Beware psychiatrists bearing gifts.
If psychology wants to remain a science based upon the understanding of human behavior — both normal and abnormal — and helping those with the “abnormal” components, it would do well to avoid going down the road of prescription privileges. But perhaps it’s already too late.
We first noted this disturbing trend in 2006, how they were shot down 9 out of 9 times trying to gain prescription privileges in 2007, and why prescription privileges for psychologists will eventually drive psychiatrists out of a job. We also noted that one of the programs setup to help psychologists get prescription training wasn’t a “college” at all.
The fundamental problem with psychologists gaining prescription privileges is the inevitable decline over time in the use of psychotherapy by those same psychologists. This is precisely what happened to psychiatry — they went from the psychotherapy providers of choice, to the medication prescribers of choice. Now it’s hard to find a psychiatrist that even offers psychotherapy.
Psychologists claim that they are somehow “different,” and that their training makes it less likely they would simply go to an all-prescription practice over time. But those claims ring hollow to me.
By switching to a heavily prescription-based practice, a psychologist will be able to nearly double their salary. Can you imagine any other field where you can double your salary with an additional 2 years’ worth of training? Are proponents actually suggesting that money has little or no significant impact in helping a person make career decisions? (We only have a few decades’ worth of research to demonstrate how money does indeed influence our decision-making process.)
My good colleague Dr. Carlat has the first salvo — in anticipation of his upcoming book (which is a must-read when it’s published in May) — on his blog, Psychologists Prescribing: The Best Thing That Can Happen to Psychiatry. His argument in a nutshell:
[P]sychiatrists are not [yet] losing business [in the 3 states where psychologists can prescribe]. But as more and more states approve prescribing psychologists, this will probably change. I predict that patients will vote with their feet and preferentially see prescribing psychologists once they realize that such practitioners provide one-stop shopping—meds and therapy combined.
And herein lies the great opportunity for psychiatry. As psychologists gradually become serious competitors for our patients, we will have to re-evaluate how we practice and how we are trained. We will have to take a close look at our catastrophically inefficient medical school-based curriculum. We will have to decide which medical courses are truly necessary and which are not.
So what evidence does Dr. Carlat have that psychologists will continue to offer both psychotherapy and medications? Sure, the initial psychologists will stick close to home — psychotherapy — and use medications as a sometimes-adjunct to help therapy get its kickstart. That makes sense, as they’re likely to be a little older and well-established in the field.
But as more and more psychologists gain prescribing privileges, what’s to stop the profession from following in psychiatry’s footsteps? Why wouldn’t a large group of clinical psychologists — perhaps even a majority in a few decades’ time — just turn to the same “dark side” psychiatrists have turned to … What’s to stop them from going to the 3 or 4 medication check-in appointments per hour that most psychiatrists do?
I suspect proponents of psychologist prescription privileges believe that because of psychologists’ fundamental, significant training in psychological methods and behaviors, this makes them less likely to be influenced by pharma’s siren call. But without specific data one way or another, I’d defer to the evidence that we already have:
- Psychiatry went from primarily doing psychotherapy to primarily prescribing medications in the course of a few decades.
- A significant body of research demonstrates the influence of money on human decision-making
- Psychologists have not demonstrated why or how they would forgo the influence of money and follow psychiatry into the same pharma-focused model of treatment (psychotherapy is hard; medication is easier and people prefer ‘easy’)
For these reasons, psychologists shouldn’t prescribe — it’s likely to dilute psychology’s focus and function. They should remain the primary psychotherapy experts that their four years of didactic training — mixed in with direct clinical experience during most of that time plus the additional year of internship — have provided. To gain prescription privileges is to open the door to losing that expert position in the future.