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The Dawn of the 21st Century
In our last column we had the pleasure of describing the new psychopharmacology training program being developed by Ron Levant and Gene Shapiro at NOVA Southeastern University, based upon a “psychology model” which is respectful of psychology’s broad and comprehensive training and expertise as diagnosticians, researchers, and clinicians. In many ways, this initiative evolved from the vision and dedication of Florida Psychological Association (FPA) President Nancy Bacher, whose convention theme this year most appropriately was – “Entering the New Millenium: A Step Ahead.” Nancy wanted to be sure that prior to FPA’s legislative efforts to obtain prescriptive authority, that her colleagues would have access to high quality and equally importantly, locally-based training programs. At the same convention in which NOVA Southeastern announced its program, Ron Rozensky announced the University of Florida’s effort. Ron’s report: “Our program is designed to meet the growing demand for psychopharmacology education for practicing colleagues. In response to these educational needs and its own legislative initiatives, the Florida Psychological Association approached the University of Florida to prepare the curriculum necessary to upgrade the State’s 3200 psychologists’ knowledge base in psychopharmacology education. In response to initial positive reaction to this program, the University of Florida will be offering our training module in selected sites across the country. Planning for this effort has produced a dynamic team whose goal is to deliver high quality education to practicing psychologists without forcing those working professionals to attend traditional, campus-based programs. The team is made up of faculty from the University of Florida Health Science Center, content experts from around the country, and the Intelicus Professional Programs. Anita Brown, a graduate of the Department of Defense (DoD) program, is curriculum director and Glenn Ashkanasi is program manager. “Intelicus Professional Programs is a University of Florida partnership created to develop technologically advanced, user friendly, cost-effective educational programs designed to meet the unique needs of the working healthcare professional. The new program is based upon a proven ‘distributed learning model’ currently utilized to educate over 500 students around the country in various University of Florida/Intelicus’ degree-based and continuing education programs. These include both the doctor of audiology (AuD) and doctor of pharmacy (PharmD) programs. The unique format allows the student to participate in the program without regard to time or place. The program utilizes videotaped presentations from experts in their respective field and distributes these tapes to each student. This frees the student from the confines of attending regularly scheduled classroom sessions. However, the program facilitates a high level of communication and interactivity through Intelicus’ communication system. This leading edge internet site provides the practicing psychologist, as consumer of continuing education, with threaded discussion boards (message boards) and ‘live’ interactive discussion rooms. Students interact regularly with faculty, experts and fellow students in an environment free from the confines of space and time. The program does not sacrifice peer interaction. Regional knowledge interaction meetings are utilized to provide students with face-to-face access to faculty and fellow students. These informative meetings are held on the occasional weekend throughout the country, minimizing the student’s travel requirements and expenses. “Our new PsychoPharmacology Program will be based upon the APA’s model curriculum and takes a ‘problem based’ approach to learning — an approach becoming increasingly popular within medical schools. Built upon Anita’s own training experiences in the DoD project, her years of practice as a prescribing psychologist and leader within organized psychology at both the national and local level, and her own expertise as a teacher, this program will be designed to meet the educational objectives of psychopharmacology education with an approach relevant to the training needs of today’s practicing psychologist.” “We have developed what we believe is the optimum educational delivery system for upgrading the knowledge base of the working professional healthcare provider. We have a responsibility to assure a quality educational curriculum and teaching faculty who meet the highest standards of the University of Florida. Our faculty oversight committee will make certain that at every step of the way we build a continuing education program that assures that those who receive their certificate at the end of their course work can be proud of their academic accomplishment. As I indicated, the program will utilize professionals from around the country along with the recognized leaders from the University of Florida Health Science Center to develop a world-class curriculum. We will not overburden the practitioner’s personal and professional tine constraints. We expect the program to admit its first group of psychologists in January, 2000 and it is expected to be comprised of eight courses over a two year period.” [www.intelicus.com]. International Developments: This July APA Past-President Bob Resnick participated in the VI European Congress of Psychology in Rome, making the first presentation regarding prescriptive authority for psychologists. Frankly, Dr. Bob was a bit surprised when the Congress accepted his proposal. “There is real interest in the prescriptive authority agenda here. To an audience of 20-25 colleagues, I presented the history, evolution and present status of the movement including the success on Guam. [Those on the APA Council of Representatives recently learned from Ray Fowler that there are only 16 APA members there.] Their questions and concerns were essentially the same as American psychology ten years ago with the exception they were not as concerned about psychiatric opinions, hostility or views. The number of attendees was impressive because the convention hotel turned off the air conditioning from 9 a.m. to 2 p.m. to save on electricity. My presentation was at 1:00 p.m. It was a balmy 95 degrees or so in the meeting room.” Prior to our Boston convention Ray Fowler received a similarly enthusiastic response from colleagues at the African Regional Congress on Psychology, a meeting which brings colleagues together from all over the continent. Recall that Saths Cooper, Past-President of the South African Psychological Society, has reported that: “The Medicines Act in force here allows ALL health professionals prescription rights. We as psychologists need to submit a list of meds to the Medicines Council (our office will be doing this ASAP) which competent practitioners will be able to prescribe after taking our psychopharm course which begins next month and lasts ten months. We are on top of it and you may want to include us in whatever meaningful associations are key to this common end.” Excerpts from Ray’s talk, lest we collectively be tempted to forget that: “The past is prologue for the future”: “For over a century, psychology as a scientific discipline has made remarkable and steady progress in the United States. The establishment ofthe American Psychological Association in 1892 brought together scholars from several disciplines who began to identify themselves as psychologists and to expand the study of behavior and the human mind. From a handful of founders, the membership of APA has expanded to over 150,000, including 40,000 graduate students in training and thousands of international affiliates in countries all over the world. Psychology is recognized as a scientific discipline in virtually every college and university in the United States.” “The development of the professional side of psychology, the applications of psychology to human problems, came more slowly and had to overcome substantially more resistance than the scientific side. Several of the founders of APA were interested in the applications of psychology. William James, arguably the most important of our founding group, was a physician, a philosopher, an educator and a clinician....” “The resistance of the medical profession, and particularly of psychiatry, to the development of professional psychology has been strong and consistent throughout the history of professional psychology in the United States. A century ago, the medical society of the state of Massachusetts tried to pass laws to limit the practice of psychotherapy to physicians only. William James, then president of APA, prevented that by appearing before the Massachusetts legislature and declaring that neither psychologist nor physicians knew much about psychotherapy, but the promise for future progress lay more in the providence of psychology than in medicine.” “But William James could not be everywhere. The efforts of organized medicine to resist the expansion of psychological practice continued and, in fact, continue today. Medical societies have used their much greater financial and political strength to block or at least to delay almost every expansion in the scope of practice of psychologists: Let me name just a few. In the early days of psychological testing, laws were passed requiring that even the determination of an IQ, based entirely on the results of testing by a psychologist, had to be confirmed by a physician.” The use of psychological testimony in court was delayed for years by the efforts of medical groups to discount their significance. Psychiatrists tried for decades to prevent psychologists from diagnosing mental disorders, claiming that that was exclusively a medical functioning. “The resistance of organized medicine to the practice of psychology greatly intensified after World War II as increasing numbers of psychologists moved into the practice of psychotherapy. In many hospitals and clinics, psychologists were regarded as psychometricians and could only do psychotherapy under the supervision of a psychiatrist. Psychoanalytic training institutions, largely dominated by psychiatrists, routinely excluded psychologists until that exclusion was challenged in court. “Psychiatrists were particularly eager to prevent competition in the private practice of psychotherapy. When psychologists initiated licensing laws to regulate the practice of psychology and protect the public, medical societies, and particularly psychiatrists used their money and influence in an effort to defeat these laws. They eventually lost the battle – every state now has licensure – but they were successful in delaying licensure in some states by up to 20 years.” “But medical groups were not alone in resisting the progress of professional practice. Many academic programs considered it a distraction to the development of scientific psychology and for over a half century training in professional psychology was virtually excluded from most psychology departments. Some powerful academic psychologists considered psychological testing as an activity suitable only for women and only at the sub-doctoral level, and sided with physicians in declaring psychotherapy as exclusively the providence of the medically trained. Some psychology department heads even testified before legislatures to prevent the passage of licensing laws, fearing that the professionalization of psychology would inhibit the progress of psychological science. Even today, some psychological scientists look down on applied and professional psychology and devalue its importance.” “I have briefly reviewed this history to provide a context for the current efforts to further expand that scope of practice to the prescribing of medicine. The struggles by professional psychologists in the United States to expand psychology’s scope of practice have been difficult and often long delayed, but progress has been steady and virtually all of the battles eventually won. The current efforts recapitulates that century long struggle. The American Psychological Association believes that psychology’s efforts to seek prescription privileges is simply part of the natural growth and development of the profession in response to continuing unmet patient needs....” Why Should Psychologists Prescribe? Psychology has far exceeded psychiatry as the largest doctoral level provider of mental health services. In many communities, psychologists are the primary providers of mental health care and psychiatrists are virtually absent. Fewer and fewer psychiatrists are being trained, and many of those have little or no training in psychotherapy.... Up to 80 percent of psychotropic drugs are prescribed by physicians who are not specially trained in treating psychological disorders. Only five percent of individuals with mental disorders are ever referred by physicians for mental health services.... This gap in mental health services in the U.S. is compounded by the scarcity of skilled mental health providers in the less populated areas. Many of these mostly rural areas simply do not have psychiatrists, but do have psychologists.... “OPPOSITION. The effort to obtain prescription privileges for psychologists is following a path similar to other expansions of the scope of practice over the years. First, a new concept is described and promoted by a few visionaries, and gradually, as the idea becomes more familiar, increasing numbers of psychologists begin to support it. This happened with psychotherapy, with licensure and now is happening with prescription privileges. When initially proposed, few psychologists supported the idea, but over the past few years, a consensus on the issue seems to have developed. On the basis of surveys, it appears that about 3/4 of psychologists are in favor.... But as expected, the movement is not without opposition. Within the profession, the loudest opposition comes from a small, but very vocal minority of mostly academic psychologists who actively oppose prescription privileges. Like their predecessors who opposed licensure, they often write articles and letters expressing their opposition, and at times have even testified against pending legislation. Their main fear – one we believe to be unfounded – is that prescription privileges will somehow ‘change’ the profession or lead psychologists to abandoning their core training in assessment and intervention – particularly psychotherapy.” “Outside of the profession, as you can imagine, some health care provider groups have raised concerns about providing psychologists with prescriptive authority. Organized medicine, especially psychiatry, has stridently opposed our efforts to obtain prescription privileges. Their main arguments center on patient safety, and the contention that no professional can safely prescribe unless they have completed medical school....” ADVANCES. In spite of this opposition, there has been progress on a number of fronts.... The (DoD) prescribing psychologists themselves stated that they believed they were received well by their peers, including military psychiatrists. Since there is a tendency in the U.S. for psychoactive drugs to be over-prescribed, it is notable that the prescribing psychologists frequently use their prescription privileges to remove patients from medication.... WHAT DOES THE FUTURE HOLD? Clearly, the fight for prescription privileges has been and will continue to be a significant challenge for psychologists in the United States. However, our recent successes make us cautiously optimistic that we will succeed in the near future. We will continue our efforts to: • Pass laws allowing psychologists to independently prescribe medication. • Train psychologists in anticipation of such a law passing, and • Continue to develop the profession in new and creative ways that will help us help bridge the gaps between what patients need, and what psychologists can provide.” Back At Home: Former APA Congressional Fellow Danny Wedding recently shared with us his vision regarding whether there are “too many psychologists in Missouri.” Noting that there is growing concern about what is perceived as a marked oversupply, Danny strongly urged his colleagues to branch out into previously often overlooked areas, such as providing services for traditionally underserved populations such as the chronically mentally ill, urban poor, rural citizens and incarcerated individuals. “The opportunities to serve the rural poor seem especially compelling for Missouri, where there are a large number of counties that have few or no doctoral level mental health providers.” There are 75 percent more licensed psychologists than psychiatrists in Missouri. “In addition, we can actively work to support Senate Bill 503. This bill would significantly enhance the scope of practice for appropriately trained psychologists, allowing them to prescribe psychotropic medications appropriate for the treatment of their patients. With passage of this bill, patients in the 17 Missouri counties in which there are psychologists but no psychiatrists would potentially be able to have their medications prescribed and monitored by a doctoral-level behavioral health provider without being required to travel long distances for this care. It is also likely that the passage of SB 503 and the enhanced scope of practice it would provide would encourage psychologists with training in psychopharmacology to migrate to Missouri; some of these practitioners would likely be attracted to positions in the rural areas of the state in which they could offer comprehensive treatment including psychosocial interventions, behavior therapy and psychopharmacological services.” Those Congressional Science Fellows truly see the “bigger picture.” According to Allan Barclay, the Missouri legislation had been reintroduced, having been voted out of the Senate Committee the previous session with a five to one majority. Term limits has become a significant factor in the Missouri legislature, thus providing psychology with the opportunity of educatingentirely new players. Allan is confident that the most recent, and highly positive, GAO report on the DoD prescribing psychologists will have a significant impact during the coming legislative session. From The Front Lines: [Bob Nevels] – “In May, I finished the didactic series of training with the Prescribing Psychologists’ Register (Series 17), having started Series 1 in 1995. With one annual update in 1996, there was a total of 319 didactic hours across all categories and subcategories as recommended by APA’s panel on psychopharmacy training. The training was thorough and, at times, quite taxing. I took 18 legal pads full of notes, read close to 3000+ pages of handouts and 2000+ pages in texts. (The total PPR Series material covers a space of approximately six feet on my library shelf.) In addition, I spent my Friday and Saturday nights, in otherwise interesting places like L.A., San Francisco and New York, going over notes, handouts, books and exchanging questions with my home state PPR roommate, Eldridge Fleming. Okay, we toured and played some. Instructors for this training included folks like John Preston, Clifford Lazarus, several physicians and a Pharm. D., and James Meredith, one of the DoD prescribing psychologists. All were excellent lecturers and notable contributors to the field of psychopharmacy as researchers, authors and practitioners. I am now in the process of completing a 100 patient preceptorship and am amazed at the recall I am experiencing though, with the exploding plethora of psychotropics and other medications, I frequently check and double check for drug interactions, side effects, half lives and dosages/dosing schedules. I have been greatly enhanced by this training and have found it invaluable in treating my clients.” [David Pritchard] – “I started Georgia’s psychopharmacology training program for psychologists with some trepidation. I had not been in a classroom as a student nor sat for grade-determining examinations in over 20 years. But as my anxieties quieted and my confidence built, I became fascinated with the complexities of psychopharmacology. There was as much here to learn as in psychology itself! After two years of classroom work, I realized that psychopharmacology shared with psychology the same ever-changing theories, the same empirical ambiguities and the same methodological limitations. My training in psychology had prepared me well for the uncertainties of psychopharmacology. Yet, I was uncomfortable applying my newfound psychopharmacological knowledge to real patients (at this point, simply monitoring their response to medications prescribed by others, but hopefully in the future actually prescribing medications myself). Anticipating how a patient may react to a certain medication or combination of medications requires more than a general understanding of psychopharmacological principles; recognizing a patient’s complaint as an adverse effect of a drug or of an interaction of drugs requires detailed knowledge of the kinetics and dynamics of each drug. I simply could not store and retrieve such a wealth of detailed information. I therefore set out to write a computer program which I could use in my clinical work that would store and retrieve information about individual psychotropic drugs and apply it to individual patients. The program would need to include information about currently used psychotropic medications and information about individual patients that might pose a risk for a particular medication. The result is a computer program (‘Medication Manager’) that allows input of patient identifying information, selection from over 250 different patient risk factors and ‘prescription’ of over 250 different psychotropic medications. Whether used to actually prescribe a new medication (e.g., by a physician, physician’s assistant, nurse practitioner or psychologists in Guam) or to simply monitor a patient on medication, Medication Manager brings together in one place the information needed to safely deal with psychotropic medications. In addition, all information in the program (e.g., drug information, risk factors, laboratory values) are modifiable by the user and new information can be added as research by scientists and product development by pharmaceutical companies progresses. I feel more confident now that I can speak intelligently about the possible effects of a medication on a particular patient. Although there are still uncertainties in psychopharmacology and in clinical practice, Medication Manager does what computers do best – it stores and retrieves relevant information needed for informed decision making. Medication Manager can be downloaded from www.stonewallsoftware.com.”
Pat DeLeon, Ph.D., J.D.. is president of APA and a long-time columnist with The Independent Practitioner. |
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| Patrick DeLeon, Ph.D., J.D. | |||||
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