There are so many ways that our colleagues have, over the years, made a significant difference in the lives of our nation's citizens. Caught up in the day-to-day crises of practice, we often do not take the time to collectively reflect upon how fortunate we are to belong to the family of psychology. As we enter the 21st century, increasing numbers of colleagues are beginning to understand that we are one of the healthcare professions. A Wyoming Visionary and Nurse Clinical Specialist - Former Division President Mike Enright is truly a role model for the next generation of innovative practitioners as evidenced by his successful quest for prescriptive authority (RxP) through the process of obtaining his professional nursing degree. Ranger Mike, always on the cutting-edge of change: "The Nurses in Wyoming just passed a new practice act that will likely become the model for the country. We already had a good law but this new legislation eliminated the requirement for a plan for 'collaboration' with another 'health care provider.' Advanced practice RNs [APNs] in Wyoming are now totally autonomous providers. The law includes Clinical Specialists (like me) as well as Nurse Practitioners [NPs].

"At a time when forces opposing prescriptive authority have convinced pharmacists in some states (i.e., Alabama, Kentucky, Nevada, New Jersey and Texas) to place the names of the 'Collaborating Physician" on the label of the prescription bottle instead of the prescribing APN, the Wyoming legislation is ground breaking. With the new nursing practice act this can't happen in Wyoming.

"Wyoming APNs have had, and continue to have authority to prescribe controlled substances – another state by state battle ground. These are the scope of practice issues that must be addressed in the psychology prescriptive authority initiative. I can attest to the importance of being able to practice without hostile supervision and with a full formulary, since many of the conditions that I treat require Schedule II & III agents. I continue to believe that psychologists can learn important lessons from the experience of our nursing colleagues –especially in the area of writing legislation free from oversight or required 'collaboration' from state boards of medicine.

"Although I have not been active in APA over the past four years, I continue to be the lone behavioral health voice on the National Advisory Committee on Rural Health and Human Services. It is vitally important to maintain a psychologically oriented professional at this level of policy debate and formulation. I hope this brief missive finds you well my friend. Keep your feet in the stirrups and your eye on the sky line. Ranger Mike." Not only is Mike a former President of our Division, he has also been a candidate for the office of APA President. A Karl F. Heiser Award winner in 1993, Mike will soon share that special honor with California legislative visionary and psychologist-Nurse Practitioner Ann Carson.

A New Mexico Prescribing Psychologist - Elaine LeVine: "I have been prescribing for about a month now. I have had a number of positive experiences already. Given the grueling efforts needed to pass a prescribing psychologist law, my short life as a prescribing psychologist highlights why it is worth psychologists pursing this path. For example, a pediatrician and I tried for three months to get a very troubled youngster an appointment with a local psychiatrist. When he finally got the appointment, the psychiatrist, who is very skilled but overwhelmed by his case load, saw the mother for twenty minutes, told her he would write for the boy's record and get back in touch with her, and never followed through. I then became a prescriber. The pediatrician and I embarked upon a plan (he had not wanted to do this before I was credentialed to prescribe and before we attempted to contact a psychiatrist), and it has been remarkably successful. The parents and teachers are thrilled with his progress, and most importantly, the patient says he is very much improved

"I am finding that the collaborative relationship with the primary care physician is working very well. The physicians are quite willing to discuss the patients' care and, so far, have been 100% open to my medication recommendations. Before I was a prescriber, if I recommended a specific medication, the physician might respond, if he or she was unfamiliar with the drug, that he or she would evaluate the patient and decide what to do. As an example, I might recommend a mood stabilizing medication for a bipolar disorder. If the physician was not familiar with these classes of medications, the physician might prescribe an antidepressant (with the obvious potential effect of stimulating a manic episode). Now that I have a license/certificate to prescribe, the physicians have been quite willing to defer to my judgement regarding the specific medication. Their input regarding the medical management of the patient has been very helpful. There are new issues every day in this new territory. For example: Who should take my call when I am unavailable?

The best person would be a prescribing psychologist because no one else is prepared to deal with both the psychological and the medication issues, but so far there are only two of us in the State! There are issues regarding getting a DEA license; the government has not figured out there are prescribing psychologists yet. Pharmacists wonder how to code us. Pharmaceutical companies wonder if they can sample us. All this commotion is actually kind of fun. It doesn't have the same vicious underpinnings as our legislative battles. Out here in the primary care, everyone seems to have the same goal of getting care to the patients, in an underserved and overburdened medical arena. The question is how to get through and over all the hurdles. I will stay in touch about what happens next."

Improving Access - The Prescriptive Authority quest has always fundamentally been about providing the highest possible quality of care in a timely and cost-effective fashion. It provides educated consumers with a real choice. As Russ Newman has consistently emphasized, the psychological perspective regarding the use (or non-use) of psychotropic medications is qualitatively different from the historical perspective of medicine. From a public policy perspective, we should not have been surprised when DoD Prescribing Psychologist Morgan Sammons informed us that the Robert Wood Johnson Foundation concluded that: "Texas, New Mexico, and Louisiana have the highest proportion of working adults without healthcare coverage.... Nationally, 41 percent of uninsured adults report being unable to see a doctor when needed in the past 12 months, due to cost, compared with nine percent of adults who have healthcare coverage." Our RxP colleagues are on the front line in these areas providing vitally necessary health care. Earlier this year, APA Council Representative Glenn Ally reported: "On February 18, 2005, the first prescription was written by a civilian 'medical psychologist' in Baton Rouge, Louisiana under the new RxP law signed by Governor Blanco. Dr. John Bolter wrote the first prescription – a prescription for Remeron (for the trivia folks). This was an historic moment for the Louisiana Academy of Medical Psychology, for the citizens of Louisiana, and for psychology as a profession." Former APA Congressional Science Fellow Danny Wedding notes from the AMA: "So far only two psychologists in New Mexico and two in Louisiana have completed the certification process. Another 40 psychologists are in various stages of training in New Mexico and are expected to qualify over the next two years. In Louisiana, 50 psychologists are expected to receive prescribing certificates by the year's end." The ICEBERG described in our last column is definitely migrating.

In Hawaii, one can definitely feel the flow tide for psychology where two colleagues who work within our state's community health centers, Jill Oliveira-Berry and Robin Miyamoto, have taken the lead on behalf of HPA's RxP legislative efforts. Jill is a Native Hawaiian and member of the APA Committee on Rural Health. Health centers are the "safety net" for the uninsured with Native Hawaiians receiving more health care at the centers than any other ethnic group. After extensive public hearings focusing upon the critical issue of access - and with the enthusiastic support of the Hawai'i Primary Care Association and each of the center medical directors –two Senate Committees recommended the enactment of legislation which would have allowed appropriately trained psychologists to prescribe within federally qualified health centers. HPA was one vote short on the Senate floor. However, subsequently House Concurrent Resolution #255 passed both bodies, "Establishing An Interim Task Force On The Accessibility Of Mental Health Care To Consider The Feasibility Of The State Authorizing Trained And Supervised Psychologists To Safely Prescribe Psychotropic Medications For The Treatment Of Mental Illness." Jill: "The resolution basically seeks to form a task force that will consist of the chairs from the House and Senate Health Committees, along with two appointees from HPA and the Hawaii Psychiatric Medical Association." These two legislators know the issues well and it is anticipated that implementing legislation will be introduced next session.

Serving Our Nation With Distinction - Lt. Blake Mitchell: "The members of the USS Abraham Lincoln Carrier Strike Group were able to have an opportunity few others in the armed forces have: we were afforded the opportunity to lend humanitarian aid and disaster relief to hundreds of thousands of people who were affected by the tragic tsunami that struck Southeast Asia on 26 December 2004. For over 35 days, the crew worked tirelessly, seven days a week lending assistance off of the coast of Banda Aceh, Sumatra, Indonesia. In planning for this new mission, an attempt to psychologically prepare the crew for the unexpected was developed. We created a pre-brief and mandated that all members assigned to go to 'the beach' attend. We prepared a brief, from what little information we did have, detailing what will likely be experienced on the beach - the destruction, human casualties, etc. - and some of the common human reactions to seeing things like that. We also promised continued follow up at any time and once the mission was complete.

"Once we began to wrap up our portion of the mission, we again gathered those who went ashore and participated in the efforts for a post-brief. The sailors gathered, told their stories and were again, told to watch out for one another and to follow up with any of the providers should anything arise at any time. Fortunately, the overwhelming topic of conversation throughout the post-brief was the indescribable joy and excitement that they experienced as they were able to go and assist their fellow man at such a time of unspeakable disaster. We all left knowing that we were the ones that truly received the most by our presence in Banda Aceh.

"It was a very rewarding endeavor for the entire ship. However, just like any other mission, there were those who struggled with mental health issues. First, the change in mission extended the amount of time we were all going to be away from homeport. And, for the first several weeks of that time, we did not know how long that extended separation was going to last (rumors ranged from no extension to a three month extension). Also, many people who had selflessly volunteered to help found themselves unable to get off of the ship and participate in the effort, causing considerable feelings of frustration and uselessness. Finally, over the first 7-10 days of our time on station, we witnessed a large number of human bodies floating out near the ship, approximately 5-15 miles from land. The bodies witnessed by the crew members ranged in ages from very young to adult.

"The emotional distress resulting from these experiences tended to cause a wide variety of emotional problems for some of the sailors: depression, anxiety, anger management difficulties, and so on. My goal was to offer a wide variety of resources to help counter these emotional struggles. Fortunately, I am not alone in my endeavor. We have an excellent Chaplain department, which does a considerable amount of individual counseling, an MWR (morale, welfare, recreation) division that offers a wide variety of opportunities to enjoy life out here (gyms, games, movies...) and an excellent substance abuse treatment program. I rely heavily on their outstanding services.

"However, as a mental health provider, my psychiatric technician (HM1) and I offer a wide variety of services to help improve the mental health of those on board and within the strike group. We spend a large portion of our time in individual assessment and counseling. Members present either to main medical during regular sick call hours or we get phone calls/e-mails directly from members and/or their chain of command. We make an initial assessment on all individuals brought to our attention and then make the most appropriate referral.

"We have a variety of groups that take place on board. We offer a weekly anger/stress management group that can be attended after an initial interview. We also offer a women's anger/stress management group (run by our female HM1 psych tech) where the female population on the boat is able to come and discuss issues specific to the unique struggles they face as females in a very male dominated environment (approximately 90% male). We also offer Alcoholics Anonymous group and more formal Continuing Care groups for those who have recently completed alcohol treatment and are looking to maintain sobriety for an extended period of time. We also give anger management and suicide awareness briefs to a variety of the commands and organizations embarked on the USS Abraham Lincoln.

"However, my opinion is that being out and about the ship, being seen and known by the crew (officers and enlisted) is the most important part of my job. I have attempted to integrate myself into the daily workings of the ship by receiving a qualification to stand a combat watch, working on my surface warfare qualification and making the effort to ride on several of the other ships in our strike group in order to assist them whenever possible. After having been here for several months and trying to be approachable and allowing my shipmates to get to know me, an environment has been created where they appear to feel very comfortable stopping me in the passageways, calling me on the phone or e-mailing me any time questions or concerns arise. Many of my 'counseling' sessions are impromptu encounters when a sailor, chief or officer stops me and tells me about some experiences and I offer a quick word or two of encouragement. It is very different from how I was trained, but it is equally, if not more effective. And, just like our sailors said as we were leaving Banda Aceh, I hope that the people I had the opportunity to help have received as much as half of the benefits I have received from being a part of this outstanding team. I know that I am a better person for having had these wonderful experiences." [views expressed are personal and not that of the DoD or the US Navy.]

Aloha and Mahalo

Pat DeLeon is a former APA President

Return to Top