A pretty significant thing occurred recently, although I don't doubt that most readers may have missed it so far. The state of New Mexico recently approved a law allowing properly trained and licensed Psychologists to prescribe psychiatric medicines. This new law, is the first of its kind in the United States. It is groundbreaking legislation that has the potential to significantly reform for the better the current inefficient mental health care delivery system. Or change it around anyway.
Everyone knows that the mental health care system has undergone massive changes over the past decades. Power has increasingly shifted away from doctors and towards health insurance and drug companies. Traditional health insurance plans have all but died out, replaced by more `efficient' managed care models. Drug company breakthroughs have also occurred, so that it is now possible to treat most mental disorders with medicine, rather than with psychotherapy alone. As a result, when mental health care is offered these days, it is generally first offered in the form of medicine. Drug companies, for their part, now market directly to potential patients who, in turn ask their doctors to prescribe specific medicines. Patients and physicians both have come to expect a medical solution to mental health problems.
But this reliance on medicine to fix mental health problems has created a bottleneck. In a truly just world with unlimited resources, psychiatric medicines should be prescribed by a knowledgeable licensed physician who possesses expert knowledge of mental health issues, (a Psychiatrist). The thing is, though, that we don't live in a truly just world, and there just aren't nearly enough Psychiatrists around to meet demand. This shortage of qualified Psychiatrists is particularly acute in rural areas of the United States.
Two alternative classes of professionals exist who might be able to fit the bill; General Practitioner physicians, and Psychologists. General practitioner physicians are able to prescribe psych medicines, to be sure, but, by necessity of their general medical calling, cannot treat mental illness as more than just a sideline. Psychologists, in contrast, are expert with regard to mental illness, but are generally disqualified from prescribing regardless of how well trained they might be to do so because they are not physicians.
It does make sense for Psychologists to be able to prescribe psychiatric medicines if they are properly trained and licensed to do so. Psychologists have typically completed five or more years of doctoral clinical training in mental health diagnosis and treatment, have completed a year long hospital residency, and have practiced under supervision for 2000 hours (a full year) before being allowed to practice independently. Psychologists already deal with psychiatric medicines on a regular basis (many of their patients are on them and they must become aware of what medications are used for what in order to do good work). In many cases, Psychologists are actually in a better position than Psychiatrists to know when medication adjustments should be made; They see their patients multiple times per month (in the course of psychotherapy) while Psychiatrists are lucky to see a given patient six times in a year. Other things to keep in mind are that making psychiatric prescriptions is not really rocket science (although it clearly does require a rigorous course of study, supervised practice, licensure, and continuing education in order to be done properly and accountably), and that Psychologists are generally very bright people who can learn how to do it right. By and large, prescription-making is not a creative art, but rather a matter of learning standard dosages, drug interactions, side effect profiles and how to handle emergencies. Psychologists will only gain prescription privileges for a limited subset of medications relevant to their work; they will not become licensed to offer surgery or anything really complicated like that. It just makes sense that prescribing and psychotherapy functions could be rolled up into one profession to achieve significant cost and communications savings. And there will be significant cost savings - because Psychologists are willing to work for less money than Psychiatrists.
There is another motive too, a little more guild-related, to which I (as a Psychologist) will admit to. The profession of Psychology is in and has been in a crisis of identity for some time. In the 1940's, Psychiatrists provided psychotherapy and Psychology didn't really exist as a clinical field. Throughout the 50's, 60's and 70's, Psychiatry started to move away from psychotherapy (partially because the dominant Freudian school of thought didn't produce results, and partially because the new psychiatric medicines that were introduced during those decades did). Clinical Psychology (as doctoral a profession as Psychiatry) moved in and appropriated psychotherapy, turning it into a measurably useful set of methods for treating mental illness. However, the rise of managed care and the continuing introduction of new and ever more useful psychiatric medications in the 80's and 90's resulted in less funding for and less access to psychotherapy. At the same time, a host of masters level professions (lead by Social Work) started becoming psychotherapists too - and Social Workers are willing to work for even less money than Psychologists. . . Psychology is thus today squeezed between Psychiatry (prescription privileges) and Social Work (cheap therapy) and fighting for ground. Among other purposes, prescription privileges will help Psychologists to have a place to go.
It goes without saying that many Psychiatrists don't like this new law. For Psychiatrists, any prescription ground gained by Psychologists will be perceived as a loss. But it is ultimately money that rules the day in America, and not guild prestige. If Psychiatrists are going to be successful in holding on to their turf, they'll have to convince those with power that they are fighting prescription privileges for Psychologists on grounds more substantial than that they don't want to earn less money.
Perhaps more surprisingly, many Psychologists oppose prescription privileges for Psychologists. Generally, the argument within Psychology against prescription privileges goes something like, “Right now, Psychologists are expert at psychotherapy. We will lose this expertise and become nothing more than junior physicians if we go down the path of prescription privilege”. Generally, this argument is made either by senior therapists, already finished with retirement planning and putting kids through college, or by academicians who have an investment in an idea of professional purity.
There is some merit to this argument, I think, but it is short-sighted and a little petrified too. The main stream of treatment has been drifting away from psychotherapy as exclusive treatment, (from being a part of treatment at all in some cases) and towards medicine. For Psychologists to not pursue expertise as prescribers of medicine is foolish for the profession, and (dare I say it) ultimately harmful to those persons served by Psychologists who deserve the best and most integrated care that our strained healthcare system can afford to fund.
And so, if it wasn't apparent before, hopefully it is now: The new New Mexico law is the first beachhead in a turf battle between mental health care professions. Having lost professional ground to Social Workers who showed merit as psychotherapists, Psychologists have been using the same tactics on the medical profession, and have now won a significant battle. But a battle is not a war. It remains to be seen how well the prescribing Psychologists of New Mexico will do, and how tenaciously the Psychiatrists will hold on to their monopoly. I'm betting on the Psychologists myself although it will probably take a few more decades before the dust settles. Why? Because we can do it for less. Maybe the Psychiatrists should consider taking up surgery? For that matter, maybe the Social Workers should take up surgery.
Mark Dombeck, Ph.D.