallen, at times, into personalized and ad hominem language, with each side accusing the other of distorting data. Although it appears to me that some of the heat and light are the results of how prescriptive authority has been piggybacked onto the turf of other, long-standing and heated conflicts between research clinical psychologists and practicing professional psychologists, neither the discipline nor the issue are helped by this kind of polarization. Ironically, it appears as if the firmly closed minds are as well distributed among advocates of science, who would usually keep open minds until a hypothesis is tested, as among other psychologists. Room for principled and reasoned debate about this matter needs to be able to be contained within psychology rather than prematurely 54

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closed off, as if this, or any debate about the nature and value of psychological practice, is intolerable. However, psychologists who would argue for a premature closure of the debate on the grounds that there is no need for further discussion point to the fact that the field of psychology must offer a united front in the face of external opposition. In the next section I briefly review that external opposition, which, not surprisingly, has come almost entirely from organized psychiatry.

PSYCHIATRIC OPPOSITION TO PRESCRIBING PSYCHOLOGISTS As a group, psychiatrists have the most to lose should psychologists gain the right to prescribe even a limited formulary of psychotropic medications. As the training of psychiatrists increasingly neglects psychotherapy, and is equally increasingly focused on knowledge and prescription of medications, clinical psychopharmacology has become the identifying hallmark of psychiatry. More and more psychiatrists make their living primarily from prescribing medications, often for the patients of psychotherapists who cannot prescribe, such as psychologists, social workers, and counselors. This situation understandably creates psychiatric opposition to prescriptive authority for psychologists. The arguments advanced by members of organized psychiatry have been brief and simple: Medications, they argue, are interventions that require full medical training in order to be used safely and effectively. At a minimum, a person prescribing should be primarily oriented to physical medicine, as is the case in states where advanced-practice nurses and physician assistants may now prescribe. Psychologists have none of this training; ergo, psychologists should not be in the prescription business. If they wish to prescribe, let them go to medical or nursing school and obtain the requisite education in the anatomy and physiology of the whole body. Do not put mental health patients at risk medically by allowing nonmedically trained persons to give drugs. The psychiatric opposition has exploited rifts within the discipline of psychology in its lobbying against psychologists’ prescriptive authority when relevant bills have been proposed at the state level. It is true that concerns for patient welfare may, at least ostensibly, motivate psychiatrists and antiprescription psychologists. However, a close reading of most psychiatric opposition to prescriptive authority for psychologists suggests that the concern is less for patient welfare and more for the protection of turf. Many of the arguments now being advanced against psychologists prescribing were previously used against psychologists practicing psychotherapy; then against psychologists receiving insurance reimbursement for psychotherapy; and, more recently, against hospital practice by psychologists, so the credibility and sincerity of the patient protection argument in such historical context begin to lose weight. DOUBTS ABOUT PRESCRIBING

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This is not to suggest that some, if not many, individual psychiatrists have reasonable concerns for the health and safety of clients should psychologists be able to prescribe. In my own experience, many thoughtful psychiatrists who work in respectful, equal partnership with psychologists are deeply worried by the potential for risk to vulnerable people. Advancedpractice psychiatric nurses who now have prescriptive authority, which is the case in my state, have also expressed such sentiments. Often these concerns are accompanied by impressive real-life vignettes from a nonpsychologist’s practice illustrating the real perils and pitfalls of prescribing medications, particularly with medically complex individuals. It has ironically more often been the case that physicians from other specialties, particularly primary care, are at least open to, and sometimes actively supportive of, the concept of psychologists as prescribers of psychotropic medications. This may in part be the case because, functionally, psychologists are often doing de facto prescribing, by means of phone calls to collaborating primary care providers who, because of their extreme unfamiliarity with mental health issues, are more than happy to defer to the expertise of a psychologist regarding both the need for medication and the type of medication most likely to be helpful. As one primary care physician expressed it to me, “You know depression. You’ve seen what drugs help depressed people. So I’m going to listen to you when you call me up and say, give her X instead of Y drug.” This physician has had repeated positive experiences with psychologists who were knowledgeable about psychotropic medications. Additionally, like many primary care physicians in my location, this physician was trained in a family practice residency whose staff included a psychologist. Thus, she and her colleagues have learned to respect what psychologists know and can offer about medication and can also raise systemic health cautions for individual patients when necessary.

CONCLUSION The dynamic tension over the value of psychologists as prescribers of psychotropic medications persists within the discipline of psychology. At the organizational level, the debate is over. Organized psychology has decided to pursue this choice for psychologists, and funding and energy are going into making it happen at the legislative level. As with any transformation of a discipline, the premature closure of debate can be dangerous. Boundaries become rigid, polarization occurs, and the careful and empirical assessment of the outcome of the transformation can be clouded or lost. As scientist– and scholar–practitioners, whatever one’s stance on this issue, psychologists need to not declare the debate closed or over. Rather, in the continuing movement toward the acquisition of the legal right to prescribe, psychologists must take into account the principled 56

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concerns of colleagues who see this change as risky, both to the discipline and to individual psychologists and their clients. Psychologists who oppose prescriptive authority must equally retain a willingness to assess with open minds the actual outcomes of this new experiment and must become selfaware of the subtle as well as more apparent reasons for their opposition. The predictions of the death of psychology that accompanied clinical practice, behavioral therapies, and you-name-the-paradigm-shifting-addition, have been inaccurate. Psychology has stretched, grown, and become more vibrant with change. But something was lost at each step when debate was foreclosed and minority voices silenced or excluded. If psychologists are to have prescriptive authority, then those who exercise such authority will benefit only from a careful and thoughtful, even if critical, consideration of the concerns raised by colleagues who wish to retain the notion that “psychologists give tests; psychiatrists give drugs.” REFERENCES American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Blumenfeld, S. J., & Wood, S. F. (1997). Women’s health care: Federal initiatives, policies and directions. In S. J. Gallant, G. P. Keita, & R. Royak-Schaler (Eds.), Health care for women: Psychological, social and behavioral influences (pp. 3–10). Washington, DC: American Psychological Association. Breggin, P. (1983). Psychiatric drugs: Hazards to the brain. New York: Springer. Breggin, P. (1991). Toxic psychiatry: Why therapy, empathy and love must replace the drugs, electroshock and biochemical theories of the “new psychiatry.” New York: St. Martin’s Press. Breggin, P., & Cohen, D. (1999). Your drug may be your problem. New York: Perseus Books. Brown, L. S. (1997). The private practice of subversion: Psychology as tikkun olam. American Psychologist, 52, 449–462. Dunivin, D. L., & Foust, M. J. (1999). Case study from the Department of Defense Psychopharmacology Demonstration Project: Mania and neurosyphillis. Professional Psychology: Research and Practice, 30, 346–351. Hamilton, J., & Jensvold, M. (1995). Sex and gender as critical variables in feminist psychopharmacology research and pharmacotherapy. Women and Therapy, 16, 9–30. Kramer, P. (1993). Listening to Prozac. New York: Viking. Routh, D. K. (1994). Clinical psychology since 1917: Science, practice and organization. New York: Plenum Press. Walker, E. A., Katon, W. J., Harop-Griffith, J., Holm, L., Russo, J., & Hickok, L. R. (1988). Relationship of chronic pelvic pain to psychiatric diagnoses and childhood sexual abuse. American Journal of Psychiatry, 147, 75–80. DOUBTS ABOUT PRESCRIBING

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Walker, E. A., Katon, W. J., Roy-Byrne, P. P., Jemelka, R. P., & Russo, J. (1993). Histories of sexual victimization in patients with irritable bowel syndrome or inflammatory bowel disease. American Journal of Psychiatry, 150, 1502–1506. Yeoman, B. (2001). Drugs online: The new danger. Ladies Home Journal, 98, 76–84.

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4 THE PRESCRIPTIVE AUTHORITY AGENDA: EVOLVING STRUCTURES AND EFFORTS IN THE AMERICAN PSYCHOLOGICAL ASSOCIATION RUTH ULLMANN PAIGE AND ELIZABETH A. ROBINSON

The history of prescriptive authority in the American Psychological Association (APA) is the history of a discipline evolving in tandem with societal changes. Knowledge about the biological substrates of behavior has mushroomed, and biological treatments have burgeoned. How could members of a responsible health care discipline not prepare themselves to recognize and deal with those changes? Answers to that question have not always been obvious to all in psychology. Psychology has moved toward obtaining prescriptive authority since the late 1980s, but the progress has not always been smooth. Instead, it has been punctuated by all the issues that typically attend significant change in the profession, both within and outside of APA. Should the emphasis in training be on traditional or evolving areas? How much should practitioner preferences and needs influence curricula? How should allocation of resources be prioritized among training, research, and advocacy? Who is involved in advocacy? Who should be involved in advo59

The founding of Division 55—Morton’s Steakhouse, Washington, DC, February 1997. (From left to right) Back row: Morgan Sammons, Robert Resnick, Mike Enright, Jerry Morris; Middle row: Paul Craig, Elizabeth Robinson, Kathy McNamara, Tommy Stigall, Alan Entin, Ron Rozensky, Margaret Heldring; Front row: Ruth Ullmann Paige, Pat DeLeon; Not pictured: Gil Hill.

cacy? How much can and should psychology affect public policy? How much will psychologists’ training be influenced by public need? Will psychology allow the force of organized medicine to influence APA’s and psychology’s initiatives? Although the activities related to the acquisition of prescriptive authority have triggered heated discussion and controversy, the issues raised are actually not unique to the prescriptive agenda; the questions that are raised surface repeatedly, regardless of the specific subtext. The disputes reflect philosophical differences among psychologists. How does APA fit into all of this? APA, the professional voice of 160,000 psychologists and psychology graduate students, is the largest association of psychologists in the world. Characteristically, psychology’s issues are APA’s issues. At times APA merely reflects psychology’s concerns, at other times APA leads efforts to change, and at other times APA lags behind developments that have already occurred elsewhere. Activities related to obtaining prescriptive authority in APA have pushed change in other contexts: training in universities, legislative advocacy in state associations, and consideration of new practice areas by state licensing boards. Perhaps most important, these activities have converged to influence the way psychologists see themselves and their work. Now, thousands of psychologists understand prescribing to be an appropriate practice skill. In the not-too-distant future, most psychologists trained for practice will likely include this skill in their preparation and will see it as an integral part of their training. APA activities are thus highly significant, as APA both leads the discipline to its highest potential and reflects its many questions, tensions, and areas of agreement. One of the first activities within APA that related to psychologists prescribing was the creation of a Board of Professional Affairs (BPA) task force 60

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document, “Psychologists’ Use of Physical Interventions,” written in the 1980s. The task force proposed a new definition of psychology that included physical interventions, such as biofeedback. Rogers Wright (1980) wrote that “the practice of psychology encompasses the observation, assessment, and/or alteration of behavior and/or concomitant physiological functioning through behavioral procedures. The techniques available to effect such alterations may include both physical as well as purely psychological interventions” (p. 17). Prior to that time, most psychologists thought of themselves as limited to verbal interventions, behavioral assessment, or psychological testing. The BPA report served as an impetus for exploring a new self-concept for professional practitioners that eventually would include the use of pharmacological interventions. The report was associated with a flurry of articles on prescriptive privileges in the 1980s and early 1990s (e.g., Brentar & McNamara, 1991; Burns, Chemtob, DeLeon, & Welch, 1988; Dawley, 1991; DeLeon, Folen, Jennings, Willis, & Wright, 1991; DeLeon, Fox, & Graham, 1991; Wiggins, 1980). These made the case for psychologists prescribing by changing the question from “Should we?” to “Can we?” and concluded with “Of course.”

CONTRIBUTION OF VARIOUS APA BOARDS AND COMMITTEES The BPA and Its Historic, Transformational Retreat The first APA meeting devoted entirely to the topic of prescriptive authority for psychologists was held by the BPA. The 1989 BPA, under the visionary leadership of chair Norma Simon, made a vital decision to learn about prescriptive authority for psychologists by focusing its entire retreat on an in-depth examination of this topic. Simon recounted in her own words the transformation during this historic retreat of BPA members from skeptical to converted: At the fall meeting in 1988, when I was the chair-elect of the Board of Professional Affairs (BPA), we had a rather lengthy discussion to choose the subject for the BPA retreat meeting to be held in the Fall of 1989. . . . Toni Bernay, who was a retiring member of the Board, suggested that the group focus on prescription privileges for psychologists. This generated a great deal of discussion and a decision was made to have the retreat on this subject. This was the first time that the organization would be discussing this subject in an organized manner. I worked with Russ Newman. . . . We decided that we needed everyone who knew anything about this to come to the meeting and we needed some interesting materials for the Board to read prior to the meeting. EVOLVING STRUCTURES AND EFFORTS IN APA

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Sheila Forsyth and Penny Warren, with Russ’ input[,] did an excellent job of putting together materials. A number of these were articles from other professions such as nursing and pharmacy that explained how they had gotten prescription privileges. If I were to have taken a vote prior to this retreat, I do not believe that three people on the Board would have been in favor of prescription privileges for psychologists. We were skeptical to say the least. The Board members attending the retreat in addition to myself were: Judith Alpert, Diane Willis, Ben Schneider, Rod Hammond, Bob Resnick, Ruth Ullmann Paige, Nate Azrin and Jerry Resnick. When we arrived for the retreat, the members of the board were electric. Everyone had read all the materials and change was in the air. The thing I heard most from members of the Board was that if these other professions could have privileges, certainly psychologists, whose academic preparation was greater than these other professions, could be well qualified to have this privilege. The speakers, who all spoke eloquently on this subject and provided the Board with excellent information, included Allan Barclay. Allan had put together the first curriculum on psychopharmacology for Wright State School of Professional Psychology where he was Associate Dean of Academic Affairs; Gregory Laskow, an officer in the service and Chief of Psychology Services at Walter Reed Army Medical Center[, also spoke]. Greg spoke of the potential in the service for psychologists who were trained to prescribe and the proposed Department of Defense program; Dan Egli, who is a clinician in rural western Pennsylvania [, presented]. Dan had become one of our first clinician experts on psychopharmacology as he was considered the mental health expert in his rural area and the physicians turned to him for knowledge about appropriate medications to give patients. Because of this, he made it his business to learn and teach about psychopharmacology; Laurie Flynn, Executive Director of the National Alliance of the Mentally Ill (NAMI)[,] spoke about the relationship of the organization to psychology; Marlyne Kilbey, a science advisor at NIDA, came as a representative of Division 28, Psychopharmacology. She talked about psychology’s role in psychopharmacology research. She believed that her Division and scientist/researchers in the field would be supportive of clinicians getting the needed training and being able to prescribe. The final speaker for the day was Floyd Jennings. Dr. Jennings was, at that time, the only psychologist in the nation who had prescriptive authority for a period of time. Dr. Jennings had been the psychologist working on Indian Reservations for the Public Health Service. He had been given the authority to prescribe needed medication for this population. Floyd had explained that during his training and while continuing to work in hospitals, he had been trained along with the psychiatric residents in psychopharmacology. Thus he had the background to assume this role. He did say that he didn’t do this for more than a few years because he found it too lonely to be out there with no back up in

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psychology. He believed that psychology could do this work with the training that he had but he also said how important it was to have a cadre of psychologists doing this at the same time so there would be support and understanding. Being the only one he found too heavy a burden to carry. At the end of the day it was clear that the entire Board unanimously agreed that involving APA in an effort to obtain prescription privileges for psychologists should become a priority for the organization and the profession. In all my years serving on committees and boards at APA, this day stands out as one of the most exciting and informative. It was clear we were on the cutting edge and proposing something revolutionary for psychology. (N. Simon, personal communication, April 24, 2001)

BPA firmly placed the issue of prescriptive authority for psychologists on the APA agenda by drafting and unanimously passing the following resolution at the conclusion of its retreat: BPA strongly endorses the immediate research and study intervention feasibility and curricula development in psychopharmacology for psychologists in order to provide broader service to the public and to address more effectively the public’s psychological and mental health needs. BPA strongly recommends moving to the highest APA priority a focused attention to the responsibility of preparing the profession of psychology to address the current and future needs of the public for psychologically managed psychopharmacological interventions. (BPA, 1990)

Council of Representatives Psychopharmacology Task Force In the year following the retreat, BPA requested that the APA Board of Directors create a special task force on psychopharmacology. The board agreed and requested that the Council of Representatives, the most representative and policy-setting body of APA, fund the endeavor. These were indeed exciting times. Every step taken during these earliest endeavors raised many questions: Would the immediate action be successful, or would it be knocked down by opponents? How should the strongest strategy to overcome opposition or disinterest be identified? How much support money could reasonably be requested? A decision by the council to provide the money needed by the proposed task force might imply support for the notion that psychologists should prescribe psychotropic medications. In 1990, this was still a very controversial idea. Many psychologists, even those who were on the council at the time, had never considered the concept, and those who had entertained the notion of psychologists as prescribers were ambivalent at best. Opponents of the idea, both within and outside of APA, were also beginning to organize. The ensuing council deliberations, even before the actual vote was taken, led to a paradigm shift in thinking in the highest governing body EVOLVING STRUCTURES AND EFFORTS IN APA

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of APA and, in turn, throughout much of APA governance. Although the vote concerned simply whether to establish a task force “to determine the advisability and feasibility of psychopharmacology prescription privileges for psychologists” (APA, 1990), the results of the discussion made people think in a new way about expanded roles for psychologists. What had before been unthinkable now became possible. Pat DeLeon, a member of the board at that time, wrote: In all candor, those of us on the Board of Directors who strongly support psychology becoming active in the psychotropic medication arena, had no idea how Council would react, and especially to the request that it spend $16,275 of its own funds on this issue. . . . Seventeen members of [the] Council expressed a wide range of views—including the possible impact on the homeless, women’s health care, the elderly, rural America and psychology’s historical ability to develop responsive and responsible training programs. . . . The final vote in favor of the motion was 118–2, an outcome that no one could have predicted. (1990, pp. 10–11)

The seven-member Ad Hoc Task Force on Psychopharmacology was created in 1990 with representation from science, education, and practice. The task force’s reports (APA, 1992; Smyer et al., 1993) concluded that training psychologists to prescribe psychopharmacological agents was not only feasible but also desirable. The authors made a strong case for psychologists prescribing. Smyer et al. (1993) concluded: Practitioners with combined training in psychopharmacology and psychosocial treatments can reasonably be viewed as a new form of health care professional, expected to bring to health care delivery the best of both psychological and pharmacological knowledge. The contributions of this new form of psychopharmacological intervention have the potential to dramatically improve patient care and make important new advances in treatment. (p. 403)

The report outlined an educational model for three levels of involvement in psychopharmacology: Level 1 represented the basic educational background needed by all psychologists in order to be competent practitioners, Level 2 described the training needed by psychologists for collaborative practice in order to interact knowledgeably with physicians about patients, and Level 3 called for the development of a curriculum to prepare psychologists to prescribe independently. The Council of Representatives accepted the report and took additional steps to flesh out the details of the curriculum that would be needed to prepare psychologists to be effective pharmacological practitioners. Council members directed the BEA to establish a task force to develop a detailed training module for Level 1 and guides for Level 2. To this day, the Level 1 guidelines written by the original task force provide direction to doctoral programs that embrace education in psychopharmacology and form the core 64

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requirements used by state licensing boards when they require predoctoral psychopharmacology training prior to licensure. BEA and Board of Scientific Affairs (BSA) Activities BEA, joined by the Board of Scientific Affairs (BSA), readily agreed to the Council of Representatives’ request to develop training modules. They saw that there had been significant developments in understanding the neurobiological bases of behavior as well as the psychopharmacological treatment of psychological conditions; this new knowledge called for expanded preparation of psychologists in these areas regardless of whether psychologists actually prescribed. The Center for Mental Health Services (CMHS) concurrently recognized that there was a growing need to combine psychological interventions with psychopharmacological treatments. At the same time, this need could not be fulfilled, because there was a shortage of professionals qualified to do both. To address this problem, BEA and BSA sought to develop the Level 1 and Level 2 curricula that psychologists would need to be responsive. Activities related to the Level 1 and 2 curriculum reports (APA, 1995, 1997) were supported by a $10,000 grant from the CMHS, the Substance Abuse and Mental Health Services Administration, and the U.S. Department of Health and Human Services; the APA Board of Directors provided funding for the working groups as well. In 1994, BEA approved the formation of a working group to establish a psychopharmacology curriculum (APA, 1994). Level 1, the basic training recommended for all psychologists, included eight modules (49 hours); biological bases and principles of psychopharmacological treatment; introduction to clinical psychopharmacology; and introductions to psychopharmacologic treatment of psychoactive substance disorders, psychotic disorders, mood disorders, and anxiety disorders. M. Marlyne Kilbey was chair of the Psychopharmacology Working Group, the members of which included Edward F. Bourg, Ronald T. Brown, Robert D. Coursey, Pat DeLeon, Carl Eisdorfer, Charles France, Dale Johnson, Neil M. Kirschner, Joan Martin, Carolyn Mazure, Lynn Rehm, Travis Thompson, Morgan Sammons, Edward P. Sheridan, Tony Strickland, and Rudy E. Vuchinich. Paul F. Wohlford (CMHS/Substance Abuse and Mental Health Administration Project Officer) was a liaison to both the Level 1 and Level 2 working groups. Clearly, this was a broad and diversified group, with each working group member representing several constituencies. The Level 1 curriculum has become a prototype for training programs for practitioners. More and more training programs offer certificates in psychopharmacology or have a predoctoral track in clinical psychopharmacology. Some licensing boards now require basic training in psychopharmacology for all psychology candidates for licensure. Licensing board involvement is extremely significant. First, because the boards are regulatory bodies that are EVOLVING STRUCTURES AND EFFORTS IN APA

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independent of APA, their involvement substantially broadens the impact of efforts to obtain prescriptive authority. Their function is consumer protection, and when they require Level 1 training for all licensure candidates they declare, in effect, that knowledge of psychopharmacology is required for appropriate practice. Second, because the boards mandate what the knowledge base should be, requiring Level 1 training may influence the content of university training programs. This is yet another example of how each aspect of the process in a changing discipline affects every other aspect and where APA events affect, and are affected by, groups external to APA. A subsequent working group outlined an approach for collaborative practice with physicians (Level 2) aimed at four specific underserved populations: (a) children and adolescents, (b) individuals with mental retardation or developmental disabilities, (c) individuals with serious mental illness, and (d) the elderly population (APA, 1997). Specifying the meaning of Level 2 involvement has proven to be more challenging. Individual licensing boards have interpreted collaboration and, relatedly, training for collaborative practice in various ways. As the movement to obtain prescriptive authority advances perhaps the greatest foci will be on Level 1, knowledge base, and on Level 3, independent prescribing. Committee for the Advancement of Professional Practice Activities Currently, the Committee for the Advancement of Professional Practice (CAPP) has primary responsibility for moving the prescriptive authority agenda through APA, but CAPP needed to go through its own evolution in the early 1990s before it fully supported prescriptive authority for psychologists. CAPP’s earliest concerns were about what would be best for practice and whether obtaining the right to prescribe would affect the viability of long-term psychotherapy. The growing impact of managed care and its emphasis on cost cutting in the form of limiting access to mental health care also affected CAPP’s deliberations regarding prescribing for psychologists. CAPP’s concerns in this area as well reflected uncertainty in the larger psychology community. Early committed CAPP members, including Ruth Ullmann Paige and Ron Levant, both aware of practice and marketplace realities and increasing changes in the delivery of health care, convinced CAPP that psychologists needed to expand their scope of practice in order to respond to the public’s changing demographics, as well as to the explosion of new knowledge about biological bases of behavior, in order to meet the need for integrated comprehensive and responsive treatment from psychologists. Once other members of CAPP were of a like mind, and supported efforts to obtain prescriptive authority, a synergy followed along with a major increase in activity in CAPP and in APA. It was apparent that if psychologists were to have prescriptive authority, then changes in state laws and regulations governing psychology would 66

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be needed. It was also clear that a curriculum for independent prescribing (Level 3) needed to be developed for psychologists who were already practicing and wanted to add this skill. To that end, Ron Levant, chair of CAPP in 1994, established the CAPP Task Force on Prescription Privileges to consider and advise on advocacy and practitioner education issues. The initial task force included Dan Egli (Chair), Margery Chisholm, Joseph Pachman, Patricia Pimental, Morgan Sammons, and Ruth Ullmann Paige (CAPP liaison). Elizabeth Cullen served as the highly capable legal staffperson. The task force has since become an ongoing CAPP subcommittee. The report of the first CAPP task force was accepted by CAPP in 1995. Its recommendations have been followed and formed the foundation for future and current CAPP activities. The task force recommended that CAPP (1) reach out to selected state psychological associations (SPAs) with financial support and national guidance, particularly in rural states; (2) facilitate communication on prescription privileges among SPAs; (3) work with other committees and divisions within APA which are exploring related aspects of the prescription privilege agenda, as well as outside organizations; (4) assist with efforts to educate members, legislators, and the public about the merits of prescription privileges; and, (5) develop recommended legislative provisions and a model post doctoral fellowship in psychopharmacology for distribution to SPAs. (CAPP Task Force on Prescription Privileges, 1995, pp. 2–3)

That initial comprehensive and far-reaching report still to a great extent undergirds CAPP’s strategy of advocacy. The task force recognized the need for uniformity and consistency between legislative efforts and curricula development. Task force members further understood that actual legislative change would occur in each state on a state-by-state basis. Therefore, they recommended that CAPP provide financial support and guidance to individual states in efforts to educate their members, legislators, and the public about the merits of prescriptive authority. The task force called on CAPP to develop model legislative language that could be used by any state in changing its rules or laws. The task force completed the model legislative language document, which has served as a foundation for current state legislative activities. It became APA policy in 1996 by virtue of action by the Council of Representatives (APA, 1996a). The task force also called for CAPP to collaborate with BEA and BSA in developing a template for postdoctoral Level 3 training. CAPP recognized that changing state laws would be very costly and that states could not begin to work on this issue without substantial financial support from the national association. The CAPP Grants Committee and the Task Force on Prescription Privileges jointly recommended that the existing CAPP state grant program provide financial support for the state associations that tackled these issues in their legislatures. Grant support was also EVOLVING STRUCTURES AND EFFORTS IN APA

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available for local educational endeavors, such as states developing Level 3 training programs. The emphases of the prescriptive authority grants to states have shifted some over time. Initially, grants supported states that were ready to move forward with enabling legislation or to create educational programs that would prepare psychologists to prescribe. To assess a state’s readiness, CAPP used the comprehensive checklist created for that purpose by the Task Force on Prescription Privileges. More recent grants, funded in part by APA Board of Directors contingency funds, and made available largely because of the leadership of Ron Levant and Pat DeLeon, are now also being offered to states that are in the formative stages of readiness. Funds are available for states that are still building consensus among members, developing materials for legislators, or establishing a grassroots psychopharmacology advocacy network. Most recently, CAPP and the Practice Directorate have added another emphasis focusing intently on a few states that have taken substantial steps toward obtaining prescriptive authority for psychologists. Each of the advanced states has engaged in several effective activities. The plan is to teach each of the states what the others have done well so that all will move forward. The objective is that one or more will soon pass licensing laws that will authorize prescriptive authority. Prescriptive authority activities at APA are currently centered in CAPP and the Practice Directorate, where they are enthusiastically and energetically handled. The momentum around prescriptive authority is growing. The level and intensity of activity continue to mount. Rochelle Jennings was hired in 2000. She is the first APA full-time staffperson whose sole responsibility is supporting prescriptive authority activities. APA Council Policy Resolutions Even with much activity in this area within APA, a central piece was missing: APA had never officially endorsed efforts by psychologists to obtain prescribing rights. Some psychologists, both APA members and nonmembers, saw efforts to obtain prescribing rights as marginal or even hostile to the discipline. They repeatedly declared that supporters of efforts to obtain rights to prescribe did not speak for APA. The missing piece could be addressed only by an APA-wide action. An APA policy was slow in coming, even though during the early 1990s substantial prescriptive authority activity occurred at APA within many of its major boards. In addition, there was growing outside-of-APA national and state action dedicated to psychologists obtaining prescriptive authority. Yet the Council of Representatives, APA’s policymaking body, had never taken an overarching position endorsing psychologists obtaining prescriptive authority. The vibrancy and initiative of the movement came primarily from the practitioners and the states, with 68

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some support from the education and science community. Some concern was expressed that raising this issue in the Council of Representatives might highlight a lack of unity among APA’s elected leaders, and if that were so, this could be used by opponents of prescriptive authority in state legislatures and to resist offering training in this additional area. It was not clear whether the council would support prescriptive authority for psychologists, and if a measure failed it could undermine work in progress. It was not until August 1995, therefore, that APA officially went on record as supporting prescriptive authority for psychologists. Jerry Clark, a council representative from California, courageously introduced a resolution to obtain APA-wide authorization. It passed with resounding success, but not without tireless groundwork by Jerry and others. Jerry, who was so respected, so well liked, and so trusted by many constituencies, obtained 69 cosponsors—enough to ensure passage of the resolution in which the Council of Representatives reaffirmed the 1986 policy on psychologists’ use of physical interventions (APA, 1986) and further stated: The Council specifically notes that the practice of psychology includes the use of physical as well as psychological interventions when such interventions are (a) in the consumer’s interest and (b) within the training, experience, and competence of the attending psychologist. Specifically, this current action contemplates and supports Association activities in seeking prescriptive privileges for psychologists. Such activities may include, but are not limited to, support and assistance for the development of appropriate training curricula and training programs, [and] support and assistance for legislative advocacy, etc. (APA, 1995)

Again, the excitement in the council chamber prior to the actual vote was almost palpable. This resolution passed by an overwhelming margin. Finally, APA had a policy on this issue. Bob Resnick, the 1995 APA President, told the council that this is another milestone in the continuing evolution of the practice of psychology. This action will allow us to meet the needs of all patients by giving us the right to initiate a medication as well as the right to stop a medication. (Resnick, 1995, p. 6)

Pat DeLeon, a longtime advocate of prescriptive authority for psychologists and a father of the efforts to obtain prescriptive rights, noted that when psychologists are able to prescribe they will be able to help stop overprescription of medications to the elderly and to young people with attention-deficit/ hyperactivity disorder—that is, that the power to prescribe is also the power to unprescribe. “Prescription privileges give psychologists the power not to prescribe” (DeLeon, 1995, p. 6). In passing this resolution, the Council of Representatives further called for CAPP, BSA, and BEA to collaborate in developing curriculum and model legislation, steps necessary to implement the process of preparing psychologists to prescribe (APA, 1995). EVOLVING STRUCTURES AND EFFORTS IN APA

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To that end, Bob Resnick appointed a task force composed of representatives from practice (Ron Fox, chair; Ruth Ullmann Paige, and George Taylor), science (Bob Balster, Marlyne Kilbey, and Samuel Turner), and education (Lynn Rehm and Kathy McNamara). This group was charged with implementing the CAPP recommendations regarding training for independent prescribing—Level 3—and developing model language for states to use with state legislatures. The group easily reached a consensus on model legislative language, but it was harder to obtain agreement on a curriculum. Education and science representatives wanted to ensure that training was comprehensive, thorough, and rigorous. Although the practice representatives wanted that as well, they also sought to make sure that training would be user friendly. The practice representatives wanted the instruction to be accessible to and practical for practicing psychologists; for example, they wanted learning to be available through a variety of means, such as the Internet, weekend seminars, and distance learning, not only through traditional full-time university settings. Because psychologists sometimes set overly high standards and create unnecessary obstacles for themselves, much discussion revolved around the appropriate number of supervised practicum hours needed to prepare a psychologist to prescribe safely versus how many hours would place an unneeded burden on a practicing psychologist. The group recommended a minimum of 300 contact hours of didactic instruction in neurosciences, pharmacology and psychopharmacology, physiology and pathophysiology, physical and laboratory assessment, and clinical pharmacotherapeutics. In addition, the task force called for a clinical practicum that included a minimum of 100 patients seen for medication in inpatient and outpatient placements. These recommendations were based on the template for postdoctoral Level 3 training developed by the original CAPP task force (CAPP Task Force on Prescription Privileges, 1995). The work of the task force was completed when the Council of Representatives approved two resolutions in 1996 that formally endorsed the model legislation and the recommended postdoctoral training in psychopharmacology (APA, 1996a, 1996b). Creation of Other Needed Infrastructures Examination Development: College of Professional Psychology All of the activities just described highlighted a new problem and underscored the need for yet more infrastructure. Although the APA Council of Representatives approved an outline for postdoctoral Level 3 training, “Recommended Postdoctoral Training in Psychopharmacology for Prescription Privileges” (APA, 1996b), it did not identify a means of evaluating the training and readiness of psychologists to prescribe. Psychologists were already being trained in psychopharmacology for independent prescribing at 70

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various institutions, but they had no uniform way to demonstrate that they had met training criteria. Concurrently, while the Practice Directorate was helping states with their attempts to obtain independent prescriptive authority, CAPP and the practice community realized that, even if a state granted prescriptive authority, states had no authoritative way to identify psychologists who were qualified to prescribe. There were no standardized criteria, and there was no national examination. Stanley Graham’s vision of an APA credentialing organization, realized in 1994 when the council established the APA College of Professional Psychology, became the vehicle for evaluating preparation for autonomous prescribing. In 1997, the Council of Representatives authorized the College of Professional Psychology to develop an examination for use by states that grant prescriptive authority for psychologists. In 1998, a panel of experts was convened and developed the test. The Psychopharmacology Examination for Psychologists: An Examination for Practitioners was completed in 1999. Psychologists have been taking the examination since 1999 and banking their scores. Because most states do not yet authorize psychologists to prescribe, the examination results are archived and will be available when needed. (See chapter 10, this volume, for more information about the examination.) Psychopharmacology as a Recognized Proficiency Area The APA Commission for the Recognition of Specialties and Proficiencies in Psychology proposes recognition of specialties and proficiencies to the Council of Representatives. The council endorses such proposals after they have been through a thorough general governance review. The commission proposed psychopharmacology as a proficiency for psychologists in April 2001. The Council of Representatives approved this action in August 2001. The earlier work on Level 2 by the BEA Task Force became the foundation for the petition to the Commission for the Recognition of Specialties and Proficiencies in Psychology for recognition of psychopharmacology as a proficiency area. Increasing Exposure to General Psychology Audiences: Psychopharmacology Miniconventions Concurrent with these other APA activities, in 1997, and again in 2000, the board of directors, under the leadership of Pat DeLeon and Ron Levant, sponsored miniconventions in psychopharmacology at the annual APA convention. During each miniconvention, presentations focused on legislative action, state activities, training developments and activities, experiences of the Department of Defense graduates, and general information designed to raise the awareness of psychologists regarding the need for and feasibility of prescriptive authority for psychologists. EVOLVING STRUCTURES AND EFFORTS IN APA

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An APA Home for Friends of Prescribing in Psychology The “magic” that Norma Simon described as occurring during the transformational BPA retreat in 1989 occurred again in February 1997 during a dinner at Morton’s Steakhouse in Washington, DC, at the time of the February Council of Representatives meeting (see photo, p. 60). Pat DeLeon, psychology’s foremost advocate for prescriptive authority, had decided to run for President of APA, and a group of like-minded friends and supporters gathered to celebrate the official announcement of his candidacy. Jack Wiggins described the group’s sense of anticipation: The initial dinner table of three or four quickly expanded to eight, then twelve, with more Council members wanting to be there for this unique meeting with no official agenda. Thanks to the deft staff work of Gil Hill, a private dining room at Morton’s was arranged on short notice to accommodate “the group.” Those in attendance were largely comprised of members of Division 42, as well as those interested in rural issues where the demand for action was the greatest. Attendees included Drs. Paul Craig, Pat DeLeon, Michael Enright, Alan Entin, Margaret Heldring, Kathy McNamara, Jerry Morris, Ruth Paige, Bob Resnick, Elizabeth Robinson, Ron Rozensky, Morgan Sammons, Tom Stigall and Gil Hill, Staff. (Jack Wiggins, personal communication, May 3, 2001)

Excitement and a sense of possibility prevailed. Activities in various divisions—Clinical Psychology, Independent Practice, and Psychopharmacology—had been occurring for more than 10 years. The Council of Representatives had approved several positive policy positions, but there was not a single governance entity within APA dedicated entirely to creating an implementation plan that would get prescriptive authority for psychologists. The Morton’s group wanted to see the prescription agenda move quickly; it was an action-oriented group. People felt that under Pat DeLeon’s presidential leadership important things could happen. The dinner quickly evolved into an organizational meeting. Jack Wiggins wrote: This was the first time the psychologists interested in prescriptive authority had a chance to meet and discuss their ideas and plans to push this initiative forward . . . there was a positive tension that had built up along with an expectancy that something needed to happen. The meeting crystallized thinking that the prescriptive authority (RxP) movement needed a centralized home to succeed rather than being scattered among various APA Divisions. The scattering of interests among different APA Divisions had divided the thrust and diminished the impact of RxP. Although the Division of Psychopharmacology was created in 1967, the focus of this Division was largely on research with a small minority of its membership interested in practice or prescriptive authority. The energy was certainly there at Morton’s but it needed to be housed and directed to be a productive force within APA. It was Elizabeth Rob-

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inson, the presiding President of the Division of State and Provincial Psychological Association Affairs, who offered that Division as the logical home for the initiative. Scope of practice issues, such as passage of legislation authorizing prescribing, require state or provincial legislation and this Division was the logical place for such state advocacy. After lively discussion this solution was agreed upon. (Jack Wiggins, personal communication, May 3, 2001)

There were a few gaps in the RxP plan, which had not been addressed at the Morton’s meeting. The Division of State and Provincial Psychological Associations bylaws did not actively provide a means for development of a section and for dues collections, and because the overall goals of the division were more global than prescriptive authority, it became apparent that psychologists interested in advancing prescriptive authority would benefit by creating a new division of APA, one dedicated exclusively to advancing the prescriptive authority agenda. Members got to work after the 1999 APA convention with renewed energy: The momentum generated at the convention, in addition to the difficulties encountered in trying to maintain this interest group inside of Division 31, clinched the decision to seek independent division status as the American Society for the Advancement of Pharmacotherapy (ASAP). No one was overjoyed with the new name, but everyone resonated well to its acronym of ASAP. This left only 4 months to meet the deadlines of getting 1% of APA members to sign a formal Petition for Division status. This was a Herculean task to be done by e-mail solicitation, but the members of ASAP responded asap! More than 1,200 (per Jack Wiggins) petitions were signed, and more than 1,000 were validated, which exceeded the 816 minimum membership requirements of APA. ASAP was given status as a provisional division under APA bylaws at the February 2001 APA Council of Representatives meeting and was granted full divisional status at the February 2002 council meeting. . . . This robust growth of an idea into a division took place in only 3 years—a record for modern day APA. (Jack Wiggins, personal communication, May 3, 2001)

This speed clearly demonstrated the increased enthusiasm about obtaining prescriptive authority both in APA and in psychology. Thus was born Division 55, ASAP, the most recent governance structure addressing practitioners and psychopharmacology in APA.

CONCLUSION Why is APA’s involvement critical? Without the structure, resources, and energy provided by APA, this effort would still be floundering and disjointed. The success of a concerted national strategy was recently demEVOLVING STRUCTURES AND EFFORTS IN APA

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onstrated with the successful passage of legislation in New Mexico. The evolving structures and efforts in APA to obtain prescriptive authority clearly reflect the slow, sometimes uneven, but unstoppable movement of a vibrant dynamic discipline. The profession is interwoven with and influenced by social, scientific, and systems changes in a dynamic interaction much as the colors in a palette blend to create new hues. Some might say that APA has moved too quickly, whereas others would undoubtedly say that change has been glacial. Neither is true; although the vision of a few led the discipline, the process ultimately and appropriately involved all of APA’s broad professional constituencies: education, science, practice, and public interest. The process has allowed people to come to terms with professional and societal change. The movement toward prescriptive authority is a natural developmental outcome of a society and a profession in dynamic flux. Knowledge about biological bases of behavior has exploded over the past 30 years. Medication to treat everything from anxiety to impotence to phobic disorders has proliferated, with a concomitant increase in the number of people who are using medication. Psychologists see these people daily and are called on to make judgments and recommendations. A profession that has at its disposal all of the available effective interventions best serves the public’s health care needs. A profession that would not prepare its current and future members to be maximally informed, instructed, and effective is not serving society well or ethically. Fortunately, APA is looking to the future and has responded to the challenge.

REFERENCES American Psychological Association. (1986). Joint Resolution from Divisions 12 and 22, Council of Representatives. Washington, DC: Author. American Psychological Association. (1990). Proposal for an APA task force on psychopharmacology, Council of Representatives. Washington, DC: Author. American Psychological Association. (1992). Report of the Ad Hoc Task Force on Psychopharmacology. Washington, DC: Author. American Psychological Association. (1994). Curriculum for Level 1 training in psychopharmacology. Washington, DC: Author. American Psychological Association. (1995). Prescriptive privileges for psychologists. Washington, DC: Author. American Psychological Association. (1996a). Model legislation for prescription privileges. Washington, DC: Author. American Psychological Association. (1996b). Recommended postdoctoral training in psychopharmacology for prescription privileges. Washington, DC: Author. American Psychological Association. (1997). Curriculum for Level 2 training in psychopharmacology. Washington, DC: Author

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Board of Professional Affairs, American Psychological Association. (1990, April 1). Minutes from meeting. Washington, DC: Author. Brentar, J. B., & McNamara, J. R. (1991). Prescription privileges for psychology: The next step in its evolution as a profession. Professional Psychology: Research and Practice, 22, 194–195. Burns, S. M., Chemtob, C. M., DeLeon, P. H., & Welch, B. (1988). Psychotropic medication: A new technique for psychology? Psychotherapy, 25, 508–515. CAPP Task Force on Prescription Privileges. (1995). Final recommendations of CAPP Task Force on Prescription Privileges. Washington, DC: Author. Dawley, Jr., H. H. (1991). Report of the Task Force on Professional Privileges. National Organization of VA Psychologists Newsletter, 9, 5–12. DeLeon, P. H. (1990). Psychotropic medications—The evolution continues: The Boston experience. The Psychotherapy Bulletin, 25, 10–14. DeLeon, P. H. (1995). APA to pursue prescription privileges. The Monitor, 26, 6. DeLeon, P. H., Folen, R. A., Jennings, F. L., Willis, D. J., & Wright, R. H. (1991). The case for prescription privileges: A logical evolution of professional practice. Journal of Clinical Child Psychology, 20, 254–267. DeLeon, P. H., Fox, R. E., & Graham, S. R. (1991). Prescription privileges: Psychology’s next frontier? American Psychologist, 46, 384–393. Resnick, R. J. (1995). APA to pursue prescription privileges. The Monitor, 26, 6. Smyer, M. A., Balster, R. L., Egli, D., Johnson, D. L., Kilbey, M. M., Leith, N. J., et al. (1993). Summary of the report of the Ad Hoc Task Force on Psychopharmacology of the American Psychological Association. Professional Psychology: Research and Practice, 24, 394–403. Wiggins, J. G. (1980). Psychotropics, consultation and psychology. Professional Psychology: Research and Practice, 11, 689–690. Wright, R. (1980). The Board of Professional Affairs Task Force on Psychologists’ Use of Physical Interventions. The Clinical Psychologist, 33, 16–17.

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5 THE DEPARTMENT OF DEFENSE EXPERIMENT: THE PSYCHOPHARMACOLOGY DEMONSTRATION PROJECT GREGORY B. LASKOW AND DENNIS J. GRILL

It is an understatement to say that the Department of Defense’s (DoD) Psychopharmacology Demonstration Project (PDP) was a political hot potato that had the potential to break many of the paradigms of training for psychologists as well as for other health care professionals. Of foremost importance, the PDP represented the attainment of a new frontier for psychology: The profession of psychology was about to cross over an intervention frontier requiring a biomedically “invasive” format for ameliorating psychological discomfort. Given the considerable advances in behavioral medicine and clinical neuropsychology of the 1980s, perhaps this movement was not as radical a departure for psychology as first envisioned. Also, although such a step set a precedent within the profession, the trail had already been partially cleared by optometrists, nurse practitioners (NPs), and other nonphysician provider groups who had already adopted noteworthy expansion of credentials in their profession, increasing their independent practice, treatment The opinions expressed by the authors are personal views and do not represent the official views of the U.S. Army or Department of Defense.

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interventions, and decision-making authority. But the PDP was unique in that (regardless of whether organized medicine recognized it at the time) it challenged the very heart of time-honored and traditional methods for the training of psychiatrists. The designers of the PDP faced several challenges that were radically different from those previously encountered in establishing psychology training programs. The primary challenge was to devise a training model that would make the PDP a reality in the short time frame allowed by the Congressional directive to establish the program. It was equally important to structure a program that would extend well beyond the initial Congressional mandate, as the PDP would likely set the foundation for similar programs in the civilian sector in the near future. However, the major challenge to program designers lay in the primary charge of the PDP: to prepare psychologists who, with the necessary training and supervision, could safely and effectively use psychotropic medication as one component of their clinical armamentarium, thereby affording patients a comprehensive intervention package from a single provider. This charge was unique in the history of curriculum development for psychology. Psychologists had long acquiesced to the necessity of forming collaborative relationships with colleagues in psychiatry to provide medication as a component of the treatment plan. In a bold step forward, however, the PDP compelled psychology educators to train psychologists to provide pharmacotherapy as a component of the total heath care delivery plan, thereby consolidating a full range of treatment options within the credentials of a single, nonmedical provider. In this chapter we do not present a historical, date-by-date or event-byevent recounting of the design, implementation, and evaluation of the PDP, as this has been more than adequately archived in various interim reports to Congress (U.S. Army Office of the Surgeon General, 1992, 1993, 1994) and other publications describing the program (DeLeon, Sammons, & Sexton, 1995; Dunivin & Orabona, 1999; Newman, Phelps, Sammons, Dunivin, & Cullen, 2000; Sammons & Brown, 1997). Instead, we present a glimpse of the behind-the-scenes activity that took place over the course of this process. In this way, we hope readers will gain a realistic appreciation of the forces working against a logical “But of course” answer to the basic question “Can a psychologist be trained to safely and effectively prescribe psychotropic medication?” In retrospect, it is truly remarkable that not only did the PDP stay the course and successfully graduate 10 Fellows but also that it did so during the DoD’s major downsizing efforts and base realignments and closures and at a time of major international actions in Somalia, the Balkans, and Iraq. The true energy behind the steadfastness of the program, however, was due unequivocally to the efforts of the Fellows who successfully completed the PDP. They did so even in the face of uncertain outcomes and in the midst of the political maelstrom that resulted. 78

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MANDATE FOR THE PDP History In 1987, Sen. Daniel K. Inouye (D–HI) asked the Assistant Secretary of Defense for Health Affairs (ASDHA) about the possibility of the DoD setting up a pilot demonstration project allowing psychologists to prescribe psychoactive drugs (Office of the U.S. Senate, 1987). Later, the ASDHA appointed the U.S. Army as the executive agent for the project. The official language of the U.S. Congress implementing the demonstration project was found in the DoD Appropriations Act of 1988 (H.R. Report, 1988). This was followed shortly thereafter by a letter from the ASDHA to the then-Assistant Secretary of the Army: The language delineates the focus of the demonstration pilot training program for us . . . I would like the Army to act as executive agent for me on this matter. I am sure you are sensitive to the need that we proceed with appropriate caution and safeguards on exploring this precedentsetting project. (Office of the Assistant Secretary of Defense for Health Affairs, 1988)

As Sen. Inouye indicated, there was, however, little precedent from which to draw as a starting point. Other complications were encountered when the ASDHA began to receive numerous communications from individuals opposed to the proposed program. In response, the ASDHA provided assurances to the contrary and indicated that the DoD wanted to see the pilot project up and running by September 1988: While I agree that these concerns are worthy of serious consideration, I believe it would be in our best interest to explore this issue further. Accordingly, I request that you set up a pilot project by 15 September 1988, to determine the effect on the quality and efficiency of patient care of granting clinical privileges to licensed clinical psychologists with the appropriate credentials (carefully limited and closely monitored and supervised in every case) to prescribe psychoactive drugs. (Office of the Assistant Secretary of Defense for Health Affairs, 1988)

Those who were vehemently opposed included some of the Army Surgeon General’s psychiatric advisors. Initial objections focused on the adequacy of prerequisite training, education, and experience of the prospective candidates for the program. Although these were legitimate concerns that ultimately needed to be addressed (and ones that a subsequently established external evaluation panel tackled on numerous occasions), there simply were no models from which to draw at the time. These objections notwithstanding, the ASDHA, in response to an inquiry from the American Psychiatric Association, indicated that the ASDHA was willing to allow such questions THE DEPARTMENT OF DEFENSE EXPERIMENT

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to remain unaddressed for the moment to provide an opportunity for the PDP to be tested. In 1988, in an attempt to stress some practical utility behind the initiative, the Congressional Appropriations Committee stated that the prescription credential would better enable psychologists in combat to treat battle fatigue. This strategy, however well intended, was misplaced and ultimately delayed the onset of the program. Unfortunately not only was the term battle fatigue outdated, but also pharmacological treatment of this normal reaction to the stress, strains, and horrors of combat is generally unnecessary and usually a treatment of last resort. In addition, the Army’s psychiatric formulary for battlefield units included only three psychotropic medications. These medications were from the Deployable Medical Systems wartime stocks. Specific guidance in regard to the use of psychotropic drugs in the management of battle fatigue was found in the Deployable Medical Systems policy, which listed the drugs as the following: benzodiazepines (Valium), neuroleptics (Thorazine and Haldol), and an anti-Parkinsonian (Cogentin; U.S. Army Medical Department, 1987). As a result, despite the good intent of the Congress, this language only served as additional ammunition for the opponents of the program, who then said that a training program ought to prepare psychologists to prescribe only from this limited formulary. It was ultimately decided that this strategy of limitation was inconsistent with the original Congressional language, and it was abandoned as a model. Examination of Training Models Many hours were spent staffing and exploring the concept of the PDP within the U.S. Army Office of the Surgeon General to familiarize that organization with the details of the Congressional mandate establishing the program. Needless to say, much resistance was encountered and, for a period of almost 2 years, no definitive response to the mandate was made. A series of letters in 1989 from various Congressional staff offices to the Army Surgeon General made it clear that the Congress was growing impatient. In the fall of 1989 the newly appointed chief clinical psychologist of the U.S. Army realized that more concrete progress would have to be made, and quickly. Ironically, the first definitive opportunity for action resulted from the recommendation of the U.S. Army’s chief psychiatrist that a blue ribbon panel be convened by the U.S. Army Surgeon General to address possible training designs for the PDP. In the fall of 1988 the Deputy U.S. Army Surgeon General recommended that the RAND Corporation be contracted to study the feasibility of the PDP proposal. In parallel with this recommendation, a triservice (U.S. Army, U.S. Air Force, and U.S. Navy) panel with the participation of other professional associations (e.g., the American Medical Association, the American Psychiatric Association, the American Psychological Association [APA], the American Association of 80

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Medical Colleges, the Accreditation Council for Graduate Medical Education, and the medical school of the Uniformed Services University of the Health Sciences [USUHS]) was convened to assess which portions of a basic science medical school curriculum were necessary for the PDP participants. USUHS’s participation on this blue ribbon panel would later prove to be of critical importance to the successful design of the PDP. In the spring of 1989, however, the RAND Corporation, citing a lack of expertise in the area of training psychologists in psychopharmacology, declined to participate in the requested study. Therefore, the DoD initiative was still lacking a powerful and sound feasibility study providing a foundation for a reasonable configuration of the didactic coursework for the program. The absence of such a study had significant repercussions on subsequent curriculum development for the PDP. In his initial guidance, the Deputy U.S. Army Surgeon General used terms such as postdoctoral fellowship as a suggested model for PDP training. This description lent positive support to the project because: (a) the PDP and the privilege to prescribe psychotropic medication was viewed as more of a supplemental, or advanced, credential rather than a core credential for psychologists, and (b) the U.S. Army had in existence several in-house postdoctoral training programs in pediatric psychology, health psychology, and clinical neuropsychology. There were thus precedents for the advanced training of psychologists in the DoD on which the PDP could be built. In the fall of 1989, as an independent course of action, APA commissioned Wright State University to design a postdoctoral training program for psychologists in psychopharmacology. Eventually, the Wright State model would be one of the models examined by the first blue ribbon panel convened by the U.S. Army Surgeon General. Also at this time, APA published its first public endorsement of the concept to train psychologists to prescribe psychotropic medications: The American Psychological Association is aware of the Department of the Army in pursuing a Congressionally mandated project to train appropriately qualified psychologists to prescribe psychotropic drugs from a limited formulary. This matter has been broadly reviewed by the relevant groups within the Association, by relevant Divisions of the Association, and has been recognized as having potential value in providing for the needs of service personnel, particularly in isolated areas. Based on these reviews, it is the conclusion of the Board of Directors that there is both scientific and professional merit in the continued pursuit of a demonstration training program for military psychologists in the use of psychoactive medications in specified circumstances and with appropriate education and training. (APA, 1989)

Equally noteworthy is the fact that during this session of Congress the combined Congressional Committee on Appropriations published language THE DEPARTMENT OF DEFENSE EXPERIMENT

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remonstrating DoD for its tardiness in activating the PDP and insisted that a program be up and running during the 1990 fiscal year. Nevertheless, DoD, reacting no doubt to strong opposition from the military psychiatry community, continued to approach the matter very cautiously and was slow to respond. Evolution of the USUHS Model to Support the PDP In February and again in August 1990, the U.S. Army Surgeon General convened two blue ribbon panels (U.S. Army Office of the Surgeon General, 1990a, 1990b). Achieving consensus on a training model for the PDP was difficult because of the highly contentious atmosphere on all sides. Six training formats were reviewed and considered by the first blue ribbon panel: (a) the physician assistant (PA) model, (b) the registered nurse/NP model, (c) the battle fatigue model, (d) the model curriculum proposed by the American College of Neuropsychopharmacology (ACNP), (e) the Wright State model, and (f) the model related to the curriculum from the medical school of USUHS. The PA and registered-nurse models were, in short order, judged to be inadequate, insofar as both these professions could prescribe only under physician supervision. This arrangement was felt to be inapplicable because of the independent scope of practice of psychologists. The battle fatigue model was rejected (as just noted) because it was rightfully considered a poor paradigm for training in psychotropic medication. ACNP presented a very detailed model for training in psychopharmacology. This model had initially been developed to improve the training of psychiatry residents in the use of psychotropic medication. It initially attracted significant interest, but eventually the ACNP model was considered inappropriate. Its narrow focus on psychopharmacological agents alone, without other training in biological sciences and clinical medicine, made it more suited for general psychiatry residency training programs than for psychologist prescribers in training. Among the various models considered, the Wright State model received considerable attention by the panelists. This model proposed the following components, in this sequence: preparatory, independent study in biological sciences at the candidate’s home duty station; 2 months of intensive psychopharmacology coursework at Wright State University; 6 months of supervised clinical practicum at the duty station; return to Wright State for 1 week of additional intense training; and culminating in a return to the duty station for an additional 3 months of a supervised practicum (U.S. Army Office of the Surgeon General, 1990a). The Wright State model was reviewed in detail, but the panel was reluctant to endorse this format for pragmatic reasons. Because it would place the training, and its evaluation, largely within a civilian institution outside of direct DoD oversight, military planners declined to support it. 82

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The USUHS model received the most thorough review and, by the closing of the first blue ribbon panel, was endorsed by a majority of the panelists. The USUHS model specifically enrolled the candidates in the existing medical school curriculum at the F. Edward Hebert School of Medicine followed by what was then labeled a clinical clerkship at Walter Reed Army Medical Center (WRAMC). Unfortunately, the USUHS model was initially designed to be a concurrent model over the 2-year span of the program; the participants were expected to complete extensive medical school courses alongside first- and second-year medical students while at the same time engaging in an intensive clinical practicum at WRAMC. The only detail of the clinical practicum addressed at this point was that the Fellow would be engaged in the pharmacological management of approximately 100 psychiatric patients, the majority being inpatient with some outpatients. (This compressed formula was unrealistic, involving as it did the bulk of the first 2 years of medical school simultaneously with what was, with little change, a full-time psychiatry residency. Some individuals speculated, not without reason, that it was proposed to maximize chances of failure for the participants.) The impracticality of this proposal was immediately noted by the external evaluation team for this project, ACNP. This initial proposal, however (i.e., the off-the-shelf medical curriculum combined with a psychiatric residency), survived and, although later versions of the USUHS model were refined and sculpted as had been anticipated (U.S. Army Office of the Surgeon General, 1990a), it formed the nucleus of all subsequent training in the PDP. The major shortcoming of the USUHS model was that, although the medical school curriculum was fairly clear, it did not include a more detailed description of the clinical practicum (which became the focus for the followon blue ribbon panel 3 months later). Accordingly, the panelists recognized the need to reconvene to define the clinical practicum, even though the basic format of the psychiatric residency was spelled out during this first meeting. As we have stated, the recommended USUHS model called for a 2-year postdoctoral fellowship of concurrent (i.e., 50% didactic plus 50% clinical practicum) experiences. The didactic component called for the Fellows to follow the existing initial 2 years of medical school at USUHS with only slight modification (see Table 5.1). The Fellows were concurrently slated to undergo practicum training on the inpatient psychiatry wards at WRAMC. It was envisioned that the Fellows would spend 50% of their time in the classroom at USUHS and the other 50% engaging in supervised clinical practice alongside the second-year psychiatry residents at WRAMC. Although this arrangement was advertised as “rigorous but do-able,” it was the impression of the psychology managers of the PDP that this was a very aggressive design, requiring the simultaneous completion of a demanding medical school curriculum and taxing residency program, and was considered a near impossibility. THE DEPARTMENT OF DEFENSE EXPERIMENT

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TABLE 5.1 The USUHS Curriculum: Iteration 1 (Year 1) Course

Contact hours

Courses taken by both PDP Fellows and medical studentsa Anatomy I: Introduction to Cell and Tissue Biology, Embryology Anatomy II: Gross Anatomy of the Human Body Anatomy III: Anatomy of the Head, Neck, and Central Nervous System Anatomy IV: Microscopic Anatomy of Organs and Organ Systems Total for Anatomy I–IV Biochemistry Introduction to Clinical Medicine I Medical Physiology Total PDP

341 160 86 198 785

Courses taken only by medical studentsb Fundamentals of Diagnostic Parasitology, Medical Zoology Epidemiology and Biometrics Human Context in Health Care Medical Psychology Military Studies and Medical History Military Medical Field Studies—Summer Total

44 66 66 44 132 110 1,247

Note. USUHS = Uniformed Services University of the Health Sciences; PDP = Psychopharmacology Demonstration Project. From “The Psychopharmacology Demonstration Project: An Evolving Experiment in Postdoctoral Education for Psychologists” by M. T. Sammons and A. B. Brown, 1997, Professional Psychology: Research and Practice, 28, p. 110. Copyright 1997 by the American Psychological Association. Reprinted with permission. aHours include actual class and laboratory contact hours. bHours are based on calculations from the USUHS catalog of approximately 22 contact hours per hour of course credit; may contain some nondirect contact hours.

This decision was a momentous one for the structure of the program. Because the initial iteration did not have a curriculum tailored to psychologists prescribing, the Fellows entered into the same curriculum as all medical students at USUHS (see Sammons & Brown, 1997, for a complete delineation of courses taken). Thus, the entire projected 2 years of training were committed to the first two basic science years of medical school, unaltered. Although the psychology program designers were reluctant to add to the length of the program, it was eventually decided that because it was highly improbable that a specifically tailored curriculum would be available in time, on behalf of the intent of the program the initial iteration needed to be extended to 3 years to accommodate the medical school curriculum and inpatient psychiatry residency experiences. ACNP provided active input during the deliberations of the first blue ribbon panel. As a result, the panel encouraged the ASDHA to consider ACNP as a potential contractor for the external evaluation of the PDP. This 84

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was an unusual move, because DoD is traditionally quite sensitive to any appearance of bias in awarding contracts to outside vendors (which had not yet been instituted by the PDP directors). However, outside of APA and the American Psychiatric Association, ACNP represented a source of unique expertise on the project. It was therefore urged that its application as external monitor be considered. By February 1990, it seemed that a PDP model based on the traditional medical school curriculum and housed at USUHS was at least tentatively acceptable to most parties. But USUHS had much to do before the program could be brought to fruition. Two complicating factors existed. First, the U.S. Army, as the executive agent for the PDP, had no authority to request that USUHS (a DoD entity) even support this program. Second, Congress was growing more and more impatient and expressed this impatience to the ASDHA, which in turn requested that the Army develop a modified PDP “psychiatric residency” for two psychology Fellows and initiate this plan by September 1990. It is our impression that this ultimately proved to be another distraction, but one that could not be avoided at the time. In response to Congressional pressure, the Army’s program designers examined the PA program at the U.S. Army’s Academy of Health Sciences at Fort Sam Houston in San Antonio, Texas, as an alternative. It was eventually decided that two Fellows would spend 4 months completing coursework (human anatomy, inorganic chemistry, physiological chemistry, laboratory services, pharmacology, and orientation to physical exam) and then return to WRAMC for an 8-month clinical practicum. Two Army psychologists were identified and stationed at Fort Sam Houston in San Antonio, Texas, for this requirement. Meanwhile, in a proposal to institute this program coauthored by the U.S. Army’s chief psychiatrist and chief clinical psychologist, the chief psychiatrist once again emphasized the earlier language of battle fatigue as the congressional intent and insisted on a highly restricted, four-medication formulary. He also introduced the idea that patients treated by the Fellows during their practicum needed to provide informed consent because the PDP was experimental in nature and needed to follow established research protocols. Both of these approaches were viewed as distracters, and the chief clinical psychologist said as much. The notion that the PDP was an “experiment” requiring investigatory protocols approved by an institutional review board and informed consent from all patients became a delaying strategy that was used (albeit ultimately ineffectively) throughout several iterations of the program. In August 1990 the second blue ribbon panel (U.S. Army Office of the Surgeon General, 1990b) was convened with essentially the same constituency as the first. The panelists held no regard for the modified program based on PA training and recommended that ASDHA return to the initial panel’s original recommendation of the USUHS model. A start date of July 1991 THE DEPARTMENT OF DEFENSE EXPERIMENT

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was set. It was also during these proceedings that the notion of independent practice was reviewed and endorsed, along with the recommendation that the program ought to be of 2 years’ duration. In September 1990, ASDHA accepted the recommendations of the second panel and put into motion the necessary impetus to officially engage USUHS in support of the PDP.

FIRST ITERATION OF THE PDP Now at last things began to move rather quickly. Four Fellows were selected, two each from the U.S. Army and U.S. Navy. The selection criteria were quite general in scope: an officer in the U.S. armed services, who possessed a doctorate in clinical or counseling psychology, whose state license was in good standing, and who considered, by virtue of a statement of intent, that this additional psychopharmacological credential would enhance his or her ability to deliver effective and qualitative health care to patients. USUHS and WRAMC were officially instructed by their respective authority commands to support and supply resources for the PDP. From April through May 1991, a steering committee at USUHS used off-the-shelf coursework from Years 1 and 2 of the medical curriculum to form the PDP basic science core. Additional direct costs for the program were identified (e.g., computers, text material, office space, and what would become the major ongoing expense of the program: the cost of the external evaluation). A major issue reviewed during the meetings of the first blue ribbon panel re-emerged at this point: What entity could provide a fair and objective external evaluation of the PDP and its effectiveness? This was a subject of considerable debate. Because of the vociferous opposition from organized psychiatry, the program organizers were skeptical that an unbiased evaluation body could be located, and there was a high degree of concern that a negative evaluation would compromise the intent of the program. When a request for a proposal for a contract for the external evaluation of the PDP was published, both the American Psychiatric Association and APA submitted bids. There were several other bidders but, for a variety of reasons, they were eliminated from the process by the WRAMC contracting office. The contract was awarded to ACNP in January 1992 even though the program had begun in August 1991, thereby requiring that ACNP’s initial portion of the analysis be retroactive. In the first iteration of the PDP curriculum there were 1,365 hours of classroom requirements (see Tables 5.1 and 5.3). During one of the initial evaluation site visits, ACNP soon recognized that the concurrent aspect (i.e., basic sciences plus clinical practicum) of the USUHS model was indeed not an optimal arrangement and would soon lead to absolute burnout for the Fellows. 86

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During the second evaluation visit in the spring of 1991, ACNP recommended extending the program for an additional 9 months to allow for a suitable clinical practicum experience for the Fellows and to permit them the time to concentrate fully on their extremely demanding basic science coursework. The credibility of this recommendation became more apparent and needed when in January 1992, in addition to their basic science coursework, the Fellows began working in WRAMC’s Continuing Care Clinic. Working in the Continuing Care Clinic provided an outpatient practicum experience in the management of patients who were on long-term psychopharmacological regimens. This eventually would be followed by two additional clinical practicum experiences in inpatient psychiatry and psychiatric consultation liaison service. The latter provided the Fellows exposure to concomitant medical conditions (i.e., Axis III of the Diagnostic and Statistical Manual of Mental Disorders; American Psychiatric Association, 1980). Simultaneous completion of all these program requirements was simply too demanding, and again, was a clear prescription for failure. After considerable deliberation, the 9-month extension recommended by ACNP in 1991 was approved in the spring of 1993 (see Table 5.2). The PDP was not without its casualties. One Fellow from the first PDP class withdrew from the program in November 1992, feeling that the coursework and the resulting commitment on completion of the PDP were not consistent with his career aspirations. Another left the program because he felt that his performance in the PDP to date was so rewarding that he chose to pursue a full-time career in medicine. Also, from a programmatic standpoint, the PDP lost an opportunity to use an established examination format to assess a practitioner’s psychopharmacological knowledge in the context of comprehensive mental health care. This examination, the Psychiatric Resident in Training Examination (PRITE), has a heavy psychopharmacology component, is routinely given to psychiatry residents throughout their training to assess core competencies,

TABLE 5.2 Clinical Practicum Hours Rotation Inpatient psychiatry Consult–liaison psychiatry Outpatient psychiatry Outpatient psychology Total

Iteration 1

Iteration 2

1,880 160 — 40 2,080

1,040 430 220 220 1,910

Note. Hours assume a 40-hour work week. Outpatient work performed by Fellows in Iteration 1 was subsumed under Inpatient Psychiatry rotation hours. From “The Psychopharmacology Demonstration Project: An Evolving Experiment in Postdoctoral Education for Psychologists” by M. T. Sammons and A. B. Brown, 1997, Professional Psychology: Research and Practice, 28, p. 111. Copyright 1997 by the American Psychological Association. Reprinted with permission.

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and is often used preliminary to board certification exams. In fact, the Fellows in the first PDP iteration took the PRITE at the very beginning of their fellowship and fared rather well. As might be expected, their scores generally surpassed those of psychiatry residents on portions of the exam that dealt with differential diagnosis or psychopathology. In areas of physical assessment or diagnosis of medical conditions, they (not surprisingly) did not do as well. The PRITE was useful as it provided the candidate with a confidential self-report as to his or her fund of medical/psychiatric knowledge in multiple areas. However, when the vendors of the examination discovered that it had been used as a baseline for the PDP Fellows they objected on the grounds that it was intended and designed only for psychiatry residents. Because the vendors threatened to withdraw provision of the test to the entire WRAMC psychiatry residency program, the decision was made to withdraw the Fellows from this process. This was unfortunate, because at the time the PRITE was the only truly standardized evaluation process for the PDP (and could also directly correlate the performance of PDP Fellows with that of psychiatry residents, something that the test vendors may or may not have wanted). In any event, the loss of the one extant objective measure of performance for the PDP heightened the importance of procuring the external evaluation contract to conduct a fair examination process. During the spring 1992 evaluation visit ACNP recommended that a director of training for the program be designated. Up to this point there existed no day-to-day source of psychopharmacology expertise to guide the program’s design and evaluation. The initial design relied on individuals who were in opposition to the program who reluctantly and hesitantly assisted in the process. Furthermore, with this recommendation, more one-on-one mentoring and coaching for the Fellows could take place—a critical requirement for their morale. Last, it was also at this time that ACNP recommended that the PDP begin working on a 1-year didactic plus 1-year clinical practicum for the next iteration. In July 1992 the ASDHA accepted and adopted ACNP’s recommendation for a director of training. The 1-year clinical practicum component then became one of the principal targets for the newly appointed director of training of the PDP. This director-of-training position recommendation was approved throughout the command structures of the U.S. Army Office of the Surgeon General. The position was established within the Department of Psychology at WRAMC, which was in and of itself an unprecedented event.

SECOND ITERATION OF THE PDP Now that the PDP had gained momentum, the combined Congressional Appropriations Committee again directed ASDHA to have each of 88

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the three branches of the armed services appoint at least one candidate for the next class of the PDP, to start in July 1993. Obviously, those in opposition vehemently protested this directive, claiming that the merits of the program’s first design had not been fully and adequately evaluated. In terms of understanding the development of the PDP, it is helpful to appreciate that at this time there was significant interest in Congress in the development of psychology in the federal sector. To illustrate, at this time the same Congressional language stipulated that the armed services develop a PhD program in clinical psychology at USUHS and that each branch of service provide two slots for this training. Furthermore, each service was asked to allocate one training slot for postdoctoral fellowships at USUHS in child and adolescent psychology or forensic psychology. At the same time, there was pressure on USUHS to expand the scope of its programs, because the threatened closure of the medical school was being seriously considered as a cost-cutting move by some congressional staffers. Therefore, USUHS was hardly in a position to protest the development of the training programs for nonphysicians, given the degree of scrutiny it faced from Congress and the Clinton administration. By January 1993, halfway through Year 2 of the first iteration of the PDP (see Table 5.3), the director of training had been appointed by USUHS as chairman of the Curriculum Committee to devise the 1-year basic sciences component for subsequent iterations of the PDP. The committee was handsomely resourced with seven department chairs from USUHS. This committee met for a total of seven sessions and developed the newer curriculum, which was approved by ASDHA in June 1993, just in time for the second class of the PDP. Two new Fellows were allocated, one each from the U.S. Air Force and U.S. Army. Iteration 2 represented 651 hours of classroom time—a 52% reduction compared to Iteration 1 (see Table 5.4). There was at this time an additional push by ACNP to better define the clinical practicum for the first class of Fellows who would begin this process in a few short months. Working with the Professional Education and Training Committee of WRAMC, the PDP director of training fashioned the design of the clinical practicum, which was closely coordinated with the Department of Psychiatry. The design called for an inpatient psychiatry rotation (treating at least 100 patients over a 9-month period) as well as ongoing seminars in psychopharmacology and night call rotations. Another opportunistic event that supported the PDP clinical practicum was the slowly diminishing numbers of residents in general psychiatry, nationwide as well as in DoD health care training facilities. In fact, during that year, the psychiatry program at WRAMC had experienced a 50% shortfall in new resident enrollment. Therefore, in July 1993, with the PDP Fellows having successfully completed their basic science coursework, the attending staff of WRAMC’s Inpatient Psychiatry Service was pleased to have the additional manpower. The director of training for the PDP, a psyTHE DEPARTMENT OF DEFENSE EXPERIMENT

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TABLE 5.3 The USUHS Curriculum: Iteration 1 (Year 2) Course

Contact hours

Courses taken by both PDP Fellows and medical studentsa Clinical Concepts Clinical Pharmacology Pathology Pharmacology Introduction to Clinical Medicine II Total

100 47 215 86 132 580

Courses taken only by medical studentsb Ethical, Legal, and Social Aspects of Medical Care Human Behavior Medical Microbiology and Infectious Diseases Military Studies II Preventive Medicine Radiographic Interpretation Total

22 88 220 44 66 22 462

Note. USUHS = Uniformed Services University of the Health Sciences; PDP = Psychopharmacology Demonstration Project. From “The Psychopharmacology Demonstration Project: An Evolving Experiment in Postdoctoral Education for Psychologists” by M. T. Sammons and A. B. Brown, 1997, Professional Psychology: Research and Practice, 28, p. 110. Copyright 1997 by the American Psychological Association. Reprinted with permission. aHours include actual class and laboratory contact hours. bHours are based on calculations from the USUHS catalog of approximately 22 contact hours per hour of course credit; may contain some nondirect contact hours.

chiatrist, became the attending physician for those patients treated by the Fellows. In the spring of 1994, the two Fellows of the first PDP class successfully passed all examination requirements developed by ACNP. The examination consisted of the following components: (a) a written examination of 250 questions, including 120 multiple choice, 120 true–false, and 10 essay questions, and (b) an oral examination using up to four clinical cases across a variety of diagnostic categories and presenting clinical problems with psychopharmacology as the central component of the treatment plan. The oral examination board consisted of at least three members of ACNP, including at least one licensed psychologist. Both the written examination and the oral examination were to be administered at the end of each of the years of the fellowship. At a very impressive ceremony at WRAMC, on June 17, 1994, the Fellows of the first PDP graduated along with several hundred other health care professionals. The Commanding General of WRAMC pointedly gave special recognition to the two officers. Having endured 3 years of arduous training, 2 years of biomedical science coursework at USUHS, and 1 year 90

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of clinical practicum experience at WRAMC, each of these officers was assigned to major naval medical centers, where they would begin independently prescribing from an initial formulary of psychotropic and adjunctive medications. Throughout the first PDP iteration a supporting budget began to grow very slowly. For fiscal year 1992 the projected budget was $168,000, and the actual budget was $157,251. For fiscal year 1993 the projected budget was $177,046, and the actual budget was $153,323. These expenses covered the entire gamut of expenditures except for the salaries of the PDP director and director of training. The costs of training the Fellows were relatively minor, as they partook in extant coursework at USUHS and worked in an existing clinical training program at WRAMC. The vast majority of the cost of the PDP involved funding ACNP for providing ongoing external monitoring of the process. The cost of the program, however, became a major source of controversy later, during a hotly contested General Accounting Office audit of the program (see next section).

THIRD ITERATION OF THE PDP Another opportunity arose to further improve the basic science curriculum supporting the PDP when the School of Nursing at USUHS was given the task of training nurse anesthetists and NPs. The PDP and School of Nursing Directors of Training collaboratively designed a curriculum, referred to as Iteration 3, which would meet the requirements for both professions. In fact, some of the coursework was also accessible to the clinical neuropsychology Fellows of the Department of Psychology at WRAMC. The total classroom hours of Iteration 3 was 660, which, although including a slight increase of 9 hours over Iteration 2, truly represented a more balanced and realistic alignment of the coursework subject matter (see Tables 5.4 and 5.5).

ROLE OF ACNP The role of ACNP in the success of the PDP cannot be underestimated. From its initial involvement in the DoD’s blue ribbon panel, ACNP demonstrated that it is an organization committed to excellence, professionalism, and the advancement of psychopharmacologic services. From the inception of the program, ACNP provided comprehensive consultation to the PDP. Each ACNP PDP team was composed of three psychologists and three psychiatrists. Efforts were also made to balance the composition of the team in regard to gender and theoretical orientation. Although the composition of the team changed over the 9 years that ACNP evaluated the PDP, the team members’ commitment to objectives of their contract was always held THE DEPARTMENT OF DEFENSE EXPERIMENT

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TABLE 5.4 The USUHS Curriculum: Iteration 2 (Year 1: 1993–1994)

Course

Contact hours

Courses designed especially for the Psychopharmacology Demonstration Project (PDP) Survey of Human Anatomy Survey of Biochemistry Physiology Neuroanatomy–Neurophysiology Psychopharmacology Courses for medical students, taken in whole or in part by PDP Fellows Pathology I and II Clinical Concepts Pharmacology Clinical Pharmacology Introduction to Clinical Medicine Total

Change from Iteration 1 (hours)

54 54 39 42 21

–287.0 –106.0 –133.0

102 100 83 21 135 651

–113.0 0.0 –3.0 –26.0 –7.5 –654.5

+21.0

Note. USUHS = Uniformed Services University of the Health Sciences. Total hours changed as a result of compression of the academic training into one year and consolidation of courses. Neuroanatomy–Neurophysiology was a new class offered for this iteration. From “The Psychopharmacology Demonstration Project: An Evolving Experiment in Postdoctoral Education for Psychologists” by M. T. Sammons and A. B. Brown, 1997, Professional Psychology: Research and Practice, 28, p. 110. Copyright 1997 by the American Psychological Association. Reprinted with correction with permission.

TABLE 5.5 The USUHS Curriculum: Iteration 3 (Year 1: 1994–1995)

Course Anatomy Biochemistry Neurosciences Physiology Pathophysiology Clinical Medicine Clinical Concepts Pharmacology Clinical Pharmacology Psychopharmacology Introduction to Primary Care Total

Hours

Change from Iteration 2 (hours)

48 57 54 39 60 121 100 83 21 21 56 660

–6.0 +3.0 +12.0 +1.0 –42.0 –3.5 0.0 0.0 0.0 0.0 +56.0 +19.5

Note. USUHS = Uniformed Services University of the Health Sciences. From “The Psychopharmacology Demonstration Project: An Evolving Experiment in Postdoctoral Education for Psychologists” by M. T. Sammons and A. B. Brown, 1997, Professional Psychology: Research and Practice, 28, p. 111. Copyright 1997 by the American Psychological Association. Reprinted with permission.

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paramount. Their opinions and recommendations were always well received at all levels: within the PDP training faculty, the U.S. Army Office of the Surgeon General, and ASDHA’s office. The ACNP was contracted to (a) evaluate the progress, both academic and clinical, of the PDP Fellows; (b) make recommendations for improvements in the PDP curriculum; and (c) evaluate the practice of graduates of the PDP after they had finished the program. ACNP conducted evaluation site visits to USUHS and WRAMC at least three times during each academic year. Each site visit usually involved the concurrent evaluation of two classes of PDP Fellows. In an overlapping fashion, when it became evident that the clinical practice of PDP graduates would need to be evaluated and documented, ACNP’s contract was amended to add this additional requirement. ACNP evaluation teams conducted site visits with PDP graduates in all three branches of the armed services at military installations across the country. The ACNP interim and final reports on the PDP have been well documented in other sources (Newman et al., 2000; U.S. General Accounting Office, 1997), but it is safe to say that the PDP would not stand as the successful training model it does today if it were not for the professional dedication and objectivity of every member of the ACNP evaluation team.

THE DOD ADVISORY COUNCIL TO THE PDP After the first Fellows had graduated in 1994, it was clear that a mechanism was necessary to provide credentialing guidelines for this new breed of mental health provider. To this end, a DoD advisory council to the PDP was established in April 1994 at the recommendation of ACNP. This advisory council was designed to advise the ASDHA on policy issues regarding the training and utilization of PDP graduates. There were a number of issues that the ACNP identified during its evaluation of the PDP Fellows and the training program itself which, by now, had gone beyond the scope of the objectives of the actual training program. These issues involved the development of credentialing guidelines and procedures that would be used by military hospitals incorporating prescribing psychologists as members of their staff, as well as assignment recommendations for PDP graduates. Active participation in their development and approval by all three branches of the armed services would be required. The PDP training faculty did not have the authority to coordinate such an undertaking; therefore, the chief psychologist of the U.S. Army, acting as the ASDHA executive agent program coordinator, recommended to DoD that an advisory council be assembled that would be composed of the chief clinical psychologist from all three branches of the armed services, the chief psychiatrist from all three branches of the armed services, a quality-improvement representative from all three branches of THE DEPARTMENT OF DEFENSE EXPERIMENT

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the armed services, two representatives from USUHS, and a representative from the Professional Education and Training Committee of WRAMC. The director of the PDP and the director of training of the PDP were included as nonvoting members. Over the course of five meetings at the Pentagon from July 8, 1994, to February 9, 1995, the advisory council was charged with formulating policy recommendations regarding PDP in the following areas: (a) scope of practice, (b) prerequisite selection criteria, (c) formulary, (d) privileging procedures, (e) extent of physical assessment, (f) continuing-education requirements, and (g) utilization of PDP graduates. The advisory council was an interesting mix of health care professionals, including psychologists, psychiatrists and other physicians, and a pharmacologist. All were aware of the high visibility of the PDP and the political nature of the prescriptive authority movement. Subcommittees were established to formulate preliminary recommendations regarding the seven areas just mentioned. A concerted effort on the part of the chairperson was made to ensure that the composition of each subcommittee was balanced, that is, that clinical psychology and psychiatry were both represented. In some cases, a third subcommittee member was added to achieve balance. Formal votes were taken on each recommendation that the advisory council considered. It was decided that in the official minutes, majority and minority reports would be presented to present the decision-making process through which the advisory council had progressed to arrive at its conclusions. As the advisory council members worked together over the course of almost 9 months, their concern for patient welfare and their recognition of the political realities of the PDP grew concomitantly. What resulted were recommendations that ultimately protected the patients being served, the prescribing psychologist, and the medical treatment facility that gave the PDP graduate prescriptive authority. Scope of Practice The most contentious issue of the advisory council proved to be the delineation of the scope of practice of the PDP graduates. At a very basic level, ASDHA had not up to that point specified what the official title of a graduate of the PDP would be once that graduated Fellow began his or her first assignment. The title of PDP Fellow or PDP graduate seemed inappropriate. The title that the advisory council adopted was pharmacopsychologists. This title, however, proved to be too cumbersome for commanders and medical staff and ultimately was replaced by prescribing psychologist in most medical treatment facilities. Also at the core of the scope-of-practice issue was whether the prescribing psychologist would be an independent health care provider or whether his or her practice would remain supervised. The scope-of-practice subcom94

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mittee chairperson stressed the importance of the context in which the recommended scope of practice was developed. The subcommittee recommended a conservative approach to the development of a scope of practice for PDP graduates. The recommendation was essentially a replication of the process by which NPs and PAs gained prescriptive authority. The proposed PDP scope of practice was modeled after the state of Florida’s NP’s scope of practice. As in that model, psychologists were to begin prescribing medications under physician supervision, but as they demonstrated competence in prescribing medications, supervision would be reduced. The recommended scope of practice called for supervision by a physician. The subcommittee also recommended that the proposed scope of practice, which was based on a supervision model rather than a totally independent practitioner model, be re-evaluated in 1 year. The advisory council recommended that the supervisor of the prescribing psychologist be any physician who was also privileged to prescribe the same psychotropic medications. The consensus was that during the first year following graduation from the PDP, the prescribing psychologist would be supervised by a psychiatrist, and after that year the prescribing psychologist would be supervised by any physician privileged to prescribe the same psychotropic medications, but not necessarily a psychiatrist. The scope-of-practice recommendation was the only recommendation that was not carried by unanimous approval. The principal reason for the unanimity of all other recommendations was that the scope-of-practice recommendation set the ground rules for all other recommendations. The two dissenting advisory council members were the chief psychologist of the U.S. Army and the psychopharmacology professor from USUHS. Both felt that the recommended scope of practice—that is, prescriptive authority under supervision—was in contradiction to the intent of the Congressional mandate. It was further recommended that the local privileging authority at the appropriate medical treatment facility would determine the procedures by which the prescribing psychologist orders medications. This indeed is what transpired. All graduating Fellows practiced under some form of supervision or proctorship in the initial period after graduation. The terms of these proctored arrangements were dictated by the credentialing authority in each facility where they were assigned; thus, arrangements varied widely between graduates. Within a year or so after graduation, however, all Fellows had extensive reductions in their supervisory requirements, to the point that eventually all Fellows were practicing in an independent fashion, as was the original intent of the program’s designers. Formulary The subcommittee on formulary members felt that graduates of the PDP should be comparable to the educational requirements to PAs and NPs. THE DEPARTMENT OF DEFENSE EXPERIMENT

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It was pointed out during the meeting, however, that the PA–physician relationship has been, and is intended to remain, a dependent one, whereas the NP–physician relationship is collaborative and thus provides for the development, based on agreement, for a greater level of clinical independence. The recommended formulary included two broad classes of medications: (a) psychotropic medications and (b) adjunctive medications. Psychotropic medications were of five general classes, including (a) neuroleptics (antipsychotics), (b) antidepressants, (c) antimanics and mood stabilizers, (d) anxiolytics and hypnotic agents, and (e) medications used in the treatment of alcohol dependence and substance abuse. The other broad class was made up of adjunctive medications (e.g., anticholinergics for drug-induced Parkinsonian symptoms (see Table 5.6). The adoption of a formulary that delineated specific drugs, rather than a formulary organized more generally into broad classes of drugs, created considerable dissent. Some individuals argued that a formulary by specific drug might represent a deliberate strategy to limit psychologists’ scope of practice. This group argued that a by-drug formulary was too static and that when new drugs became available psychologists would have to continually struggle to include each one of these on their formulary. Individuals opposed to a byclass formulary argued that this provided insufficient guidance to supervisors or program overseers. An agreement was eventually reached to include specific drugs, but with the disclaimer that these simply represented examples of each class. In practice, the formulary of each prescribing psychologist has evolved separately, in accordance with the wishes of the credentialing bodies of the facilities where they practice. In general, they are given relatively wide latitude to prescribe within the classes delineated previously. Extent of Physical Assessment The subcommittee dealing with the issue of physical assessments believed that the clinical practicum year of the PDP did not adequately address their lack of physical assessment knowledge, skills, and experience. It was felt that the lack of breadth in terms of patient variety and exposure did not allow for the optimum development of the necessary skills required to provide for independent performance of physical exams. The addition of a mandatory rotation for the PDP students on an internal medicine or family practice service and a separate rotation on a neurology service would provide a method for improving the students’ capabilities. The subcommittee noted that a similar approach was already used by both dentists and podiatrists. The adjusted curriculum eventually required that Fellows complete two courses in clinical medicine, involving both didactic and experiential components. Fellows were proctored in physical exams and then performed a number of these under supervision. When assigned to work on the wards, Fellows were responsible for completing physical exams on the patients 96

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TABLE 5.6 Initial Formulary for Prescribing Psychologists Class

Generic name

Brand name

Psychotropics Neuroleptics (antipsychotics)

Antidepressants

Antimanics and mood stabilizers Antianxiety and hypnotic agents

Drugs used in the treatment of alcohol dependence

Chlorpromazine Prochlorperazine Thioridazine Mesoridazine Perphenazine Trifluoperazine Fluphenazine Thiothixene Loxapine Molindone Haloperidol Risperidone Imipramine Desipramine Amitryptaline Nortriptyline Amoxapine Doxepine Clomipramine Fluoxetine Sertraline Buproprion Trazodone Venlafaxine Lithium carbonate Valproic acid Clonazepam Diazepam Lorazepam Oxazepam Temazepam Buspirone Zolpidem Disulfiram

Thorazine Compazine Mellaril Serentil Trilafon Stelazine Prolixin Navane Loxitane Moban Haldol Risperdal Tofranil Norpramin, Pertofrane Elavil Pamelor, Aventyl Ascendin Adapin, Sinequan Anafranil Prozac Zoloft Wellbutrin Desyrel Effexor Eskalith Depakote Klonopin Valium Ativan Serax Restoril BuSpar Ambien Antabuse

Adjunctive agents Drugs used in the treatment of side effects secondary to psychotropics

Benztropine Trihexyphenidyl Amantadine Diphenhydramine Cyproheptadine Propanolol Atenolol Bethanecol Psyllium Docusate sodium

Cogentin Artane Symmetrel Benadryl Periactin Inderal Tenormin Urecholine Metamucil Colace

Note. Although this was the initial approved formulary, each prescribing psychologist’s formulary was ultimately determined by the credentialing authority in the facility where he or she worked. Thus, formularies differed, and continue to differ, significantly among graduates of the program.

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admitted to their teams and were trained in other invasive skills, such as phlebotomy. Prerequisites The initial report of the subcommittee presented a minimal set of prerequisites, motivated by the recorded intent of the original blue ribbon panel that the PDP be open to all military psychologists. The advisory council’s discussion of this set of prerequisites elicited the opinion that some of the PDP Fellows had a difficult time managing the science courses at USUHS and a suggestion that preparatory courses in chemistry and biology would make life easier both for the Fellows and for the faculty. The council recommended that the prospectus supplied to candidates for enrollment in the PDP should include information concerning useful preparation for the fellowship and that all candidates for the fellowship complete the following courses before applying for the fellowship: (a) a college-level course in a biological science, such as physiology or biochemistry; (b) a college-level course in chemistry, physical chemistry, or both; and (c) college-level courses in mathematics up to and including basic calculus. The approach emphasized that such preparation was optional for the candidate. Utilization The subcommittee on utilization recommended that the guiding principles in the assignment of prescribing psychologists should include increased access to additional mental health services (i.e., the provision of psychotropic interventions in the context of full mental health services to underserved populations in the military). Assignments should be primarily in an outpatient setting, but inpatient assignments were possible. The subcommittee recommended no specific career path for prescribing psychologists. This was in keeping with the accepted practice that clinical psychologists in all three branches of the armed services completing any postdoctoral fellowship program (i.e., neuropsychology, health psychology) did not function exclusively in their area of postdoctoral expertise but attempted to optimize service provision in whatever area they were assigned. The priority of assignment location was recommended in the following order: (a) medical centers with a clinical psychology internship, psychiatry residency training program, or both; (b) operational and deployed units as well as small hospitals; and (c) medical centers without a clinical psychology internship or psychiatry residency training program. Continuing-Education Requirements In addition to meeting their continuing-education state licensure requirements, it was recommended that prescribing psychologists complete a 98

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minimum of 20 Category I hours per year in psychopharmacology or closely related medical programs. The focus on psychopharmacology was to ensure currency in the area of psychopharmacology. The local military treatment facility’s credentials committee was charged with monitoring adherence to this requirement, as is customary for all providers’ continuing education.

THE VECTOR RESEARCH, INC., AND U.S. GENERAL ACCOUNTING OFFICE REPORTS After the inception of the PDP, Congress called for an outside evaluation of the PDP, specifically, a determination of the PDP’s effectiveness. In September 1995, in response to that Congressional directive, the ASDHA initiated a contract with Vector Research, Inc. (VRI) to examine the cost effectiveness of the PDP as well as its feasibility. The director of the PDP at WRAMC prepared the specifications for the contract and monitored it to completion. Through a series of telephone surveys, VRI found that DoD primary care physicians, psychologists, social workers, and health care beneficiaries were supportive of the notion that a psychologist who could prescribe medications would improve the quality of health care and increase access to those services. Most important, though, VRI determined that the yearly lifecycle costs per PDP graduate were significantly lower than for psychiatrists, internists, and family physicians. This finding would later be challenged as well as VRI’s own methodology used to establish contradictory results. In any case, the VRI report was the first external examination of the cost effectiveness of the PDP, and findings were in favor of continuing the PDP. In 1996, Congress mandated another formal evaluation of the PDP. This study was conducted by the U.S. General Accounting Office (GAO), an agency external to the DoD. Political forces most assuredly contributed to the establishment of this requirement by Congress. The PDP had already undergone three curriculum improvement iterations and was now producing graduates who were actually prescribing psychotropic medications in military medical treatment facilities. Psychiatry increased its lobbying efforts in Congress, claiming that granting prescriptive authority to psychologists within the DoD was too costly. Congress requested the GAO conduct a cost–benefit analysis of the PDP as well as an examination of utilization requirements. In 1997, the GAO issued its final report to Congress (U.S. General Accounting Office, 1997) and concluded that the PDP was in fact too costly: a total of $610,000 per PDP graduate. Also, the GAO report concluded that prescribing psychologists were unnecessary for DoD to meet its military medical readiness mission. On the basis of the GAO report results, it became impossible for ASDHA to continue to support the continuation of the PDP. The report was THE DEPARTMENT OF DEFENSE EXPERIMENT

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challenged by the chief psychologist of the U.S. Army as well as the director and director of training of the PDP. As an example, there had always been a well-documented shortage of psychiatrists with the U.S. Army, but despite the communication of these data to the GAO team, the conclusion in the GAO report was that no such shortage existed. Also, the cost estimates used by the GAO team erroneously included expenditures for facilities and faculty that were already in place at USUHS regardless of whether PDP fellows attended classes there. The cost estimates used by the GAO team were vastly different from those arrived at in the VRI report (1996). It became obvious that politics had prevailed. In 1997, the Senate appropriations bill contained language explicitly prohibiting the enrollment of new Fellows into the PDP. Existing fellows were allowed to continue their training, and those who had graduated were allowed to continue practicing as prescribing psychologists, but the PDP itself had fallen victim to the politics of organized medicine.

CONCLUSION Without a doubt, the PDP proved that a training program could be formulated to train psychologists to prescribe psychotropic medications and that graduates of that program could prescribe those psychotropic medications safely and effectively. Regardless of whether a fellow health care provider was philosophically in favor of or opposed to psychologists being trained to prescribe medication, once that provider had personal contact with or worked alongside a prescribing psychologist trained through the PDP, confidence in his or her prescribing knowledge and skills was quickly gained. No threat to patient safety emerged once PDP graduates were assigned to field positions. Contrary to the dire predictions of program opponents, no patients died, and to date no quality-of-care issues have arisen regarding the practice of any PDP graduate—quite the contrary; the PDP served to create a core group of prescribing psychologists whose clinical practice could be followed and evaluated. This core group would train other psychologists in the importance of the adjunctive use of psychotropic medication. Last, the PDP has served as the benchmark training program on which similar civilian programs would be built.

REFERENCES American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychological Association. (1989). Correspondence to the Secretary of Defense. Washington, DC.

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DeLeon, P., Sammons, M. T., & Sexton, J. (1995). Focusing on society’s real needs: Responsibility and prescription privileges. American Psychologist, 50, 1022–1032. Dunivin, D. L., & Orabona, E. (1999). Department of Defense Demonstration Project: Fellows’ perspective on didactic curriculum. Professional Psychology: Research and Practice, 30, 510–518. H.R. Report. (1988). No. 100-1002. Newman, R., Phelps, R., Sammons, M., Dunivin, D., & Cullen, E. (2000). Evaluation of the Psychopharmacology Demonstration Project: A retrospective analysis. Professional Psychology: Research and Practice, 31, 598–603. Office of the Assistant Secretary of Defense for Health Affairs. (1988). Correspondence from Dr. Mayer to the Department of the Army. Washington, DC. Office of the U.S. Senate. (1987). Correspondence from Senator Inouye to the Assistant Secretary of Defense for Health Affairs. Washington, DC. Sammons, M. T., & Brown, A. (1997). The Department of Defense Psychopharmacology Demonstration Project: An evolving program for postdoctoral education in psychology. Professional Psychology: Research and Practice, 28, 107–112. U.S. Army Medical Department. (1987). DEPMEDS policies/guidelines and treatment briefs: Patient Conditions 304, 305, 314, 315 and 318. Washington, DC: Author. U.S. Army Office of the Surgeon General. (1990a). Blue Ribbon Panel I: Training of military psychologists in limited psychopharmacology. Washington, DC: Author. U.S. Army Office of the Surgeon General. (1990b). Blue Ribbon Panel II: Training of military psychologists in limited psychopharmacology. Washington, DC: Author. U.S. Army Office of the Surgeon General. (1992). Interim report of Year I of the Department of Defense Psychopharmacology Demonstration Training Program for Military Psychologists. Washington, DC: Author. U.S. Army Office of the Surgeon General. (1993). Interim report of Year II of the Department of Defense Psychopharmacology Demonstration Training Program for Military Psychologists. Washington, DC: Author. U.S. Army Office of the Surgeon General. (1994). Interim report of Year III of the Department of Defense Psychopharmacology Demonstration Training Program for Military Psychologists. Washington, DC: Author. U.S. General Accounting Office. (1997). Defense health care: Need for more prescribing psychologists is not adequately justified (GAO/HEHS-o7-83). Washington, DC: Author. Vector Research, Inc. (1996). Cost-effectiveness and feasibility of the DoD Psychopharmacology Demonstration Project: Final report. Arlington, VA: Author.

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6 EXPERIENCES OF A DEPARTMENT OF DEFENSE PRESCRIBING PSYCHOLOGIST: A PERSONAL ACCOUNT DEBRA LINA DUNIVIN

The U.S. Department of Defense (DoD) Psychopharmacology Demonstration Project (PDP) is one of psychology’s grandest experiments. It assessed the feasibility of training clinical psychologists to prescribe psychotropic and adjunctive medications through the development of a 2-year postdoctoral fellowship and the provision of opportunities to use that training in a variety of clinical settings and training environments. I am very privileged to have been a part of that experiment. The PDP provided the profession of psychology with an unprecedented opportunity to explore the way specially trained psychologists would practice clinical psychopharmacology. The results are unequivocal regarding the actual practice of psychopharmacotherapy by psychologists who have completed this postdoctoral training. The success of the The opinion or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the U.S. Department of Defense.

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project in terms of training psychologists to safely and effectively prescribe has been substantiated by repeated and extensive evaluations: one by Vector Research, Inc. (1996), two studies by the U.S. General Accounting Office (1997, 1999), and an extensive assessment spanning almost 7 years by the American College of Neuropsychopharmacology (ACNP; “The Department of Defense,” 2000). In this chapter I provide a personal account of my experiences as a psychologist participating in the demonstration project. It should not be taken as representative of the experiences of all the PDP Fellows and graduates, because each was different. Neither do these comments represent official policy of the Departments of the Army or Defense. This is simply the story of one psychologist, now credentialed to prescribe psychotropic and adjunctive medications by virtue of specialized postdoctoral training and demonstrated efficacy of pharmacotherapy practice.

BACKGROUND To provide the necessary context, I begin this story by going back 25 years to my graduate school training. I participated in the clinical psychology doctoral program at St. John’s University in New York. While there, I studied psychoanalytically oriented psychotherapy, family therapy, and group psychotherapy for 4 years at the Long Island Institute for Mental Health. I then worked as a school psychologist at the Jersey shore for several years and maintained a part-time private practice. In 1984, I moved to paradise, a little island in the middle of the Pacific Ocean called Maui. For 8 years I maintained a general family practice of psychology—working with the school systems, family and juvenile courts, department of vocational rehabilitation, and the police department conducting interviews of children suspected of having experienced abuse and trauma. I found my time in Hawaii very rewarding. It truly fulfilled a dream, providing many opportunities for creative practice and professional activities. Hawaii was a small enough community that individuals could make a significant difference. For example, a family court judge with a vision to make life better for children of divorced parents enlisted the aid of two psychologists (of which I was one) to design a court-based psychoeducational program into which all divorcing families were mandated. This became a model program and was emulated throughout the United States. I was intrigued that a simple legislative change in a state statute enabled hundreds of children and their parents to benefit from psychological expertise. Many members of the community would otherwise never have had that opportunity. Coupled with my experiences as president of the Hawaii Psychological Association and my consequent involvement in legislative activities, I decided it would be enormously helpful to learn more about the interface between psychology and public policy in order to effect the kinds of societal change in which I was interested. I decided to apply for 104

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an American Psychological Association (APA) Congressional Science Fellowship and was selected in 1992. My friends and colleagues had been watching my unusual career moves with some interest. When I left New York for the Jersey shore, they told me I was headed for an analytic wasteland. When I left New Jersey for Hawaii, they had said there was no chance for a thriving practice in such a place. And when I left a busy, rewarding practice in Maui for a fellowship on Capitol Hill, they could not understand why I would want to leave paradise and take a cut in income to learn about the political process. When I accepted Sen. Daniel K. Inouye’s invitation to remain in the fellowship for a second year, they questioned whether my practice in Maui would survive. It was my next career move, however, that left my friends, family, and colleagues incredulous: After almost 2 years in the Congressional fellowship, I announced that I was not going back to Hawaii to resume my practice as planned—I was going to join the Army. I wanted to participate in what I saw as a critical experiment in the development of the profession of psychology. I wanted to see firsthand what would happen when psychologists were trained to prescribe medications. I thought about all the children on Maui whom my colleagues and I had had to send off the island for psychiatric care. There were never enough mental health professionals on the island to provide all the services needed. I wondered if prescriptive authority for psychologists might be a way to address that need in the community I loved. While I was involved in the governance of the Hawaii Psychological Association (HPA), and during the Congressional fellowship, I had been following closely within the discipline, and actively encouraging within HPA, the debate about prescriptive authority. I had discussed the issue with respected colleagues on both sides of the argument, and I wasn’t sure about it. If anything, I entered the PDP with a healthy skepticism—I’d like to say with an open mind—and a strong need to find out for myself if this was a good thing for the profession and the people psychologists serve.

EXPERIENCE OF THE PDP So, in June 1994, I raised my hand and took an oath that obligated me to 8 years of military service, 5 of which were to be served on active duty. I entered the Army via direct accession into the PDP. I was one of two civilians recruited into the Army for participation in this fellowship and was part of the third and largest class of fellows. Although the Army was lead agent for the PDP, it had not been successful in producing a graduate. There were two Army psychologists in the first PDP class and one in the second class, all of whom left the program for different reasons. (One left the PDP because he did not want to attend medical school, and the first class of Fellows was required to attend the first 2 years of medical school at the Uniformed SerA PERSONAL ACCOUNT

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vices University of the Health Sciences [USUHS]. Another Fellow left the PDP because he did want to attend medical school, entered USUHS, and took those same 2 years of courses over again. He is currently completing a psychiatry residency and is very pleased with his decision. The third Army psychologist left the PDP because he was passed over for promotion and anticipated a mandatory separation.) Of the three Army psychologists who eventually graduated from the PDP, I am the only one still on active duty. Two of the three Navy graduates, and all of the three Air Force graduates, remain on active duty. The PDP didactic curriculum and clinical training evolved throughout the 6 years that psychologists were trained in the postdoctoral fellowship. There was a total of four iterations. The first iteration was of 3 years’ duration: 2 years of off-the-shelf medical school courses at USUHS and 1 year on the inpatient psychiatry ward at Walter Reed Army Medical Center (WRAMC). The second and subsequent iterations were 2 years in duration. The didactic year essentially condensed the first 2 years of medical school courses into a single year by combining courses with the second-year medical students, advanced-practice nurses (family practitioners and nurse anesthetists), and a fast-track review course in biochemistry designed for medical students returning to the classroom after a break in academia since college. The second year of Iterations 2–4 comprised supervised clinical practicum experience in both inpatient and outpatient settings. The clinical experience involved treatment of a minimum of 100 patients in settings that varied somewhat depending on the iteration and the Fellow’s branch of service. Some of the Fellows rotated through the psychiatry consultation/ liaison service, but that rotation was discontinued early in the program. For five of the Fellows, the second year of training included 6 months on the inpatient psychiatry service and 6 months in the outpatient psychiatry clinic at WRAMC. For two of the Fellows, the second year consisted of 6 months on the inpatient psychiatry service (which included a significant portion of dual-diagnosis patients, i.e., comorbid psychiatric and substance use disorders) and a 6-month outpatient rotation (which included practicum experience in the outpatient psychiatry service and primary care triage unit) at Malcolm Grow Medical Center, Andrews Air Force Base. For one of the Fellows, myself, the clinical experience was expanded to 2 years. I entered the fellowship program with the third class and graduated with the fourth class. My clinical training consisted of 8 months in the WRAMC inpatient psychiatry service, 1 month in the Malcolm Grow Medical Center dualdiagnosis residential treatment program, and 15 months in the WRAMC outpatient psychiatry service. By the time I graduated I had treated close to 200 patients, some over the course of 2 years, and earned one of the highest scores on the final examination created by the ACNP for the fourth class. Despite the differences in practicum sites, there were several important commonalties among the clinical experiences in the various settings. 106

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The Fellows assumed primary clinical responsibility for managing the care of the patients treated; each was closely supervised by a senior psychiatrist, usually with advanced training in psychopharmacology; and all patients were seen within the military health care system, which permits access to comprehensive treatment records (laboratory and radiological studies, medication profiles) and close collaboration with other treating health care providers. (Readers who wish to learn more about the evolution of the PDP curriculum, evaluation of the program, one of the supervisory relationships, and personal experiences of the Fellows are referred to DeLeon, Dunivin, & Newman, 2002; DeLeon, Sammons, & Sexton, 1995; Dunivin & Foust, 1999; Dunivin & Orabona, 1999; chapter 5, this volume; Newman, Phelps, Sammons, Dunivin, & Cullen, 2000; Sammons & Brown, 1997.) At the time I entered the PDP, in 1994, the first class was graduating. Two Navy psychologists completed what turned out to be a 3-year fellowship: 2 years of off-the-shelf medical school courses at USUHS and 1 year on the inpatient psychiatry ward at WRAMC. It took quite some time (6–9 months) for those first graduates to be credentialed to prescribe, and my classmates were concerned that perhaps the Fellows would never be credentialed to do what they were being trained to do. I, on the other hand, was convinced that would be resolved, and I was focused on more immediate concerns—for example, struggling every day not to pass out in the anatomy laboratory. (I found that Vicks VapoRub placed around the nose under a surgical mask was the best approach to block out the dizzying odor of the chemical used to preserve the cadavers.) Nowhere was the paradigm shift from psychology to medicine more evident than in the first summer of classes, when we were immersed in biochemistry, neuroscience, and human anatomy. It was considered didactic training, but I assure you that it had a significant experiential component to it. The PDP produced 10 graduates, all of whom have been credentialed to prescribe psychotropic and adjunctive medications. Credentialing is site specific, and so are the formularies used. The first 3 graduates remained in the national capital region or not too far away in the Virginia Tidewater region. A DoD advisory committee had recommended a year of proctoring by a psychiatrist with 100% review of all pharmacotherapy patients initially, then an increasingly smaller number to a minimum of 10%, reviewed at the proctor’s discretion. Although all 3 graduates from the first class were prescribing independently in practice, they remained under supervision on paper while at their first assignments after graduation. They were all given independent status at their second duty stations postgraduation, however. The next 7 graduates were sent outside the national capital region—to Texas, Washington State, Mississippi, Florida, and Georgia—and were credentialed very quickly, sometimes within 1 week of arrival at their first assignment. After a year in the proctored-credentialing status, each graduate attained a level of independent prescribing with only the same kind of A PERSONAL ACCOUNT

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peer chart review required for quality assurance of any health care provider at military facilities. Collectively the PDP psychologists have treated thousands of patients. Their patients have been treated safely and effectively as determined by all supervisors and evaluators and, for the most part, the patients have been treated somewhat differently than they would have been had they received traditional psychiatric care. The PDP curriculum is based on a traditional model of medical education, and despite this immersion into medical school education and training each of the PDP psychologists maintained a primary professional identity as a psychologist and continued to practice psychology, along with the added interventions of clinical psychopharmacology, within the psychological model. The PDP essentially created a hybrid health care professional: a psychologist with specialized training heretofore received only by physicians. It became clear to the PDP participants—the psychologists, their trainers, their evaluators, and their patients—that these health care professionals were practicing pharmacotherapy differently than their physician colleagues. The psychologists were adept at establishing therapeutic alliances and incorporated the medication intervention, when appropriate, into an already-existing array of psychological, behavioral, and environmental interventions. Despite predictions by individuals opposed to prescriptive authority for psychologists, there have been no untoward incidents in the practice of pharmacotherapy by the PDP graduates. They have earned the respect of their colleagues: the nurses, physicians—and, yes, even the psychiatrists—with whom they have worked. They have also earned the gratitude of their patients, many of whom recognized that they had been treated differently than they had in the past and articulated this recognition. A few clinical vignettes illustrate how being treated by prescribing psychologists improved care for the individuals served. Two scenarios concern the treatment of patients with chronic conditions; these patients have been in the system for many years, treated by a number of health care professionals. In both situations, either the patient or a family member articulated how treatment provided by a psychologist was different than what they had previously experienced. The third clinical vignette illustrates the principle that the authority to prescribe is also the authority to not prescribe. The final vignette concerns another population psychologists serve: psychologists in the training pipeline. The first scenario involves a 62-year-old woman treated as an inpatient. She suffered from chronic paranoid schizophrenia; this was the last of about 12 hospitalizations. As a young woman, this patient was bright and articulate; she was a Navy nurse advancing quickly in her career when she married. Her husband was a health professional as well. Not too long after they married, she suffered her first psychotic break. The patient and her husband had raised several children to healthy adulthood despite her illness. A comment the patient’s husband made to me was telling. He said, 108

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“In the 35 years my wife has been treated, there have been many health care professionals involved in her care. You are the first to ask me how I’m doing. I wonder if that’s because you’re a psychologist?” Perhaps. The second vignette involves a 64-year-old woman with bipolar disorder treated as an outpatient sequentially by several of the PDP Fellows. She remained stable during the several years of treatment in the PDP clinic despite a less-than-supportive familial situation. She was aware that the program was ending and that she would be referred back into the psychiatry service. During the final session she said in her broad, expansive manner, “Well, now it’s back to business as usual!” When asked what she meant by that, she replied, “Well, that’s when you come in, they ask you how your meds are doing, and say, ‘See you next month!’” She left me with the definite impression that the PDP Fellows had been some of the few providers who had really talked with her. Perhaps this does have something to do with being psychologists. The third clinical vignette is that of a 46-year-old nurse, a senior military officer who far outranked me, the PDP graduate to whom she had been referred. She presented 6 months after aortic valve replacement and coronary bypass surgery. She was still working what she called “half days,” that is, 7:30 a.m. to 5:00 p.m. She was concerned about the postsurgery difficulties she was experiencing in memory and concentration. Neuropsychological testing did reveal some attentional inefficiencies that were expected to remit in time. She also experienced some depression and irritability for which she sought psychopharmacological consultation. On the first session she came in already having decided that she needed an antidepressant medication. By the third session, it was agreed that psychotherapy was the treatment of choice. By the fifth session, we had decided that a combination of individual and marital therapy was indicated rather than a course of pharmacotherapy. The authority to prescribe is, after all, the authority to not prescribe; it is also the authority to unprescribe. The PDP graduates report that it is a heart-warming experience every time they have taken an elderly patient off a drug that is draining his or her energy or causing a loss of balance and a potential fall. The PDP graduates maintain that it is very gratifying to streamline the polypharmacy of their patients and enhance their quality of life in that way, by unprescribing. These vignettes are only a few of the many experiences the DoD prescribing psychologists have had with patients, other health professionals, and administrative staff who have articulated what they have seen that is different about the prescribing psychologists. The PDP graduates are a unique breed, a hybrid. As psychologists who prescribe (without a medical or nursing degree), they are health professionals unlike any others who have come before them. And yet, without exception, each of the 10 PDP graduates maintained a professional identity as a psychologist, despite the fact that the postdoctoral training was entrenched in the medical model. A PERSONAL ACCOUNT

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The final vignette of improved care is not a clinical example; it concerns service to the population of psychologists-in-training. The psychology interns supervised by the PDP graduates have provided yet another perspective about what it means to be a prescribing psychologist, that is, what it’s like for psychologists-in-training to have a prescribing psychologist as a supervisor. My first duty assignment after graduation from the psychopharmacology fellowship included a faculty position on an APA-approved psychology internship program, portions of which were integrated with a psychiatry residency program. Supervision of the psychology interns (called residents in military settings) and third-year psychiatry residents for initial interviewing and disposition planning, as well as for group psychotherapy, was conducted by teams of staff psychologists and psychiatrists. When I assumed supervisory responsibilities several months into their internship, the psychologists-in-training described a distinct shift in their formulations of patients. They reported that the bio in biopsychosocial model had taken on a new significance. Learning to incorporate concomitant medical conditions and family histories of mental disorders with psychological, interpersonal, cultural, and environmental factors was described as a difficult and valuable experience. These broader, more balanced formulations enriched their understanding of the patients they served and, consequently, the interventions they provided. The interns reported that their supervisory experiences with a prescribing psychologist also enhanced their appreciation of their patient’s pharmacotherapy and increased their comfort level when discussing these issues with the prescribing medical and nursing colleagues and their patients. Many of the military internship programs, all accredited by APA, have chosen to incorporate didactic psychopharmacology training by the prescribing psychologists. (Details of one such curriculum may be found in Dunivin & Southwell, 2000.)

CONCLUSION From this demonstration project, we have learned a great many things. First and foremost, the PDP is a viable model for training psychologists to practice clinical psychopharmacology; this fact is substantiated by all external evaluations of the PDP (Newman et al., 2000; Vector Research, Inc., 1996; U.S. General Accounting Office, 1997, 1999). The conclusions of the U.S. General Accounting Office (GAO) regarding the safety and effectiveness of the military prescribing psychologists are often overshadowed by its focus on wartime medical-readiness requirements and costs (as reflected in the titles of the reports and as discussed elsewhere in this volume). In considering their comments, it may be helpful to understand something about the distinction between readiness requirements during wartime and peacetime situations: 110

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The preferred course of treatment for combat stress is adequate rest, counseling, and a quick return to the front lines. Soldiers who require medication are generally evacuated to hospitals located away from combat areas. Psychologists’ counseling skills can be valuable front-line tools to handle stress, although this can be accomplished without the special training given to prescribing psychologists. A service-level medical readiness official told us that the most effective techniques to minimize combat stress are proactive—that is, counseling troops upon their arrival in the combat zone to reduce their anxiety level before combat. According to officials, the social workers, psychologists, and psychiatrists who provide this type of proactive counseling have a far greater effect on the well-being of the troops in battle than those who treat personnel after combat stress has set in. This proactive approach does not require prescribing authority. (GAO, 1999, p. 10)

In the same report, the GAO (1999) went on to say although the PDP graduates’ prescribing skills may not be needed in combat situations, the graduates reportedly improve medical readiness at their peacetime locations. According to officials, the graduates improve readiness by reducing the time that patients must wait for treatment or by increasing the number of patients who can be treated. (p. 10)

Despite this focus on readiness and costs, one of the conclusions from the first GAO report is as follows: “Concerning the PDP’s implementation, [DoD] has demonstrated that it can train clinical psychologists to prescribe psychotropic medication, and these psychologists have shown that they can provide this service in the [Military Health Services System]” (GAO, 1997, p. 22). With respect to quality of care provided, the GAO (1999) had the following to report: Overwhelmingly, the officials with whom we spoke, including each of the graduates’ clinical supervisors, and an outside panel of psychiatrists and psychologists who evaluated each of the graduates[,] rated the graduates’ quality of care as good to excellent. Further, we found no evidence of quality problems in the graduates’ credential files. The graduates’ clinical supervisors have the most extensive knowledge about the graduates’ clinical performance because they have been responsible for reviewing the graduates’ charts, discussing cases with the graduates, and observing the graduates’ interactions with patients. Without exception, these supervisors—all psychiatrists—stated that the graduates’ quality of care was good. One supervisor, for example, noted that each of the graduate’s patients had improved as a result of the graduate’s treatment; another supervisor referred to the quality of care provided by the graduate as “phenomenal.” The supervisors noted that the graduates are aware of their limitations and know when to ask for advice or consultation or when to refer a patient to a psychiatrist. Further, the supervisors noted that no adverse patient outcomes have been associated with the treatment provided by the graduates. (pp. 8–9) A PERSONAL ACCOUNT

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The most extensive evaluation of the PDP was conducted by ACNP. Their May 1998 final report was released by DoD Health Affairs in June 2000 after multiple Freedom of Information Act requests and was subsequently published in the ACNP Bulletin (“The Department of Defense,” 2000). The results of their 7-year evaluation of the PDP and the performance of its graduates includes this final comment: As the preceding synopsis and the following detailed report indicate, the PDP graduates have performed and are performing safely and effectively as prescribing psychologists. Without commenting on the social, economic, and political issues of whether a program such as the PDP should be continued or expanded, it seems clear to the Evaluation Panel that a 2-year program—one year didactic, one year clinical practicum that includes at least a 6-month inpatient rotation—can transform licensed clinical psychologists into prescribing psychologists who can function effectively and safely in the military setting to expand the delivery of mental health treatment to a variety of patients and clients in a cost effective way. We have been impressed with the work of the graduates, their acceptance by psychiatrists (even while they may have disagreed with the concept of prescribing psychologist), and their contribution to the military readiness of the groups they have been assigned to serve. We have been impressed with the commitment and involvement of these prescribing psychologists to their role, their patients, and the military establishment. We are not clear about what functions the individuals can play in the future, but we are convinced that their present roles meet a unique, very professional need of the DoD. As such we are in agreement that the Psychopharmacology Demonstration Project is a job well done. (“The Department of Defense,” 2000, p. 8)

Furthermore, we have learned that it is feasible to teach medicine to clinical psychologists and expect that they will retain professional identity as psychologists. We have learned that appropriately trained clinical psychologists practice pharmacotherapy differently than many physicians, ostensibly due to the different paradigms underlying their disciplines (Dunivin & Newman, 2002; Newman, 2000; Sammons & Schmidt, 2001). We have learned that one of the particular values/skills psychologists bring to the practice of pharmacotherapy is their ability to establish a therapeutic alliance and take the time to listen to their patients and develop an appropriate treatment plan with their patients based on the patient’s individual needs. From the professional practice of the 10 DoD prescribing psychologists we have also learned that psychologists tend to rely less on exclusive pharmacologic treatments than their colleagues in medicine and to more frequently integrate pharmacotherapy with psychotherapy. This difference in practice patterns was the subject of much discussion as the psychologist Fellows were taught medicine. It has clearly been the subject of debate among advocates 112

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and opponents of prescriptive authority for psychologists. Readers should be reassured by the comments of the distinguished ACNP panels of psychologists and psychiatrists who evaluated the program over a 7-year period and concluded that: The PDP was not designed to replace psychiatrists or produce minipsychiatrists or psychiatrist extenders, and it did not do so. Instead, the program “products” were extended psychologists with a value-added component prescriptive authority provides. They continued to function very much in the traditions of clinical psychology (psychometric tests, psychological therapies) but a body of knowledge and experience was added that extended their range of competence. (“The Department of Defense,” 2000, p. 7)

At a personal level, I have also learned a great many things; not the least of what I learned was something about the outer limits of my capabilities. The particular challenges of beginning a military career during the fifth decade of life must be experienced to be fully understood. The physical challenges of officer basic training paled in comparison to those of the officer advanced course that I took in the fall of 2000. The physical injuries of rigorous training stand alongside the incredible opportunities for professional development rarely encountered in other types of psychological practice. I can honestly say that I find it unlikely that I would otherwise have pursued such activities as firing weapons, rapelling from structures several stories high, or crawling in the mud while carrying a “patient” on a stretcher through an obstacle course. The challenges inherent in assimilating massive amounts of new information taxed my capacity for memorization and required honing rote-memorization skills I had not found useful in clinical practice but were essential in medical school and in the military schools as well. I was convinced early on entering the PDP that it was a story that had to be told, and I began organizing what has become an almost annual update at APA conventions. Most of my PDP classmates had not been involved in APA governance, had never presented at a national convention, and didn’t think that people would want to hear what they had to say. Indeed, the symposia were very well attended; our colleagues were most interested in hearing the panel of PDP participants year after year. The feedback we have received from psychologists and legislators throughout the country indicates that hearing the stories, impressions, and data from psychologists who are actually prescribing is the most persuasive argument for prescriptive authority. The annual convention updates and other presentations delivered, the book chapters and articles written, all provide a body of important information about how psychologists trained in certain aspects of medicine will practice pharmacotherapy for psychological and behavioral disorders. The most striking lesson for me on a personal level was to learn how entrenched A PERSONAL ACCOUNT

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I was in the psychological model, how strong was my identity as a psychologist. Had I not been immersed in a traditional model of medical education for this fellowship, I doubt that I could have appreciated fully the distinction between the medical and psychological models and the impact of these differences on the way psychologists practice their profession. Some people have asked “how each PDP psychologist maintained the primary professional identity as a psychologist with added interventions” and “what formula can be given to others . . . to preserve the psychology identity.” For me today, the answer is simple (although this may, of course, change over time with development of different training models): years of experience practicing psychology prior to taking on additional training in medicine, pharmacology, and psychopharmacology. Several years of practice as a licensed independent provider of psychological services will allow consolidation of one’s professional identity while providing ample opportunities to observe the effects of one’s psychological interventions over time. I cannot overemphasize the importance of knowing firsthand the impact of one’s interventions without pharmacotherapy before adding this particular intervention to one’s scope of practice. The training that psychologists have in viewing the individual as part of a system and the experience intervening in that system to treat the individual is essential in understanding how best to incorporate pharmacologic intervention into the range of treatment interventions. I did not learn these things through the didactic coursework in medicine or the experiential clinical practicum training of the PDP; rather, I learned these lessons by incorporating this knowledge into what I already knew and had learned through the traditional practice of psychology. I entered into this experiment to see firsthand what would happen when a practicing psychologist learned enough medicine to prescribe psychotropic agents. We have learned from the PDP that incorporating clinical psychopharmacologic interventions into the service provision of psychologists with specialized training is feasible and that psychologists can learn enough medicine to practice pharmacotherapy safely and effectively while still practicing from within a psychological model. Based on the extensive evaluations by varied sources, there is no doubt that the PDP is a viable training program. I think the most convincing argument is the quality of patient care provided by the graduates; patients notice the difference, and they say so. Medical staff notice the difference, and they refer their residents and colleagues for whom an integrated approach is the treatment of choice. The PDP is an excellent program, yet it was based in the medical model. It is time now to establish postdoctoral training programs based in the psychological model, a model that incorporates into the pharmacologic interventions all that is known about the intrapsychic, interpersonal, and cultural worlds in which our patients live. Psychologists can do this. Psychologists are ready to do this. Some psychologists are already doing this. And the patients served will benefit from more psychologists doing this. 114

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REFERENCES DeLeon, P. H., Dunivin, D. L., & Newman, R. (2002). Commentary—the tide rises. Clinical Psychology: Science and Practice, 9(3), 249–255. DeLeon, P. H., Sammons, M. T., & Sexton, J. L. (1995). Focusing on society’s real needs: Responsibility and prescription privileges? American Psychologist, 50, 1022–1032. The Department of Defense Psychopharmacology Demonstration Project: The ACNP evaluation report and final summary [Special issue]. (2000). ACNP Bulletin, 7(3). Dunivin, D. L., & Foust, M. J. (1999). Case study from the DoD Psychopharmacology Demonstration Project: Mania and neurosyphilis. Professional Psychology: Research and Practice, 30, 346–351. Dunivin, D. L., & Newman, R. (2002). The psychological model and the psychological practice of pharmacotherapy. Unpublished manuscript. Dunivin, D. L., & Orabona, E. (1999). DoD Psychopharmacology Demonstration Project: Fellows’ perspectives on didactic curriculum. Professional Psychology: Research and Practice, 30, 510–518. Dunivin, D. L., & Southwell, G. D. (2000). Psychopharmacology training in psychology internships: A brief curriculum. Professional Psychology: Research and Practice, 31, 610–614. Newman, R. (2000, March). A psychological model for prescribing. Monitor on Psychology, 31, 45. Newman, R., Phelps, R., Sammons, M. T., Dunivin, D. L., & Cullen, E. A. (2000). Evaluation of the Psychopharmacology Demonstration Project: A Retrospective Analysis. Professional Psychology: Research and Practice, 31, 598–603. Sammons, M. T., & Brown, A. B. (1997). The Department of Defense Psychopharmacology Demonstration Project: An evolving program for postdoctoral education in psychology. Professional Psychology: Research and Practice, 28, 107–112. Sammons, M. T., & Schmidt, N. B. (2001). Combined treatments for mental disorders: A guide to psychological and pharmacological interventions. Washington, DC: American Psychological Association. U.S. General Accounting Office. (1997). Defense health care: Need for more prescribing psychologists is not adequately justified (GAO/HEHS-97-83). Washington, DC: Author. U.S. General Accounting Office. (1999). Prescribing psychologists: DoD demonstration participants perform well but have little effect on readiness or costs (GAO/HEHS99-98). Washington, DC: Author. Vector Research, Inc. (1996). Cost-effectiveness and feasibility of the DoD Psychopharmacology Demonstration Project: Final report. Arlington, VA: Author.

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7 TRAINING PROGRAMS RONALD F. LEVANT, JUDITH E. N. ALBINO, ANITA B. BROWN, SAMUEL A. FELDMAN, RAYMOND A. FOLEN, PEGGY KACZMAREK, ELAINE S. LEVINE, ROBERT E. MCGRATH, GLORIA D. PICKAR, A. EUGENE SHAPIRO, STEVEN R. TULKIN, AND CAL VANDERPLATE

After the success of the Department of Defense (DoD) Psychopharmacology Demonstration Project (Sammons & Brown, 1997) in training military psychologists to prescribe psychoactive medications, civilian psychopharmacology training programs for psychologists began to develop. Over the past decade, a number of training programs have come into existence, and many psychologists have undertaken the rigors of postdoctoral training in psychopharmacology, even though (until the startling success of the New Mexico Psychological Association in passing a law on March 6, 2002), no U.S. state had yet passed a law that would allow civilian psychologists to prescribe psychoactive medication. Today, 11 programs offer postdoctoral training in psychopharmacology. It is estimated that more than 900 psychologists have pursued or are pursuing such training. Over the past decade, three types of programs have evolved: (a) postdoctoral programs that award certificates, continuing education credit, The first author planned and edited the chapter, wrote the introduction and conclusion, and coauthored the section on Nova Southeastern University’s program. The other authors contributed program descriptions and are listed in alphabetical order. These program descriptions are drawn from a symposium “Education and Training for Prescriptive Authority” that was conducted as part of the Presidential Miniconvention on Prescriptive Authority for Psychologists at the 2000 Annual Convention of the American Psychological Association.

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or both; (b) postdoctoral programs that award master’s degrees; and (c) a predoctoral program that awards cooperative degrees with a school of nursing. This chapter presents in some detail the specifics of all three types of programs. One key element in the development of these programs has been the collaboration with state psychological associations. For example, in Georgia and New Mexico the state associations played the key roles in organizing the program. In other states, such as Louisiana, Texas, Oregon, and Florida, the programs were built on collaboration between the state association and an academic training program. Several training programs have found that, after an initial enthusiastic response to their program, it has been difficult to get enough students to fill subsequent classes. Although this phenomenon may change with the passage of legislation in New Mexico, it is still worth analyzing. Some people theorize that this trend is due to the fact that early classes enrolled the “pioneers” in this new field of prescribing psychology and that others are waiting for a law to be passed in their state enabling psychologists to prescribe before they invest the considerable time, effort, and money to get the advanced training. If this were true, it would be very unfortunate for the profession, for at least three reasons. First, laws are not likely to be passed until there exists a significant cadre of well-trained psychologists who are invested in obtaining laws and willing to expend the resources to get their state legislatures to pass one. Second, such a wait-and-see approach is likely to result in psychology being left out in the cold as health care evolves in the 21st century with emphasis on e-health, primary care, and the creation of prescribing professionals. Third, as is elaborated later in the chapter, graduates of programs have already reported positive outcomes on their practices, even though they cannot yet prescribe. The American Psychological Association (APA) model curriculum calls for a supervised practicum experience of treating a minimum of 100 patients. Outside of the DoD Psychopharmacology Demonstration Project, and before the passage of legislation in New Mexico, it was not possible for prescribing-psychologists-in-training to actually conduct psychopharmacological treatment, because psychologists could not legally prescribe in civilian practice in most U.S. states. This issue has been discussed in numerous APA meetings on education and training for prescriptive authority. It seems clear that until training laws (e.g., laws, such as the one in New Mexico, that would enable psychologists to prescribe under supervision) are passed, practicum training will of necessity be, to some degree, “virtual” training—that is, psychologists in such training programs may be able to offer a proposed prescription, but the prescription would have to be written by the supervising prescribing professional. Psychologists who have undertaken the training are very positive about their experiences. For example, the New Mexico program conducted an eval118

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uation (reported later in this chapter) that found a high degree of satisfaction with the training program. Several case vignettes are presented later that illustrate how such advanced training in psychopharmacology has greatly enhanced the practice and knowledge of trained psychologists. In Florida, the Nova Southeastern University program found that students reported that the training program has enhanced their ability to practice in such diverse areas as collaborative health psychology practice, neuropsychology, forensic psychology, and hospital-based practice. Many reported an increased number of referrals from physicians with whom they have collaborated. Elaine Mantell (personal communication, March 20, 2002), one of the DoD psychologists, recently noted: Something very exciting happened today that I just had to share with you. I am still on a “high” from it. Today I assessed a patient that another medical provider was calling a “psychogenic case.” But my medical exam revealed that the patient was showing a sudden onset of pill rolling, cogwheeling and acute akathisia. I insisted that he did not look like a “psych” case at all and immediately referred him to a neurologist who ordered [a magnetic resonance imaging/a magnetic resonance angiography scan] and discovered he had a bilateral dissected carotid artery. The neurologist immediately hospitalized the patient and said that he would have died without immediate medical intervention. He said that my referral saved the patient’s life. So, who says that prescribing psychologists are a medical menace!! I thought I would share this with you because you are all supporters of [prescriptive authority] and I want you to understand the impact you may have on our profession and those who seek treatment/consultation from us. I hope this little anecdote, provides you with greater “fuel” for your efforts. I know that it has given me a deep sense of gratification as well as gratitude for the training.

We now turn to a discussion of a representative selection of the three types of training programs: (a) postdoctoral programs that award certificates, continuing education credit, or both; (b) postdoctoral programs that award master’s degrees; and (c) predoctoral programs that award joint degrees. The program descriptions were written by the key people involved in each of the programs. Within each category they are presented in chronological order, from the earliest to the more recent programs.

POSTDOCTORAL CERTIFICATE OR CONTINUING EDUCATION PROGRAMS Prescribing Psychologists’ Register (Samuel A. Feldman) The psychopharmacology training program of the Prescribing Psychologists’ Register (PPR) was the first to be established, in 1992. PPR has the lonTRAINING PROGRAMS

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gest history and the most graduates of current training programs and meets APA’s recommended guidelines for psychopharmacology training at Levels 1, 2, and 3. More than 1,000 graduates have completed the seven courses toward designation as a board-certified Diplomate–Fellow in psychopharmacology. The first course is offered either as an independent home video or live presentation, and the remainder have been offered in live presentation seminars (offered at sites in California, Florida, Oklahoma, Illinois, Texas, Ohio, Pennsylvania, and New York). Since 1998, the PPR series of courses has been available via Internet distance-learning connection through the Fielding Institute, a regionally accredited institution. This program also is the first of its kind. The costs for courses in home video and live seminar presentations is $150 per course. Internet distance-learning courses earning formal academic credits on transcript range from $250 to $350 per course. Each course earns 18 continuing education units toward the 300 required for completion of the program. Preceptorships are arranged with an MD or DO licensed to prescribe in the state in which the psychologist practices. The preceptor must submit to PPR periodic clinical reports and quarterly reports on the progress of the psychologist and sign off on at least 100 patient clinical progress records. Georgia Psychological Association Collaborative Program (Cal VanderPlate) In 1997, the Georgia Psychological Association (GPA) began a postdoctoral psychopharmacology training curriculum for psychologists in cooperation with Georgia’s two premier state universities. This section provides an overview of the development process leading to that curriculum and highlights factors that resulted in the success of this endeavor. GPA established a task force on prescriptive authority in 1992 with the intent of gathering information, encouraging debate among Georgia psychologists, and formulating an association stance on the issues. By 1995, we were seriously at work implementing a training program in Georgia. The goals of the task force were twofold: (a) offer comprehensive, rigorous, highquality training to psychologists to prepare them as expert prescribers and (b) pass legislation that would enable these psychologists to use their training. We considered each goal complementary and perhaps essential for the success of the other. Legislators are about the business of “fixing things that are broken” and may be reluctant to grant prescriptive authority when there were no psychologists trained to use it. Similarly, psychologists with busy lives and professional careers would be reluctant to commit substantial time and money for training without a reasonable prospect that legislation would be passed, thus making their efforts worthwhile. Several criteria were developed that guided our development of training. First, our clear preference was for an in-state training program at a major 120

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state university. The quality and rigor of the curriculum could best be assured in a university setting where academic faculty provided the coursework. In addition, our training program would have considerably more credibility in the state legislature when housed at a trusted university. Second, our curriculum followed the APA model curriculum adopted in 1995 by the APA Council of Representatives. Third, we wanted to take advantage of the extensive training and experience of the DoD Psychopharmacology Demonstration Project graduates. Their training has been accepted even in most medical circles as rigorous and comprehensive. Fourth, all classes and practicum needed to be “practitioner friendly”; class times needed to be arranged with the busy lives of practicing psychologists in mind. Courses have been offered on an every-other-weekend schedule. Fifth, we wanted to use distance learning to provide training in rural Georgia. The Georgia state university system has one of the more advanced distance-learning systems, allowing economical, interactive training at sites around the state. Finally, it was most important that the curriculum be based on a “psychology-based paradigm” (Dunivin & Orabona, 1999, p. 515). Rather than offering off-the-shelf courses based on a medical model, all courses were redeveloped to suit the particular needs of psychologists. The overriding philosophy of the psychology model is that the curriculum reflect psychologists’ unique training, broadly humanistic tradition, and biopsychosocial model (Sammons & Levant, 1999). Psychologists practice differently than other medication providers. They view the client in the context of the whole environment, focusing on coping skills and support system. Psychopharmacology will be seen as one tool among many available to assist clients. Beginning in 1995, GPA began working with the Georgia State University (GSU) Center for Brain Sciences and Health and the University of Georgia College of Pharmacy to develop a comprehensive, seamless curriculum. Along with the Georgia Institute of Technology, GSU and the University of Georgia are the premier universities in Georgia’s state system. GSU is an urban university located in Atlanta. The Center for Brain Sciences and Health of GSU is a free-standing center that focuses on brain studies. Faculty have expertise in psychopharmacology and neurobehavioral psychopharmacology. The University of Georgia College of Pharmacy is the sole public school of pharmacy in Georgia and has a tradition of innovative, nontraditional training programs for nonpharmacy students. The curriculum is designed as eight 40- to 50-hour courses taught on a semester basis covering neurosciences, neuroanatomy, pathophysiology, clinical pharmacology I and II, psychopharmacology, and physical assessment and laboratory technique. A proseminar series focuses on special issues involving ethnicity, gender, and age as well as ethics, chemical dependency, pain management, and so on. Finally, a 100-patient practicum, being developed by GPA, will integrate office practice with a required institutional setting component. Mandating a percentage of training in an institutional setting will guarantee experience TRAINING PROGRAMS

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with a broad range of psychopathology, ensure continuity of care, and allow for collaborative and consultative experience. The development and ongoing coordination of this program has been a unique and challenging experience for GPA. Organizationally speaking, the state psychological association identified and coordinates the curriculum. Both universities remain neutral regarding the issue of psychologists prescribing. All courses are offered as continuing education to ensure maximum flexibility. Each course instructor and his or her respective university are responsible for the quality of their course and certify that students have passed a mastery exam for their course. GPA oversees the overall program and certifies successful completion of the curriculum to the Georgia Psychology Licensing Board. Classes began in September 1997 with 25 students, 19 of whom have now completed the 2½-year curriculum. Uniformly, students have been impressed with the quality and relevance of training. The second cohort of 16 students began classes in September 1998 with live-time distance learning at two sites (Savannah and Valdosta). The third cohort of 14 students began classes in September 2000, with a distance-learning site in Savannah, and it is still in progress. Several factors led to the success of this endeavor. When GPA established its task force on prescribing in 1992, several groups were considered critical to the success of curriculum development and legislation. First, GPA membership of necessity had to support these initiatives. Several years of education and debate were devoted to ensuring strong support of the psychological community in Georgia. A poll of GPA members several years ago showed that 74% were supportive of prescriptive authority for psychologists (with 60% indicating that they were strongly supportive). Only 14% were opposed. Fifty-two percent said they would take the training if offered. Next, the leadership of GPA needed to be firmly committed to implementing training and seeking legislation. Past presidents, the president and presidentelect, and several other state association leaders attended task force meetings and assisted in developing our strategy. In addition, if curricula were to be developed in state, then educators needed to be involved. Consequently, training directors from clinical doctoral training programs were invited to participate, laying the groundwork for success. Training requirements will be broadly defined by law, with the state licensing board refining the process through interpretation of rules and regulations. Therefore, it was considered essential to have the licensing board involved and supportive from the beginning. A licensing board member has attended most of our curriculum planning meetings and approved all of the countless decisions necessary for implementation of a program. Without strong support, cooperation, and concerted effort on the part of these diverse participants, a state training or legislative effort is less likely to be successful. Even with such support it is most important that legislative initiatives be seen as a process the success of which will likely take several 122

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years. GPA first introduced a bill for prescriptive authority in the Georgia legislature in January 1998. The bill was reintroduced in January 1999, 2000, and 2001. Considerable progress has been made, although the legislative agenda is complex and challenging. In our talks with legislators from around the state, the recognized quality and credibility of the curriculum has made training less of a major point in the larger debate. Legislation is now pending in the 2002 session. New Mexico State University Collaborative Program (Elaine S. LeVine and Peggy Kaczmarek) When the New Mexico Psychological Association Task Force on Prescriptive Authority was established in 1996, the members determined that educating a cadre of psychologists in psychopharmacology was a primary goal. This task force reasoned that the trained psychologists would be able to speak with knowledge throughout the state on issues and benefits of giving psychologists the authority to prescribe psychotropics. Furthermore, these psychologists would be informed leaders within the state, able to make wise decisions regarding legislative efforts to gain prescriptive authority. The goals for the psychopharmacology training were as follows. First, the program should be housed within New Mexico, preferably under the auspices of a state university. The task force reasoned that a state educational program would be compelling to the legislature, as it would demonstrate that New Mexico has psychologists ready to prescribe psychotropic medications and prepared to educate more psychologists to be safe and effective prescribers of psychotropic medications on the passage of prescriptive authority legislation. Second, the educational program should be built on a psychological foundation that fulfills the Level 3 requirements established by APA’s Ad Hoc Task Force on Psychopharmacology (Cullen & Newman, 1997). The New Mexico task force’s goal is for graduates of the program to prescribe as psychologists, using psychotropic medications as one of the various tools in their armamentarium. The third and last goal is that the educational program needed to integrate all necessary learning from the medical field so that the graduates would be safe prescribers who would practice competently and collegially with the respect of physicians and others in the allied health field. A great challenge was to provide this program in an economically poor and sparsely populated state (with only 350 active licensed psychologists). Program goals needed to be accomplished in an economically conservative structure that could prevail with a relatively limited number of students. Curriculum and Course Structure The curriculum is a postdoctoral certificate program in psychopharmacology for psychologists housed at New Mexico State University in Las Cruces. It is the first postdoctoral certificate program in New Mexico. The TRAINING PROGRAMS

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program is taught in a weekend format that meets approximately every 6 weeks for a total of 17 weekends, which is 306 hours of didactic instruction. The first 7 weekend courses follow the curricula developed by the PPR. These seven courses provide an intensive overview of pharmacology and psychopharmacology, neuroanatomy, diagnosis and treatment (psychologically and pharmacologically) of mood disorders, anxiety disorders, sleep disorders, psychotic disorders, organic disorders, and disorders of children and the elderly. With the support of PPR and the aid of pharmaceutical companies, as well as student tuition, courses have been taught by national and state scholars in psychopharmacology (mainly psychiatrists and some PhD-level psychologists and pharmacists with advanced training in psychopharmacology). On completion of the first 7 weekend courses, the students receive the designation of Fellows of the PPR. The first 7 weekend courses are followed by a 6-weekend graduate-level course in pathophysiology and physical assessment taught by graduate-level nursing faculty of New Mexico State University. Each of the classes focuses on a different body system; students learn how to conduct a physical examination of that system, analyze pathophysiology associated with that human system, and develop basic treatment strategies. The 6 weekend courses of physical assessment and pathophysiology are followed by 2 weekends in which students study pharmacology in depth. The 17-weekend series ends with 2 weekends in which professional, ethical, cultural, and practical issues of being an effective prescribing psychologist are explored. The educational program includes two practicum experiences: The first is a 70-hour practicum, to be completed in a primary care setting, in which students observe and practice basic skills of physical assessment, diagnosis, and treatment. The second practicum is the preceptorship recommended by APA in which psychologists observe and treat 100 patients under the supervision of a licensed medical practitioner. The Students’ Perspective A survey instrument was designed to obtain feedback from participants. At the time of data collection, seven didactic courses based on the curriculum from the PPR had been completed, and four weekends of the experiential nursing coursework had been completed. There were 13 students registered for the weekend class, and 12 returned the survey, for a return rate of 92%. The students commuted from locations in New Mexico and Arizona, some traveling 8 hours to attend. Eight of the students were female, and 4 were male. The ethnic composition of the participants was as follows: 9 were White, 2 were Hispanic, and 1 endorsed “other.” The mean age of the group was 40 years; the mean number of years in practice was 12 years. The questions assessing the PPR and the nursing coursework used a 5-point Likert-type scale that ranged from 1 124

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(strongly agree) to 5 (strongly disagree). The mean responses for these items were as follows: “The seven Prescribing Psychologists Register courses have”: “improved my diagnostic skills” (M = 1.4), “improved my ability to make referrals for medication evaluation” (M = 1.7); “The nursing coursework has”: “increased my knowledge of medical problems that can produce emotional symptoms” (M = 1.4), “improved my diagnostic skills and problem solving ability” (M = 1.7). On the open-ended questions the respondents indicated that the PPR courses improved diagnostic skills, helped clinicians recognize bipolar disorders, increased understanding of when to refer patients for medical or medication consultation, improved relationships with primary care physicians, and increased knowledge of medications. In reference to the nursing coursework, respondents indicated that it had increased their general knowledge of body systems; provided more awareness of medical complications contributing to mental health; and increased their sensitivity to medical issues, which has translated into more effective ways to assist clients with chronic illnesses and a greater appreciation of the whole person and the mind–body connection. Discussion Students in the New Mexico Interdisciplinary Program for Prescription Privileges endorsed both types of training as having a positive impact on their skills, especially in the area of increased diagnostic skills. They also felt better able to consult with physicians and more competent about recognizing medication side effects and facilitating client consultations with physicians. A strength of the postdoctoral certificate program in psychopharmacology for psychologists at New Mexico State University is that it maintains a psychological perspective while demonstrating that psychologists can learn necessary medical skills even without becoming a physician or nurse. The students are mastering the same readings, coursework, practica, and tests that are required of the master’s-level nurse practitioners, clinical nurse specialists, and clinical pharmacists who have gained prescriptive authority in New Mexico. Furthermore, the program offers a quality yet economically feasible alternative for this rural state.

POSTDOCTORAL MASTER’S DEGREE PROGRAMS Alliant International University, California School of Professional Psychology (Judith E. N. Albino and Steven R. Tulkin)1 The postdoctoral master of science program in clinical psychopharmacology at the California School of Professional Psychology (CSPP) of Alliant International University (AIU) admitted its first class of students 1The

authors thank Wendy Stock, PhD, for her contributions to this section. TRAINING PROGRAMS

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in 1998. In early discussions of the development of postdoctoral training in psychopharmacology, we envisioned a certificate program rather than an MS degree. Qualifying our students for prescriptive authority was not a major consideration. Our decision to offer an MS degree resulted from our collaboration with the Louisiana Psychological Association, which had approached us requesting that we offer our program in Louisiana. In fact, perhaps the most salient aspect of the psychopharmacology program at AIU–CSPP is that its development was the result of our working relationships with state psychological associations. The needs articulated by our colleagues within state associations were central in informing our planning and curriculum development. We return to this theme after we describe the rationale for our program. Background Our motivation in developing postdoctoral training in psychopharmacology derives from our commitment to a public health model of psychological services. It became increasingly clear over the past decade that educating psychologists in the area of psychopharmacology would improve public health. The practices of managed care dictate that the large majority of psychotropic medications are prescribed by primary care physicians who have neither specialized training in mental health nor sufficient time to evaluate the mental health needs of their patients. Prescribing psychologists with the requisite level of training could increase public access to comprehensive mental health care. The documented shortage of mental health professionals trained to meet the mental health needs of rural and underserved populations is a second aspect of the public health need. Finally, the need for continuity of care, combining psychotherapy and psychopharmacology, has been demonstrated in outcome research to be the most effective treatment for many mental health disorders. With these needs in mind, the following mission statement was developed for the program: The Psychopharmacology Program will provide licensed psychologists with coursework in clinical psychopharmacology, based on a psychological model of treatment. Courses cover the scientific foundations and clinical applications of psychopharmacology, and emphasize sensitivity to cultural, ethnic, gender, and economic influences on the development and treatment of psychological disorders. The curriculum will provide our students the knowledge necessary to remain informed of developments in clinical psychopharmacology, and to contribute to research and practice of psychopharmacology.

From Certificate to Master’s Degree The development of the certificate program was well on its way when we were approached by colleagues active in the Louisiana Psychological 126

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Association. Dr. John Bolter, who then chaired the Louisiana Psychology Association’s committee on psychopharmacology, reported that his proposals to Louisiana higher education institutions about the development of a program in psychopharmacology for psychologists had met with reactions ranging from disinterest to active resistance. It was obvious that there were powerful interests within medical schools that opposed psychopharmacology training for psychologists. Of course, this created a sort of Catch-22 for the Louisiana psychologists, who were, indeed, working with members of the state legislature to develop a prescriptive authority bill. They had assured those legislators that a training program could be developed that would ensure beyond any doubt that psychologists completing this training would have the necessary knowledge and skills to warrant prescriptive authority. In the absence of such a program, of course, the opposition would have an argument against prescriptive authority. As we began conversations with Dr. Bolter and others about our emerging program, they encouraged us to consider offering a degree rather than a certificate. Of course, this was possible, but it meant additional work, so we expanded the curriculum and began the process of obtaining approval of a postdoctoral master’s degree program by our own academic senate and by our regional accrediting agency, Western Association of Schools and Colleges (WASC). The 35 individuals in the first Louisiana cohort began the program before final approval of the degree, committing to 36 weekends of study scheduled over a period of almost 18 months. Next came Texas, where we graduated 44 students in January 2001, and Oregon, whose state association is sending students down to our classes in San Francisco until they develop the numbers needed for an on-site program. Other states are working with us currently to develop the infrastructure and the support of regulatory agencies to offer our program. Working With State Associations It is noteworthy that in neither Texas nor Oregon was there unanimity on the boards of the state psychological associations about whether they should advocate for prescriptive authority. In both of those state associations, however, key members of the prescriptive authority committees first approached us about offering the master’s program. In Texas, we worked with Dee Yates, the chair of the Texas Psychological Association’s Psychopharmacology Task Force, to develop a program that was ultimately delivered via videoconferencing in six separate sites in Texas. In Oregon, we are working with Susan Patchin, chair of the Legislative Committee, to develop a program for that state. Obviously, these psychopharmacology and legislative committees have a political agenda: They support prescriptive authority for psychologists. It is clear to all that they have a long and difficult road ahead that includes convincing not only legislators, the public, and other external audiences, TRAINING PROGRAMS

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but also opponents within their own state psychological associations, that the idea has merit. An affiliation with an accredited institution, preferably one with APA-approved programs, is seen as strengthening the credibility of their political argument, which is that psychologists can be trained to prescribe with effectiveness and safety and that these prescribing psychologists will improve the quality of care and the cost-effectiveness of mental health service delivery. Hence, the AIU–CSPP postdoctoral master’s degree program in clinical psychopharmacology has been shaped in great measure by the needs of our partners within state psychological associations. The decision to offer a degree program rather than a certificate program stemmed from the belief of state association psychologists that legislators would more quickly recognize and understand the meaning of a degree. Because the postdoctoral master’s degree had not been specifically required in training guidelines, we have been seen by some people as perhaps raising the bar too high and possibly diminishing the work being done in other kinds of psychopharmacology programs, but that has not been the intention. Rather, our decision to structure the program as a postdoctoral master’s degree was directly responsive to requests from our state association partners. There is no question that it is possible to learn this content within a certificate program—or even through self-directed study. However, there is also no question that a degree will always carry the status and credibility associated with a structured, academically endorsed learning experience. Moreover, our students have told us that after investing this amount of effort, they want a degree to show for it. The Current Curriculum At AIU–CSPP, where the primary focus is, and always has been, on high-quality education in the field of psychology, the request from state psychological associations that the program be thorough and demanding in terms of content, and rigorous in terms of standards and evaluation, was seen as consistent with the institutional mission. Our curriculum incorporates crucial elements from two precursors: (a) the DoD training program, which has now been recognized by a key California legislative committee as having adequately prepared a small group of psychologists for prescriptive authority, and (b) the standards set out in 1995 by a task force from APA’s Committee for the Advancement of Professional Practice. The program is demanding in terms of time and effort and involves a 2year commitment of weekend classes. The faculty have determined that the majority of student evaluation should be based on in-class, closed-book exams. There are other rules, too. Neither students nor faculty have objected to complying with the guidelines and policies in place that assure quality control. In addition to the 96 hours of classes in psychopharmacology, students are required to master complex content in clinical biochemistry; neuroscience; pathophysiology and clinical medicine; various aspects of pharmacol128

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ogy; chemical dependence; pharmacotherapeutics; basic physical assessment and laboratory examinations; and professional, ethical, and legal issues. Given that the coursework is demanding, we designed the program taking into account the realities of our students’ lives. Many of the students entering the program have not been in school for some time, and they come to us with real differences in their degree of prior exposure to the hard sciences. Most also are working full time and have family and personal responsibilities. Although we cannot compromise on content or on the level of mastery expected, we do use a number of strategies to help students deal with the demands of the program. For example, all classes are videotaped to accommodate students when their other commitments or personal circumstances necessitate missing a class. We encourage students to form study groups, so that those who are more comfortable with hard science content can help those who need to become comfortable with it. Copies of lecture notes, as well as copies of slides, are posted on our Web site for students to review at their convenience. Each geographic site has a regional academic coordinator who can meet with students individually to discuss course material. We also ask program faculty to provide the students with practice questions and study guides, which students can use to prepare for examinations. To date, the AIU–CSPP program provides didactic training that meets or exceeds APA recommendations for Levels 1 and 2 as established by the Committee for the Advancement of Professional Practice guidelines. Recommendations for psychopharmacology training at Level 3 require a clinical component or practicum. The guidelines suggest that a minimum of 100 patients should be seen by the psychologist–trainee, who would assume direct clinical responsibility in order to achieve competency in treating a diverse patient population. AIU–CSPP does not offer the clinical or practicum component of education in clinical psychopharmacology, although we have developed a system for documenting the practicum experiences and supervisor evaluations forwarded to us by our graduates. We are working to build cross-disciplinary relationships that will allow us to place students in supervised field settings and have secured agreements with several physicians, including internists and psychiatrists. Current Status and Program Plans As of 2002, AIU–CSPP has awarded more than 150 postdoctoral MS degrees in clinical psychopharmacology to psychologists in four states. In addition to offering the program in several new states over the next few years, we are developing a range of options for psychologists who want to educate themselves in psychopharmacology but choose not to complete a full postdoctoral program. Today, we offer two shorter certificate programs: one in the “Biochemical Foundations of Psychopharmacology” and one in “Advanced Study in Psychopharmacology.” Each program requires about 100 hours of TRAINING PROGRAMS

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didactic instruction and, if students take the course examinations, they will have the option to apply these courses to the master’s degree if they enter the program within a 5-year period. We also offer some of our shorter courses for home study continuing education credit by using the videotapes from our classes. Current offerings are listed on our Web site: http://www.alliant.edu. Finally, we are planning to expand our capacity to offer distance-learning classes in states that may not have sufficient enrollment for an on-site program. As our professional colleagues and the general public come to understand the important public health benefits that prescribing psychologists could offer, in addition to their already substantial armamentarium of mental health treatments, it is clear that interest and enrollment in postdoctoral psychopharmacology programs will increase. We at AIU–CSPP are proud to play a role in the evolution of this important development extending the scope of practice of clinical psychology. Nova Southeastern University (Ronald F. Levant and A. Eugene Shapiro) Nova Southeastern University (NSU), through its Center for Psychological Studies (CPS), is the first and only regionally accredited university in Florida to offer a postdoctoral master of science degree in clinical psychopharmacology for licensed psychologists. The curriculum was developed in cooperation with the Florida Psychological Association. Several months of planning between the Florida Psychological Association and CPS resulted in the implementation of a rigorous, high-quality curriculum taught in cooperation by faculty of CPS, faculty within the NSU Health Professions Division, and the medical staff at the NSU Community Mental Health Center (CMHC). The curriculum is based on the APA-recommended postdoctoral training in psychopharmacology approved by APA in 1996. This model for training is now being implemented in numerous states around the country. Like other programs, we drew from the experience of the DoD program. This program is based on a “psychology-based paradigm” (Dunivin & Orabona, 1999) and is respectful of the unique training of psychologists and their broad, comprehensive background and expertise as diagnosticians, researchers, and clinicians in the mental health arena. Training is consistent with psychologists’ tradition and biopsychosocial orientation, in contrast to a strictly medical model, which stresses biological interventions for psychological problems. In this training, prescribing psychoactive medications is viewed as one tool among many psychotherapeutic interventions available, augmenting the broad array of treatment approaches psychologists are trained to use. The program is a 31.5 credit hour master’s program that includes a practicum experience conducted in the NSU CMHC. There are seven 130

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parts to the curriculum. First, there is an introduction to organic chemistry and biochemistry. Second, there are four courses in the neurosciences: (a) neuroanatomy, (b) neuropathology, (c) neurophysiology, and (d) neurochemistry. Third, there is a course in pathophysiology. Fourth, there are four courses in clinical and research pharmacology and psychopharmacology: (a) general pharmacology, (b) clinical psychopharmacology, (c) developmental psychopharmacology, and (d) chemical dependency and pain management. Fifth, we teach physical assessment, laboratory examinations, and differential diagnosis. Sixth, there are four courses under the rubric of special issues in pharmacotherapeutics: (a) pharmacoepidemiology; (b) professional, ethical, and legal issues; (c) psychotherapy and pharmacotherapy interactions, and (d) computer-based practice aids. Finally, and this is where we are most unique, we offer practicum training. We provide each student with 200 hours of practicum training and an opportunity to see a minimum of 100 patients under supervision of the CMHC psychiatrists. To accommodate the schedules of professional psychologists, classes meet for 3 full days (Friday, Saturday, and Sunday) approximately once per month, with the exception of the practicum. Students register, receive syllabi, and purchase texts 1 month prior to the first class meeting and complete assigned readings prior to the first class session. Because the practicum is one of the most important elements of the program, we have developed a comprehensive training program that provides each student with practical experience with patients of various ages and varied diagnoses. This portion of the program requires two 100hour intensive supervised clinical experiences scheduled in two consecutive summer terms. The clinical rotation for main campus students takes place at the CMHC on the main campus. Students may also obtain some experience at the geriatric residential treatment center and day treatment program and the dual-diagnosis residential treatment center and day treatment program. Other clinical settings may be developed. Students observe psychiatric evaluations and medication follow-up visits. Each student spends 3 half-day blocks per week (a total of 12 hours/week) with a clinic psychiatrist. The student spends 8 hours in the clinic, observing clinical interactions involving psychopharmacologic treatment of clinic patients. In addition, students participate in a 4-hour clinical seminar, scheduled on Saturdays, in which an experienced clinical instructor/psychiatrist reviews case material observed by students during the week. As part of the training process, students present clinical cases. Each 8-week clinical rotation consists of approximately 100 hours, including observation and clinical discussion. One goal of the clinical rotation is for students to observe particular patients over the course of several weeks of treatment and to be able to observe the clinical effects of psychotropic medications developing over time. Students keep a log of their clinical activities as part of the record of their training. TRAINING PROGRAMS

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Graduates of this program are prepared to demonstrate competence in nationally accredited examinations in psychopharmacology. The APA College of Professional Psychology has developed such an examination (see chapter 10, this volume). An APA designation of a proficiency in psychopharmacology is now being considered. Should Florida pass legislation that would enable psychologists to prescribe, our graduates should meet the criteria for eligibility. In any event, students completing this program will be able to discuss their patients’ needs for psychopharmacological interventions with their patients’ medical doctors. Moreover, they will be prepared to practice as consultative psychopharmacologists. One of the unexpected outcomes of this training program has been the positive rewards that our students have accrued midway through the program. The students have reported that referrals to their practices have increased, that their knowledge of psychotropics has enhanced the value of their testimony and credibility in the courtroom, and that they have been in demand as consultants in hospital practice. Referring physicians seem to be pleased with the informed suggestions that our students bring to discussions about patients’ needs. In addition, the training has allowed our students to expand their roles and offer an educational component to benefit patients who may be noncompliant and place their health at risk when, for example, they decide to abruptly discontinue medications or to combine medications with alcohol or other drugs. In essence, psychologists do not have to wait for prescriptive authority to reap benefits from an investment in advanced education. To be admitted into this program, candidates must have a doctoral degree in psychology, an unencumbered current state license as a psychologist, and authorization to practice as a health service provider psychologist as defined by state law where indicated. What is most interesting about this program is the interplay between the state psychological association and a private university’s CPS to implement a curriculum that APA adopted to fulfill an APA policy decision that psychologists should eventually be competent to prescribe. Furthermore, to our knowledge, this is the only university-based program that offers both didactic coursework and clinical training. As of this writing, we have graduated our first class. This took place on July 1, 2001, at the NSU graduate commencement, at which Patrick H. DeLeon was (fittingly) the commencement speaker. We have learned a great deal, particularly from our brave band of students, but also from our faculty, who have been drawn from several schools of NSU. We began our second class in September 2001. In September 2002 we will be starting a new format for the program. Called the “Fly-In Program,” it will require five extended weekends per year for 2 years. This bimonthly program is the same 31.5 credit hour program that we have successfully used since 1999 in a monthly weekend format. 132

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However, to accommodate distant participants, the new program will meet only five times a year on Thursday, Friday, Saturday, Sunday, Monday, and Tuesday, from 9:00 a.m. to 5:00 p.m. Scheduling classes over a long extended weekend means that practice schedules will be minimally affected. Suitable accommodation arrangements have also been arranged. In addition to the classroom activities, a chat room and other distance-learning techniques will be used. Most states allow continuing education credits for these learning activities. More information is available at our Web site: http: //www.cps.nova.edu. The Fairleigh Dickinson University/Global HealthEd Psychopharmacology Postdoctoral Training Program (Anita B. Brown, Robert E. McGrath, and Gloria D. Pickar) The Psychopharmacology Postdoctoral Training Program originally emerged out of a collaborative relationship between the Fairleigh Dickinson University School of Psychology and Global HealthEd. The latter organization has developed a unique model for distributed learning intended to deliver critical knowledge to health care providers using the latest distance-learning delivery technologies. Initially the program was intended to be a certificate program that offered Level 2 training only, designed to enhance psychologists’ ability to interact and collaborate in the management of their patients by providing a strong knowledge base in psychopharmacology. Launched in August 2000, the program uses a unique learner-centered distributed-education delivery model that allows students to complete the program while maintaining their professional careers. Program objectives include the provision of core knowledge in the areas of basic science that are foundational to the use of psychotropic medications as well as comprehensive knowledge of clinical psychopharmacology, patient assessment, and patient management. The purpose is to integrate psychopharmacological treatments and enhance practice skills. Throughout the entire curriculum, a modified problem-based learning approach is taken, providing a virtual practicum for each of the content areas. The Fairleigh Dickinson University School of Psychology assumed complete oversight of the program in 2001, in preparation for conversion of the program to one that results in receipt of the postdoctoral master of science in clinical psychopharmacology degree. In addition, the Psychopharmacology Postdoctoral Training Program now offers the clinical practicum experience required for completion of the Level 3 training curriculum. Curriculum The program consists of a series of 10 courses granting 48 continuing professional education credits and 3 graduate credits per course. The program is organized into five semesters, with two courses that run consecutively per TRAINING PROGRAMS

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semester. Each course lasts 7.5 weeks, so that each semester is 15 weeks in length. A student should be able to complete the didactic program in 20 months. On the completion of the 10 courses and the APA College of Professional Psychology Psychopharmacology Examination for Psychologists, the student receives the master’s degree. Students who complete these requirements are also eligible to enroll in the elective clinical practicum. The curriculum exceeds the recommendations of APA’s model curriculum for the training of psychologists who wish to prescribe psychotropic medications to their patients (i.e., Level 3, or independent prescriptive authority) and is consistent with educational requirements outlined in the recently enacted legislation in New Mexico awarding psychologists prescriptive authority. It was developed using the skills and expertise of a graduate of the DoD Psychopharmacology Demonstration Project; faculty of that and other psychopharmacology training programs; and faculty from various schools of medicine, nursing, pharmacology, and pharmacy. The initial four courses include Biological Foundations I and II, Neuroscience, and Neuropharmacology. These courses provide the knowledge base in pathophysiology, neuroscience, and pharmacology and must be taken before the student progresses to the remaining courses. The two biological foundations courses offer an integrated approach to the study of nine primary body systems and correlate fundamental knowledge of the anatomy, physiology, and pathophysiology of a specific body system with the clinical applications (health assessment, physical examination, and laboratory assessment) pertaining to that system. This vertical organization of content by organ system aims to facilitate the learning process by presenting information in a logical progression, first providing a study of the normal organ system, progressing to a study of the mechanisms of disease for that system, and followed by pertinent clinical assessment and treatment information. These courses provide information about the biological, medical, and psychological correlates of disease and prepare students to recognize and identify signs and symptoms of medical conditions that require collaboration with and referral to other health professionals. Medical sequelae of psychotropic agents and standard medical treatments of common disease states are addressed as well. The neuroscience course focuses on the anatomy and physiology of the nervous system, beginning at the cellular level. Understanding of neurotransmitter systems is grounded in basic principles of neurochemistry, neuroendocrinology, and neuropathology. The neuropharmacology course introduces the knowledge base pertaining to pharmacology and psychopharmacology and serves as an introduction to classes of psychotropic medications. The next semester includes Clinical Pharmacology and Professional Issues & Practice Management courses. The former presents information about other major classes of drugs besides the psychotropics and their uses in clinical settings. Social, cultural, and behavioral aspects of prescribing medications are included. The Professional Issues & Practice Management course 134

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reviews ethical and legal issues in the use of medications; computer aids to the conduct of pharmacotherapy; standards of care, ranging from informed consent to documentation; and issues of interprofessional relationships and collaborative practice. The didactic program ends with four Treatment Issues in Psychopharmacology courses that address specific categories of mental disorder and address diagnosis and differential diagnosis; epidemiological issues; the biological bases of the disorders; and psychopharmacological treatment options, including mechanism of action, side effects, adverse reactions, polypharmacy, drug interactions, and patient education. The integration of treatment strategies as well as the empirical basis for treatments are presented. Disorders covered in these four courses include the affective disorders, psychotic disorders, anxiety disorders, cognitive disorders, substance abuse and chemical dependency, posttraumatic stress disorder, attention-deficit/hyperactivity disorder, sleep disorders, and others. Discussion of herbal products as treatments and as moderators of the impact of other medications is also included. Issues of life span development, gender, and ethnic diversity are integrated across the curriculum. The elective clinical practicum involves the mastery of specified objectives and clinical competencies in accordance with the APA model curriculum and subsequently developed guidelines. Each participant trains with a clinical supervising preceptor who is approved by Fairleigh Dickinson University. This experience may be arranged within the student’s local clinical community. It is expected that work will be completed in a variety of settings, both inpatient and outpatient, with at least 100 patients. Course Delivery One highly attractive aspect of the program is that it provides quality instruction and academic guidance through multidimensional distancelearning environments. There are four learning platforms of the Compass Learning System,™ the distributed-learning model developed by Global HealthEd, that incorporate the technology of the Internet and multimedia interactive software while maintaining peer-interaction techniques. The first learning environment or platform includes readings and videotaped lectures. The majority of classroom-style presentations are delivered by means of video. The course instructor, along with expert presenters, prepares and delivers this material in a studio setting, and the edited videos are distributed to each student. Students are responsible for viewing the presentations according to a weekly schedule. In addition, there are course readings from required textbooks as well as journal articles and Web sites. The use of the Internet provides the second learning platform. Students use the Internet for ongoing threaded discussions, scheduled online chat sessions, and the completion of assignments and examinations. Students are assigned to a regional group at the beginning of each course and must “attend” TRAINING PROGRAMS

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the weekly regional chat for their group via computer. Each regional group has a facilitator, a clinician involved in health care activities appropriate to the course, usually a nurse practitioner who specializes in prescriptive practice with psychiatric patients. Transcripts of each group’s weekly chats are posted for review. Students also have 24-hour access to other students, faculty, and staff through discussion boards, e-mail, and telephone contact. For example, they can view and post responses to the discussion boards at any time. The third learning environment is the Regional Interaction Session, a 2-day group meeting scheduled for a weekend at the end of the semester. These are scheduled at various sites throughout the country. Five times during the course of the didactic program students come together at a regional interaction session proctored and facilitated by their regional facilitator. Students are required to attend these sessions. The student’s professional practice setting is the fourth learning environment and offers many opportunities for real-world application and reinforcement of what has been learned. Interaction and collaboration with patients, professional colleagues, and clinical supervisors provide a platform for putting knowledge and skills to work. The supervised clinical practicum elective is intended to serve as an integrative experience at the conclusion of the program. Depending on each student’s background and prior education in the field of psychopharmacology, it is estimated that each student will spend a minimum of 6–8 hours/week successfully completing the program. Students must purchase their own textbooks and equipment and possess the minimum required computer equipment. The Psychopharmacology Postdoctoral Training Program provides an approach to learning that permits students to spend more time on meeting the knowledge objectives of this cutting-edge area than on traveling to and from the course-delivery site. It is comprehensive yet logical in its organization and offers a variety of mechanisms and technologies for learning, ranging from the traditional lecture and reading approach to Internet- and software-based tools and real-world case example based content. Additional information about the program is available at its public Web site: http: //www.rxpsychology.com.

COOPERATIVE DEGREE PROGRAM: ARGOSY UNIVERSITY/HAWAII CAMPUS (RAYMOND A. FOLEN) In the summer of 2000, participants in the first Argosy University (formerly American School of Professional Psychology–Hawaii Campus) Postdoctoral Program in Clinical Psychopharmacology finished their 325 hours of instruction in psychopharmacology and received certificates of 136

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completion at the school’s commencement in the fall of 2001. Nine of the initial 14 participants who signed up for the 2½-year program made it to the end. Before the second iteration of the program was advertised, some adjustments were made based on first-round observation and participant feedback. Most notably, the program was changed from an intermittent 16-hour weekend schedule to a 4-hour weekly program held on Saturday mornings. In August 2000, the program was advertised, and brochures were sent to all licensed and recently graduated psychologists in the Hawaiian islands. Unfortunately, there appeared to be little private-sector interest in the program at that time. Many of the independent practice psychologists contacted held a wait-and-see attitude toward psychopharmacology training and expressed a desire to sign up after enabling legislation had passed through the legislature. I understand from several mainland programs that this situation is not unique to the islands. Public-sector psychologists continued to show considerable interest in postdoctoral psychopharmacology training, however, and one government agency recently contracted with Argosy University to provide a 1-year, 320-hour program of instruction for licensed government psychologists and postdoctoral psychology trainees. Although postdoctoral education of practicing psychologists is a necessary and important component of the psychopharmacology training initiative, we have also focused our attention to training within the graduate program itself, as many doctoral students have expressed interest in receiving this training as part of their clinical psychology program. The challenge for educators is to figure out how to include this coursework and experience within an intensive existing training program. Also important is that, should such training occur, how are opportunities for practice in the near future created? With this in mind, Argosy University and the University of Hawaii School of Nursing have, over the past 2 years, pursued establishment of a coordinated psychology–nursing training program. This ambitious goal will allow doctoral psychology students the opportunity to concurrently receive two degrees in nursing. The 6-year graduate program (including internship) exposes students to an extraordinarily broad biopsychosocial perspective of health and provides the training necessary to practice as both a psychologist and advanced-practice nurse. Such training will prepare students to provide a variety of health care services, including the authority to prescribe appropriate medication under the statutory authority afforded to nurses. As currently conceived, matriculated Argosy University doctoral students will be allowed to submit an application for concurrent admission into the University of Hawaii Clinical Nurse Specialist program. Students who are admitted will participate in a rigorous 6-year program of psychology and nursing courses, practicum, and internship experiences. At the completion of the program the successful student will receive a BS in nursing, an MS in nursing, and a PsyD degree. Both the BS and MS degrees will be awarded by TRAINING PROGRAMS

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the University of Hawaii; the PsyD will be awarded by Argosy University/ Hawaii Campus. The program is designed so that successful students will be able to meet the academic and training requirements necessary for licensure as a psychologist, a registered nurse, and recognition as an advanced-practice nurse in the State of Hawaii. Over the 6-year period, the concurrent programs will require that students take approximately 90 graduate credit hours in psychology, 19 credit hours in basic science courses (such as chemistry and microbiology, if the candidate has not completed these courses as an undergraduate), 38 undergraduate nursing credit hours, and 32 graduate nursing credit hours. In the first 2 years of graduate school, students complete the prerequisite basic science coursework in anatomy, physiology, and chemistry, in addition to the standard graduate curriculum in clinical psychology. In Years 3 and 4 of the program, students continue to take psychology graduate courses, finish the last basic science course, and complete approximately 8 registered-nurse (RN) and MS nursing courses, such as pathophysiology and advanced health assessment. During Years 5 and 6 students participate in a 2-year, half-time psychology internship and complete the RN and MS nursing coursework. The last 2 years are quite intensive, as they include most of the clinical nursing courses and actual hands-on clinical experiences. All nursing courses are to be taken during the regular term, during summer school, and on-line, when available. Students who enter the program with an RN degree are given advanced-placement status. Internship placements at major medical or comprehensive community health centers will allow students to conduct psychology internships and nursing practica activities at a single site. The National Council Licensure Examination, required for licensure as a nurse, will be taken after the sixth year, in the spring semester. Students may apply for licensure as an advanced-practice registered nurse after the sixth year, during the summer session. Licensure in psychology and recognition in advanced-practice nursing will require clinical psychology postdoctoral supervision, a passing score on the psychology licensing exam, and a passing score on the clinical nurse specialist certification exam. Graduates can then practice as psychologists and advanced-practice nurses, opening the door for many employment opportunities and a very broad scope of practice. The process of establishing this program has highlighted the differences between the two schools: one is a private, action- and results-oriented organization, the other a traditional academic institution; one can bring about change within a year, the other thinks of change within a decade. When initial agreement was reached and a timeline for implementation established, administrators at Argosy University quickly began to market the program. They were disappointed when the University of Hawaii champions of the program subsequently reported delays as a result of institutional limitations. Progress, although slow, continues to be made in this important endeavor. 138

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CONCLUSION We have completed our tour of the newly emerged postdoctoral training programs in psychopharmacology for psychologists, covering those that award certificates, continuing education credit, or both; those that award master’s degrees, and those that award joint degrees. At this point, some general observations are in order. First, it is striking, given the diverse origins of these programs, that there is such widespread use of the APA Recommended Postdoctoral Training in Psychopharmacology approved by APA in 1996. This not only demonstrates how influential the APA recommendations were but also helps ensure some degree of uniformity of training across a variety of program types. Second, it is also noteworthy that there is such extensive use of the DoD Psychopharmacology Demonstration Project graduates, not only as role models who can demonstrate that psychologists can be trained to prescribe psychoactive medications safely and effectively but also as leaders and consultants to state psychological associations and universities that are developing training programs. Third, it is most interesting that so many programs have chosen a psychology-based paradigm for training psychologists to prescribe. Such a model of training is advantageous in that it highlights “many significant aspects of care often neglected or underemphasized in medically based training,” such as the “psychological aspects of treatment compliance, the significance of prescribing within the context of a therapeutic relationship, and the integration of pharmacotherapy with psychotherapy” (Dunivin & Orabona, 1999, p. 515). It is also worth noting that the programs emphasize thorough and rigorous training. As an anecdotal aside, at one point students in the NSU program were struggling with the course material and were asked if they would want the program made any easier. Their answer was a resounding “No.” They told us that the material is indeed tough but that that is as it should be given their goals of eventually being credentialed to prescribe. Finally, it is very important that the graduates of programs have already reported positive outcomes on their practices, even though most cannot yet prescribe.

REFERENCES Cullen, E. A., & Newman, R. (1997). In pursuit of prescription privileges. Professional Psychology: Research and Practice, 28, 101–106. Dunivin, D. L., & Orabona, E. (1999). Department of Defense Psychopharmacology Demonstration Project: Fellows’ perspectives on didactic curriculum. Professional Psychology: Research and Practice, 30, 510–518. Sammons, M. T., & Brown, A. B. (1997). Department of Defense Psychopharmacology Demonstration Project: An evolving program for postdoctoral education in psychology. Professional Psychology: Research and Practice, 28, 107–112. TRAINING PROGRAMS

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Sammons, M. T., & Levant, R. F. (1999). Combined psychosocial and pharmacological treatments: Introduction. Journal of Clinical Psychology in Medical Settings, 6, 1–10.

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8 THE STRUGGLE IN THE STATES TOMMY T. STIGALL, CHARLES A. FALTZ, RAYMOND A. FOLEN, AND CAL VANDERPLATE

Since the adoption by the American Psychological Association (APA) in 1995 of an official policy endorsing state legislation that would authorize appropriately qualified psychologists to prescribe psychotropic medication (DeLeon, 1996), an increasing number of states have seen the introduction of such legislation. In 1998, the Territory of Guam became the first jurisdiction to enact prescriptive authority legislation for psychologists. Despite fierce opposition from organized medicine, especially from the psychiatric community, steady progress toward the goal has been made (Thomas, 2000). States such as California, Louisiana, Hawaii, and Georgia have been among the early leaders in the prescriptive authority initiative, and the list of states that have already introduced legislation or are preparing to do so is growing year by year (Jennings, 2001). In the spring of 2001, the New Mexico legislature considered a bill that was introduced with broad-based support on behalf of the New Mexico Psychological Association (NMPA). The bill advanced through committees of jurisdiction in both houses and passed the House, only to die on the floor of the Senate without ever coming to a vote in that chamber (Foxhall, 2001). The near success of the NMPA-sponsored bill in the first year of introduction 141

testifies to the careful and thorough preparation by the NMPA leadership as well as the close coordination and partnership between the state psychological association and APA, leading to successful passage in 2002. Interest in prescriptive authority for psychologists has been growing for at least the past 10 years (Fox & Sammons, 1998). The Department of Defense Psychopharmacology Demonstration Project has produced solid evidence demonstrating that psychologists can indeed be trained to prescribe psychotropic medications safely and effectively (Newman, Phelps, Sammons, Dunivin, & Cullen, 2000). Opportunities for postdoctoral training in psychopharmacology are expanding (Foxhall, 2000). A national examination has been developed by the American College of Professional Psychology that can be used by state licensing authorities to evaluate the qualifications of psychologists with advanced training in psychopharmacology (see chapter 10, this volume). Other evidence of the interest in prescriptive authority is the approval of the American Society for the Advancement of Pharmacotherapy as a division of APA and the submission of a petition to APA for formal recognition of psychopharmacology as a proficiency in professional psychology. Although a national consensus on prescriptive authority for psychologists appears to be emerging, the responsibility to seek enactment of enabling legislation falls mainly to the respective state and provincial psychological associations (SPPAs). The struggle in the states to achieve prescriptive authority for psychologists is a reminder of the historic role of the SPPAs and psychologists working at the grassroots level to advance the profession. The maturing of legislative advocacy for prescriptive authority can be seen in the multiyear efforts of four state associations: Hawaii, California, Georgia, and Louisiana. HAWAII At the 1984 annual convention of the Hawaii Psychological Association (HPA), Sen. Daniel K. Inouye stunned the organization when he challenged the membership to acquire prescriptive authority “in order to more capably meet the needs of the unserved and underserved populations” (Inouye, 1984). One psychologist, Sim Granoff, took the challenge to heart and that year introduced the nation’s first prescriptive authority legislation into the Hawaii state legislature. Granoff was able to get his bill heard and provided the lone supporting testimony in favor of prescriptive authority for psychologists. HPA took a strictly neutral position and provided no testimony, but organized psychiatry came out in force to kill the bill. During the next 5 years, HPA took no action on prescriptive authority, citing other more pressing agendas, and a task force independent of the association was formed. In 1989, the Hawaii RxP Task Force was successful in having six separate prescriptive authority bills considered during the legislative 142

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session. This effort resulted in the nation’s first positive legislative outcome on prescriptive authority. The Hawaii legislature passed a resolution directing the state’s Alternative Dispute Resolution Center to conduct roundtable discussions with all interested parties, facilitate mediation/resolution on the issue, and report to the legislature on the outcome. Unfortunately, the Alternative Dispute Resolution Center mediator demanded consensus on all recommendations before they would be forwarded to the legislature and, as expected, members of organized psychiatry refused to support any prescriptive authority initiatives for psychologists. Although no recommendations were presented to the legislature, organized psychiatry interpreted this action as a finding against prescriptive authority for psychologists and presented this inaccurate information in opposing testimony for the next 12 years. In 1991, the RxP Task Force discovered that the Hawaii State Department of Health, as is the case in many other states, had the administrative authority to allow state-employed psychologists to prescribe without the need for legislative approval. The task force pursued this approach as an opportunity to demonstrate, within this subset of Hawaii psychologists, the positive impact prescriptive authority would have on the quality of care received by the state’s unserved and underserved populations. A zero-cost training proposal was presented to the Director of Health for the State of Hawaii, who was struggling at that time with a dysfunctional mental health care system and related federal lawsuits. The director initially responded to the proposal with considerable interest, but the idea stalled when the state’s chief psychiatrist was brought into the discussions. In 1993, a psychologist mildly supportive of prescriptive authority was elected to the Hawaii state legislature and, wanting to make good use of this opportunity, the independent task force resumed legislative efforts. Despite the fact that HPA had received a grant from APA’s Committee for the Advancement of Professional Practice (CAPP) based partially on a planned prescriptive authority initiative, the association strongly lobbied the task force not to introduce a bill for fear that such legislation would have a negative impact on HPA’s Medicaid and hospital privileges initiatives. The psychologist–legislator also asked that the task force wait until the nurses’ association, which had introduced its own bill, secured the right to prescribe. This delay resulted in a significant loss of momentum and, over the next several frustrating years, the independent task force continued to promote prescriptive authority with limited success. HPA continued to maintain lukewarm support for the initiative, despite submitting applications and receiving CAPP grants in support of the issue. Bills introduced in 1995 and 1996, even those introduced by the psychologist–legislator, failed to get past the committee level. Efforts resumed in earnest with the successful introduction of three bills in 1997 with the intent that they be heard in 1998, the second year of the 2-year legislative session. In 1998, a modified version of the 1997 bills was introduced. This THE STRUGGLE IN THE STATES

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bill, which allowed properly trained psychologists to prescribe, was subjected to an unprecedented attack by the Hawaii Psychiatric Association and its associated lobbying organization. Psychiatrists flooded the legislative offices with letters and messages, and their association urged members to encourage patients to write letters of opposition. Sample patient letters that included syntax and words portraying the writer as mildly ignorant and illiterate, were provided for the psychiatrists to give to their patients. The attack by the psychiatrists and their patients was successful, and the bill was not heard. Within a week of this disturbing activity, however, psychology was successful in having House Concurrent Resolution 51 (HCR 51) introduced. The resolution called for the legislature’s research office, the Legislative Reference Bureau, to review the safety record of non-MD prescribing health care providers. Given the unwavering argument by organized medicine that prescribing by non-MD providers was dangerous to society, the purpose of the resolution was to introduce independent, factual information into the legislative process. HPA was confident that the results of the study would reflect quite favorably on non-MD prescribers. The intense response that followed the introduction of this resolution is described here in detail, as these tactics will continue to be used in the future by opponents of prescriptive authority for psychologists. HPA and the newly renamed Hawaii Psychopharmacology Certification Task Force presented testimony in support of HCR 51. APA also submitted supportive testimony. Two key points were addressed: First, the resolution was written to address the issue of safety only. Despite the fact that podiatrists, dentists, doctors of osteopathy, optometrists, and nurses continue to have excellent and safe records as prescribers, organized medicine asserted, and continues to assert, that the practice is dangerous, a ploy that scares patients and community groups into taking a negative position without offering them the opportunity to review the facts. Second, constituents were not receiving adequate mental health medication services. The vast majority of psychoactive medications prescribed in Hawaii was, and continues to be, prescribed by primary care providers with minimal mental health training. Psychologists receiving psychopharmacology training were willing to commit their time and energy in the treatment of the unserved and underserved. Over a period of 10 years, psychologists in Honolulu demonstrated their commitment to unserved populations by participating in a pro bono mental health network at the rate of 10 psychologists per psychiatrist. Psychologists were also more accessible to the unserved and underserved. Unfortunately, when these patients were in need of medication, psychologists were, and continue to be, faced with an ever-increasing number of refusals from psychiatrists to accept medication referrals. APA and HPA strongly supported HCR 51. Although a small but vocal group of psychologists, representing less than 1% of practitioners, opposed prescriptive authority for psychologists, they did not reflect the opinions of 144

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the vast majority of psychologists in practice. HPA stated its willingness to stand or fall on the result of an objective study, and the task force was willing to underwrite the cost of the project. Psychiatry embarked on a campaign of misinformation and distortion. The strategy, of course, was to confuse the issue to the point that clear, rational discussion was prevented. Without a doubt, this was the most disheartening aspect of the legislative effort. Twenty-one psychiatrists and 4 nonproviders provided testimony against the resolution. Eighteen psychologists, mostly representing the American Association of Applied and Preventative Psychology (AAAPP), also provided written testimony in opposition. AAAPP submitted identical testimony, by simply changing names and addresses, for 15 of the 18 opposing psychologists. Although the legislature was not fooled by this attempt to “stuff” testimony, it did nevertheless have a negative psychological effect. The AAAPP testimony stated that although some psychologists support prescriptive authority, there was not a consensus. They emphasized that prescriptive authority could result in greater risk to the consumer and that although paramedical providers, such as nurses and optometrists, can prescribe, psychologists provide services that do not physically invade the body—a surprising statement given that one of the psychologists submitting this testimony was nationally known for his work with fecal incontinence, using biofeedback instrumentation that requires insertion of sensors into the patient’s rectum. They further stated that to train psychologists to prescribe would be extremely costly to taxpayers, ignoring the fact that everyone in the private sector would receive no government subsidy for training. Training psychologists to prescribe was seen as duplicative and something that would change psychology training at the graduate and undergraduate level, despite the fact that the only type of proposed training has always been postgraduate training. The AAAPP testimony stated that there was no shortage of psychiatrists in the state, the contrary results of an independent study notwithstanding, and that prescriptive authority would impair the public’s access to psychological services. They concluded that psychologists who wish to prescribe should go to medical or nursing school. Twenty-one physicians, nearly all of them psychiatrists, wrote testimony opposing the resolution. They argued, predictably, that medications are dangerous: For psychologists to prescribe, “they would have to go to medical school” and “coming in through the back door” of medical licensure by participating in a psychopharmacology training course was a “fraud.” Misery, suffering, and death were common themes, as more patients would “die needlessly of medical illnesses” because of psychologists’ inability to differentiate between physical and psychological etiology, and patients “would be doped up instead of getting the care they need.” Physicians stated they complete more than 10,000 hours of training and that “even cosmetologists study more hours to do nails than psycholoTHE STRUGGLE IN THE STATES

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gists are proposing to prescribe medications.” Having a psychological association claiming that properly trained psychologists were qualified to prescribe, they continued, would be like “a flight attendant association claiming that flight attendants are qualified to pilot the plane.” Many cited the “failure” of the Department of Defense Psychopharmacology Demonstration Project, and one went so far as to state that the program was a failure in the eyes of the psychologist trainees themselves! All references to training were described as a single course. Finally, the resolution to study the safety of non-MD prescribers was equated to a “study to determine the safety of allowing children to play with matches.” Although the negative testimony from psychiatrists was expected, proponents of the legislation were appalled by members of their own profession, many of whom profess to be the standard-bearers of science-based practice, who opposed a resolution that attempted to introduce factual, unbiased information into this highly charged issue. Despite this testimony, the chairman of the legislative committee scheduled the resolution for continued hearing. At that point, legislators started receiving phone calls from psychiatric patients. This was more then they could bear, and the resolution was quietly withdrawn. In January 1998, Argosy University (formerly American School of Professional Psychology—Hawaii Campus) started a 2½-year postdoctoral program in clinical psychopharmacology. The first graduates of the program completed their didactic training in August 2000. In the fall of 2000, Argosy University began work on developing a cooperative PsyD–BS–MS in Nursing program in collaboration with the University of Hawaii School of Nursing. HPA’s prescriptive authority effort has always involved a precious few dedicated individuals, a pattern that appears to be consistent in all but a few exceptional states. Although this fact of life is not likely to change in the future, it need not be cause for discouragement. It is most impressive that considerable progress has been made, for example, by a small cadre of individuals in New Mexico and that success has been achieved in the Territory of Guam as a result of the efforts of a single psychologist. Hawaii’s current and future efforts will focus on building relationships with legislators, community organizations, the state licensing board, underserved and unserved populations, and the community of psychologists. It is these relationships, along with money and intense lobbying efforts, that will ultimately prove to be successful. Prescriptive authority will certainly not be won on the basis of supportive data or a carefully reasoned argument alone. CALIFORNIA The California Psychological Association (CPA) began actively considering prescriptive authority in the early 1990s. After securing recognition 146

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for psychologists as independent practitioners in inpatient settings, CPA was interested in achieving a good collaborative working relationship between California psychologists and psychiatrists. Unfortunately, in the midst of good-faith negotiations between CPA and organized psychiatry, the California Psychiatric Association secretly introduced a measure in the final day of the legislative session that would have stripped psychologists of independent practice authority. That act made it clear that organized psychiatry had no intention of negotiating a collaborative relationship with independently practicing psychologists. The only choice for California psychologists was to achieve the authority to deliver all modalities of treatment independently. Organized psychiatry in California was not going to adopt a policy recognizing psychologists as independent collaborators with skills that complement those of psychiatrists. In 1992, Thomas Marra was the chair of the CPA Governmental Affairs Committee when it formally introduced the topic of prescriptive authority as a potential legislative priority. Marra developed an educational program that presented the topic of prescriptive authority for psychologists in the context of the overall existing patterns of psychotropic prescribing and documented the nature of the training required for all providers who lawfully prescribe. That presentation became a prototype for many introductory presentations about prescriptive authority for psychologists that occurred in subsequent years. After considering and discussing the issue for 2 years within governance and in local meetings throughout California, the CPA Board of Directors voted unanimously in 1994 to make prescriptive authority one of the highest priorities of CPA’s legislative agenda. That priority has been reaffirmed in succeeding years and is still the policy of the association. Charles Faltz formed the CPA Professional Education Task Force to lay the foundation for starting the legislative effort for prescribing in California. The name was chosen so that it would not be obvious to psychiatrists from published materials that CPA had started to prepare for prescribing. Before introducing a prescriptive authority bill, CPA needed to address the issue of training. Supported by an APA CAPP grant, CPA collaborated with the California School of Professional Psychology (CSPP) to convene in 1994 the historic Blue Ribbon Panel. In January 1995, the panel reported its recommendations to the CPA Professional Education Task Force (Faltz & Olmedo, 1995). Those recommendations were soon adopted by APA as guidelines for programs intending to prepare psychologists to prescribe. All of the subsequent prescriptive authority bills introduced in the various states contemplate, either implicitly or explicitly, these training guidelines that were developed by the CPA task force. For 4 consecutive years, 1995–1998, CPA sponsored full prescriptive authority bills in the California legislature. In the first 2-year legislative session the bill received widespread publicity in California and across the THE STRUGGLE IN THE STATES

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nation. Unfortunately, the Senate policy committee that addressed scopeof-practice issues was chaired by a staunch opponent of nonphysicians expanding their scopes of practice. Nevertheless, as intended, the first bill did educate the legislators about psychologists and prescribing. In the second 2-year legislative session the bill was approved by a subcommittee for a hearing by the full Senate policy committee. The chair of the committee and the bill’s author, Sen. Richard Polanco, held a successful public hearing in Los Angeles. Many independent experts documented the lack of access by many California residents to adequate medication services. It took a massive, expensive political effort by organized psychiatry to defeat the bill in committee. In 2000, CPA introduced another bill that would have provided full prescriptive authority for the Department of Defense Psychopharmacology Demonstration Project Fellows. The bill was approved by the Senate Business and Professions Committee. In the subsequent hearing in the Senate’s fiscal committee, the bill was within one vote of being approved when the session ended (Hausman, 2000). CPA is one of the state associations that has not sponsored a program to train psychologists to prescribe as a corollary to introducing its prescriptive authority legislation. When CPA began its prescriptive authority agenda, there were no training programs or APA-recommended curricula in existence. Accordingly, to initiate this early legislative effort, CPA first needed to create a blueprint for a model training program to illustrate to the legislature that the profession had carefully considered the issue of training. The Blue Ribbon Commission that was previously described was formed to create a model training curriculum to broadly illustrate to legislators the breadth and depth of preparation in psychopharmacology that psychologists were ready to undertake. Nevertheless, the bill itself did not ask the legislators to make expert decisions about a curriculum but to place in statute the principle that psychologists would be appropriately trained to prescribe medications. The bill further provided for an expert panel to make recommendations about a required curriculum to the agency that licenses psychologists. The licensing authority for psychologists would make the final judgment about the appropriate training for psychologists. California had an advantage in that the state had trained in a pilot program, and at a doctoral level, nonphysician mental health professionals to provide psychological treatment and to prescribe medication. For several years, in the early 1980s, about 80 students were trained in a curriculum that used psychology courses from the University of California, Berkeley, and courses from the medical school at the University of California, San Francisco. The program included training the students to prescribe psychotropic medications in the same settings that psychiatric residents were being trained to prescribe. The performance of the nonphysicians in prescribing was found to be at least comparable to that of the psychiatric residents. Unfortunately, 148

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there was not yet any law in California that provided for licensing this new mental health professional. Accordingly, after this intensive doctoral-level training, the graduates of the program were unable to prescribe. When CPA consulted with these graduates, it was learned that most of them were frustrated about having undergone training to provide a service before a law was in place that permitted them to provide that service. Based on their experience, they cautioned CPA about the frustrations that could occur among psychologists who are trained to provide a service that the law does not permit them to deliver. The most important achievement of CPA’s legislative work on its prescriptive authority agenda is that the California legislators’ attitudes have been changed. California’s elected officials and others now understand that psychologists could directly provide most of the modalities of treatment that are within most behavioral health treatment plans. When CPA began this educative effort, most California elected officials did not take seriously the assertion that psychologists could provide biological treatments in addition to psychobehavioral treatments. After 6 years, Sacramento officials now regard prescriptive authority for psychologists as a major policy initiative that could address important problems that exist in California. The American Psychiatric Association has reported that if prescribing for psychologists happens in California, it will happen everywhere (Hausman, 2000). That prediction highlights the importance of the California prescriptive authority effort. GEORGIA The Georgia Psychological Association (GPA) formed a task force on prescribing in 1990–1991 to explore prescribing issues, educate membership, and recommend action. GPA leadership and training directors from doctoral psychology programs participated in the task force. In 1995, the decision was made to institute psychopharmacology training for psychologists in Georgia as a prelude to introducing legislation. U.S. Navy Commander Morgan T. Sammons, a graduate of the Department of Defense Psychopharmacology Demonstration Project (Sammons & Brown, 1997), served as a consultant in the development of the program. Training was based on the APA Model Curriculum (APA, 1996). The GPA-sponsored training program began in September 1997 with courses offered in consortium through the University of Georgia College of Pharmacy and the Georgia State University Center for Brain Sciences and Health. Training was university based with live, interactive distance learning around the state. The program’s philosophy is based on a psychology model (Newman, 2000). There are now close to 50 psychologists who are enrolled or have graduated from the program. GPA’s efforts in the prescriptive authority initiative culminated in legislation introduced in the Georgia House of Representatives in January THE STRUGGLE IN THE STATES

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1998. The goal of the first year was not to actively promote the bill but rather to further a low-key educational effort for legislators. In January 1999, the first year of Georgia’s 2-year legislative cycle, GPA pursued legislation in earnest with introduction of House Bill 353 and Senate Bill 202. Efforts were made more difficult by an optometrists’ bill to increase their prescriptive scope of practice that resulted in bitter partisan wrangling in the House committee. Following the 1999 session, a comprehensive strategy was implemented to contact every legislator in the House and Senate, ascertain their position, and target undecided legislators. Constituent psychologists in every district were enlisted to meet with their legislators, work in campaigns, host fundraisers, and contribute to re-election campaigns. Early progress was made in the 2000 legislative session, as prescriptive authority legislation passed favorably out of the 16-member Health and Ecology Subcommittee in the House on the second day of the session. Despite early optimism, it became apparent the vote would not be successful in the full Health and Ecology Committee in the House or the Health and Human Services Committee in the Senate. Prescriptive authority legislation received strong support from both House and Senate leadership, but the strength of the Medical Association of Georgia (MAG) in the committees could not be successfully countered. Although close to a majority in both committees supported the bill, the final few necessary votes remained elusive. For the 2-year legislative cycle beginning with the January 2001 session, GPA introduced House Bill 329 and Senate Bill 102. A professional 5-minute videotape was produced and given to each legislator to simply and effectively communicate a rationale for prescriptive authority for psychologists. Considerable progress was made in educating legislators and answering their concerns; however, several factors worked against success. In the early days of the session, attention was consumed by efforts to change the Confederate emblem on the Georgia state flag. In addition, the optometrists’ prescribing bill again took the forefront. After passing the House quickly, it failed by only one vote on two separate occasions on the Senate floor. Both psychologist prescriptive authority bills carried over to the 2002 legislative session. In retrospect, GPA members realized that it was not helpful to introduce legislation the first year (1998) with a low-key approach. The Georgia Psychiatric Physicians Association and MAG mobilized their considerable resources to fight the legislation. MAG has 18,000 members, whereas GPA has about 1,200. Each year MAG has funded 10–15 lobbyists and devoted hundreds of thousands of dollars to defeating nonphysician scope-of-practice bills. One tactic was to purchase radio spots in key Georgia urban markets telling consumers that legislators wanted to keep them from getting their medicine from physicians. Psychologists were called “untrained behavioral

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counselors.” A full, all-out effort is necessary to counter their sizable influence of the medical–psychiatric coalition. Clearly the most effective strategy has been personal, local connections. The strongest legislative support has come from longtime friends of psychology, or legislators who were contacted early in the debate by psychologist constituents who showed their support for their legislators with assistance in their campaigns. The issues are complex. It takes time and repeated educational efforts to answer concerns, especially regarding the issues of training and safety. Psychologists who visited the state capitol gained a new understanding of the legislative process and the importance of local community connections and involvement. Students of the psychopharmacology training program have been the most convincing advocates in helping legislators understand the depth and breadth of their training. Mental health consumers have been especially helpful advocates, writing letters and calling legislators with personal accounts. The arguments of organized psychiatry have been quite predictable. Psychiatrists maintain that psychologists’ background ill prepares them to take on prescriptive authority. They contend that psychologists’ training cannot compare with that of physicians, and the result will be compromised patient safety. In Georgia, these issues have been fairly thoroughly discussed, and the battle is now more political than educational. Expert advice from lobbyists and help from political strategists have been essential. Fundraising has been indispensable. Finally, persistence and determination have been critical. The process is complex and can be seemingly capricious when, for example, membership of key committees changes immediately before the session. The Georgia experience leads to several suggestions for states contemplating legislation. First, it is essential that the state psychological association leadership and members be solidly behind the effort. Unanimity may not be possible, but there needs to be a critical mass of supporters, advocates, and contributors in the organization. Development of a concrete strategic plan with fundraising goals prior to legislation is helpful. Legislative leadership and committee chairs should be targeted first. Without the support of the governor, who must sign any bill that passes, all efforts are futile. When possible, talk to legislators before the opposition does, and visit after the opposition visits them to answer concerns that have been raised. Quiet, discreet contacts with legislators before the announcement of legislation can be very effective. However, once legislative intentions are known, expect an all-out effort from the medical community. Take advantage of every personal connection to legislators to open doors and establish a trusting relationship. Prepare association membership for a protracted battle. This is without doubt the most difficult legislative initiative GPA has championed. State association members need to commit themselves to ongoing support and involvement over several years. THE STRUGGLE IN THE STATES

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LOUISIANA When the leadership of the Louisiana Psychological Association (LPA) first began deliberating the issue of prescriptive authority, a strategic question arose: Should the initial emphasis be on legislation that authorizes psychologists to prescribe or on postdoctoral training that would prepare them for doing so? It was a given that both components would be needed and that they would complement each other. But where to begin? On the assumption that psychologists would be more likely to make the rather significant commitment associated with advanced training if a law were already on the books, the decision was made to pursue legislation first. As subsequent events would prove, this turned out not to have been the right question to ask, but it provided a valuable lesson for LPA. The Louisiana legislature meets in alternate years for regular and fiscal sessions. LPA’s first venture into the prescriptive authority arena was in 1995 with a bill that did not even get out of committee. During the 1997 regular session, the LPA prescriptive authority bill passed the House Health and Welfare Committee by an 8–1 vote, only to die in the House debate when a motion to return the bill to the calendar was sustained by a 2-vote margin. Complicating the situation for LPA and proponents of the prescription privileges legislation was the introduction of another bill to expand the scope of practice of licensed professional counselors. LPA often was forced to deal with both bills at the same time during the session, which diffused lobbying efforts and sometimes was confusing to legislators. (Stigall, 1997, p. 1)

LPA would not have another opportunity to advance a prescriptive authority bill until 1999, by which time a decision had been made to explore possible venues for postdoctoral psychopharmacology training in the state. The leadership had come to believe that having a cadre of psychologists well trained in psychopharmacology would also mean that there would be a nucleus of psychologists personally invested in and committed to advancing prescriptive authority legislation. The vagaries of Louisiana’s legislative cycle proved to be an incentive for LPA to move toward a multidimensional strategy for success. John Bolter, chair of the LPA Psychopharmacology Committee, was tireless in his search for a suitable in-state training site. Initial contacts with several Louisiana institutions of higher education were disappointing and led to a widened search outside the state. Negotiations with CSPP proved more fruitful. A cooperative agreement was worked out for training to be offered in Louisiana under the joint auspices of LPA and CSPP. Bolter was involved in such matters as curriculum development, local arrangements, and recruitment of qualified instructors acceptable to CSPP. He was also responsible for the recruitment and enrollment of students. The 152

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curriculum followed APA’s guidelines for psychopharmacology training and was influenced by experience with the Department of Defense Psychopharmacology Demonstration Project. The program initially was designed as a coordinated sequence of postdoctoral continuing education modules to be taught over a period of 16 months (Bolter, 1997). It has evolved into a program offering a postdoctoral master of science degree in clinical psychopharmacology. By the time the first class of 35 Louisiana psychologists had graduated in July 1999, the Louisiana legislature had disposed of LPA’s second attempt to see prescriptive authority legislation enacted, but not before recording favorable votes on the bill in both the House and Senate Health and Welfare Committees. Speaking at the graduation ceremonies was Patrick DeLeon, then president-elect of APA. Citing the consistent opposition of organized psychiatry to advancement of professional psychology, DeLeon asserted that it is already too late to stop the use of psychotropic medication by psychologists, since psychologists have demonstrated that they are capable of acquiring the relevant knowledge and skills to prescribe safely and effectively. (Stigall, 1999, p. 4)

A second cohort of 20 psychologists was enrolled for the psychopharmacology training class beginning in the spring of 2000, adding to the ranks of Louisiana psychologists committed to the enactment of prescriptive authority legislation. One year later, LPA was ready to introduce, for the fourth time, a prescriptive authority bill. House Bill 414 of the 2001 regular session provides for the issuance of a “certificate of prescriptive authority” by the Louisiana State Board of Examiners of Psychologists. To qualify for certification, a psychologist must be licensed to practice in Louisiana “with an applied clinical specialty as defined by the board” and must have completed either a postdoctoral master’s degree in psychopharmacology or a fellowship in psychopharmacology under the auspices of the Department of Defense Psychopharmacology Demonstration Project. The postdoctoral master’s degree must be from a regionally accredited institution that also offers an APA-accredited doctoral program in psychology. Candidates must pass the national examination in psychopharmacology offered by the APA College of Professional Psychology (see chapter 10, this volume) or an equivalent examination approved by the board. A provision mandating consultation with the patient’s primary or attending physician was inserted into the bill in an effort to make explicit what is generally done in practice when more than one health care practitioner is involved in patient care and to reassure legislators concerned about this issue. The bill’s language assigns controlling authority to the medical doctor to determine whether a medication prescribed by the psychologist may be contraindicated by the patient’s physical condition or other medications. SatisTHE STRUGGLE IN THE STATES

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factory completion of specified practicum training under the direction of a licensed physician is a condition of renewal of the certificate to prescribe. With an off year in 2000 to prepare and plan for the continued legislative struggle, and with the introduction of HB414, LPA was once again ready to move forward on prescription privileges in 2001.

A STRATEGIC PARTNERSHIP The struggle in the states represents a strategic partnership between APA and SPPAs. APA has contributed resources and technical support that are not always available on a local level. The result has been a more effective overall advocacy effort. Much progress has been made toward achieving the goal of prescriptive authority for properly qualified psychologists. But much more remains to be done, and the road ahead will not be easy. Not all of the challenges to prescriptive authority come from outside the profession of psychology. There is a risk of fragmented and competitive efforts to achieve prescriptive authority due to frustration; impatience; unresolved antagonisms; or failure to appreciate the need for a long-term, coordinated national strategy. External opposition is a given in legislative advocacy. It is to be expected, and it can be overcome. However, nothing is so hard to deal with as divisiveness within the profession. Few things undermine the credibility of state-level advocacy as much as contradictory messages being received by legislators from constituents, all of whom are identifying themselves as psychologists. A strategic partnership between APA and SPPAs can help minimize this risk. Why APA, and why SPPAs, instead of other organizations of psychologists? The struggle for prescriptive authority will be played out in legislatures, state by state. SPPAs are the organizations most representative of the community of psychologists in each state, and a major reason for their existence is to monitor and influence legislation affecting psychology. SPPAs have a track record of effective advocacy, and they constitute a network of grassroots leaders who are accustomed to working with APA on a wide range of issues. As the largest organization of psychologists in the world, APA has the governance mandate, staff, and other resources to support the state-level advocacy that will be necessary to achieve the goal of prescriptive authority. APA already has laid the groundwork for this effort, and it is likely to remain a high priority for the foreseeable future (Fowler, 1999). The following are some of the things that APA has done, and continues to do, to promote prescriptive authority for psychologists: ■

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developed statutory language that can serve as a model for states seeking to introduce prescriptive authority legislation; provided on-site consultation to the leadership of state associations that have indicated their readiness to advance the prescriptive authority agenda in their respective states; provided financial assistance through grants to SPPAs in support of state-level prescriptive authority initiatives, including funds specifically targeted at consensus-building among psychologists; through its College of Professional Psychology, funded the development of a psychopharmacology examination that can be used by state licensing boards to evaluate candidates seeking prescribing credentials following enactment of enabling legislation (see chapter 10, this volume); and provided staff technical support, data analysis, and dissemination of information through publications, e-mail lists, and professional meetings to facilitate the development of a coordinated national strategy.

LEARNING FROM EXPERIENCE What can be learned from past experience about the need for consensus-building among psychologists and the importance of having a national strategy? The first thing to recognize is that securing prescriptive authority will take awhile. Between 1945, when Connecticut became the first state to pass a licensing law, and the enactment of the Missouri statute in 1977, it took 32 years for all states to enact licensing laws for psychologists. Opposition to prescriptive authority is likely to be at least as great as that faced during the struggle for state licensure. Another lesson psychologists should have learned is the importance of uniform standards for practice. Even with APA’s leadership and model language to guide states, state laws today are far from uniform with respect to important matters such as scope of practice, education and training requirements, and level(s) of license. This state of affairs serves neither the profession nor the public well. Can psychologists do better with prescriptive authority legislation? Returning to the theme of partnering, one might also find a lesson in the record of successful advocacy over the years since the creation of APA’s Practice Directorate and the commitment to build strong and effective SPPAs. Today, every state association has at least one paid staff member, and the larger ones have budgets and staff in sufficient numbers to support extensive advocacy programs on behalf of their members. The grant program administered by CAPP, and the training provided by APA through the THE STRUGGLE IN THE STATES

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Practice Directorate’s annual State Leadership Conference, help to assure the continued viability and effectiveness of organized psychology at the grassroots level. The special APA assessment paid by practitioners helps to fund these efforts. A partnership between APA and SPPAs for helping states obtain prescriptive authority is likely to benefit from following the same proven formula of resource sharing. A fourth lesson to be learned is that securing prescriptive authority will be a very costly proposition. Between 1993 and 2000, 11 state associations were recipients of CAPP grants for prescriptive authority. Funds have been sought mainly to pay for additional lobbyist services. During this period, requests for such grants have grown exponentially, while the pool of grant funds has increased only modestly. Given the fact that grant monies are also needed to fund other critical legislative, organizational development, and special project needs of SPPAs, it is apparent that additional sources of revenue will need to be found. It will require the combined efforts and creativity of both APA and the SPPAs to provide these resources. History has shown the APA–SPPA partnership to be a potent political force. Finally, the importance of maintaining positive relationships with state licensing boards cannot be overstated. It is the state regulatory authorities who will have the responsibility to administer the provisions of future prescriptive authority legislation. Board members are a key constituency in building a consensus of support for prescriptive authority. Where relationships have been neglected—or, worse, become adversarial between SPPAs and state licensing boards—both the profession and the public have suffered. A coordinated liaison function between APA and the Association of State and Provincial Psychology Boards at the national level, and between SPPAs and their respective state licensing boards, should be an ongoing part of the national strategy for prescriptive authority.

FUTURE DIRECTIONS Although the political circumstances in each state are different, and there is no one-size-fits-all strategy, it is difficult to imagine a situation in which APA–SPPA partnering would not be useful. The responses from states where consultative site visits have taken place have been uniformly positive. Site visits provide an opportunity for state leaders to engage in concentrated planning for prescriptive authority together with APA Practice Directorate staff and consultants. A common problem in all states is the need to inform psychologists about the benefits of psychopharmacology training and prescriptive authority. As in the past, with other major advocacy initiatives of organized psychology, the proponents cannot assume that other psychologists will necessarily agree that change is needed. Typically, a core group of psychologists 156

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are strongly supportive, a minority may be vocal in their opposition, and a rather large group are either indifferent or uncommitted. Surveys suggest that support for prescriptive authority is growing (Sammons, Gorny, Zinner, & Allen, 2000), but it should not be assumed that this trend will continue in the absence of effective internal public relations efforts. Opposition to prescriptive authority legislation from organized psychiatry is encouraged by, and has been known to exploit, pockets of active opposition from within psychology (Hayes & Heiby, 1996). In some states, advocacy for prescriptive authority is absent from, or is just beginning to show up on, the radar screen of the SPPA leadership. Elsewhere, the leaders may be far ahead of the rank-and-file membership. With these concerns in mind, CAPP approved in 1999 a new subcategory of special projects grants to support consensus building in states where SPPA leadership has demonstrated a commitment to move forward. Grant funds could be used to pay for such things as attitude surveys, meetings, educational programs, and the development and dissemination of position papers. Most psychologists who have taken the time to reflect on the prescriptive authority initiative would probably agree that it represents an enormous investment of time and treasure for organized psychology. One can think about the cost as a long-term capital investment that will be amortized over future years. Ultimately the cost must be borne by individual psychologists who are willing to contribute the resources that will be needed. Difficult choices about advocacy priorities may have to be made along the way.

REFERENCES American Psychological Association. (1996). Recommended postdoctoral training in psychopharmacology for prescription privileges. Washington, DC: Author. Bolter, J. F. (1997). Psychopharmacology training scheduled to begin in August. The Louisiana Psychologist, 18(2), 4. DeLeon, P. H. (1996). Proceedings of the American Psychological Association, Incorporated, for the year 1995. American Psychologist, 51, 841. Faltz, C., & Olmedo, E. (1995). Report of the Blue Ribbon Panel. Professional Education Task Force. California Psychological Association and the California School of Professional Psychology–Los Angeles. Fowler, R. D. (1999, Fall). Obtaining prescription privileges for psychologists in the United States: A progress report. Advance, 4, 14–16, 21. Fox, R. E., & Sammons, M. T. (1998, September). A history of prescription privileges [Electronic version]. APA Monitor. Retrieved February 2, 2001, from http: //www.apa.org/monitor/sep98/prescrip.html Foxhall, K. (2000, March). Training in psychopharmacology gathers steam. Monitor on Psychology, 31(3), 42–44. THE STRUGGLE IN THE STATES

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Foxhall, K. (2001, May). New Mexico comes up on the inside. Monitor on Psychology, 32(5), 22–23. Hausman, K. (2000, July 7). Psychologist prescribing bill advances in Calif. legislature. Psychiatric News. Hayes, S. C., & Heiby, E. (1996). Psychology’s drug problem: Do we need a fix or should we just say no? American Psychologist, 51, 198–206. Inouye, D. K. (1984, November). Keynote address. Presented at the annual meeting of the Hawaii Psychological Association, Honolulu. Jennings, R. (2001). Three new states move into position to introduce prescriptive authority bills. Practitioner Focus, 13(1), 6, 9. Newman, R. (2000, March). A psychological model for prescribing. Monitor on Psychology, 31(3), 45. Newman, R., Phelps, R., Sammons, M. T., Dunivin, D. L., & Cullen, E. A. (2000). Evaluation of the psychopharmacology demonstration project: A retrospective analysis. Professional Psychology: Research and Practice, 31, 598–603. Sammons, M. T., & Brown, A. B. (1997). The Department of Defense Psychopharmacology Demonstration Project: An evolving program for postdoctoral education in psychology. Professional Psychology: Research and Practice, 28, 107–112. Sammons, M. T., Gorny, S. W., Zinner, E. S., & Allen, R. P. (2000). Prescriptive authority for psychologists: A consensus of support. Professional Psychology: Research and Practice, 31, 604–609. Stigall, T. T. (1997). Prescription privileges bill clears committee but derails in House. The Louisiana Psychologist, 18(3), 1, 8. Stigall, T. T. (1999). Louisiana class first to graduate from CSPP psychopharmacology program. The Louisiana Psychologist, 20(4), 1, 4. Thomas, J. (2000, September–October). New sense of optimism emerges on prescription issue. The National Psychologist, 9(3), 1, 3.

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9 ALLIANCES WITH CONSUMER GROUPS AND OTHER ASSOCIATIONS LINDA F. CAMPBELL AND PAT GARDNER

Individuals diagnosed with mental illness are often cast from their moorings like ships floating on a black sea with no course or bearings. Our pasts deserted us and we could not return to who we had been. Our futures appeared to us to be barren, lifeless places in which no dream could be planted and grow into reality. As for the present, it was a numbing succession of meaningless days and nights in a world in which we had no place, no use, and no reason to be. (Deegan, 1997, p. 74)

The story of psychology’s consumer and professional alliances in the pursuit of prescriptive authority cannot adequately be told without a candid and personalized view of the journey taken by the pioneers and advocates in the struggle with mental illness and with the systems that have historically determined their course. Psychologists’ alliances with consumers, families, and mental health professionals grow from mutual and intersecting goals for better legislation, improved mental health systems, and the underlying power of advocacy as the vehicle for change. This chapter includes a history and description of the current status of the mental health movement as seen through the eyes of consumers, 159

families, and professionals as a context for the history and status of alliance building within psychology, particularly within state association advocacy. These emerging new paradigms for treatments, embraced by consumers and increasingly by professionals as well, are described and applied to the psychosocially based model for psychotropic service provision as espoused by the American Psychological Association (APA). The role for psychologists in fostering continued and new alliance partnerships within the new paradigms is explained, and strategies for successful alliance-building and pitfalls to avoid are discussed from the perspective of individual psychologists’ initiatives and state association collaborative efforts. HISTORICAL PERSPECTIVES OF CONSUMERS, SURVIVORS, EX-PATIENTS, AND FAMILIES IN THE MENTAL HEALTH SYSTEM Views of mental illness held by society and by mental health practitioners have stigmatized individuals who are labeled as mentally ill and have greatly impeded treatment and research efforts by casting a veil of hopelessness and resignation over those who are touched by this condition. Individuals associated with the advocacy and consumer movements created the term Consumer/Survivor/Ex-patient (C/S/X) to convey the varying perspectives with which individuals view themselves in this process. Some people identify with being a consumer of a service, yet others, who react to the involuntariness of treatment for mental illness, reject the term consumer and adopt the term survivor of the mental health system as a statement of victimization by the system. Still others, who are even more militant, declare themselves expatients, to signal their intention to no longer participate in the mental heath system in the role of patient (Stricker, 2000). Treatment practices that developed out of conventional beliefs about mental illness have persisted, even in the face of the development of new generations of medications, new research, empirically supported psychosocial models for promoting recovery, and programs for family and peer support. These attitudes and practices stymie progress and continue to stereotype the consumer/patient and the experience of mental illness. These entrenched attitudes (referred to as myths by consumers/patients) are increasingly targeted and rejected by consumers (Glass & Arnkoff, 2000): 1. Involuntary inpatient hospitalization is the most intensely rejected aspect of conventional treatment (Lucksted & Coursey, 1995). Individuals feel objectified, isolated, and robbed of their dignity and respect as human beings. Bassman (2000) recalled the terror of the experience: Worse was the knowledge that I could be stripped of everything: memory, identity, dreams, ideals, freedom to move or even to

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think. All this could be brought about with my tormenters feeling self-righteous, and those who cared for me thinking they were acting in my best interest. (p. 1402)

2. Human beings should not be, but are, defined by their diagnosis. This involuntary life sentence demarcates life into “before” and “after.” Self-constructs shift irrevocably and create new internal and external landscapes (Marsh, 2000). A diagnosis of mental illness is seen as robbing patients of their individuality and putting them on track for a one-size-fits-all treatment plan of containment and medication. During the 1992 National Mental Health Consumers’ Association meeting, a mission statement was adopted that identified six areas that focused on consumers’ quality of life: (a) employment, (b) housing, (c) benefits, (d) mental health systems, (e) self-help, and (f) nondiscrimination (Frese & Davis, 1997). 3. Symptom reduction and maintenance have been the primary goals of psychiatric treatment. Increasing numbers of studies are identifying the fact that mental health service recipients attribute much more importance to quality of life than to symptom reduction (Coursey, Alford, & Safarjan, 1997; Coursey, Farrell, & Zahniser, 1992; Felton, Carpinello, Massaro, & Evans, 1996). 4. Consumers further reject forced medication. High dosages and side effects of medication are more tolerable than the treatment belief that a lifetime of psychiatric drugs is central to the treatment of major mental illness because otherwise one has no control over symptoms (Glass & Arnkoff, 2000). The psychiatric community is perceived as continuing to place great significance on symptom reduction over quality-of-life pursuits. Additional attitudes or myths about mental illness identified by Bassman (2000) are (a) that mental illness is irreversible and recovery is nonexistent; (b) psychotherapy is ineffective for individuals diagnosed with schizophrenia, and therefore the focus should be on maintenance and stabilization rather than on personal growth; and (c) patients should accept their diagnosis and implied limitations, reduce life expectations, maintain lowstress lifestyles, and accept that experts know best and that forced treatment is appropriate when treatment is refused. On the other hand, consumers assert that choice is fundamental and critical to growth and recovery (Bassman, 1997). Virtually all consumer pioneers oppose the right of the government to commit to mental health facilities individuals who are not dangerous (Frese, 2000; Frese & Davis, 1997). Phrases such as “I am not a case, and you are not my manager” and “Label jars, not people” have become the symbols for the consumer movement that ALLIANCES WITH CONSUMER GROUPS AND OTHER ASSOCIATIONS

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sets the stage for change (Estroff, 1991). The importance of capturing this bird’s-eye view of the consumer’s experience with the mental health system is that the practices that cause dissatisfaction with psychiatric services invite change and movement into the psychosocial realm of psychological treatment.

CURRENT STATUS OF CONSUMERS AND FAMILIES IN TREATMENT The Recovery Process The most visible theme among consumers now is one of recovery. Deegan (1997) described recovery as a “journey of the heart.” Recovery interviews were held with consumers. The most common answers to questions regarding what people are “recovering from” were loss of self and hope, loss of roles and opportunities, multiple traumas, devaluing and disempowering programs, and stigma and discrimination. Facilitators of recovery included hope, good treatment, social and peer support, coping skills, self-help skills, therapy, meaningful work, and connections with others (Marsh, 2000). The Psychologist’s Role in Recovery Psychologists embrace a recovery framework when they collaborate with consumers to better cope with challenges of mental illness and when they realize the person’s potential as an individual who is not defined by that illness (Frese & Davis, 1997; Levant, 1998). Gagne (1999) presented results of the Recovery Research Project at the APA Mini-Convention on Consumers and Psychologists in Dialogue. As psychologists adopt the role of mental health professionals with prescriptive authority, they are skilled and prepared to offer a psychosocial model of comprehensive treatment that corresponds to the long-standing needs and preferences of the consumers’ group. Some needs often cited by consumers as treatment goals include the following (Marsh, 2000): ■

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Coping strategies—including taking medication properly, avoiding alcohol and drugs, monitoring stress, learning to prevent relapse, and coping with specific symptoms, even learning to manage if one chooses to not seek treatment—need to be developed. Consumers emphasize the importance of collaborative partnerships with therapists who value and respect choice and will work on quality-of-life issues rather than symptom reduction only (Carling, 1995; Coursey et al., 1992). Lynch (2000, p. 1431) observed that “choice and partnership are critical to reCAMPBELL AND GARDNER

covery.” Consumers consistently report that they value psychotherapy and want continued collaboration with a good therapist (Blanch & Dvoskin, 1993). Therapeutic concerns important to consumers/clients include life issues, self-management, dealing with the effects of disability, and psychosocial skills (Coursey et al., 1997). The prescriptive authority agenda gave birth to a new conceptualization of the psychosocial model of treatment, health, mind–body functioning, and person-in-environment perspectives that psychology has for years embraced. These concepts have grown into theoretical and clinical practice areas of prevention, health psychology, human factors, and psychological aspects of medical care. Similarly, the psychological model, which is shaping the developing identity of prescribing psychologists, is responsive to historical roots of psychological practice rather than the medical/prescription paradigm. This model was introduced and described most articulately and specifically by Newman (2000), who explained that the psychology model of treatment, in contrast to medicine, is a systems-oriented, holistic, integrative approach. He further explained that, in contrast to medicine, in which the patient is typically in a passive, receptive role and the physician in an authoritative, hierarchical role, the psychology model emphasizes client/consumer empowerment. Treatment planning involves an active, problem-solving approach by the client/consumer. Collaboration is the norm (Newman, 2000). As psychologists who were trained in a psychosocial model of psychotherapy treatment also become trained in the prescription of psychotropics, they are poised to offer an integrated treatment approach that is aligned with the recovery model for mental illness (Jeffries, 1995). Consumers and families will be able to receive the holistic, collaborative, and individualized treatment approach that has not been widely available in the mental health system (Jeffries, 1995). The psychology model, in fact, would seem to be tailor made for the consumers and advocates of equitable treatment for individuals with serious mental illness. These consumers/patients want to see the same doctor each time, and they want someone who will listen to them, an attribute that is characteristic of psychologists and that has been emphasized in APA’s public education campaign theme: “Psychologists: Doctors Who Listen.” National Initiatives A small but growing number of psychologists are integrating the concept of recovery into a new paradigm for treatment of mental illness. Ronald F. Levant, a member of APA’s Board of Directors, in conjunction with the late APA board member Catherine Acuff and with Bob Coursey and Ron Bassman from the APA Task Force on Serious Mental Illness, developed and ALLIANCES WITH CONSUMER GROUPS AND OTHER ASSOCIATIONS

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coordinated a miniconvention on psychologists’ role in serious mental illness for the 1999 APA Convention. Its title was “Consumers and Psychologists in Dialogue.” Themes that emerged from the miniconvention focused on the integration of services and recovery. In opposition to the medical model’s focus on disease or pathology, emphasis is placed on potential for growth and change. Integrated treatment models call for the coordination of medical, psychological, and social interventions (McGuire, 2000). The recovery model is based on psychosocial rehabilitation. About 4,000 treatment programs across the United States have adopted this model. The programs include work and social skills training; educating patients about their conditions; and explaining to patients why medication may help maintain their quality of life, symptom management, and therapy. Directed toward practical treatments, psychosocial rehabilitation teaches consumers how to access resources such as health services and housing and how to go about regaining independent functioning (McGuire, 2000). These skills are inherent in the training and philosophy of psychologists. An opportunity to more fully participate in the recovery model and adopt the psychosocial rehabilitation paradigm to practice awaits prescribing psychologists. State Initiatives A significant development in the alliance between psychology and the National Alliance for the Mentally Ill (NAMI) occurred during the beginning of the New Mexico legislative session of 2001. In the face of strong opposition from organized psychiatry, the NAMI board in New Mexico voted 7–3 to endorse the psychologists’ bill for prescriptive authority. This is the first time NAMI has formally supported a prescriptive authority for psychologists bill in any state. The New Mexico Psychological Association also acquired letters of endorsement from the Association for Retarded Citizens and Parents Reaching Out. This collaborative effort, in concert with continuous, effective strategic initiatives by psychologists, resulted in New Mexico becoming the first state to grant prescriptive authority to psychologists. This monumental success is of the greatest significance for the profession and signals even greater opportunities for psychologists to work collaboratively with consumers and their families toward realization of new models for improving the lives of people who are seriously mentally ill.

PSYCHOLOGY’S RELATIONSHIP WITH CONSUMERS Historical Perspectives Until recently, psychologists had a mixed record regarding involvement in the consumer mental health movement. Consumers’ very negative view of mental health professionals is largely leveled at psychiatry as the 164

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professional force that directed patients into involuntary hospitalization and forced medication. On the other hand, consumers and families ask, “Where are the psychologists, and where were they then?” In actuality, the few psychologists who formed the Radical Therapy movement in the early 1970s were there for the consumers in the early days of the movement for mental patients’ rights. However, these early initiatives fizzled out, and psychologists were pushed aside during the community mental health center cutbacks in the 1980s to the point that (until recently) they virtually vanished from care in the public sector of individuals diagnosed with serious mental illness. Because some consumers and families may perceive that psychologists have not been there to meet their needs, a delicate balance must be achieved as they are approached to support prescriptive authority for psychologists. APA’s Involvement During the early 1980s, there was no section of any APA division that was home to psychologists who worked with people who are seriously mentally ill. Division 18, Public Service Psychologists, seemed the most appropriate home. Fred Frese and others worked with Pat DeLeon in developing Section V, Community and State Hospital Psychologists, of Division 18, and today it is the division’s third largest section. Even though this group is committed and intensely determined to improve mental health services for this population, psychologists have not played as integral a role in public sector mental health care as they have in other areas. There are many reasons for this: (a) Psychiatry has controlled the administration of psychotropic medications for this population; (b) psychosocial treatments, all of which are within psychology’s purview, have been erroneously deemed ineffective with those who are seriously mentally ill; (c) inpatient hospitalization has largely precluded treatment by psychologists; and (d) training programs have not included curriculum components on treatment for this population (Frese, 2000). Psychology’s Relationship With NAMI Psychology’s relationship with NAMI qualitatively varies based on several factors, such as legislative positions on specific bills, general alliance efforts, prioritization of mental health issues, and state- versus national-level alliances. Each state has a unique relationship with NAMI and other mental health associations. Some have forged alliances over the years and remain consistent, with occasional ruptures. Some states have periodic or sporadic alliances as needs develop on specific legislation (i.e., parity). The American Psychiatric Association and NAMI have had a longer standing political relationship than APA has had with NAMI. NAMI has not viewed psychologists as being integrally involved with the seriously mentally ill, and even though NAMI is often at odds with psychiatry, NAMI ALLIANCES WITH CONSUMER GROUPS AND OTHER ASSOCIATIONS

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sees psychiatry as holding considerable influence and certainly as an unquestionable ongoing presence in the treatment of people with mental illness. APA and NAMI experienced a deterioration in working relationship during the 1960s, when psychology supported the etiological concept that the development of mental illness was affected by poor nurturance and that biologically based etiological explanations were unfounded. But since those earlier times, psychological research has offered continued enlightenment on the nature of mental illness and continues to broaden the understanding of the causes and treatments of schizophrenia. Over the years, APA and NAMI have resolved some of the difficulties that lay in overly simplistic heuristic explanations for mental distress, making way for collaboration in current and future initiatives. In 1996, APA and NAMI developed a coalition to support the Mental Health Parity Act. Successful strategic planning and advocacy have resulted from this coalition. Furthermore, NAMI has worked with APA on the Patients’ Bill of Rights and continues to participate with APA in promoting that legislation. On the state level, however, some states have had mixed experiences with NAMI, particularly with state-level parity bills. On occasion, NAMI and state-level psychological associations have developed a coalition along with other professional or patient advocacy associations. Because NAMI tends often to be much more focused on advocacy for the seriously mentally ill, NAMI would support limited legislation that affected only individuals who are seriously mentally ill, rather than broader legislation supported by the psychological associations and others. These are understandable differences, but they still created skepticism and caution in working together. State Psychological Association Initiatives It is never too late to begin developing an alliance network in promoting and nurturing cooperation. The strength of alliances, however, is built on long-term reliability and trust. Several factors contribute to the success of state associations in forming working alliances with consumers and other mental health professionals. Our experience in the state of Georgia will be offered, not as a prototype but as an example of partnership efforts across time and shared objectives. The local presence of nationally known associations such as NAMI, as well as the National Association for Rights Protection and Advocacy, National Mental Health Association, and Children and Adults with Attention-Deficit/Hyperactivity Disorder varies by state, and the effectiveness of these associations can change over time. State psychological associations should be alert to the family and consumer associations that demonstrate consistency over time in their advocacy and legislative activities.

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Our participation in alliance building began 20 years ago, when Pat Gardner, executive director of the Georgia Psychological Association (GPA), became involved in the National Mental Health Association and helped develop the Mental Health Services Coalition in Georgia. Some membership has changed, but ongoing participants have included GPA, Georgia Alliance for the Mentally Ill, the Georgia Psychiatric Physicians’ Association, the Georgia Mental Health Consumer Network, several metropolitan county regional boards, Mental Health/Mental Retardation/Substance Abuse (MH/MR/SA) services, representatives from public and private psychiatric hospitals, and approximately 10 other groups. Over the years, the alliances have been strengthened and maintained through reciprocal support of advocacy and legislative goals. Three successful alliance endeavors have been (a) passage of the Mental Health Parity Act, (b) funding for the state mental health system, and (c) support for reorganization of a system to implement community-based services. Consumers and other mental health associations have to know that their focus is understood and respected and that the state association will be there to support them. The two most important factors in alliance building are personal relationships and the successful seeking out of goals wherein consensus can occur. Once cohesion is built through the pursuit of common goals, an advocacy group is more likely to support a goal that they may not share but that they will support because they trust the motives and values of the individuals representing psychology. The active pursuit of goals through organized and persistent advocacy is important, as is a victory or two. GPA has sponsored a Psychologists’ Day at the Georgia capitol for some years. After participation in the Mental Health Services Coalition began to grow, GPA merged the Psychologists’ Day into Mental Health Day in order to include other mental health advocacy groups. As a result, psychologists lost the distinctiveness of an identified day with legislators but gained the group participation, commitment—and, most important—the sense of alliance. Mental Health Day still includes regional board advocates, consumers, providers, families, and professionals. Additional events that GPA cosponsors with NAMI and the Georgia Psychiatric Physicians’ Association are Mental Health Awareness Week and assistance in fundraising efforts such as NAMI’s “Food For Thought.” The National Mental Health Association in Georgia sponsors a golf tournament yearly. GPA supports and participates in the tournament. Recently, Pat Gardner sponsored the addition of a tennis component to the tournament, with finals played at the governor’s mansion. Participants of the games included legislators and the governor’s wife (who played in the finals). These are opportunities to promote psychologists’ mental health message and to further strengthen their coalitions. These are but a few examples of ways in which the foundation for cooperation can be established through

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shared goals before a more potentially contentious need for cooperation (i.e. prescriptive authority for psychologists) arises. NAMI has had a consistent and important presence in Georgia. Individuals with whom psychologists have primarily worked are family members of consumers. Family members have been concerned about legislation that they think is helpful to families in managing a family member’s illness. These interests can range from commitment laws, to availability of new medications, to jail diversion programs. The Consumer Network has emerged in more recent years and is represented by consumers of mental health services who often have a different focus on advocacy than NAMI representatives. The Consumer Network has been interested in the quality-of-life factors previously mentioned such as jobs, housing, hope, choice of treatment, and lifestyle. They have successfully advocated for peer counselors in the mental health system and continue to advocate for empowerment and hope models as replacement for the disease-and-diagnosis model. A role for psychology in the emerging differing goals of the system, consumers, and families is one of mediation through coalition participation. This type of activity again reinforces the perception that psychologists are consistently present and involved, even when they do not have a direct interest in an issue (Bassman, 1997; Marsh & Johnson, 1997).

CURRENT STATUS OF PSYCHOLOGISTS’ ALLIANCE WITH CONSUMERS Psychotherapy and Medication Families of consumers, and many consumers of psychological services outside of the mental health system, are optimistic about the new generation of psychotropic medications. Families continue to favor medication treatment more than do the consumers themselves. Individuals who are receiving psychotherapy from psychologists, however, are more likely to be favorable to psychologists prescribing than other people treated in mental health systems, who may see prescribing psychologists as merely another group of treatment officials who can force patients to take medications. Many consumers are in settings wherein they are not receiving continuity of care and are passed from one psychiatrist to another. These individuals are positive about the improvement of medication evaluation when done by a psychologist/therapist who sees the patient as an individual and who respects and responds to the patient as an individual (Bassman, 1997). It is important for psychologists, in their advocacy with alliance groups, consumers, and legislators, to emphasize the psychosocial model of treatment that is unique to psychological practice (Bedell, Hunter, & Corrigan, 1997). Vehicles for educating and orienting consumers and professionals regarding 168

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the psychosocial application of treatment in the prescribing of medication include participation on regional boards and alliance association committees; willingness to present a topic to mental health association meetings; and, in general, to be available and visible to these groups in a consistent and ongoing way. This level of participation is time intensive, but in time one gains relationships, trust, and a perception of dependability that is invaluable in the advocacy process. Public Sector Psychologists The presence of psychologists in the public mental health system is critical in laying the groundwork for prescribing psychologists in the public sector, regardless of whether those particular psychologists support the prescriptive authority agenda. Administrators, families, and consumers develop a familiarity with and trust of psychologists who stay and work among them. The presence of an urban training/teaching hospital is a true advantage for psychologists’ attempts at building alliances with other professions and with consumers. Psychologists who work in the public sector often have a private practice or at least have a working relationship with psychologists in private practice. The crossover effect is advantageous in reinforcing psychologists’ credibility and dependability as they seek alliance support for expansion of their scope of practice. Furthermore, public sector settings, including teaching hospitals, penitentiaries, Veterans Affairs hospitals, community mental health agencies, and regional mental health boards, will most likely be the initial sites for psychologists’ postdoctoral clinical experiences with prescribing. The presence of and roles played by psychologists in such settings will influence the openness with which these sites consider the training. State associations can foster the role of public sector psychologists in several ways. As an example, one of the divisions within the GPA is Division C, Public Sector Psychologists. This division engages in various legislative, clinical, and policy-oriented activities to support public sector presence in the mental health community, including within the GPA prescriptive authority agenda. In fact, the ability to prescribe would benefit the public sector psychologists greatly in view of the critical shortage of psychiatrists in departments of corrections, mental health, and juvenile justice. Psychologists have endured years of underutilization and a diminishing role in public sector systems because they could not prescribe or take responsibility for the treatment plan under the clinic option. This initiative would actually add value to the services they can provide. In fact, they could become part of the solution to the access problem, particularly if they can provide psychotropics, initially under clinical supervision by psychiatrists in those systems. It is important that the state associations and other advocates for prescriptive authority for psychologists understand that it may be very difficult ALLIANCES WITH CONSUMER GROUPS AND OTHER ASSOCIATIONS

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or impossible for some mental health associations to straightforwardly support the prescriptive authority agenda. Consistently, there is pressure from medical associations and other factions to block support from groups who might support psychologists’ agenda. The goal of relationship building with other associations and consumers before a legislative cycle is to neutralize the opposition. In fact, educational efforts in addition to good relationships have inspired individual letters from leaders in various organizations. Favoring legislation is of course the ideal, but a position to not oppose often carries as much weight.

STRATEGIES FOR THE FUTURE: PROPOSED ROLES FOR PSYCHOLOGISTS AS SEEN BY CONSUMERS AND FAMILIES Bassman (1997) asked a provocative question: Will psychologists join in creating new paradigms that change an ineffective system, or will they be left on the sidelines to watch as managed care organizations provide less access and increased intrusiveness? Psychologists have been underrepresented in working with individuals who are seriously mentally ill in providing psychological services, partnering in community service activities, and in policy development. The landscape of mental health service delivery is significantly changing, and opportunities for psychologists are emerging. Observations have been made by psychologists, consumers, and families on the important role of psychologists in the mental health paradigm of the future (Levant, 1998). In the face of the conventional stance that psychotherapy is ineffective with those who are seriously mentally ill, consumers have expressed resounding confidence in the effectiveness of psychotherapy as delivered by psychologists (Bassman, 2000; Deegan, 1997; Walsh, 1999). Most certainly, psychologists’ credibility with consumers as they integrate prescriptive authority into their scope of practice will rest on the “service record” they have earned in providing consumers services that are within their scope. The positive benefits of psychotherapy continue to be a connecting bond between psychologists and consumers (Blanch & Dvoskin, 1993). The psychotherapy landscape for treatment of those who are seriously mentally ill is now reflecting positive findings through very specific treatment models and promising new directions for the future. Most treatments shown to be effective with people with serious mental illness are based in social learning theory and behavior therapy models (as cited by Bedell et al., 1997). They describe and present several innovative treatments, several of which are summarized as follows: 1. Targeted-intermittent long-term therapy provides intense focus by a treatment team during periods of high symptomatology 170

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and transition to maintenance intervention during stabilized periods (Bedell & Ward, 1989). 2. Social skills training is the most important treatment development for people with serious mental illness. The once-singular social skills model now boasts numerous applications. Benton and Schroeder (1990) reported the findings of a meta-analysis of 27 well-designed studies that evaluated social skills training for people with schizophrenia: Social skills training reflects significant improvement in anxiety and assertiveness, superior social functioning, and lower rates of relapse. 3. Training programs that have demonstrated greatest success have multiple components, including problem solving (Bedell & Michael, 1989; Penn et al., 1993), assertiveness, and communication skills (Brown & Carmichael, 1992) and, the most successful combination thus far, communication and problem solving for individuals (Bedell & Lennox, 1997) and families (Fallon, McGill, Boyd, & Pederson, 1987), singly or in combination with medication and behavioral management (Ward & Naster, 1991). 4. Other approaches include individual psychotherapy with a cognitive–behavioral approach (Kingdon & Turkington, 1994) and a problem-solving approach for major depression (Nezu, Nezu, & Perri, 1989); personal therapy (Hogarty et al., 1995) that takes a multifaceted approach in which information processing is matched with levels of functioning; therapeutic contracting (Heinssen, Levendusky, & Hunter, 1995); and new approaches to case management (e.g., assertive community treatment teams; Chamberlin & Rogers, 1990). There are steps that psychologists must take, however, to ensure that they evolve from traditional perspectives to understanding and incorporating the new paradigms of mental health treatments into their training and practice. A commentary written by our late colleague and mental health advocate, Catherine Acuff (2000), asked “Are we listening to the message?” She identified the messages that are consistently sent psychologists’ way by mental health consumers and families: ■

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Labels are stigmatizing, hurtful, and destructive of self-identity. Pathology-based models destroy hope and belie recovery. Valuing individuality is just as important for individuals with mental illnesses as it is for others. Alternative treatments and new approaches must be valued and pursued. ALLIANCES WITH CONSUMER GROUPS AND OTHER ASSOCIATIONS

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Peer support and self-help initiatives provide comfort and strength and foster a belief in one’s capacity to change. The training of psychology students in predoctoral and internship experiences must include a more deliberate and systematic component in serious mental illness, in both didactic and clinical experiences. Services should be recovery oriented. Psychologists have fallen prey to the same mind set that shapes policy, treatment, and the role that society and the mental health system impose on individuals with mental illness.

Advances in psychopharmacology are extraordinary. As psychologists gain prescriptive authority, their psychosocial model will lend itself to a biopsychosocial approach. Prescribing psychologists will be in uncharted territory, charged with the responsibility to nurture and respect a new, complex, and powerful treatment model. The National Council on Disability (NCD) is a federal agency that makes recommendations to the President and Congress on issues affecting the 54 million Americans with disabilities. Rae Unzicker, former president of the National Association for Rights Protection and Advocacy, is the first person with a mental disability to serve on the council. In January 2000, the NCD identified 10 core recommendations that serve as guidelines for changing public policy in mental health delivery. These include the following: ■

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Laws that allow involuntary treatments are incompatible with self-determination. People labeled with psychiatric disabilities should have a major role in the design of their own services. Treatment should be about healing, not punishment. Employment and training must incorporate the range of skills and abilities of people labeled as having psychiatric disabilities. Government agencies must work together to reduce the placement into correctional facilities of children and young adults with disabilities. (National Council on Disability, 2000, p. 3)

These recommendations are compatible with psychology’s code of ethics and in fact echo the various guidelines psychologists have developed to ensure respect and dignity for their patients and others who receive their services. Exemplifying movements within the new paradigm that offer opportunities for psychologists to partner with consumers are assertive community treatment teams (Chamberlin & Rogers, 1990). These are treatment teams; many of them are sponsored by Veterans Affairs facilities that provide ser172

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vices in nonpsychiatric community settings. The focus of the services is on rehabilitation and support in the consumers’ natural environment (Dixon, Hackman, & Lehman, 1997). Emerging from the assertive community treatment initiative is the role of assertive community treatment workers. Functions of assertive community treatment workers include conducting assessments and planning interventions, home visits, facilitating psychiatric and other medical services, providing interagency resource brokering and advocacy, and working in partnership with families (Witheridge, 1989). Few psychologists have made the transition from hospital-based treatment to participation and partnering in these community-based models (Frese & Davis, 1997).

LESSONS LEARNED FROM ALLIANCES Psychologists/psychotherapists and researchers continue to find that the working alliance is more than a desirable set of core conditions for psychotherapy but that, in fact, it facilitates the effectiveness of treatment outcome (Horvath & Greenberg, 1994; Lambert & Bergin, 1994). It is equally true, although not often observed, that establishment of an effective working alliance with other mental health professions also largely determines the outcome of cooperation and collaborative advocacy. Strategies That Have Been Successful Developing and maintaining relationships with other mental health professions is critical to state associations’ ability to achieve significant legislative advances. Partnering with other stakeholders in mental health advocacy also demonstrates to legislators that psychologists consistently engage in collaboration and pursue legislative action in a fair and straightforward way. At least in the state of Georgia, the majority of legislators return for another day and another year. Although legislation that we may have supported either successfully or unsuccessfully has gone by the boards, the legislators remember whether we were cooperative, helpful to them, and engaged in fair play. Countless legislators over the years have told our leadership that even though they may disagree with us, they know that we are consistent and reliable and that they can trust us. The prescriptive authority agenda has been more challenging to develop and has taken much more grassroots networking, fundraising, advocacy, and internal and external educative initiatives than other major legislation psychologists have achieved. It has been difficult for mental health associations to openly support the prescriptive authority agenda because of the influence of the Medical Association of Georgia. Furthermore, individual psychologists work with, and sometimes report to, psychiatrists. They too ALLIANCES WITH CONSUMER GROUPS AND OTHER ASSOCIATIONS

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cannot openly support psychologists’ prescriptive authority agenda. An important tactical understanding, however, is that, legislatively, a neutral position or a lack of an opinion by another association or consumer group is as good as support. Often legislators will try to determine who is against a bill and how powerful the group is. NAMI was engaging in discussions with psychologists on the prescriptive authority agenda, but the psychiatrists were able to intervene. Because of our long-standing and positive association with NAMI, NAMI did not oppose psychologists but simply remained neutral, despite enormous pressure by the psychiatric lobby. GPA and the students who have graduated from the psychopharmacology training program have been exploring potential clinical sites for their postdoctoral supervised experience. Systems that do not have a political or financial stake in psychologists’ legislative success are sometimes open to collaboration in ways that help psychologists accomplish their goals, and thus they assist them. Strategies That Have Not Been Successful GPA has not attended to alliance building with consumer networks as well as it should or will. The Consumer Network has become an important, strongly functioning entity in Georgia. GPA members have continued to invest their energies and time where their alliances are strong, in this case with NAMI of Georgia and the National Mental Health Association of Georgia. GPA’s alliance with these two groups is critically important, and GPA highly values its association with them. GPA has not been as successful in developing an alliance with the graduates of psychopharmacology training programs; neither has it yet been as successful in assisting graduates in locating supervised experience sites as members would like. GPA leadership overestimated the willingness of sites to participate in this pilot project of developing practicum experiences before legislation passes. Many sites have directly indicated a willingness, and often an enthusiasm, for setting up a site after the legislation is passed. Veiled or blatant threats from physicians on staff or serving as consultants have stymied efforts at establishing sites. The hospital association that had remained neutral during GPA’s efforts to acquire hospital privileges succumbed to the psychiatrists’ demand that they oppose psychologists’ prescriptive authority in the name of “maintaining quality.” Efforts to neutralize them have been unsuccessful although this may be related to their own tenuous financial status and need for support from physicians. The uncertainties of the legal issues involved and the lack of clear definition of the experience were detrimental to GPA’s efforts. For legal and political reasons, this challenge has been difficult. In retrospect, GPA’s tenuous relationship with psychiatrists might be more positive had a psychiatrist been involved in our training curriculum. 174

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For both political and practical reasons, we continue to consider this possibility. Also, in retrospect, we would work harder to develop an alliance or partnership with pharmaceutical companies. As we have said about other alliances, tenure and trustworthiness matters. We have not taken time over the years to foster that relationship except in connection with workshops and smaller sponsored activities. During the last several legislative sessions, the psychiatric physicians have influenced the pharmaceutical companies’ stance toward psychology and the prescriptive authority bill. One pharmaceutical representative reported that the psychiatric lobby had communicated that they would take some action against the company should they support psychologists in any way. GPA has considered the advantages and disadvantages of framing its prescription curriculum program as a degree program. A master’s degree after one had already received a PhD seemed excessive, and we chose to follow the model of respecialization that is common in medicine and in psychology. Of course, the degree program would have required another level of commitment from our premier universities and might have taken considerable time, and this would have allowed the organized medicine lobby time to attempt another intervention. In any case, we now think that a degree program might have been more persuasive and definitive, although our current curriculum continues to draw respect and authority. It is incumbent on organized psychology to facilitate the entry of practicing psychologists into new mental health delivery systems. Opportunities include new curriculum components in predoctoral training programs, internship tracks in community-based mental health delivery, and state association sponsored continuing education with a focus on public sector partnering with consumers and the recovery paradigms (Acuff, 2000). We conclude with Dr. Acuff’s words: The strength of our profession is that it offers a biopsychosocial perspective to the treatment of mental illness. We must see the whole person in his or her context, and recovery must be the focus and the goal. By creating collaborative partnerships with those in the c/s/x movement, by truly listening to their voices, by recognizing the individuality of those with whom we work, by rejecting pejorative labels and going beyond pathology-based models, by being open to alternative therapies and selfhelp approaches, and by training our students and ourselves about the true hope of recovery, we can create a profession that is prepared for the future and the promise it holds. (Acuff, 2000, p. 1464)

REFERENCES Acuff, C. (2000). Commentary: Listening to the message. In Session: Psychotherapy in Practice, 56, 1459–1465. ALLIANCES WITH CONSUMER GROUPS AND OTHER ASSOCIATIONS

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Bassman, R. (1997). The mental health system: Experiences from both sides of the locked doors. Professional Psychology: Research and Practice, 28, 238–242. Bassman, R. (2000). Agents, not objects: Our fights to be. In Session: Psychotherapy in Practice, 56, 1395–1411. Bedell, J. R., Hunter, R. H., & Corrigan, P. W. (1997). Current approaches to assessment and treatment of persons with serious mental illness. Professional Psychology: Research and Practice, 28, 217–228. Bedell, J. R., & Lennox, S. S. (1997). Handbook of communication and problem solving skills training: A cognitive–behavioral approach. New York: Wiley. Bedell, J. R., & Michael, D. D. (1989). Teaching problem solving skills to the chronically mentally handicapped. In D. Upper & S. M. Ross (Eds.), Handbook of behavioral group therapy (pp. 83–118). New York: Plenum. Bedell, J. R., & Ward, J. (1989). An intensive community based treatment program alternative to state hospitalization. Hospital and Community Psychiatry, 40, 533–535. Benton, M. K., & Schroeder, H. E. (1990). Social skills training with schizophrenics: A meta-analytic evaluation. Journal of Consulting and Clinical Psychology, 55, 741–747. Blanch, A., & Dvoskin, J. (1993, July). Planning the future of psychology in the public mental health system. NYSPA Notebook, 5(5), 1–36. Brown, G. T., & Carmichael, K. (1992). Assertiveness training for clients with psychiatric illness: A pilot study. British Journal of Occupational Therapy, 55, 137–140. Carling, P. (1995). Return to community: Building support systems for people with psychiatric disabilities. New York: Guilford Press. Chamberlin, J., & Rogers, J. A. (1990). Planning a community-based mental health system: Perspective of service recipients. American Psychologist, 45, 1241–1244. Coursey, R. D., Alford, J., & Safarjan, B. (1997). Significant advances in understanding and treating serious mental illness. Professional Psychology: Research and Practice, 28, 205–216. Coursey, R. D., Farrell, E. W., & Zahniser, J. H. (1992). Consumers’ attitudes toward psychotherapy, hospitalization, and aftercare. Health & Social Work, 16, 155–161. Deegan, P. E. (1997). Recovery as a journey of the heart. In L. Spaniol, C. Gagne, & M. Koehler (Eds.), Psychological and social aspects of psychiatric disability (pp. 74–83). Boston: Boston University Center for Psychiatric Rehabilitation. Dixon, L., Hackman, A., & Lehman, A. (1997). Consumers as staff in assertive community treatment programs. Administration & Policy in Mental Health, 25, 199–208. Estroff, S. E. (1991). Everybody’s got a little mental illness: Accounts of illness and self among people with severe, persistent mental illnesses. Medical Anthropology Quarterly, 5, 331–369.

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Fallon, I. R., McGill, C. W., Boyd, J. L., & Pederson, J. (1987). Family management in the prevention of morbidity of schizophrenia: Social outcome of a two-year longitudinal study. Psychological Medicine, 17, 59–66. Felton, C. J., Carpinello, S. E., Massaro, R., & Evans, M. (1996, May). Multiple stakeholders: Perceptions of outcomes. Paper presented at the meeting of the National Conference on Mental Health Statistics, Washington, DC. Frese, F. J. (2000). Psychology practitioners and schizophrenia: A view from both sides. In Session: Psychotherapy in Practice, 56, 1413–1426. Frese, F. J., & Davis, W.W. (1997). The consumer–survivor movement, recovery, and consumer professionals. Professional Psychology: Research and Practice, 28, 243–245. Gagne, C. (1999, August). Recovery from mental illness: Results from the Recovery Research Project. Paper presented at the 107th Annual Convention of the American Psychological Association, Boston. Glass, C. R., & Arnkoff, D. B. (2000). Consumers’ perspectives on helpful and hindering factors in mental health treatment. In Session: Psychotherapy in Practice, 56, 1467–1480. Heinssen, R. K., Levendusky, P. G., & Hunter, R. H. (1995). Client as colleague: Therapeutic contracting with the seriously mentally ill. American Psychologist, 50, 522–532. Hogarty, G. E., Kornblith, S. J., Greenwald, D., DiBarry, A. L., Cooley, S., Flesher, S., et al. (1995). Personal therapy: A disorder-relevant psychotherapy for schizophrenia. Schizophrenia Bulletin, 21, 379–393. Horvath, A. O., & Greenberg, L. S. (Eds.). (1994). The working alliance: Theory, research, and practice. New York: Wiley. Jeffries, J. J. (1995). Working with schizophrenia: A clinician’s personal experience. Canadian Journal of Psychiatry, 40(3), 22–25. Kingdon, D. G., & Turkington, D. (1994). Cognitive–behavioral therapy of schizophrenia. New York: Guilford Press. Lambert, M. J., & Bergin, A. E. (1994). The effectiveness of psychotherapy: Handbook of psychotherapy and behavior change. New York: Wiley. Levant, R. F. (1998). Psychology and long-term mental illness. Psychotherapy Bulletin, 33(4), 13–15. Lucksted, A., & Coursey, R. D. (1995). Consumer perceptions of pressure and force in psychiatric treatments. Psychiatric Services, 46, 146–152. Lynch, K. (2000). The long road back. In Session: Psychotherapy in Practice, 56, 1427–1432. Marsh, D. (2000). Personal accounts of consumer/survivors: Insights and implications. In Session: Psychotherapy in Practice, 56, 1447–1457. Marsh, D., & Johnson, D. L. (1997). The family experience of mental illness: Implications for intervention. Professional Psychology: Research and Practice, 28, 229–237. ALLIANCES WITH CONSUMER GROUPS AND OTHER ASSOCIATIONS

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McGuire, P. A. (2000). New hope for people with schizophrenia. Monitor on Psychology, 31(2), 24–28. National Council on Disability. (2000, Spring–Summer). Core recommendations. The Rights Tenet, 3. Newman, R. (2000). Professional point. Monitor on Psychology, 31(3), 30–32. Nezu, A. M., Nezu, C. M., & Perri, M. G. (1989). Problem solving therapy for depression: Theory, research, and clinical guidelines. New York: Wiley. Penn, D. L., Van Der Does, A. W., Spaulding, W. D., Garbin, C. P., Linszen, D., & Dingemans, P. (1993). Information processing and social cognitive problem solving in schizophrenia: Assessment of interrelationships and changes over time. Journal of Mental and Nervous Disease, 181, 13–20. Stricker, G. (2000). Introduction: Listening to the voice of the c/s/x: Consumer/ survivor/expatient. In Session: Psychotherapy in Practice, 56, 1389–1394. Walsh, D. (1999). Coping with a journey toward recovery: From the inside out. In R. P. Marinelli & A. E. Dell Orto (Eds.), The psychological and social impact of disability (4th ed., pp. 55–61). New York: Springer. Ward, J., & Naster, B. (1991). Reliability of an observational system used to monitor behavior in a mental health residential treatment unit. Journal of Mental Health Administration, 18, 64–68. Witheridge, T. F. (1989). The assertive community treatment worker: An emerging role and its implications for professional training. Hospital and Community Psychiatry, 40, 620–624.

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10 PSYCHOPHARMACOLOGY EXAMINATION FOR PSYCHOLOGISTS DEVELOPED BY THE AMERICAN PSYCHOLOGICAL ASSOCIATION PRACTICE ORGANIZATION’S COLLEGE OF PROFESSIONAL PSYCHOLOGY PATRICIA M. BRICKLIN AND JANET CIUCCIO

This chapter describes the development of the Psychopharmacology Examination for Psychologists (PEP). This examination was developed by the American Psychological Association (APA) College of Professional Psychology primarily to be made available for use by state and provincial psychology, licensing authorities when they set requirements to implement newly enacted laws permitting the prescribing of psychotropic medications by qualified psychologists. In this chapter we describe the history and the steps in development and the current status and use of the examination. The chapter concludes with information on how the PEP contributes to the prescriptive authority agenda. The idea of developing an examination in psychopharmacology that would meet potential credentialing standards and measure credibly the 179

knowledge-based competence necessary to prescribe developed from discussions among the members of the APA Committee for the Advancement of Professional Practice (CAPP); the APA College of Professional Psychology; and Russ Newman, the Executive Director of the APA Practice Directorate. The assumption was made that the creation of such an examination would advance the prescriptive authority agenda. Its very existence would give evidence to the public and to state and provincial legislatures of the seriousness of the prescriptive authority agenda for psychologists. A valid, legally defensible, and secure examination would give additional reassurance to state and provincial legislatures that psychologists who had the appropriate education and training and passed the examination would be qualified to prescribe.

AUTHORIZATION TO DEVELOP THE EXAMINATION APA’s College of Professional Psychology went to the APA Council of Representatives in 1997 to propose that the former assist the prescriptive authority goals by overseeing the development of an examination to be offered for use by states and Canadian provinces in granting prescriptive authority to psychologists. The immediate response of the Council was “You want to do what?” In response, the College presented data to support it as the appropriate body to oversee such a project. This was based particularly on the College’s separation from the development of any psychopharmacology curricula, its experience in developing similar examinations, and the importance of subject matter experts and selection of the right testing firm. The College believed that, in 1997, this was truly an idea whose time had come. It takes time to develop a valid examination—at least 1 year, usually longer. Thus, if the College started developing the exam in 1997, then, when legislation was passed, the exam would be readily available for use, shortening the time between implementation of laws and psychologists’ ability to prescribe. In the meantime, the fact and process of its development would continue to give support to the legislative advocacy agenda. Accordingly, in August 1997 the APA Council of Representatives authorized the development of the examination in psychopharmacology by the College of Professional Psychology for use by state and provincial licensing authorities (should they choose to use it) in granting prescriptive authority to psychologists (APA Council of Representatives, 1997).

A COMMUNICATION AGENDA Before we describe the process used to develop the examination, it is worth noting that in the interest of advancing the prescriptive authority agenda the College focused on communicating to potential users its efforts 180

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and purpose in developing the examination. First, the College communicated with the practice community through continuous conversation with APA’s CAPP and its prescriptive authority subcommittee, both providing information and gathering suggestions. The College explored the important issue of whether the exam could be useful right away and still remain true to the primary purpose for its development (i.e., its use by state and provincial licensing authorities). The College conducted extensive telephone interviews with members of CAPP, state psychological associations, members of APA’s Board of Directors, members of the Board of Directors of the Association of State and Provincial Psychology Boards (ASPPB), state licensing board liaisons from state psychological associations, practice divisions, nonpractice divisions, graduates of the U.S. Department of Defense (DoD) Psychopharmacology Demonstration Project, schools of psychopharmacology education, members of the Presidential Task Force on Prescribing, and graduates of psychopharmacology training programs and psychopharmacology-related organizations external to APA. Several trends were found. Interviewed respondents wanted the College to allow graduates of psychopharmacology programs to take the exam after the didactic portion of their training. This, they said, would allow them to bank their scores for eventual licensure when legislation passed and would serve as “firepower” to take to the legislature. Respondents said that even before laws passed, licensing authorities might want a score on record. The College also communicated along the way with state and provincial licensing authorities at several national meetings of ASPPB, where Patricia Bricklin, chair of the College, and Jan Ciuccio, executive administrator for the College, presented. Their purpose was to sensitize licensing authorities to the prescription agenda, to discuss the amount of work involved for licensing authorities from the time a law is passed until it can be implemented, and to make them aware of the process of development of the exam so that they might consider ways in which it might be useful. ASPPB was working on proposed guidelines for licensing boards to use when they are developing regulations in jurisdictions where prescribing laws might pass. This activity was placed on a fast track and was circulated in 2001 (ASPPB, 2001).

DEVELOPMENT OF THE EXAMINATION Standards Maintained The exchanges with licensing authorities and with the practitioner community were helpful in the development of the next steps. Because the College was developing an exam that it believed would eventually be used in state licensure, it was necessary to adhere to procedures that are widely considered protective against legal challenges involving validity and fairPSYCHOPHARMACOLOGY EXAMINATION FOR PSYCHOLOGISTS

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ness. The specific standards that are most frequently cited in this context are the technical guidelines described in the Standards for Educational and Psychological Testing (American Educational Research Association, American Psychological Association, & National Council on Measurement in Education, 1999) and relevant sections of the Uniform Guidelines on Employee Selection Procedures (Civil Service Commission, U.S. Departments of Labor and Justice, 1978). It is critical to distinguish exams developed for credentialing purposes from exams created to measure acquisition of knowledge presented in a specific course or educational program. Both types of exams serve important but different purposes. Credentialing exams must comply with the standards just cited. Compliance with these standards involves the use of exam development methodology that results in the measurement of knowledge that is truly related to the job being performed and is not discriminatory against protected groups. In other words, the exam has validity for its intended purpose and use and is not discriminatory. The exam’s content accurately reflects what one needs to know to do the job. Appointment of an Expert Panel In compliance with these standards, the College began to ensure the production of a valid, fair, and defensible examination by appointing a properly constituted Expert Working Group. This process involved extensive outreach to relevant groups both inside and outside the profession. As shown in Table 10.1, 467 letters were sent to an extensive list of groups, inviting nominations. Fifty-four nominations were received. Nine nominees declined, and the remaining curriculum vitae were carefully reviewed with regard to education and training in psychopharmacology, neuroscience, pharmacology, medicine, and nursing and with regard to experience. Nineteen people were selected who met multiple criteria of expertise, experience, and perspective. A list of the members of the expert panel is presented in Exhibit 10.1. Experts were psychologists, physicians, pharmacists, and advanced-practice nurses. Seven of the 10 graduates of the DoD Psychopharmacology Demonstration Project were part of the group. ASPPB’s Examination Chair represented that group to the College’s expert panel. The chair of the College attended all meetings of the expert panel. Selection of a Testing Firm While the College was involved in constituting its expert panel, it was also fully involved in selecting a testing firm that would guide the development of the first versions of the examination and on which it could rely in the future to analyze candidate and item performance, to update the exam to reflect changing knowledge, and to develop additional forms of the exam 182

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TABLE 10.1 Groups Receiving Invitations to Nominate Individuals to the College’s Expert Working Group on Psychopharmacology N

Group receiving invitation State and provincial psychological association presidents State and provincial psychological association executive directors APA practice divisions and Division 28 Directors of APA-accredited educational programs Department of Defense Fellows Association of State and Provincial Psychology Boards Society of Psychologists for Prescriptive Authority Prescribing Psychologists’ Register Association of Medical School Psychologists American College of Neuropsychopharmacology

59 58 32 303 10 1 1 1 1 1

every few years. The College solicited proposals from several highly regarded national testing firms. Each firm was asked to describe its proposed methodology for determining the knowledge domain to be tested, its proposed methodology for obtaining multiple-choice items in sufficient number and quality to produce two original forms of the examination, its proposed methodology to be used for demonstrating the validity and fairness of the examination, and for setting an appropriate passing score. A description of each firm’s item-banking capabilities and procedures, including procedures for ongoing

EXHIBIT 10.1 Members of the Psychopharmacology Examination for Psychologists Expert Working Group Name, degree(s), city, state

Name, degree(s), city, state

Lewis Aronow, PhD, Las Vegas, NV Anita B. Brown, PhD, Hampton, VA Ronald T. Brown, PhD, Charleston, SC Wil Counts, RPh, PhD, Phoenix, AZ Timothy Duke, PsyD, Overland Park, KS Major Debra L. Dunivin, PhD, Washington, DC Joseph A. Hirsch, PhD, PsyD, New York, NY Irwin Lucki, PhD, Philadelphia, PA Lt. Col. John McDonough, CRNA, EdD, Naples, FL Major Elaine Mantell, PhD, Seymour Johnson AFB, NC Joseph Pachman, PhD, MD, Stamford, CT

Major Brian J. Pfeiffer, PhD, Cannon AFB, NM Lieutenant Commander Gilbert Seda, PhD, Portsmouth, VA Edward Sellers, MD, PhD, Toronto, ON, Canada Commander John Sexton, PhD, Oceanside, CA Rhea E. Steinpreis, PhD, Milwaukee, WI Tony L. Strickland, PhD, Los Angeles, CA Travis Thompson, PhD, Kansas City, KS Lynn P. Rehm, PhD, ASPPB Representative, Houston, TX

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monitoring and periodic reporting of exam statistics, as well as a description of procedures for protecting and maintaining test security, both during development and on an ongoing basis, was required. Finally, each firm’s proposed staffing plan and cost proposal was considered. After carefully evaluating each proposal, Professional Examination Service (PES) of New York was selected. With over 50 years of experience, PES is nationally regarded for the quality of its many licensing and certification examinations, including examinations for licensure in physical therapy, marriage and family therapy, veterinary medicine, and medical laboratory personnel and certification examinations for critical care nurses, nurse practitioners, clinical social workers, eye surgeons, opticians, dental hygienists, and many more. Especially of note was PES’s role in the national licensing examination for psychologists, the Examination for Professional Practice in Psychology (EPPP; ASPPB, 2002). Specifying the Knowledge Domain The development of the exam by the Expert Working Group under the guidance of PES was a complex, multiphased process (APA College of Professional Psychology and Professional Examination Service, 2000). The first task of the Expert Working Group was to specify the knowledge necessary for safe and effective practice of psychology involving psychotropic medication. In addition to the 19 experts on the panel, approximately 100 additional subject matter experts participated in critical-incidents interviews conducted by PES. Three additional experts completed independent reviews of the content areas and knowledge statements. PES conducted a large-scale survey of approximately 600 individuals to validate the content areas, knowledge statements, tasks, and roles. An overall return rate of 54% was obtained. Content areas and tasks were rated on frequency and criticality scales. Knowledge statements were rated on acquisition (when) and criticality scales. The survey differentiated contrast and target groups. The ratings of the target sample validated the contentand process-based delineations. Test specifications were developed to include percentage weightings of content areas and lists of validated knowledge statements. A rating of the contrast group and 10 psychiatrists was used to further investigate and confirm test specifications. Ten knowledge-based content areas were established. For each content area, 8–20 knowledge statements were defined. The final test specifications are shown in Table 10.2. Exam Construction During Phase 2, two forms of the exam were constructed, and a recommended passing point was developed. Exam construction involves intensive item writing, review, and editing. PES completed each of the original two 184

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TABLE 10.2 Knowledge-Based Content Areas Assessed by the Psychopharmacology Examination for Psychologists Knowledge-based content area Integrating clinical psychopharmacology with the practice of psychology Neuroscience Nervous system pathology Physiology and pathophysiology Biopsychosocial and pharmacologic assessment and monitoring Differential diagnosis Pharmacology Clinical psychopharmacology Research Professional, legal, ethical, and interprofessional issues

Emphasis 15% 8% 9% 9% 10% 13% 12% 13% 4% 7%

forms of the PEP by developing and disseminating a first round of item-writing assignments and then conducting item writing/review workshops. Items were entered into a secure database, edited, and classified. References were added. PES evaluated the match between item bank and test specifications. The Expert Working Group was assembled to create each form of examination in accordance with test specifications and to determine a recommended passing point for each form. Drafts of the exam forms were disseminated by PES to the expert panel for review and approval.

PREPARATION FOR ADMINISTRATION Computer-Based Testing and Security On completion of the development of the examination, arrangements for computer-based testing were finalized with Prometric, Inc. The PEP was first available at Prometric testing centers in September 1999. Prometric uses testing system security that is state of the art. To ensure correct candidate admission, two forms of test candidate identification are checked by test center staff. At least one must include a photograph, and both must bear signatures. Test candidates sign in and out with the time and date noted. Logs are retained. This provides an audit trail if impersonation is suspected. At least two certified test center administrators are present in the test center facility during all testing sessions to provide continuity and security. Test center staff proctor the test takers at all times through a viewing window, ensuring candidate adherence to test security practices. Parabolic mirrors enhance proctors’ view of computer workstations. Privacy panels, sound monitoring, and video monitoring are used to ensure adherence to security practices. PSYCHOPHARMACOLOGY EXAMINATION FOR PSYCHOLOGISTS

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Security of test data is ensured by media-less computer workstations without floppy disk drives or hard drives. This precludes possible tampering. All test items and test candidate performance data are encrypted in residence on the test center file server and in electronic transmission from and to the test center and client facility. Daily virus scans are performed at all test centers. An uninterrupted power supply, surge arresters, and secure file servers provide physical security. Test centers automatically transmit all completed test candidate performance data when a test is complete—or, at a minimum, every 2 hours during scheduled testing. This precludes test data loss and consequent candidate retesting. Test center file servers automatically back up all test-related data. Files are archived on a daily basis and stored in an off-site secure storage facility to be retained for several years. In addition to retention by Prometric, PES retains test data indefinitely. Requirements for Admission to the PEP Based on discussions with CAPP, other members of the practice community, and members of state and provincial licensing authorities, the College established four requirements for admission to the PEP: (a) a doctoral degree in psychology, (b) provision of health services in psychology, (c) current psychology licensure in good standing to engage in the independent practice of psychology, and (d) successful completion of a postdoctoral program of education in psychopharmacology offered in an organized program of intensive didactic instruction. With regard to the postdoctoral educational component of the requirements, the College further specified that the program of education in psychopharmacology was required to have been offered by a regionally accredited institution of higher learning, one of APA’s approved sponsors of continuing education, or an organization that was approved to provide continuing education by a state or provincial psychology licensing authority. The program of education was further defined as consisting of a minimum of 300 contact hours in the following core areas of instruction: neurosciences, pharmacology and psychopharmacology, physiology and pathophysiology, physical and laboratory assessment, and clinical pharmacotherapeutics. Psychologists are admitted to the PEP either individually or by a psychology licensing authority that can review a candidate’s education and admit him or her to the exam. In addition, a licensing authority is permitted to request that the College review a candidate’s educational credentials and admit him or her to the exam. In all cases, scores are banked for future use by licensing authorities. Candidates who take the PEP have access to their scores, how they did compared to a recommended passing point, and receive feedback on how they did in each of the 10 knowledge-based content areas (see Table 10.2). 186

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Assistance to Psychopharmacology Educational Programs and to Psychologists Considering Training The College’s PEP also supports psychopharmacology educational programs, providing them with aggregated comparative data about graduates’ performance while maintaining the confidentiality of individual examinees. At the time of this writing, a sufficient volume of test scores from any single program to permit meaningful analysis has not accumulated, although some psychologists from each program who have taken the exam have successfully passed. It is believed that practitioners who are contemplating psychopharmacology training would also find these data of assistance in evaluating available programs. PEP Quality Maintained The PEP is carefully monitored on a continuing basis and is updated by the College working with PES. Item performance analysis is conducted by PES on an ongoing basis. Yearly meetings of the expert panel and other item writers ensure the revision, replacement, and addition of new items that reflect changing knowledge. New forms of the PEP will be developed every few years. Following these procedures ensures that the PEP maintains its legal defensibility and credibility for credentialing purposes. In addition to the importance of strict attention to the scientific and technical processes in the development of the examination, advocacy and communication with the psychology community have also been critical.

PEP: PRESENT AND FUTURE It is five years since the creation of the PEP was authorized by the APA Council of Representatives and the developmental processes initiated with the oversight of the APA College of Professional Psychology. PES and the Expert Working Group continue to do their job of maintaining the examination as a current, valid, and defensible tool. The PEP is being administered, and a growing cohort of appropriately trained psychologists is taking it. These psychologists are providing evidence that they have the knowledgebased competence necessary to prescribe. At this juncture it seems appropriate to ask two questions: (a) How does the PEP contribute to the prescriptive authority agenda, and (b) What are the next steps? The PEP assists the advocacy agenda in several ways. The practice analysis, completed in Phase 1 of the exam development, established clearly through valid and appropriate research methodology what is an appropriate PSYCHOPHARMACOLOGY EXAMINATION FOR PSYCHOLOGISTS

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knowledge base for prescribers that will serve to protect the public. This information alone is a critical advocacy point that answers questions raised by many critics. The availability of a legally defensible exam to measure this knowledge-based competence is an important advocacy “talking point.” An even stronger point is the growing cohort of psychologists who have completed the necessary education and training and who have successfully passed such an exam. This point will become a stronger advocacy point as more and more psychologists take and pass the exam, demonstrating in increasing numbers the knowledge-based competence to prescribe. As the advocacy efforts to pass prescribing laws continue to be successful, the sensitization of licensing authorities to the progress of the prescribing movement in their jurisdiction is important. The passage of a prescribing law is a monumental accomplishment. Once enabling legislation passes, the drafting and approval of implementing regulations can be a long and daunting task. As boards develop education, training, and examination requirements for prescribing, the existence of a legal and defensible exam such as the PEP can be invaluable to jurisdictions from the standpoint of cost, time, and public protection. In fact, at least one jurisdiction is currently considering requesting that the College admit board-qualified psychologists to the exam so that their scores can be banked for future use by that licensing board. The PEP was created to offer states and provinces an exam that is legally defensible and constructed for credentialing purposes. The PEP will be one option for state and provincial regulators who will have a full plate as prescribing laws pass. In the meantime, the exam is useful in the overall prescribing agenda. First, it demonstrates that there is a knowledge-based competence necessary to prescribe, identified through a practice analysis research methodology. The exam gives evidence of the seriousness of the agenda for psychology. Finally, it provides documentable evidence that a growing number of psychologists have the necessary knowledge-based competence to prescribe. REFERENCES American Educational Research Association, American Psychological Association, & National Council on Measurement in Education. (1999). Standards for educational and psychological testing. Washington, DC: Author. APA College of Professional Psychology and Professional Examination Service. (2000). Steps in developing and maintaining the psychopharmacology examination for psychologists. Washington, DC: Author. APA Council of Representatives. (1997, August). Item D. Development of an examination for use by states and provinces that grant prescriptive authority to psychologists. Presented to Council, Washington, DC.

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Association of State and Provincial Psychology Boards, Committee for Education and Training for Credentialing. (2001). Guidelines for prescriptive authority. Montgomery, AL: Author. Association of State and Provincial Psychology Boards, Examination Committee. (2002). Examination for Professional Practice in Psychology. Montgomery, AL: Author. Civil Service Commission, U.S. Departments of Labor and Justice. (1978). Uniform guidelines on employee selection procedures. Washington, DC: Author.

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11 PRESCRIBING PSYCHOLOGISTS: THE FUTURE MORGAN T. SAMMONS, RUTH ULLMANN PAIGE, AND RONALD F. LEVANT

As we conclude this volume, the first dedicated solely to a review of psychology’s history of and current attempts to obtain prescriptive authority, we recognize that much has to be done but also that we have every reason to persevere. All chapters in this volume attest to our strengths in seeking prescriptive authority. Although some level of dissent remains, it can be utilized to ensure that we craft a truly psychological model of psychotropic service provision. We are, without doubt, on our way. In this chapter we briefly identify some relevant trends in the evolution of psychology that have moved psychologists from a more narrow focus in mental health care toward a broader perspective as independent health care providers who are responsive to society’s needs. We then deal with a question that is frequently raised by physician opponents to psychologist prescribers: Will the acquisition of prescriptive authority adversely affect patient safety? Rather than tackling this question from the traditional angle—that is, asking whether nonmedical practitioners can safely prescribe, we address it from what we believe to be a more logically compelling perspective. The true question, we believe, is whether the training of physicians enables those The opinions expressed in this chapter are solely those of the authors and do not reflect any official opinion of the U.S. Navy or Department of Defense.

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practitioners to safely and effectively prescribe and, if not, what can be done to improve outcomes for all prescribers? Finally, we outline the infrastructure still needed for psychology to gain the authority to prescribe and look to the future.

PRIMARY AND SPECIALTY BEHAVIORAL HEALTH CARE SERVICE PROVISION IN PSYCHOLOGY Psychology practice and science, partially in response to society’s needs for health promotion and illness prevention, are expanding and diversifying into new areas where the distinction between applied scientists and professional practitioner begins to blur. These areas include health psychology, primary care psychology, psychoneuroimmunology, applied psychophysiology, neuropsychology, rehabilitation psychology, child psychology, multicultural psychology, geropsychology, and psychopharmacology. In addition, public sector care, including treatment of people who are seriously mentally ill, is being seen anew as an area that needs psychology’s input. The redefinition of psychology, from specialty mental health care to primary behavioral health care—including the addition of prescribing—is most timely and relevant. It has long been known that 7 of the 10 leading causes of death have largely behavioral causality (U.S. Department of Health, Education and Welfare, 1979). Professional psychology has much to offer to reduce the burden of behaviorally related disease. Our society’s health and well-being require psychologists’ involvement. Surgeon General Satcher has focused on the need for a far-reaching mental health agenda for the United States (U.S. Department of Health and Human Services, 1999, 2001). He has moved mental health into the forefront of public policy problems, and psychologists are responding with ever-increasing involvement. One of the issues that has been discussed at several recent conferences is the need for psychology to become a primary health care profession. From time to time, it is also implied, if not stated outright, that psychologists should leave behind their role as a specialty mental health care profession. Although we strongly support the move into primary care, we also want to make a strong case for retaining psychologists’ role in mental health care; that is, we want to put forward a “both/and” position, but with a somewhat different perspective. Both initiatives would involve an expansion of psychologists’ professional role with the aim of making psychology the premier behavioral health care profession. Both roles would also require significant change in how psychologists now practice. As members of a specialty mental health care profession, psychologists deal primarily with people who self-identify as having psychological problems and who have access to a mental health specialist. Such individuals represent a very small fraction of those who need psychological services. 192

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As members of a primary health care profession, psychologists will be able to serve a much larger group who do not identify their primary problems as psychological or who do not have immediate access to mental health services. At least 50%, and perhaps as many as 75%, of all visits to primary care personnel are precipitated by problems with psychological origins or psychological components. Psychological issues include unhealthy lifestyle habits, such as smoking; dealing with chronic illness; and difficulty with medical compliance. Even though the prevalence of psychological factors is clear, medical professionals with minimal training in mental health care for the vast majority of people receiving mental health treatment. The breakdown of the Cartesian worldview that has long held separate mental and physical health further demonstrates the relevance of psychology’s move into primary health care where psychologists will work collaboratively with other health care professionals. A more visionary, if less probable, perspective is that health care be reorganized so that psychologists serve coequally as primary caregivers at the gateway to the health care system, diagnosing and treating the more prevalent psychological problems and referring clients to physicians when needed. Including psychopharmacology as a practice skill will move psychologists closer to fulfilling their potential as members of a premier primary health care profession. At the same time, however, psychologists need to deepen their involvement in specialty mental health care, particularly where it is needed most—namely, in the care of individuals suffering from serious mental illnesses. Psychology is not currently a major player in the public sector care or in the treatment of patients suffering from severe and persistent mental illnesses. This large and very vulnerable population receives substandard care, as is generally known. Deinstitutionalization, which was conceived in the humanitarianism and the idealism of the community mental health movement during the 1960s, has been a stark failure overall (although there have been some success stories here and there). With the clarity of 20/20 hindsight, one can see that there was insufficient investment in community-based care and psychological rehabilitation to make it work. In the end, the deinstitutionalization movement succeeded in emptying the beds of the state mental hospitals and filling the streets and jails with chronic mental patients. Hence, some argue that this phenomenon is more appropriately labeled transinstitutionalization—from the hospitals to the jails. Having worked with this population off and on over many years, we have found that many such consumers have very complex comorbidities, including (in addition to their serious mental illness) substance abuse, brain injury, posttraumatic stress disorder (particularly among women, many of whom have been victims of rape or other forms of sexual and physical assault), and Axis II characterological problems (to name some of the more common diagnoses). Also, because of the harsh lifestyle of the street that many such consumers lead, there are often untreated medical problems as well. A population this vulnerable and disabled deserves much better care than our society now offers. PRESCRIBING PSYCHOLOGISTS: THE FUTURE

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Psychologists could play a very significant role in the care of this population. First of all, there is no profession better qualified than psychology to conduct the careful diagnostic assessments that would tease out the complex comorbidities from which many of these individuals suffer. Second, because psychologists have taken the lead in developing and evaluating psychological rehabilitation and recovery methods, psychologists can surely lay claim to the role of designing, implementing, and training staff members to carry out psychological rehabilitation. Third, psychologists can provide empirically validated therapies for persons with serious mental illness. Fourth, practitioners can team up with researchers and develop the next generation of psychological interventions that might have even greater effectiveness. Fifth, psychologists can play a larger role in ensuring that pharmacological interventions are appropriately managed, with the ultimate goal of assuming authority over medication regimens, when the profession is authorized to do so. Currently, psychologists with the appropriate knowledge can function as consultative psychopharmacologists who, working in conjunction with primary care doctors or advanced practice nurses, can provide the full spectrum of care for patients who are seriously mentally ill. Finally, enhancing psychologists’ role in dealing with a public health problem of this scope will go a long way toward furthering psychologists’ aim of becoming the premier behavioral health care profession.

ABANDONING THE MEDICAL MODEL OF TREATMENT OF MENTAL DISORDERS: PSYCHOLOGISTS AS PRIMARY BEHAVIORAL HEALTH CARE PROVIDERS As the preceding section illustrates, a central principle underlying the acquisition of prescriptive authority by psychologists is that, by expanding their clinical armamentarium, psychologists can provide a greater range of cost-effective, comprehensive mental health services to a larger population of individuals with mental distress than are currently served. We believe that this is indisputable. We also believe that, in doing so, psychologists have a unique opportunity to put into place a different mechanism for the treatment of mental disorders that holds promise to remedy the inequities in service provision and access that are the hallmark of mental health treatment under the medical model. We propose this new role to be the prescribing psychologist as a primary behavioral health care provider. We posit that the creation of this role for psychologists will create a more equitable, accessible, and efficient mechanism of mental health service provision that will be of benefit not only to individual patients but also to health care planners and thirdparty payers alike. The assumption underlying this belief is that the medical model, by means of which most mental disorders are treated in the United States, is fundamentally unsuited for the treatment of most mental disorders. The medical model relies on providers who are expensively and inefficiently 194

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trained, are in chronic short supply, and primarily rely on allopathic treatments that result in symptom improvement, but not symptom resolution. These factors, we believe, render this model incapable of being transformed into a system in which both efficiency of service and maximum patient access are possible. We hold that only by placing the majority of treatment of mental health problems in the hands of nonmedically trained providers can a system be created that is equitable to both patients and payors. We now examine some of the arguments underlying this belief. Physician Prescribing The provision of mental health services in the United States continues to be dominated by the medical model. Most mental disorders are treated in a primary care setting by non-mental health trained providers. The vast majority of these practitioners have no specific training in the diagnosis or treatment of mental disorders. Because the length of an average visit to a physician, either primary or specialty care, is between 16 and 20 minutes (Mechanic, McAlpine, & Rosenthal, 2001), during which time a number of problems must be addressed, a system therefore exists in which most mental disorders are unlikely to be diagnosed by experts and in which treatment options are extremely limited. In particular, the management of depression (the most common of mental disorders) in the primary care setting appears to be substantially inadequate. Although some controlled studies of the management of depression in primary care suggest that outcomes are no different when primary care providers manage the patient or when mental health specialists do, outcomes remain less than optimal (Simon, von Korff, Rutter, & Peterson, 2001), and naturalistic surveys indicate high rates of treatment failure in the primary care setting. Recurrence of depression is high during long-term pharmacological management of depression in primary care (Lin et al., 1998; Nierenberg & Alpert, 2000). Nierenberg and Alpert (2000) noted that relapse rates in clinical samples, as opposed to research samples, are undoubtedly higher, and they suggested that perhaps 80% of patients in long-term pharmacotherapy will experience a relapse. More data indicating that nonadherence and failure rates for patients treated with antidepressants are far higher in naturalistic surveys than prospective controlled investigations come from a large-scale survey of more than 1,000 patients and 800 nonpsychiatrically trained primary care physicians (National Depressive and Manic Depressive Association, 2000). High rates of relapse may be a function of poor adherence to drug regimens prescribed in the primary care or specialty setting. Simon et al. (2001) compared outcomes for depressed patients treated in either a primary care or a psychiatry setting and found little difference regardless of setting. Less than PRESCRIBING PSYCHOLOGISTS: THE FUTURE

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50% of participants received medications at an adequate dose for more than 90 days. Perhaps more important is that they found that only 57% of psychiatrists’ patients made three or more visits in 90 days (as compared to 26% for primary care patients). Thus, regardless of the treatment setting, visits were few, and evidently even the patients treated by psychiatrists were seen generally on a monthly basis or less. Another naturalistic survey of 240,000 patients prescribed antidepressants revealed that only half had received continuous treatment for more than 6 months (Tierney, Melfi, Signa, & Croghan, 2000), again suggesting a high rate of nonadherence to prescribed treatment. Although collaborative care provided by a psychologist and a primary care physician has been demonstrated to improve adherence to medication regimens and better outcomes than treatment with medication alone (Katon et al., 1996), combined treatment is rare in the primary-care setting. It is apparent that in both psychiatric and primary care, patients are not seen with a frequency that allows effective psychotherapy to be performed, making pharmacotherapy the de facto standard of care, and that most patients respond suboptimally to this approach. It is equally clear that reliance on pharmacotherapy as the primary therapeutic modality in both psychiatry and in primary care has significantly increased in recent years. Antidepressant medications were the highest selling category of prescription drugs in 2000, with sales of those drugs 20.9% higher than in 1999 (Pear, 2001). Estimates of the percentage of patients who presented to primary care providers with complaints of depression and who were offered an antidepressant medication in primary care range from 60% (Pincus et al., 1998) to 97% (National Depressive and Manic Depressive Association, 2000). In psychiatry, the likelihood of a patient receiving medication for depression has increased significantly over the past 15 years (Olfson et al., 1998), to the point that currently approximately 90% of all patients receive medication, most commonly for depression (Pincus et al., 1998; Pincus et al., 1999). In addition, all evidence points to an increase in the use of medications to treat not only depression but other disorders, such as social anxiety, for which psychotherapy is not only effective but also may yield superior outcomes. This is true for adults and pediatric populations as well (Research Unit on Pediatric Psychopharmacology Anxiety Study Group, 2001). This is in spite of data that suggest that many patients in primary care prefer counseling to medication to treat mental distress and that counseling is as effective as medication in managing mild to moderate depression in primary care (Chilvers et al., 2001). Hence, it seems indisputable that most patients are not afforded a true choice of treatment. Pharmacotherapy is the mainstay of treatment, and medications are often the only treatment proffered. Psychotherapy continues to be regarded as a scarce resource, which may be true when access to psychotherapy is (as in many jurisdictions) statutorily regulated by medical gatekeepers and limited by managed care decisionmakers. The perception 196

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of scarcity of psychotherapy gives primary care providers some justification in offering pharmacotherapy as a reliable alternative. But the evidence just cited indicates that this justification may be unfounded, because, although almost all primary care patients with depression are given medication, few adhere to treatment recommendations, and even fewer report positive outcomes. Current Graduate Medical Education Results in a Misallocation of Services Average annual costs to train a medical student in the United States range between $72,000 and $93,000, of which only 20%–30% is covered by tuition and fees. The remainder is covered by federal and state funds, donations, and faculty practice (Academic Medicine, 1997, cited in Greene 2001b). Federal costs for subsidizing medical education are large, approximately $6 billion per year on average. Yet looming shortages of both specialty and primary care physicians, particularly in rural and underserved areas, have been predicted. Psychiatry in particular is in difficulty, inasmuch as the percentage of American medical graduates choosing to specialize in psychiatry continues to decline. In 1999, 46% of all incoming residents in psychiatry were international medical graduates. The medical education system, despite financial and other incentives, has not resulted in an appropriate allocation of resources. Physicians tend to be concentrated in urban areas, and fundamental inequities in access to care persist. Shortages in specialty care, particularly among those treating children or the elderly, are evident despite large increases in the salaries of specialty physicians (Greene, 2001a). Neither has the traditional model of educating physicians resulted in improved quality of care for most Americans. As stated in a recent Institute of Medicine report, Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge. Yet there is strong evidence that this frequently is not the case. Crucial reports from disciplined review bodies document the scale and gravity of the problems. . . . Quality problems are everywhere, affecting many patients. Between the health care we have and the care we could have lies not just a gap, but a chasm. (Committee on Quality of Health Care in America, 2001, p. 1)

The Institute of Medicine found a number of areas where overuse of medical services was a problem. These ranged from the prescription of antibiotics for viral illnesses such as the common cold to major surgery without appropriate indication. The report also briefly alluded to the underdosing of antidepressants as a quality issue. It seems apparent, however, that another quality issue not addressed by the Institute of Medicine was the overprescription of antidepressants, particularly in children and adolescents, as there PRESCRIBING PSYCHOLOGISTS: THE FUTURE

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exists essentially no empirical support for this practice (Hazell, O’Connell, Heathcote, & Henry, 2002). The Public Health Menace The arguments against prescriptive authority for psychologists rest, for all intents and purposes, on the hypothesis that nonmedically trained prescribers represent a danger to the well-being of their patients. When applied to psychologist prescribers, this hypothesis assumes that psychologists lack the necessary prerequisite training to engage in a course of study leading to prescriptive authority and that, short of replicating the medical curriculum, no amount of psychologists’ training adequately prepares them to be safe and effective prescribers. This basic argument, with some minor variation, has been used repeatedly in arguments against psychologists prescribing (cf. Adams & Bieliauskas, 1994). It interests us that psychologists opposed to prescriptive authority have adopted the same argument that has been used for decades by physician advocacy groups when attempting to discredit the initiatives of nonphysician health care provider (NPHCP) groups to prescribe—that is, that prescribing psychologists, along with other NPHCPs, represent some form of a public health hazard. This argument is made despite data that indicate that NPHCPs perform their duties, including prescribing, at least as safely as, and perhaps even more safely than, physicians. The argument is also made in spite of the fact that the ranks of NPHCPs continue to expand, with no apparent detriment to the health care seeking public and in spite of the fact that wide scope-of-practice variations exist for nonphysicians, in some cases allowing practice free from any form of physician oversight (Cooper, Henderson, & Dietrich, 1998). We address and refute these and other arguments against prescriptive authority for psychologists later in the chapter. First it is important to examine an assumption that has, to date, received little attention, that being, can one reliably assume that a medical education, as opposed to the education of any other health care provider, produces a safe and effective prescriber?

DOES MEDICAL EDUCATION PRODUCE A SAFE AND EFFECTIVE PRESCRIBER? Safety of Physician Prescribing Although it is commonly assumed that the medical education is the sine qua non of safe and effective allopathic practice, closer examination finds that the evidence supporting this assumption is uncertain at best. Indeed, there has accrued a substantial body of evidence suggesting that 198

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traditional medical education does not produce safe prescribers. This is most famously illustrated by the 1999 Institute of Medicine study, To Err Is Human (Kohn, Corrigan, & Donaldson, 1999), that found extremely high rates of iatrogenic morbidity and mortality, often associated with inappropriate prescribing. This finding was confirmed in a more recent investigation, conducted by the Department of Health and Human Services’ Agency for Healthcare Quality and Research (2001). This investigation determined that more than 770,000 people either die or are injured by adverse drug events in U.S. hospitals annually, with most errors occurring when drugs are ordered or administered. A recent large-scale epidemiological investigation found a high rate of prescription of psychotropics among the ambulatory elderly and that at least one potentially inappropriate psychotropic drug was prescribed in 27.2% of provider visits in which a prescription was written (Mort & Aparasu, 2000). More alarming is that those authors found that, according to a scale of severity of adverse outcome, 95% of potentially inappropriate prescriptions might result in a high-severity adverse outcome. Of particular pertinence to the nonphysician safety argument is that this study revealed a negative association between NPHCP status and potentially inappropriate psychotropic prescriptions—that is, NPHCPs were less likely to inappropriately prescribe than their physician colleagues. In fact, it could be said that medically trained providers practicing outside their knowledge base are a “public health menace,” likely one greater than any nonmedical, but otherwise more appropriately trained, practitioner. Results of other investigations into physician practice patterns suggest that the addition of nonphysicians to treatment teams is an important factor in enhancing safe prescribing. For example, the addition of a pharmacist to a treatment team has been demonstrated to improve outcome in a variety of settings. Gattis, Hasselblad, Whellan, and O’Connor (1999) examined the prescribing practices of physicians on a heart failure management team. Adding a pharmacologist to the treatment team improved outcome, primarily because patients had tended to be underdosed with certain drugs by their physicians. Similarly, Leape et al. (1999) found that adding a pharmacist to medical intensive care units resulted in a 72% reduction in medication errors as compared to a control unit, and multidisciplinary input including pharmacists has been shown to reduce the rate of psychotropic prescription in nursing homes (Schmidt, Claesson, Westerholm, Nilsson, & Svarstad, 1998). Errors detected by pharmacists in Schmidt et al.’s (1998) study included incomplete orders, incorrect dosing or timing of dose, inappropriate medication, or medication duplications. Pharmacists were also able to recommend viable alternative (i.e., cheaper or more effective) medications. Use of computerized medication systems has been estimated to potentially reduce medication errors by significant percentages (Agency for Healthcare Research and Quality, 2001). Hunt, Haynes, Hanna, and Smith PRESCRIBING PSYCHOLOGISTS: THE FUTURE

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(1998) reviewed studies regarding the use of computerized clinical decision programs between 1992 and 1998. Their data suggested that computerized systems designed to provide reminders in preventative care or dosing of medication were of clinical benefit, although systems purporting to aid in diagnosis were not. Electronic prescribing has the potential to not only reduce error due to illegibility of handwritten prescriptions but also to check for contraindicated drugs and conditions and coordinate prescriptions written by multiple providers. Armstrong and Chrischilles (2000) also noted that such systems will enable instantaneous computerized drug usage and review profiles to guard against incorrect doses, duplicate prescriptions, interactions, allergies, and cost. Physician reminder systems that do not require sophisticated technology or intensive allocation of personnel have also been demonstrated to enhance effective prescribing. For example, a combination of patient education and provider profiling, education, and academic detailing has been found to be effective in reducing inappropriate prescription of antibiotics (Gonzales, Steiner, Lum, & Barrett, 1999). Effectiveness of Physician Prescribing In addition to examining the issue of safety, it is equally important to examine the effectiveness of physician prescribing—for our purposes, in the particular case of psychotropic medication. Compelling evidence suggests that effectiveness is not a hallmark of psychotropic administration in the primary care setting. A recent survey of patients who had been prescribed antidepressant medication by their primary care physicians revealed, among other things, that most patients taking antidepressants achieved suboptimal results, often discontinued their medications, and did not feel adequately informed by their physicians about the medications and their side effects. (National Depressive and Manic Depressive Association, 2000). Physicians and patients were interviewed separately regarding their recollections of instructions provided the patient regarding the side effects of medication. A high percentage of physicians reported that they discussed the most common side effects of newer antidepressants (sexual inhibition, weight gain, insomnia, and nausea) with their patients. Only a very small percentage of patients recalled being informed of these common side effects. A significant number (34%) of patients surveyed reported not being informed of any side effects at all. The surveyors also found that 84% of patients relied exclusively on their provider as a source of drug information and were thus unlikely to acquire information regarding their medications from any other source. Over 50% of patients reporting side effects stopped their medication, and significant percentages required a change in medicine or dose or the addition of adjunctive agents. Perhaps it is not surprising that, given this finding, less than 25% of patients reported complete relief from depressive symptoms, even after 3–5 years of antidepressant treatment (National Depressive and Manic Depres200

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sive Association, 2000). This study and others buttress the notion that the cornerstone of effective prescribing rests on patient adherence to the recommended drug regimen. Cost has been determined to be an important component of adherence to prescribed regimens. But although physicians are apparently desirous of making cost-informed decisions regarding medications, physician knowledge of the costs of medications has historically been poor (Reichert, Simon, & Halm, 2000). Reichert et al. (2000) reviewed the responses of 134 residents and attending internal medicine physicians to a survey regarding their knowledge of drug costs. Underestimates of the cost of drugs were common, especially with expensive or brand name drugs. Only 33% of respondents felt that they had easy access to information about drug cost, and only a small percentage (13%) had received formal education about drug costs. Most interesting is that nearly one third of respondents did not know that Medicare does not cover the cost of prescription drugs (Reichert et al., 2000).

COMPARING OUTCOMES BETWEEN PHYSICIAN AND NONPHYSICIAN PROVIDERS As noted earlier, NPHCPs have significantly expanded their numbers, scope of practice, and importance in the health care marketplace. In general, the services they provide have been found to be both cost effective and well accepted by patients (Cooper, 2001). In regard to patient safety, we acknowledge that there are relatively few systematic studies of patient outcome that have compared NPHCPs and physicians. The most evidence exists for nurse practitioners. Of the studies that have compared patient outcomes of nurse practitioners and physicians, essentially all have demonstrated outcomes that were equivalent to or better than those of physicians (e.g., Mundinger et al., 2000; Wallace et al., 1999; also see Catlin & McAuliffe, 1999). This finding evidently extends to other types of NPHCPs in varying settings. A study that compared outcomes of nurse practitioners, physician assistants, and resident physicians working in acute care settings found that tasks and activities completed by all three groups were similar (although the resident physicians tended to care for patients who were older and sicker), and patient outcomes did not significantly differ among the three groups (Rudy et al., 1998). A British study of almost 1,300 patients randomized to receive care from either general practitioners or nurse practitioners found no differences in health outcomes between the two groups; in addition, nurses spent more time with patients, saw the patients more frequently, and had higher patient satisfaction ratings than did physicians (Durie, Roland, Roberts, & Leese, 2000). PRESCRIBING PSYCHOLOGISTS: THE FUTURE

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TOWARD SAFE AND EFFECTIVE PRESCRIBING OF PSYCHOTROPICS The data just described yield three conclusions: (a) NPHCPs prescribe in manners that are as safe and effective as those of their physician counterparts; therefore, (b) a medical education is not the necessary condition leading to safe and effective prescribing; and, finally, (c) the exact type of training necessary to produce a safe and effective prescriber of psychotropics or other drugs is as yet imprecisely defined. What represents the fundamental components of safe psychotropic prescribing? First, a primary philosophical shift leading to a reduced reliance on psychotropics is required. We believe it is essential to abandon the notion that mental disorders are purely, or even largely, disorders of the brain but rather are multifactorial, with environmental, personal, and biological antecedents. History has demonstrated to us that the treatment of mental disorders is not amenable to the allopathic philosophies underlying the training of physicians and psychiatrists. The allopathic model is a disease-based model and holds that there are specific cures that can be identified for specific illnesses. This flies in the face of our collective experience with psychotropics. No psychotropic drug has ever been created that has led to a cure for a mental disorder, although many provide valuable adjunctive treatment of such disorders. Nevertheless, current medical treatment standards for mental disorders (in psychiatry and in primary care) indicate that psychotropics are believed to be curative agents in that the overwhelming majority of patients presenting with mental problems are prescribed drugs and receive no other intervention. Psychotropics are unquestionably the mainstay of treatment for mental disorders in the United States. We submit that effective prescribing will involve a lessened reliance on this modality, returning it to its more appropriate adjunctive role. Safe prescribing also depends on this, as safety suffers when excess numbers of prescriptions are written for uncertain indications. To safely prescribe psychotropics it is necessary to be informed of other physical processes: Knowledge of drug metabolism and distribution in both health and disease states and the effects of common disease states on the body’s response to drugs are of paramount importance. Contrary to the arguments of others (cf. Pies, 1991), there is no evidence that a medical education is required to comprehend these variables. Psychologist prescribers will not, for example, be required to diagnose or treat infectious or neoplastic disease or the consequences of organ failure any more than do psychiatrists. A sensitivity to the potential existence of these problems; recognition-level knowledge of fundamental signs, symptoms, treatments and prognoses of these disease states; and recognition of the consequences of using psychotropics in the face of various disease states are the prerequisite skills that mental health prescribers, whether medically trained or not, must possess. The ability to factor in variables such as age, gender, and (where data indi202

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cate genetic differences in drug metabolism or response) ethnicity into the decision to prescribe is also a fundamental of safe prescribing. But ultimately, recognition of the need to appropriately refer and seek pharmacologist and physician consultation is perhaps the most important recognition-level skill psychologists and other prescribers of psychotropics will require. Safe prescribing requires more than a technical knowledge base regarding drugs and their effects on the body. Data previously cited make it abundantly clear that safer prescribing demands the use of technological advances that make it possible to instantaneously check for the existence of drug allergies or to check regimens prescribed by other providers for potential interactions or overlaps. Use of computer programs that verify appropriate doses and guard against dispensing errors is another component of safe prescribing. We believe that all training models that have been proposed to enable prescriptive authority for psychologists include these safeguards and will enable psychologists to fulfill assumptions underlying safe and effective prescribing.

BUILDING THE INFRASTRUCTURE FOR PRESCRIBING PSYCHOLOGISTS: CURRENT STATUS Training In spite of advances made over the past decade, further progress toward establishing consistent, readily accessible training programs is necessary. We continue to require quality training programs that are based on a psychological model of pharmacological service provision. We know that the medical model, with its overreliance on medications, is suboptimal. In our opinion, future curricula would benefit from a foundation in psychology with its emphasis on concept formation and the interaction between psychological, social, cultural, spiritual, environmental, and biological factors such as sex, ethnicity, age, and disease. Psychologybased training could highlight many significant aspects of care often neglected or underemphasized in medically based training. Such factors include behavioral and psychological aspects of treatment compliance, the significance of prescribing within the context of a therapeutic relationship, and the integration of pharmacotherapy with psychotherapy and behavioral interventions. Psychology-based training could also emphasize conceptual learning in the clinical context, utilizing the clinical reasoning and judgment skills developed in the practice of psychology prior to incorporating pharmacotherapy as a treatment intervention. (Dunivin & Orabona, 1999, p. 515)

Ideally, each state should house at least one training program, both to train psychologists and for political reasons. Although we recognize the PRESCRIBING PSYCHOLOGISTS: THE FUTURE

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benefits of distance learning, and would advocate for its continued existence, we also realize that legislators would like to see at least some of the prescribing psychologists locally trained. Furthermore, a large cadre of psychologists trained to prescribe will be among our most effective political advocates. Legislators, even when they have not themselves voted in favor of prescriptive authority for psychologists, have acknowledged how impressed they have been by the persuasive and knowledgeable testimony of graduates of the Department of Defense Psychopharmacology Demonstration Project. How long could legislators justify a failure to use highly trained and demonstrably safe prescribers in the face of substantial needs for more effective prescribing? Clearly, we need psychologists in every state trained to prescribe. We are most eager to see results of the implementation of training programs based on a psychological model, building on particular skills utilized by practicing psychologists (Dunivin & Orabona, 1999, p. 518). Legislative Activity Serious legislative activity has increased in the states. It is in the states where prescriptive authority for psychologists will become an added scope of practice. In addition to New Mexico, several states, as was indicated in chapter 8, have had success in at least one chamber of their legislature. Now that trained psychologists in one territory (Guam), and in one state, have prescriptive authority and have broken through the barriers of opposition set primarily by organized medicine, it is likely that other jurisdictions will follow more rapidly than was previously thought. Still, to strengthen the likelihood of legislative success in another state, preparatory activities should be occurring in all or most states. Several states have at least some important activities in place; others have few or none. Most states however, as well as the overall effort, would benefit by assuring that the infrastructure needed to pass legislation is in place. Prescriptive authority task forces are active in 31 states. Where they exist, they tend to energize and focus other members of the state psychological association (SPA). More SPA task forces are needed. Desirable state activities include meeting with uninformed or uncommitted SPA members and preparing fact sheets and videos for those members, coalition allies, and legislators. Developing alliances with other groups will be critical. State leaders agree that the more consumers, physician, and other health care provider coalitions there are, the better psychology and the public will be served. Vastly strengthened grassroots networks will be vital. Ideally, every legislator should have a relationship with an informed constituent, and the topic of prescribing by psychologists should be an ongoing part of their dialogue. Greater unanimity among psychologists in the states remains a worthy goal. Finally, continued fundraising to support these activities is needed. Continued state preparatory activity, leading to state legislative activity, is undeniably most critical. 204

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Examination and Relationships With Licensing Boards Another needed infrastructure component includes widespread use of the Psychopharmacology Examination for Psychologists by psychologists who have been trained to prescribe and been accepted by credentialing organizations such as the Association of State and Provincial Psychological Boards and the National Register of Health Service Providers in Psychology. Also, the significance of developing strong, respectful relationships with the state psychology licensing boards cannot be overemphasized. Ultimately, the boards will evaluate a psychologist’s readiness to prescribe. They must be convinced of the adequacy of the training, of the practicum, and of the examination. The support of the local boards during the legislative process will be invaluable. The Association of State and Provincial Psychology Boards (ASPPB) has already begun to explore methods of evaluating readiness to prescribe. The ASPPB Committee on Education and Training for Credentialing for Prescriptive Authority has developed draft guidelines. Although these have not yet been finalized, it is clear that the boards will eventually use them. ASPPB has initiated as well dialogue on this topic with some states. The licensing boards also add strength to the movement by requiring predoctoral knowledge, continuing education, or both, in psychopharmacology. In Washington State, the equivalent of Level 1 training is required of individuals taking the licensure examination. In Georgia, continuing education in psychopharmacology is required for relicensure. In both of those states, the licensing boards have declared that safe and effective practice of psychology requires a basic knowledge of psychopharmacology. Malpractice Insurance Yet another infrastructure piece deals with malpractice insurance. Bruce E. Bennett, chief executive officer of the American Psychological Association (APA) Insurance Trust, has indicated that he believes malpractice rates will not rise drastically, as some opponents predict. He thinks rates will remain about the same for most psychologists. Prescribing psychologists will be able to obtain a rider to the policy, and their malpractice rates may be slightly higher. When prescription privileges are granted by a specific state it should have no impact on the rates of psychologists that do not prescribe. It may have an impact on those that do receive this authority. Any rate increases would be determined at that time. There are many variables to consider, including but not limited to, the legislation granting the authority (will it require consultation with an MD or permit independent prescription?), the range of medications that may be prescribed, any mandatory insurance provisions required by the law, the number of psychologists that are granted the authority, any restrictions on prePRESCRIBING PSYCHOLOGISTS: THE FUTURE

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scribing (e.g., to specific populations), and the actuarial basis for a rate increase. . . . We (the Trust) will advocate for appropriate rates on behalf of those that are granted the authority. (B. Bennett, personal communication, August 30, 2001)

Ethics On another, related note, psychologists as a discipline must make changes in their training and licensing board regulations to reflect the reality of what they know about the constant, dynamic, mind–body interaction and about the biological substrates of behavior. This awareness must inform psychological practice. Psychologists must be trained in basic psychopharmacology, regardless of whether they prescribe, to be in conformity with the Ethical Principles of Psychologists and Code of Conduct (APA, 1992), particularly those sections that deal with doing no harm and maintaining expertise. Barnett and Neel (2000) stated that lack of knowledge will render psychologists unprepared to meet patient needs: Whether psychologists work independently or in collaboration with primary care physicians, they need to have knowledge of the effects, side effects, and interactions of the many substances patients may be exposed to in order to help ensure that those patients are afforded the highest possible standard of care. (p. 619)

In fact, as early as 1996, guidelines for ethical practice in clinical pharmacopsychology were proposed (Buelow & Chafetz, 1996). Washington State has already recognized that psychologists need education in basic psychopharmacology in order to practice competently and ethically. New professionals admitted to the licensure examination in that state will have to demonstrate completion of such basic education. Support for the notion that the training alone adds utility and makes for more ethical practice comes as well from graduates of the postdoctoral programs in psychopharmacology who have reported that their training substantially enhanced their skills and knowledge, and made them better practitioners, even without their having the right to prescribe. These are the pieces that must be in place to help psychologists in their efforts to obtain prescriptive authority. During the 2001 APA convention, in San Francisco, Russ Newman, Executive Director for Practice in APA and a leading advocate in efforts to obtain prescriptive authority, described these efforts as giving psychologists a much-needed dimension of optimism during these times of managed care assaults on health care (Newman, 2001). Still, there are those among us in psychology who have always been opposed to change of any sort in the discipline. Some are opposed to adding this particular modality; others are opposed to most change in general; and still others are using this context to fight, once again, old, ongoing political struggles. It must be made clear that every expansion of psychologists’ scope of practice, 206

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including adding assessment and psychotherapy, has been opposed not only by physicians but also by large numbers of psychologists, and always by using the same arguments, that we would be a danger to the public and would do irreparable harm to our identity as psychologists. Neither argument has ever proven to be true. As has been outlined in earlier chapters, every discipline, including medicine, that added prescribing to its scope of practice had to fight internal and external fights. Any dynamic discipline must evolve to remain relevant. The most passionate debates we have heard about psychologists’ prescription privileges center on identity issues. If we as a profession decide we cannot change to integrate new knowledge and skills into our existing repertoire; if we, the professionals who assist others in changing their behaviors, their beliefs, their self-identities, decided that our identities must remain the same, therein would lie the biggest paradox of all. (Dunivin & Orabona, 1999, p. 518)

As psychologists add prescribing, they are not losing who they are; instead, they are adding another skill to their professional repertoire. Surely they will continue to change in the future in response to new technology, discoveries, and societal realities. Ironically, whereas psychologists struggle among themselves, and try to educate legislators, others have a more elevated view of psychologists’ capabilities. During the 2000 APA convention, Surgeon General Satcher was asked his views about psychology’s prescriptive authority agenda. He responded, “I’m not sure I know all the issues involved in that, but my basic position is that the privileges should be consistent with the training. So I think clearly if we can demonstrate that psychologists have the training to prescribe, then they should be allowed to prescribe” (Satcher, 2000). When political candidates attempt to obtain endorsements, they are first called on to demonstrate their viability to the endorsing group. That is what keeps them alive. Failure to demonstrate their viability is, in effect, the end of their candidacy. Likewise, an alive, vibrant discipline—that declares interest in being responsive to society’s most pressing needs, to changes in technology, in telehealth, in market forces, and in exploding knowledge about the biological underpinnings of behavior—must evolve to remain both ethical and relevant. To keep our heads in the sand at this point in the 21st century would be to deny the public’s right to have available the new form of health care professional, the one most comprehensively trained in both behavioral and psychopharmacological interventions. That is all psychologists are doing by adding prescriptive authority to their scope of practice. As Pat DeLeon, to whom this book is dedicated, said: Psychology has an extensive repertoire of knowledge, based on both behavioral science research and clinical experience. Psychologists PRESCRIBING PSYCHOLOGISTS: THE FUTURE

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know how to solve many of today’s most pressing health and social problems. . . . Psychologists have too much to offer to stand on the sidelines. In fact, it is my belief that we have an obligation to provide leadership in addressing society’s needs. (DeLeon, 2001, p. 558)

Psychologists’ effort to obtain prescriptive authority is another step toward remaining the best trained mental health profession and the discipline that is best positioned to be socially responsive and helpful to the greatest number of people. POSTSCRIPT Although this book is about prescriptive authority for psychologists, we see in it as well a case study in how a living discipline changes to remain viable. Change—and here we discuss change that results in fundamental shifts in the structure and function of a profession—can be reactive or intentional. Reactive change is by all measures far more common and, because the profession shifts in response to external events, generally far less controversial. The growing democratization of learned professions in terms of female membership is the paradigmatic example of a reactive change. Had this change been intentional—say, by means of a pronouncement in 1960 by an APA leader that at least 60% of graduate students in psychology in the year 2000 be female—the resulting fury would likely have polarized the field for decades. Intentional change is, then, in general far more controversial. The ideas for intentional change are initially put forth by some visionary members of the discipline and may then be discussed by a small number of individuals who have a philosophical or personal allegiance to the originator. How a concept for change moves beyond this initial phase is somewhat mysterious. A few concepts take root, but most proceed no further. Certainly, if the originator of the concept has both persistence and referent authority, the idea is more likely to proceed, but we suspect that a host of other factors, including economic and cultural factors, both within and outside the profession, play important roles. If the notion has resonance, then gradually other members of the discipline begin to address the issue, although frequently from a negative or critical perspective (early surveys of psychologists regarding prescriptive authority showed that a majority of them did not agree with the concept). The issue becomes named, and a corpus of intellectual discourse begins to shape it, by means of discussion among colleagues, either informally or in symposia conducted at professional meetings. Opinions may be published in nonarchival sources such as professional newsletters, and increasingly, e-mail. If the idea engenders sufficient interest, articles in refereed journals follow. E-mail traffic concerning the idea increases, in certain instances to the point that e-mail “cascades” are formed (Levant & Seligman, 2002). At around this time, the official bodies of a profession—in psychologists’ case, 208

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APA—begin to weigh in on the idea, making resolutions, taking formal votes, and issuing policy statements. At about this time, opponents of the ideas express their views more forcefully and attempt to derail the idea. If the concept survives these challenges, and as it becomes a policy of the official voice of the discipline, other needed pieces of infrastructure gradually are developed, much as pieces of a puzzle fit together to make a whole. In the specific case of psychologists, training sites (the Department of Defense, APA panels, some private vendors, and professional schools of psychology) other than the traditional universities initially developed curricula and started actual training. Not surprisingly, the more traditional universities weighed in later. Individuals in state associations then prepare and mobilize for legislative action that may result in legal redefinition of the scope of practice of a profession. A cadre of people become trained and demonstrate the viability of the idea; examinations may be developed for regulatory agencies to use; licensing boards promote enabling regulations, and the pieces of the puzzle fit together—in order for the discipline to shift to include a new scope of practice. What we have described in this book is a template for how a discipline changes, how all the parts needed for change occur—some intentionally, some not, but with the ultimate acceptance of a new area of practice into the variegated tapestry that is the profession of psychology.

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Chilvers, C., Dewey, M., Fielding, K., Gretton, V., Miller, P., Palmer, B., et al. (2001). Antidepressant drugs and generic counseling for treatment of major depression in primary care: Randomised trial with patient preference arms. British Medical Journal, 322, 1–5. Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: Institute of Medicine. Cooper, R. A. (2001). Health care workforce for the twenty-first century: The impact of nonphysician clinicians. Annual Review of Medicine, 52, 51–61. Cooper, R. A., Henderson, T., & Dietrich, C. L. (1998). Roles of non-physician clinicians as autonomous providers of patient care. Journal of the American Medical Association, 280, 795–802. DeLeon, P. (2001). 2000 APA annual president’s report. American Psychologist, 56, 556–558. Dunivin, D. L., & Orabona, E. (1999). Department of Defense Psychopharmacology Demonstration Project: Fellows perspectives on didactic curriculum. Professional Psychology: Research and Practice, 30, 510–518. Durie, A., Roland, M., Roberts, C., & Leese, B. (2000). Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care. British Medical Journal, 320, 1048–1053. Gattis, W. A., Hasselblad, V., Whellan, D. J., & O’Connor, C. M. (1999). Reduction in heart failure events by the addition of a clinical pharmacist to the heart failure management team. Archives of Internal Medicine, 159, 1939–1945. Gonzales, R., Steiner, J. F., Lum, A., & Barrett, P. H. (1999). Decreasing antibiotic use in ambulatory practice: Impact of a multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults. Journal of the American Medical Association, 281, 1512–1519. Greene, J. (2001a, January 22). Emerging specialist shortage triggers work force review. American Medical News. Retrieved August 2, 2002, from http://www.amaassn.org/sci-pubs/amnews/pick_01/prsa0122.htm Greene, J. (2001b, April 23–30). Is it time for US to start training more physicians? American Medical News. Retrieved August, 2, 2002, from http://www.amaassn.org/sci-pubs/amnews/pick_01/prsc0423.htm Hazell P., O’Connell, D., Heathcote, D., & Henry, D. (2002). Tricyclic drugs for depression in children and adolescents (Cochrane Review). The Cochrane Library, 2. Retrieved August 2, 2002, from http://www.cochrane.org/cochrane/ revabstr/mainindex.htm Hunt, D. L., Haynes, R. B., Hanna, S. E., & Smith, K. (1998). Effects of computerbased clinical decision support systems on physician performance and patient outcomes. Journal of the American Medical Association, 280, 1339–1346. Katon, W., Robinson, P., von Korff, M., Lin, E., Bush, T., Ludman, E., et al. (1996). A multifaceted intervention to improve treatment of depression in primary care. Archives of General Psychiatry, 53, 924–932.

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Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (1999). To err is human: Building a safer health system. Washington, DC: National Academy Press. Leape, L. L., Cullen, D. J., Clapp, M. D., Burdick, E., Demonaco, H. J., Erickson, J. I., et al. (1999). Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. Journal of the American Medical Association, 282, 267–270. Levant, R. F., & Seligman, M. E. P. (2002). Trial by Internet: Cybercascades and the Lilienfeld case. American Psychologist, 57, 222–225. Lin, E. H. B., Katon, W. J., von Korff, M., Russo, J. E., Simon, G. E., Bush, T. M., et al. (1998). Relapse of depression in primary care: Rate and clinical predictors. Archives of Family Medicine, 7, 443–449. Mechanic, D., McAlpine, D. D., & Rosenthal, M. (2001). Are patients’ office visits with physicians getting shorter? New England Journal of Medicine, 344, 198–204. Mort, J. R., & Aparasu, R. R. (2000). Prescribing potentially inappropriate psychotropic medications to the ambulatory elderly. Archives of Internal Medicine, 160, 2825–2831. Mundinger, M. H., Kane, R. L., Lenz, E. R., Totten, A. M., Tsai, W. Y., Cleary, P. D., et al. (2000). Primary care outcomes in patients treated by nurse practitioners or physicians. A randomized trial. Journal of the American Medical Association, 283, 59–68. National Depressive and Manic Depressive Association. (2000). Beyond diagnosis: Depression and treatment: A call to action to the primary care community and people with depression. Retrieved August 2, 2002, from http://www.ndmda.org Newman, R. (2001, August). Prescribing psychologists in the military—Years of collaborative practice. Presentation given at the 109th Annual Convention of the American Psychological Association, San Francisco. Nierenberg, A. A., & Alpert, J. E. (2000). Depressive breakthrough. Psychiatric Clinics of North America, 23. Olfson, M., Marcus, S. C., Pincus, H. A., Zito, J. M., Thompson, J. W., & Zarin, D. A. (1998). Antidepressant prescribing practices of outpatient psychiatrists. Archives of General Psychiatry, 55, 310–316. Pear, R. (2001, May 8). Spending on prescription drugs increases by almost 19 percent. New York Times, p. A1. Retrieved August 2, 2002, from http:// www.nytimes.com Pies, R. W. (1991). The “deep structure” of clinical medicine and prescribing privileges for psychologists. Journal of Clinical Psychiatry, 52, 4–8. Pincus, H. A., Tanielian, T. L., Marcus, S. C., Olfson, M., Zarin, D. A., Thompson, J., & Magno Zito, J. (1998). Prescribing trends in psychotropic medications: Primary care, psychiatry, and other specialties. Journal of the American Medical Association, 279, 526–531. Pincus, H. A., Zarin, D. A., Tanielian, T. L., Johnson, J. L., West, J. C., Pettit, A. R., et al. (1999). Psychiatric patients and treatment in 1997: Findings from the PRESCRIBING PSYCHOLOGISTS: THE FUTURE

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American Psychiatric Practice Research Network. Archives of General Psychiatry, 56, 441–449. Reichert, S., Simon, T., & Halm, E. A. (2000). Physicians’ attitudes about prescribing and knowledge of the costs of common medications. Archives of Internal Medicine, 160, 2799–2803. Research Unit on Pediatric Psychopharmacology Anxiety Study Group. (2001). Fluvoxamine for the treatment of anxiety disorders in children and adolescents. New England Journal of Medicine, 344, 1279–1285. Rudy, E. B., Davison, L. J., Daly, B., Clochesy, J. M., Sereika, S., Baldisseri, M., et al. (1998). Care activities and outcomes of patients cared for by acute care nurse practitioners, physician assistants, and resident physicians: A comparison. American Journal of Critical Care, 7, 267–281. Satcher, D. (2000, August). Responding to mental health in a diverse healthcare environment: The Surgeon General’s prescription. Presentation given at the 108th Annual Convention of the American Psychological Association, Washington, DC. Schmidt, I., Claesson, C. B., Westerholm, B., Nilsson, L. G., & Svarstad, B. L. (1998). The impact of regular multidisciplinary team interventions on psychotropic prescribing in Swedish nursing homes. Journal of the American Geriatrics Society, 46, 77–82. Simon, G. E., von Korff, M., Rutter, C. M., & Peterson, D. A. (2001). Treatment process and outcomes for managed care patients receiving new antidepressant prescriptions from psychiatrists and primary care physicians. Archives of General Psychiatry, 58, 395–401. Tierney, R., Melfi, C. A., Signa, W., & Croghan, T. W. (2000). Antidepressant use and use patterns in naturalistic settings. Drug Benefit Trends, 12(6), 7–12. U.S. Department of Health and Human Services. (1999). Mental health: A report of the Surgeon General. Rockville, MD: Author. U.S. Department of Health and Human Services. (2001). Mental health: Culture, race, and ethnicity—A supplement to Mental health: A report of the Surgeon General. Rockville, MD: Author. U.S. Department of Health, Education and Welfare. (1979). Healthy people: The Surgeon General’s report on health promotion and disease prevention. Washington, DC: Author. Wallace, M. B., Kemp, J. A., Meyer, F., Horton, K., Reffel, A., Christiansen, C. L., et al. (1999). Screening for colorectal cancer with flexible sigmoidoscopy by nonphysician endoscopists. American Journal of Medicine, 107, 286–297.

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AUTHOR INDEX Numbers in italics refer to listings in the reference sections.

Abou-Saleh, M. T., 21, 27 Acuff, C., 171, 175, 175 Adams, C., 14, 31 Adams, K. M., 24, 27, 198, 209 Ader, R., 11, 27 Agency for Healthcare Research and Quality, 199, 209 Ahn, H., 31 Alford, J., 161, 176 Allen, R., xxi, xxiv, 157, 158 Alpert, J. E., 195, 211 American College of Neuropsychopharmacology, 104, 112, 113, 115 American Educational Research Association, 182, 188 American Psychiatric Association, 50, 57, 87, 100 American Psychological Association, 38, 44, 63, 64, 65, 66, 67, 69, 70, 74, 75, 81, 100, 149, 157, 180, 182, 184, 188, 206, 209 Antonuccio, D. O., 4, 21, 27 Aparasu, R. R., 199, 211 Armstrong, E. P., 200, 209 Arnkoff, D. B., 160, 161, 177 Assistant Secretary of Defense for Health Affairs, 101 Association of State and Provincial Psychology Boards, 181, 189 Ayd, F. J., 12, 13, 29

Benson, K., 31 Bent, R. J., 37, 44 Benton, M. K., 171, 176 Bergin, A. E., 173, 177 Berndt, E. R., xii, xxii Bieliauskas, L. A., 24, 27, 198, 209 Blanch, A., 163, 170, 176 Blumenfeld, S. J., 51, 57 Boland, R. J., 15, 29 Boles, M., 31 Bollini, P., 14, 27 Bolter, J. F., 153, 157 Boyd, J. L., 171, 177 Breggin, P., 49, 51, 57 Brentar, J. B., 61, 75 Bricklin, P. M., xv, xxiii Brown, A., 78, 84, 101, 107, 115, 117, 139, 149, 158 Brown, G. T., 171, 176 Brown, L. S., 51, 57 Brown, R. T., 22, 27 Brown, W. A., 4, 29 Buelow, G. D., 206, 209 Buie, J., 40, 44 Burdick, E., 211 Burke, W. J., 14, 27 Burns, S. M., xxi, xxii, 40, 44, 61, 75 Bush, T., 210, 211

CAPP Task Force on Prescription Privileges, 67, 70, 75 Carling, P., 162, 176 Carmichael, K., 171, 176 Carpinello, S. E., 161, 177 Carter, R. D., 9, 27 Catlin, A. J., 10, 27, 201, 209 Chafetz, M. D., 206, 209 Chamberlin, J., 171, 172, 176 Chemtob, C. M., xxi, xxii, 40, 44, 61, 75 Chernow, R., 7, 27 Chilvers, C., 196, 210 Chrischilles, E. A., 200, 209 Christiansen, C. L., 212 Claesson, C. B., 21, 30, 199, 212 Clapp, M. D., 211

Bakke, O., 11, 29 Baldessarini, R. J., 17, 28 Baldisseri, M., 212 Ballweg, R., 8, 9, 27 Balster, R. S., 75 Barclay, A. G., 35, 43, 45 Barnett, J. E., 206, 209 Barrett, P. H., 200, 210 Bassman, R., 160, 161, 168, 170, 176 Beck, A. T., 18, 30 Bedell, J. R., 168, 170, 171, 176 Beers, M. H., 21, 27 Bennett, B. E., xv, xxiii

213

Cleary, P. D., 211 Clochesy, J. M., 212 Cohen, D., 49, 51, 57 Committee on Quality of Health Care in America, 197, 210 Cooley, S., 177 Cooper, R. A., 8, 28, 198, 201, 210 Corrigan, J. M., xvi, xxiii, 199, 211 Corrigan, P. W., 168, 176 Coursey, R. D., 18, 31, 160, 161, 162, 163, 176, 177 Croghan, T. W., 4, 13, 28, 196, 212 Crow, S., 29 Cullen, D. J., 211 Cullen, E., xix, xxiii, 78, 101, 107, 115, 123, 139, 142, 158

Daly, B., 212 Danton, W. G., 4, 27 Davis, J. M., 12, 13, 29 Davis, W. W., 161, 162, 173, 177 Davison, L. J., 212 Dawley, Jr., H. H., 61, 75 Dawson, K. V., 20, 29 Deegan, P. E., 159, 162, 170, 176 DeLeon, P. H., xii, xiv, xix, xv, xvii, xxi, xxii, xxiii, 40, 44, 61, 64, 69, 75, 78, 101, 107, 115, 141, 157, 208, 210 Demonaco, H. J., 211 DeNelsky, G. Y., 4, 27 DeVane, C. L., 13, 28 Dewey, M., 210 DiBarry, A. L., 177 Dietrich, C. L., 8, 28, 198, 210 Dingemans, P., 178 Dixon, L., 173, 176 Donaldson, M. S., xvi, xxiii, 199, 211 Donohue, J. M., xii, xxii dosReis, S., 31 Doyle, J., 29 Duffy, J., 6, 28 Dunivin, D. L., xix, xxiii, 52, 57, 101, 107, 110, 112, 115, 121, 130, 139, 139, 142, 158, 203, 204, 207, 210 Durie, A., 201, 210 Dvoskin, J., 163, 170, 176

Earles, J., xxiii Eaves, G., 29

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AUTHOR INDEX

Egli, D., 75 Elkin, I., 29 Epstein, A. M., xii, xxii Erickson, J. I., 211 Estroff, S. E., 162, 176 Evans, M., 161, 177

Fallon, I. R., 171, 177 Faltz, C., 147, 157 Farrell, E. W., 161, 176 Fava, G. A., 13, 28 Felton, C. J., 161, 177 Fielding, K., 210 Fingold, S. F., 27 Fischer, J. E., 6, 28 Fisher, S., 11, 12, 28 Flaten, M. A., 11, 15, 28 Flesher, S., 177 Folen, R., xxi, xxiii, 40, 44, 61, 75 Foster, B. M., 29 Foust, M. J., 52, 57, 107, 115 Fowler, R. D., 154, 157 Fox, R. E., xii, xix, xxii, xxiii, 40, 44, 61, 75, 142, 157 Foxhall, K., 141, 142, 157, 158 Frank, E., 11, 22, 23, 28 Frank, R. G., xii, xxii Frese, F. J., 161, 162, 165, 173, 177

Gagne, C., 162, 177 Garbin, C. P., 178 Gardner, J. F., 31 Gattis, W. A., 199, 210 Gedney, J. J., xxiii Gelenberg, A. J., 14, 28 Gifford, J. F., 9, 27 Glass, C. R., 160, 161, 177 Gonzales, R., 200, 210 Gordon, N. C., 11, 29 Gorman, J. M, 16, 30 Gorny, S. W., 157, 158 Graham, S. R., xii, xxii, 61, 75 Grandi, S., 13, 28 Greenberg, L. S., 173, 177 Greenberg, R. P., 11, 12, 28 Greene, J., 10, 28, 197, 210 Greenwald, D., 177 Gretton, V., 210

H. R. Report, 79, 101 Hackman, A., 173, 176 Halm, E. A., 201, 212 Hamilton, J., 51, 57 Hammond, J., 9, 28 Hanna, S. E., 199, 210 Hardy, R., 12, 30 Harkless, G. E., 6, 9, 28 Harop-Griffith, J., 57 Hasselblad, V., 199, 210 Hausman, K., 148, 149, 158 Hayes, S. C., 157, 158 Haynes, R. B., 199, 210 Hazell, P., 198, 210 Healy, D., 5, 17, 28 Heathcote, D., 198, 210 Hegarty, J. D., 17, 28 Heiby, E., 157, 158 Heinssen, R. K., 171, 177 Henderson, T., 198, 210 Hendricks, S. E., 14, 27 Henry, D., 198, 210 Hickok, L. R., 57 Hoch, E. L., 35, 44 Hogarty, G. E., 171, 177 Hollon, S. D., 12, 17, 28, 30 Holm, L., 57 Horton, K., 212 Horvath, A. O., 173, 177 Howard, K. I., 15, 29 Hudson, J. I., 13, 29 Hunt, D. L., 199, 210 Hunter, R. H., 168, 171, 176, 177

Inouye, D. K., 142, 158 Institute of Medicine, xvi, xxiii

Jacques, D., 14, 27 James, L. C., xxiii Janicak, P. G., 12, 13, 29 Jarrett, R. B., 22, 29 Jeffries, J. J., 163, 177 Jemelka, R. P., 52, 58 Jennings, F. L., xxi, xxiii, 40, 44, 61, 75 Jennings, R., 141, 158 Jensvold, M., 51, 57 Jerome, L. W., xxi, xxiii Johnson, D. L., 18, 31, 75, 168, 177 Johnson, J. L., 211

Kane, R. L., 211 Karp, J. F., 11, 28 Katon, W., 52, 57, 58, 196, 210, 211 Keck, P. E., 29 Keller, M. B., 15, 29 Kemp, J. A., 212 Khan, A., 4, 5, 29 Kilbey, M. M., 75 Kingdon, D. G., 171, 177 Kirsch, I., 4, 11, 12, 14, 29 Klein, D. F., 12, 29 Kohn, L. T., xvi, xxiii, 199, 211 Korman, M., 36, 43, 44 Kornblith, S. J., 177 Kraft, D., 29 Kramer, P., 51, 57 Krupnick, J. L., 19, 29 Kubie, L. S., 34, 44 Kupelnick, B., 14, 27

Lambert, M. J., 173, 177 Lasser, R. A., 21, 29 Laud, P., 8, 28 Leape, L. L., 199, 211 Leese, B., 201, 210 Lefever, G. B., 20, 29 Lehman, A., 173, 176 Leith, N. J., 75 Lennox, S. S., 171, 176 Lenz, E. R., 211 Levant, R. F., 121, 140, 162, 170, 177, 208, 211 Levendusky, P. G., 171, 177 Levine, J. D., 11, 29 Lin, E., 195, 210, 211 Linszen, D., 178 Loeb, M., 11, 29 Lucksted, A., 160, 177 Ludman, E., 210 Lueger, R. J., 15, 29 Lum, A., 200, 210 Lynch, F., 31 Lynch, K., 162, 177

Madsbu, H. P., 11, 29 Maling, M. S., 15, 29 Malt, U. F., 11, 29 Marcus, S. C., 30, 211 Marder, S. R., 14, 30 Marsh, D., 161, 162, 168, 177 AUTHOR INDEX

215

Martinovich, Z., 15, 29 Massaro, R., 161, 177 McAlpine, D. D., 195, 211 McArthur-Campbell, D., 14, 27 McAuliffe, M., 10, 27, 201, 209 McElroy, S. L., 29 McGill, C. W., 171, 177 McGuire, P. A., 164, 178 McNamara, J. R., 61, 75 Mechanic, D., 195, 211 Meehl, P. R., 34, 45 Meilbach, R. C., 14, 30 Melfi, C. A., 196, 212 Meyer, F., 212 Michael, D. D., 171, 176 Miller, P., 210 Moncrieff, J., 5, 12, 30 Mondin, G. W., 31 Moody, M., 31 Morgenstern, H., 27 Morris, D. B., 10, 30 Morrow, A. L., 20, 29 Mort, J. R., 199, 211 Moyer, J., 29 Mundinger, M. H., 201, 211 Munizza, C., 14, 27

Naster, B., 171, 178 Nathan, P. E., 12, 16, 30 National Council on Disability, 172, 178 National Council on Measurement in Education, 182, 188 National Depressive and Manic Depressive Association, 24, 25, 30, 195, 196, 200–201, 211 National Institutes of Health, 20, 30 Neel, M. L., 206, 209 Newbrough, J. R., 35, 43, 45 Newman, R., xix, xxiii, 78, 93, 101, 107, 110, 112, 115, 123, 139, 142, 149, 158, 163, 178, 206, 211 Nezu, A. M., 171, 178 Nezu, C. M., 171, 178 Nierenberg, A. A., 195, 211 Nilsson, L. G., 21, 30, 199, 212

O’Connell, D., 198, 210 O’Connor, C. M., 199, 210 Oepen, G., 17, 28

216

AUTHOR INDEX

Office of the Assistant Secretary of Defense for Health Affairs, 79, 101 Office of the U.S. Senate, 79, 101 Olfson, M., 20, 30, 196, 211 Olmedo, E., 147, 157 Olsen, H., 11, 28 Orabona, E., 78, 101, 107, 115, 121, 130, 139, 139, 203, 204, 207, 210 Ouslander, J. G., 27

Palmer, B., 210 Pampallona, S., 14, 27 Pear, R., 196, 211 Pearson, L., 8, 30 Pederson, J., 171, 177 Penn, D. L., 171, 178 Perri, M. G., 171, 178 Peterson, D. A., 24, 31, 195, 212 Pettit, A. R., 211 Phelps, R., xix, xxiii, 78, 101, 107, 115, 142, 158 Pies, R. W., 202, 211 Piggott, T. A., 13, 30 Pincus, H. A., 4, 20, 21, 30, 31, 196, 211 Poffenberger, A. T., 34, 45 Pottharst, K. E., 35, 36, 43, 45 Preskorn, S. H., 12, 13, 15, 29, 30

Rafanelli, C., 13, 28 Raley, A., 78, 79, 80 Raymond, N. C., 29 Rector, N. A., 18, 30 Reffel, A., 212 Reichert, S., 201, 212 Research Unit on Pediatric Psychopharmacology Anxiety Study Group, 196, 212 Resnick, R. J., xiv, xxiii, 69, 75 Reuben, D. B., 27 Robak, O. H., 11, 29 Roberts, C., 201, 210 Robinson, P., 210 Robinson-Kurpius, S. E., xv, xxiii Rogers, J. A., 171, 172, 176 Roland, M., 201, 210 Rosenbaum, J. F., 13, 31 Rosenthal, M., xii, xxii, 195, 211 Ross, A. O., 35, 44 Routh, D. K., 34, 45, 49, 57

Roy-Byrne, P. P., 52, 58 Rudy, E. B., 201, 212 Rush, A. J., 11, 17, 28, 30 Russo, J., 52, 57, 58, 211 Rutter, C. M., 24, 31, 195, 212

Safarjan, B., 161, 176 Safer, D. J., 31 Sammons, M. T., xii, xiv, xix, xxi, xxii, xxiii, xxiv, 22, 27, 78, 84, 101, 107, 112, 115, 117, 121, 139, 140, 142, 149, 157, 157, 158 Samuels, R. M., xxi, xxii, 40, 44 Sapirstein, G., 4, 11, 12, 14, 29 Satcher, D., 207, 212 Savron, G., 13, 28 Schmidt, I., 21, 30, 199, 212 Schmidt, N. B., 112, 115 Schroeder, H. E., 171, 176 Seligman, M. E. P., 12, 30, 208, 211 Sereika, S., 212 Sexton, J., xiii, xv, xxiii, 78, 101, 107, 115 Shapiro, A. K., 11, 15, 31 Shapiro, E., 11, 15, 31 Signa, W., 196, 212 Silver, P. C., 29 Simmens, S., 29 Simon, G. E., 24, 25, 31, 195, 211, 212 Simon, T., 201, 212 Simonsen, T., 11, 28 Smith, K., 199, 210 Smith, R. A., 9, 31 Smyer, M. A., 64, 75 Sotsky, S. M., 29 Southwell, G. D., 110, 115 Spaulding, W. D., 18, 31, 178 State of California, Office of Statewide Health Planning and Development, 39, 45 Steiner, J. F., 200, 210 Stich, F., 31 Stigall, T. T., 152, 153, 158 Stricker, G., 160, 178 Stull, T., 14, 27 Sunderland, T., 21, 29 Svarstad, B. L., 21, 30, 199, 212

Tanielian, T. L., 30, 211 Thomas, J., 141, 158 Thompson, J., 30, 211

Thornley, B., 14, 31 Tibaldi, G., 14, 27 Tierney, R., 196, 212 Tohen, M., 17, 28 Tollefson, G. D., 13, 31 Totten, A. M., 211 Tsai, W. Y., 211 Turkington, D., 171, 177

U.S. Army Medical Department, 80, 101 U.S. Army Office of the Surgeon General, 78, 82, 83, 85, 101 U.S. Department of Health, Education and Welfare, 192, 212 U.S. Department of Health and Human Services, 192, 212 U.S. Department of Justice, 182, 189 U.S. Department of Labor, 182, 189 U.S. General Accounting Office, 93, 99, 101, 104, 110, 111, 115

Valenstein, E. S., 5, 31 Van Der Does, A. W., 178 Vath, R. E., 9, 31 Vector Research, Inc., 100, 101, 104, 110, 115 von Korff, M., 24, 31, 195, 210, 211, 212

Walker, E. A., 52, 57, 58 Wallace, M. B., 201, 212 Wallerstein, R. S., 34, 45 Walsh, D., 170, 178 Wampold, B. E., 16, 31 Ward, J., 171, 176, 178 Warner, H. A., 4, 29 Waterloo, K., 11, 28 Waternaux, C., 17, 28 Watkins, J., 29 Welch, B., xxi, xxii, 40, 44, 61, 75 Wessely, S., 12, 30 West, J. C., 21, 31, 211 Westerholm, B., 21, 30, 199, 212 Whellan, D. J., 199, 210 Wiggins, J. G., xvii, xxiii, 61, 75 Willis, D. J., xxi, xxiii, 40, 44, 61, 75 Winder, C. L., 35, 44 Witheridge, T. F., 173, 178 Wolfe, S. M., xii, xxiv AUTHOR INDEX

217

Wood, S. F., 51, 57 Wright, R., xxi, xxiii, 40, 44, 61, 75

Yeoman, B., 49, 58

218

AUTHOR INDEX

Zahniser, J. H., 161, 176 Zarin, D. A., 21, 30, 31, 211 Zinner, E., xxi, xxiv, 157, 158 Zito, J. M., 4, 30, 31, 211 Zuvekas, S. H., 4, 31

SUBJECT INDEX

Access to care, 196–197 benefits of prescriptive authority for psychologists, xiii, xv Acuff, Catherine, 175 Adherence, 195–196, 201 Advance-practice nurses, 8. See also Nurse practitioners Adverse effects antidepressant drugs, 22 current health care system performance, xv–xvi current medical prescribing and, 199, 200 opposition to prescriptive authority based on potential for, 50–52 safeguards against dispensing errors, 202–203 special populations and, 51 Alliant International University, 125–130 Alpert, Judith, 62 American College of Neuropsychopharmacology, 82, 84–85, 86–87, 88, 89, 91–93 American College of Professional Psychology, 142 American Medical Association, 6, 7 American Psychological Association, 26, 86 Board of Professional Affairs, xiv, 60–63 Board of Scientific Affairs, 65–66 in campaign for prescriptive authority, xiv–xv, 38, 39–40, 41, 47, 60–74 College of Professional Psychology, xv, 179, 180–181 Committee for the Advancement of Professional Practice, 66–68 in historical development of psychology education, xviii, 34, 35, 36, 37, 41 model curriculum, 118, 128, 130, 134, 139 National Alliance for the Mentally Ill and, 166 policy resolutions endorsing prescriptive authority, 68–70

psychopharmacology miniconventions, 71 Psychopharmacology Task Force, 63–65 in state legislative campaigns, 154–155 American Society for the Advancement of Pharmacotherapy, 72–73, 142 Antidepressant drugs adverse effects, 22 clinical significance of placebo response to, 5, 14–16 consumer spending, 4, 19 dose–response profile, 13–14 effect size, 11–12 effectiveness of physician prescribing practices, 24–25, 200 efficacy issues, 4–5 evidence of placebo response to, 5, 11–14 overprescription concerns, 21, 197–198 in treatment of non-depressive disorders, 13 treatment planning, 21–23 utilization, 4, 19–20 Antipsychotic drugs efficacy issues, 4, 17–18, 200–201 placebo response, 14 Argosy University, 136–138, 146 Assertive community treatment teams, 172–173 Association of State and Provincial Psychology Boards, 181, 205 Attentional disorders, overprescription concerns, 20–21 Azrin, Nate, 62

Balster, Bob, 70 Barclay, Allan, 62 Bassman, Ron, 163 Bennet, Bruce, 205–206 Benzodiazepines, 21 Bernay, Toni, 61 Bolter, John, 127, 152

219

Bourg, Edward, 65 Bricklin, Patricia, 181 Brown, Anita, xix Brown, Ronald, 65

California, 146–149 California School of Professional Psychology, 125–130 Campaign for prescriptive authority APA role in, xiv–xv, 38, 39–40, 41, 47, 60–74 consumer support for, 159–160, 164, 168–170 efficacy of psychotropic drugs and, 4–5 expenses, 156 health care utilization trends and, 4 likely course of, xxi–xxii, 208–209 by nonphysician health care providers, 7–10, 38–39 origins and development, xii, 38–41, 59 overprescription concerns and, 23–24 patient role in, 26 by physicians, 3–4, 5–7, 9–10, 49 professional development of psychology and, xiii–xiv, xix–xx, 24, 59–60 professional infrastructure for, 203–208 psychosocial model of treatment and, 162–163, 168–169, 172 quality of care benefits, xiii, 24–25 rationale, 47–48, 61, 74, 80, 126, 193–194, 207–208 relevance of past experiences in expanding scope of practice, 41–44 as social policy issue, xiii, xv state level activities for, 155–157 See also Opposition to prescriptive authority for psychologists Center for Mental Health Services, 65 Children and adolescents depression treatment, 20, 22 overprescription concerns, 20 Chisholm, Margery, 67 Ciuccio, Jan, 181 Clark, Jerry, 69 Combination therapy clinical conceptualization, 16–19, 47–48, 61 good clinical practice, 24

220

SUBJECT INDEX

implementation in depression treatment, 21–23 overprescription and, 21 Computer-assisted practice, 199–200, 203 Connecticut, 155 Consumers/survivors/ex-patients building alliances with, 173, 175 goals for future of psychology, 170–173 knowledge and understanding of medical care, xii, xxii myths of mental illness, 160–161 psychology’s historical relationship, 164–166 quality of life issues, 161 recovery concept, 162–164 reform goals, 161–162 relations with state psychology associations, 166–168 with severe mental illness, 193–194 stigmatization by diagnosis, 161 support for prescriptive authority campaign, 159–160, 164, 168–170, 173–175 Continuing-education programs, 119–125 PDP requirements, 98–99 Cost of care adherence and, 201 future of health care system, xiii mental health care spending, 4 physician knowledge of, 201 psychopharmacotherapy spending, 4, 19 Coursey, Robert D., 65, 163 Craig, Paul, 72 Credentialing and licensing, 65–66, 153, 205 continuing-education requirements in PDP, 98–99 historical development, 37 in PDP, 93–94, 107 See also Examinations and evaluations; State regulation Cullen, Elizabeth, 67

Deinstitutionalization, 193 DeLeon, Patrick, 64, 65, 69, 71, 72, 132, 153, 165, 207–208 Department of Defense, 26, 41. See also Psychopharmacology Demonstration Project

Department of Veterans Affairs, 33–34 Depression in children and adolescents, 20, 22 clinical conceptualization, 17 in elderly individuals, 21 neurobiological mechanism, 5 treatment efficacy, 17, 22–23 treatment planning, 21–23 treatment shortcomings, 195–196 See also Antidepressant drugs

Education and training for prescriptive authority, xvii APA recommendations and activities, 41, 64–65, 66–67, 70 continuing-education requirements in PDP, 98–99 cooperative degree program, 136–138 costs, 118 current status, 117, 139, 203–204 enrollment problems, 118 ethical practice topics in, 206 future prospects, xx–xxi goals of PDP, 78 historical developments, 40, 41, 117 legislative advocacy and, 204 PDP accomplishments, 103–104 PDP model, 80–86, 106–107, 108, 113–114 postdoctoral certificate/continuing education programs, 117–118, 119–125, 175 postdoctoral master’s degree programs, 118, 125–136, 175 predoctoral programs, 118 psychopharmacology as professional specialty, 71 role of state psychological associations in developing, 118 for safe practice, 202–203 school mission statement, 126 state regulation and, 118, 127–128, 148 student satisfaction, 118–119, 124–125, 132 student workload concerns, 53 types of programs, 117–118 Wright State model, 82 See also Examinations and evaluations

Education and training of physicians, 6–7 costs, 197 as model for safe prescribing practice, 202–203 quality of, 198–199 Education and training of psychologists, 26 doctoral programs, 34–35, 36, 37, 42 historical development, 34–36 professional model, 35–36 scientist–practitioner model, 34–35 Uniformed Services University of Health Sciences model, 82, 83–84, 85–86, 89 Efficacy of drug therapy antidepressant medications, 4–5 in combination with psychotherapy, 16–17, 19, 23 current physician prescribing practices, 200–201 for depression, 195–196 implications for prescriptive authority movement, 4 by itself, 16, 17, 19, 22–23 safety of drug therapy and, 202 in schizophrenia treatment, 17–18 use of antidepressants for nondepressive disorders, 13 vs. efficacy of other treatments, 10 See also Placebo response Egli, Dan, 62, 67 Eisdorfer, Carl, 65 Enright, Michael, 72 Entin, Alan, 72 Ethical practice, 206–208 clinical use of placebo response, 15 Etiology multifactorial conceptualization, 202 overlap of psychological and physical factors, 51–52 treatment approach related to conceptualization of, 202 Examinations and evaluations for psychologists, 70–71, 87–88, 90, 132 current status and needs, 205 national, 142 See also Psychopharmacology Examination for Psychologists Expectancy effects clinical use of, 15–16 in placebo response, 11 SUBJECT INDEX

221

Fairleigh Dickinson University, 133–136 Faltz, Charles, xix, 147 Florida. See Nova Southeastern University Fluoxetine, 14 Flynn, Laurie, 62 Folen, Ray, xix Follow-up care, 24 Forced hospitalization/medication, 160–161 deinstitutionalization movement, 193 Forsyth, Sheila, 62 Fox, Ron, 70 France, Charles, 65 Frese, Fred, 165

Gardner, Pat, 167 Georgia Psychological Association consumer alliance, 166–168, 173–175 curriculum development, 120–123, 149 legislative campaign, 149–151 Geriatric care, overprescription concerns, 21 Global HealthEd, 133, 135 Government action funding for development of pharmacotherapy training, 65 in professionalization of psychology, 33–34 See also Psychopharmacology Demonstration Project Graham, Stanley, 71 Granoff, Sam, 142 Guam, 141

Haloperidol, 14 Hammond, Rodney, 62 Hawaii, 39, 136–138, 142–146 Health care system care of patients with severe mental illness, 193–194 future prospects, xi, xii–xiii, xviii historical development of physician assistant profession, 8–9 importance of psychology in, xiii, xvii–xviii, 192 inadequacies of, xv–xvi medical model, 194–195 psychology as primary care profession, 192–193, 194–195

222

SUBJECT INDEX

See also Mental health care services, generally Heldring, Margaret, 72 Hill, Gil, 72 Historical development mental health care utilization, 4 nature of professional change, 208–209 nurse practitioner profession, 8 physician assistant profession, 8–9 prescriptive authority for nonphysician health care providers, 7–10 prescriptive authority for physicians, 3–4, 5–7, 49 professionalization of psychology, 33–37 psychology’s campaign for prescriptive authority, 25–26, 38–41, 60–74 psychology’s professional identity, 48–50 psychology’s relationship with consumers, 164–166 psychology’s scope of practice, 37, 38–41 relevance of past experiences in expanding scope of practice, 41–44 state campaigns for prescriptive authority, 142–154 See also Psychopharmacology Demonstration Project

Identity, professional, xiii–xiv, 48–50, 114, 207 psychology as primary health care profession, 192–194 Imipramine, 14 Inouye, Daniel, Senator, xii, 39, 79, 142 Institute of Medicine, xv–xvi Insurance, malpractice, 205–206

Jennings, Floyd, 40, 62–63 Johnson, Dale, 65

Kilbey, Marlyne, 62, 65, 70 Kirschner, Neil, 65 Kubie, Lawrence, 34

Laskow, Gregory, 62 Levant, Ronald, 66, 67, 71, 163 Licensure. See Credentialing and licensing Louisiana Psychological Association curriculum development, 126–127, 152–153 legislative effort, 152–154 Malpractice insurance, 205–206 Managed care, 3, 25 prescriptive authority as outgrowth of, 53–54 Marra, Thomas, 147 Martin, Joan, 65 Mazure, Carolyn, 65 McNamara, Kathy, 70, 72 Meehl, Paul, 34–35 Mental Health Parity Act, 166 Mind–body dualism, 47–48, 49, 193 Missouri, 155 Morris, Jerry, 72 National Alliance for the Mentally Ill, 164, 165–166, 167–168, 174 National Council of Graduate Education in Psychology, 36 National Council on Disability, 172 National Institute of Mental Health, 33–34 New Mexico, 40, 42, 74, 118–119, 141–142, 164 State University Collaborative Program, 123–125 Newman, Russ, 61, 206 Nonphysician health care providers, 3–4 prescriptive authority of, 7, 38–39 safety of prescribing practices, 198, 199, 201, 202 See also Nurse practitioners; Physician assistants Nova Southeastern University (Florida), 119, 130–133 Nurse practitioners licensing trends, 8 professional development, 8 safety of prescribing practices, 201 Obsessive–compulsive disorder, 13 Opposition to prescriptive authority for psychologists, 23–24, 25, 206–207

based on additional educational demands, 53 based on questions of drug efficacy, 10–16 as element of managed care movement, 53–54 in Georgia legislative effort, 150–151 in Hawaiian legislative effort, 143–146 in historical development of profession, xiv, 25–26, 206–207 by medical profession, 10, 41, 44, 145–146 neutrality and, 174 in PDP origins and development, 79–80, 85 premature rejection of arguments for, 54–55, 56–57 by psychiatrists, 55–56, 143–145, 147, 150–151, 174–175 by psychologists, xiv, 47, 50–55, 146, 154, 156–157, 198 quality of care concerns, xv–xvi, 26– 27, 50–52, 55–56, 144, 191–192, 198 as threat to identity of profession, 48–50, 207 Oregon, 127 Overprescription, 19–21, 51, 197–198 as effect of prescriptive authority for psychologists, 23–24

Pachman, Joseph, 67 Paige, Ruth Ullmann, 62, 66, 67, 70, 72 Patchin, Susan, 127 Patient education to prevent adverse drug effects, 200 psychosocial therapy approach, 168–169 regarding placebo effects, 15–16 therapeutic alliance and, xii PDP. See Psychopharmacology Demonstration Project Peterson, Donald, 35 Pharmaceutical industry in acquisition of prescriptive authority for physicians, 6, 9 advertising of products to public, xii, 49 nonphysician health care providers and, 9 SUBJECT INDEX

223

psychology’s relationship with, 175 research with special populations, 51 Pharmacists, 199 Pharmacotherapy, generally in combination with psychotherapy, 16–17, 18, 19, 21–23 depression treatment outcomes, 195–196 overprescription issues, 19–21, 23–24, 51, 197–198 spending, 4 therapeutic alliance effects in, 18–19 trends, 4, 196 unimodal efficacy, 16, 17, 19, 22–23 utilization, 4 See also Efficacy of drug therapy Physician assistants, 8–9 Physicians acceptance of prescriptive authority for psychologists, 56 acquisition of prescriptive authority for, 3–4, 5–7, 9–10 awareness of drug costs, 201 education and training, 6–7, 197 lack of training in mental health care, 195 mandatory consultation, 153–154 opposition to prescriptive authority for psychologists, 10, 41, 145–146 overprescription trends, 20 prescribing practices, 197–201 prescriptive expertise, 24 primary care vs. specialty care, 24–25 supply, 197 See also Psychiatry Pimental, Patricia, 67 Placebo response antidepressant medications, 5, 10–16 antipsychotic drugs, 14 as basis for opposition to prescriptive authority for psychologists, 10 clinical significance, 5, 10–11, 14–16 determinants of, 11 expectancy effects in, 11 methodology for evaluating, 11, 12–13 variation by diagnosis, 11, 13 Polanco, Richard, Senator, 148 Prescribing Psychologists’ Register, 119–120 Primary care, role of psychology in, 192–193, 194–195

224

SUBJECT INDEX

Professional Examination Service, 184 Prometrics, Inc., 185 Psychiatry depression treatment, 196 opposition to prescriptive authority for psychologists, 55–56, 143–145, 147, 150–151 practitioner supply, 197 relationship with consumers, 165–166 relationship with psychology, 174–175 Psychopharmacology Demonstration Project (PDP), xix, 134 academic preparation for coursework of, 98 accomplishments, xix, 78, 100, 103–104, 110, 112–114, 142 American College of Neuropsychopharmacology and, 82, 84–85, 86–87, 88, 91–93 assignment of graduates, 98, 107–108 clinical performance of graduates, 108–110 clinical training in, 106–107 continuing-education requirements, 98–99 contributions to military readiness, 110–111 credentialing guidelines and procedures, 93–94, 98–99, 107 development of training model, 80–86 fellow’s experiences in, 105–110 first iteration, 86–88, 106 formulary, 95–96 funding, 91 goals, 78 limitations, 54, 114 motivation of applicants, 104–105 origins, xix, 79–80 performance evaluation of, 86, 99–100, 110–112 physical assessment skills of graduates, 96–98 practice patterns of graduates, 94–95, 109, 112–113 program costs, 99–100 program design challenges in, 78 second iteration, 88–91, 106 significance, 77–78, 103, 139 third iteration, 91, 106

Psychopharmacology Examination for Psychologists, 26, 205 administration, 185–186 advocacy role, 187–188 dissemination of scores, 186–187 knowledge domain, 182 origins and development, 179–185 purpose, 179, 188 quality maintenance, 187 requirement for admission to, 186 standards, 181–182 Public sector psychologists, 169–170, 172, 192, 193 Pure Food and Drug Act, 6

Quality of care, 26–27 benefits of prescriptive authority for psychologists, xiii, 24–25 current health care system performance, xv–xvi opposition to prescriptive authority based on concerns about, xv–xvi, 50–52, 55–56, 198 PDP outcomes, 111–112 physician prescribing practices, 197–201 prescriptive authority of nonphysician health care providers and, 39 safe prescribing practices, 202–203 Quality of life, 161

Race/ethnicity, 51 Recovery model of therapy, 162–164 Rehm, Lynn, 65, 70 Resnick, Bob, xix, 62, 69, 70, 72 Resnick, Jerry, 62 Restrictions of prescriptive authority formulary, 7 for nonphysician health care providers, 7 for nurse practitioners, 8 for PDP graduates, 94–96 for psychologists, 7 Risperidone, 14 Robinson, Elizabeth, 72 Rose, Sandy, xix Rozensky, Ron, 72

Sammons, Morgan, xix, 65, 67, 72, 149

Schizophrenia placebo response to treatment, 14 treatment efficacy, 17–18 Schneider, Ben, 62 Selective serotonin reuptake inhibitors, 13–14, 20 overprescription concerns, 21 Sertraline, 14 Sexton, John, xix Sheridan, Edward, 65 Simon, Norma, xiv, 61–63, 72 Smyer, Michael, xiv Social skills training, 171 Standards of practice, 155 State regulation/legislation advocacy role of APA, 154–156 advocacy role of consumers, 173–175 advocacy role of state psychological associations, xxi, 154, 155–156, 204 course of campaign for prescriptive authority, xxi–xxii development of educational programs for prescriptive authority and, 118, 127–128, 148–149, 152 early efforts for prescriptive authority for psychologists, 39, 40, 67–68 future prospects, 204 model legislative language, 70 strategies for influencing, 154–157 trends, 141–142 uniformity, 155 See also Credentialing and licensing Stigall, Tom, 72 Stimulant medications, 20–21 Strickland, Tony, 65

Taylor, George, 70 Texas, 127 Therapeutic alliance, 108–109, 112 collaborative advocacy and, 173 consumer perspective, 162–163 patient education and, xii in pharmacotherapy, 18–19 recovery process, 162 Thompson, Travis, 65 Treatment planning recovery model, 163, 164 safe prescribing practices, 202–203 Trichotillomania, 13 SUBJECT INDEX

225

Tricyclic antidepressants, 12, 13, 14, 22 Turner, Samuel, 70

Vector Research, Inc., 99–100 Vuchinich, Rudy, 65

Uniformed Services University of Health Sciences, 82, 83–84, 85–86, 89 Utilization mental health services, 4 overprescription issues, 19–21 psychopharmacotherapy, 4, 19–20 trends, 196 Uznicker, Rae, 172

Warren, Penny, 62 Wiggins, Jack, 72 Willis, Diane, 62 Wohlford, Paul, 65 Women’s health, 51

226

SUBJECT INDEX

Yates, Dee, 127

ABOUT THE EDITORS

Morgan T. Sammons, PhD, received his doctoral degree from Arizona State University in Tempe. He is one of the first graduates of the U.S. Department of Defense’s Psychopharmacology Demonstration Project. He has written and lectured extensively on psychopharmacology and prescriptive authority for psychologists. He is an associate editor of Professional Psychology: Research and Practice. Dr. Sammons is the coeditor of the book Combined Treatments for Mental Disorders: A Guide to Psychological and Pharmacological Interventions. He is a Commander in the U.S. Navy in full-time clinical practice as head of the Mental Health Department at the Naval Medical Clinic, U.S. Naval Academy, Annapolis, Maryland. He is a Fellow of the American Psychological Association, immediate past president of the Maryland Psychological Association (2001–2002), representative to APA Council for Division 55 (American Society for the Advancement of Pharmacotherapy), and a member of the board of directors of the National Register of Health Service Providers in Psychology. Ronald F. Levant, EdD, ABPP, earned his doctorate in clinical psychology and public practice from Harvard University in 1973. Since then, he has been a clinician in solo independent practice, clinical supervisor in hospital settings, clinical and academic administrator, and academic faculty member. He has served on the faculties of Boston, Rutgers, and Harvard Universities. He is currently dean and professor of the Center for Psychological Studies at Nova Southeastern University. He has also served as president of the Massachusetts Psychological Association, president of APA Division 43 (Family Psychology), cofounder and first president of APA Division 51 (Society for 227

the Psychological Study of Men and Masculinity), two-term member and two-term chair of the APA Committee for the Advancement of Professional Practice, two-term member of the APA Council of Representatives, and Member-at-Large of the APA Board of Directors. He is currently serving his second term as recording secretary of APA and as chair of APA’s Task Force on Promoting Resilience in Response to Terrorism. Ruth Ullmann Paige, PhD, has a group practice with focus on couples and people with chronic illness (multiple sclerosis, cancer, and diabetes). She is an APA Fellow, and her Washington State Psychological Association (WSPA) governance activities include Trustee of the APA Insurance Trust, member of the APA Presidential Unity Task Force, former member of the APA Board of Directors, Council of Representatives, Board of Professional Affairs, Committee for the Advancement of Professional Practice, and President of WSPA. Advocacy on behalf of psychology has earned her an APA Presidential Citation (2000); a WSPA Sustained Contribution Award (1999); a WSPA Distinguished Psychologist Award (1990); the Karl F. Heiser Award (1994); and a Certificate of Appreciation (1997) from the Society of Psychological Study of Lesbian, Gay, and Bisexual Issues. In 2002, she was awarded the APA State Leadership Award for work that assured representation of every state and division on the APA Council.

228

ABOUT THE EDITORS