Contributing Editor’s Column
A New Direction for Professional Psychology
A year ago, we highlighted the visionary accomplishments of Prescribing Psychologists Mike Enright (Wyoming) and Elaine LeVine (New Mexico). “Ranger Mike” is a former President of the Division who set out to obtain his nursing degree. “Advanced Practice RNs (APNs) in Wyoming are now totally autonomous providers.... 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 experiences of our nursing colleagues – especially in the area of writing legislation free from oversight or required ‘collaboration’ from state boards of medicine.” Elaine, who had just begun her prescribing practice, noted: “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.” These two colleagues are truly ground-breaking role models for our next generation and all of us owe them our deepest appreciation for their dedication to the field, their persistence, and their courage in charting a “new direction.”
An Update From “Ranger Mike”: “I am embarked on a professional odyssey as a psychologist who chose to return to academia and earn an advanced degree in Nursing. My stated goal when I began this program was to enhance my practice and become the consummate mental health professional by expanding the scope of my practice to include prescriptive authority. The journey has met and exceeded my expectations. I received my MS in Nursing in 2001 and have had a DEA number (with the authority to prescribe controlled substances) for five years. Perhaps a meaningful measure of my success in becoming the only professional in Wyoming who can offer psychotherapy, psychological assessment and prescribe for my patients is the fact that several physicians in my community have asked me to provide prescriptive oversight for them personally. There can be no greater measure of acceptance and respect in the prescribing community than that of having an MD come to you for your expert opinion regarding personal care and treatment.
“I have watched the number of Advanced Practice Nurses (APRNs) grow in my community (likely in part due to the favorable nurse practice act in our state) and have been gratified to have inherited a whole new set of colleagues. As you know rural practice is, by definition, isolating – especially rural psychological practice. With this new set of colleagues the flow of information is reciprocal between our offices with psychological information flowing out of mine and current primary expertise flowing in. I have no doubt but that this has made all of us better practitioners. The collaborative nature of the nursing profession is one of the reasons why I never second guessed my decision to take up nurse training. Not a week goes by that I don’t hear from a local APRN.
“I recently attended a retirement party for a colleague and in the course of conversation with a group of psychologists my prescriptive authority came up. A senior psychologist looked at me and said: ‘I think the study of psychopharmacology would be fascinating but how can you stand seeing all the patients that you don’t really know, handing out scripts all day?’ This woman worked in a large psychiatric receiving facility and assumed that because I had prescriptive authority that I took on the role of a psychiatrist. Nothing could be further from the truth. In fact the corpus of my prescribing work is with people that are part of my practice. These are patients that I know very well. In my practice, psychotropic medication (if it is prescribed at all) is just one facet of a comprehensive treatment plan. There appears to be a misconception on the part of some colleagues that if you can prescribe, your practice radically changes in a negative way. On the contrary, my practice has radically changed – for the better. I now make ALL of the treatment decisions (in collaboration with my patients) and spend zero time trying to contact (sometimes unresponsive) medical providers in an attempt to get their permission to start, stop or change the dose of a drug. Should I need to bring a primary care provider into the decision loop I have several competent colleagues to chose from – but most of the decisions remain in my consulting room and are made between me and the person who is going to actually take the medication. After five years of prescribing I am happy to report that I continue to be a psychologist with a special expertise (made available to me through my advanced nurse training) and not a wannabe psychiatrist. I don’t think I could have dreamed of a better outcome from my studies and enhanced scope of practice.
“My training as a nurse also added a ‘fringe’ benefit. When my daughter (who is an EMT [emergency medical technician]) graduated from college last year she chose as her graduation gift to join me on a trip to Nicaragua to help set up a medical clinic in a remote village about 50 kilometers south of the Rio Coco. The NGO [Non-Governmental Organization] in Nicaragua was uncertain about having a psychologist on a primary care treatment team but became elated when they found out that I was also licensed as an APRN. My daughter, who speaks Spanish, provided triage and served as my interpreter as I saw over 400 patients in a long week of remote third world health care. Along with my primary care duties I was asked to consult on any problems that looked even remotely ‘psychological’ including several, bullet riddled, victims of the war (between the Sandinistas and the U.S. backed Contras) with lingering PTSD symptoms. The culture was somewhat hostile – we traveled only by day and had armed guards 24/seven for security – but the people were warm and generous with their friendship. It was a father-daughter trip that we will always remember and treasure – and would have been impossible without my nurse training.” [The Department of Health and Human Services (HHS) estimates that in 1984 (the year U.S. Senator Daniel K. Inouye urged the membership of the Hawaii Psychological Association to seek prescriptive authority) there were 16,886 registered nurses who reported being employed as Advanced Nurse Practitioners; representing 1.2% of all employed nurses. In 2004, it is estimated that there are 81,363 nurses employed as APNs; approximately 3.4% of all employed nurses.]
Prescribing Psychologists’ Personal Experiences: Mike’s observation regarding the preconceived notions that some of our colleagues possess as to how psychologists will actually utilize psychotropic medications in their practices is extraordinarily important. Accordingly, we asked several of our prescribing colleagues to share their experiences with us. “One of the most satisfying aspects of being a prescribing psychologist was the way in which my psychopharmacology skills were appreciated by the primary care providers with whom I worked. During my last three years in the Air Force I had an office in the Primary Care clinic and functioned as the mental health consultant to the primary care prescribing providers, which included physicians, physician assistants, and nurse practitioners. Without exception these providers welcomed having a prescribing psychologist provide the follow up and education to the patients identified as having problems that might require psychopharmacological intervention, and this was before the new FDA recommendations of increased follow up for patients placed on antidepressants. This experience was repeated when I worked as a psychopharmacology consultant to primary care providers in the VA hospital in San Antonio as well as in my collaboration with primary care providers in my private practice. These primary care providers are potential powerful allies in our efforts to get our patients timely and appropriate pharmacological interventions” [Jim Meredith].
“Early on in my prescribing career, I felt so intimidated by the process that I strictly adhered to the medical model believing that if I ensured a proper assessment and aimed for primary ‘symptom’ resolution I could not go wrong. However, it quickly became apparent to me that such was the problem with psychiatry. The physician who by definition is a product of the medical model, seeks to treat symptoms, which means that he or she must seek out pathology and ‘cure’ it. The physician does not learn the way we as psychologists do, to understand the individual as a whole person with strengths that can ultimately overcome the temporary, or even long-term complaints experienced by those who request our services. As a prescribing psychologist, I work in a practice with a psychiatrist, and I have observed that I am less likely to utilize medications and even less likely to use polypharmacy for this very reason. These differences are most apparent when I cover for his patients while he is away, and I find myself commonly refilling three or four medications for a single patient. It reminds me of how rarely I have ever seen the need to do this in my own practice, even while working on an inpatient unit. Having the authority to prescribe while maintaining my orientation as a behavior change specialist has been one of the most rewarding experiences of my lifetime because it has allowed me to alleviate human suffering by transcending the sacrosanct medical model through a more holistic, strength-based, collaborative partnership which in many cases, can be more healing than the mere swallowing of a pill” [Elaine Orabona Mantell].
“Psychology can do better. We could learn more about the medical and pharmacological aspects related to mental health. We’d then be better prepared for that one in seven who seek counseling, who have as the basis for their psychological disturbance, an organic problem. As I entered my second career at a university counseling center, I thought I would find relatively healthy patients in comparison to the military members, their families, and retirees I had treated. I have been surprised to find an organic basis for the psychological problem in approximately 15% of the students I see. Psychology can do better in nudging us to learn more about medicine” [John Sexton]. Several years ago at the California Psychological Association annual meeting, John reported that whereas his psychiatric colleagues utilized medications 61-68% of the time, only 13% of his military patients received psychopharmaceutical care, notwithstanding that the symptomology were similar.
“I am prescribing to an active duty population and each day understanding even more the ‘value-add’ of being able to provide comprehensive, integrated mental health care to patients that I treat. It is very rewarding to be able to titrate psychotherapy as well as medications over the course of treatment, without having to wait for the next appointment with the psychiatrist or other medical practitioner. Of course, there is ongoing collaboration and consultation, and for the most part there is a smooth process as I work with other psychologists as well as the physicians, nurses, social workers and case mangers involved in caring for the Soldiers we see” [Anita Brown].
As we reported in our last column, Jim Quillin, President of the Louisiana Psychological Association, submitted testimony earlier this year to the Hawaii legislature describing the Louisiana Medical Psychologists’ experiences: “With respect to safety, medical psychologists certified in Louisiana saw a total of 7,260 patients in 2005, after receiving the authority to prescribe. Of those patients, 3,863 (53%) were provided prescriptions and a total of 9,345 prescriptions were written including refills. There were no adverse events associated with this expanded practice. I should add that the patient population treated included the full range of psychiatric conditions, and many patients were also significantly medically compromised by other health conditions. Several of our members are also now specifically credentialed to provide these services in nonpsychiatric hospitals. It is my understanding that the experience of DOD trained psychologists is essentially the same as ours. Patients express an extraordinarily high degree of satisfaction with medical psychologists and we have been welcomed with open arms by rank-and-file physicians in our communities, most of whom have little interest in professional turf issues and instead value the optimized outcomes afforded by qualified health care providers working within a collaborative model of care.”
APAGS (The American Psychological Association of Graduate Students): Last Fall during a visit to the Archives of the History of American Psychology in Akron, Ohio I was able to spend some time with Nadia Hasan, now Chair-Elect of APAGS. “I am very excited about having a year to transition into my actual Chair term. This time will help me identify important initiatives that will really assist graduate students in transitioning into professional psychologists. One of my initiates is to empower graduate students with knowledge about emerging issues in psychology such as the use of technology, prescription privileges, and globalization. I have been very interested in prescription privileges. I feel it is important for graduate students to know more. I hope we can work together to educate graduate students about prescription privileges and perhaps motivate them to advocate for them within their state psychological associations.” [In 1997 APAGS adopted a formal resolution of support for RxP, pursuant to APA policy.]
That Ole Public Health Hazard Argument: In my judgment, and in that of each of the prescribing psychologists that I have talked with, providing our profession with prescriptive authority results in improved quality of care. Nevertheless, whenever any non-physician healthcare profession attempts to modify its scope of practice pursuant to evolving educational advances, organized medicine is notorious for emotionally proclaiming that those practitioners will affirmative harm their patients. Last year the American Academy of Otolaryngology-Head and Neck Surgery expressed its opposition to legislation introduced in the Congress. “Providing direct access to audiologists would remove the physician from the initial evaluation and diagnosis of a patient. Hearing and balance disorders are medical conditions and require, by necessity, a full history and physical examination by a physician and a medical diagnosis with medical management and treatment options presented and pursued by a physician. Patients provided an attempted medical evaluation by anyone other than a physician run the risk of misdiagnosis and/or inappropriate treatment. While audiologists are valued health professionals who work with otolaryngologists, they do not and should not engage in the medical ‘evaluation’ or ‘diagnosis’ of hearing and/or balance disorders.... By providing direct access to audiologists, this legislation would essentially grant non-physician providers the authority to practice medicine....” Notwithstanding, collectively we definitely are pursuing New Directions.
Aloha, Pat
Pat DeLeon has served as the APA President.
