Bitter pill: Psychologists split over right to prescribe
Prescribing drugs is way of the future, proponents say
Sunday 17 August 1997
The Ottawa Citizen
Canadian psychologists are sharply divided over whether to follow their American colleagues and lobby for legislation giving them the right to prescribe drugs.
While some say prescription privileges are the way of the future for the psychological profession, others warn that allowing psychologists to prescribe psychoactive drugs is not in the best interests of either the profession or the public.
"The consequences to society are that psychologists will become agents and pawns of the pharmaceutical industry promoting drugs like Valium, Prozac and Halcion to a society which already overuses drugs," says Tana Dineen, a former Toronto psychologist who is highly critical of her profession. Ms. Dineen's critique of the "psychology industry" is examined today in The Citizen's Weekly.
In general, only medical doctors, some specially trained nurses, and psychiatrists, who are trained in medicine, can prescribe drugs. Historically, psychologists have opposed the use of drugs, maintaining that psychotherapy is effective without medication.
This attitude has changed in recent years, and now more psychologists are saying they need prescription privileges. Prescription proponents want to develop their own model of psycho-pharmacology, using what they see as the quick potency of medication as an optional or additional element to psychotherapy.
Not everyone in the profession thinks the matter is that simple. "The push toward prescription privileges reflects an identity crisis within the field," a group of authors says in a 1995 issue of Canadian Psychology, the journal of the Canadian Psychological Association.
More recently, in the journal's February issue, a group of University of Calgary psychologists -- Jean Pettifor, a past president of the CPA, Simon McCrea, and Michael Enman -- questioned whether prescription privileges would be in accordance with the Canadian Code of Ethics for Psychologists. They concluded that from the perspective of the code of ethics, and the best interests of the public, there is no need to give psychologists prescription privileges. Still, they acknowledged the "need for national debate" on the issue.
The growing debate in Canada will probably echo that in the United States, where the topic has been hotly argued for the last decade or so. Earlier this year, the 100,000-member American Psychological Association officially endorsed the idea of prescription privileges for psychologists. In a recent issue of its monthly newspaper, the APA Monitor, the U.S. association says it expects to see pro-prescription legislation introduced in California, Missouri and Hawaii. And there are several other states where "substantial progress" toward prescribing privileges has been made.
Canadian psychologists are not so far along, but John Service, executive director of the 4,500-member Canadian Psychological Association, says the issue is heating up. "The profession is a bit split on the issue," he says, "and we are going to be having that debate in the not-too-distant future."
To date, there has been little lobbying of provincial governments to change legislation. And so far, neither the CPA nor any of the provincial psychological associations has taken a formal policy position on the issue. But that appears to be changing.
The CPA's psychopharmacology section endorsed the idea of prescription privileges at the association's recent convention. The issue will be a major topic of next year's convention in Edmonton. As well, the College of Psychologists of Alberta, which is responsible for regulating and registering that province's psychologists, will promote the idea to the Alberta government, according to College president Louis Pagliaro.
Mr. Pagliaro, a pro-prescription psychologist at the University of Alberta, says prescription privileges for psychologists are inevitable. "Psychologists will obtain prescription privileges in this country, there's no question about that," he says. "It's a question of when, not if." He dismisses those who oppose the idea as "intellectually naive," and their opposition as "professionally untenable."
Mr. Pagliaro has been promoting the issue for some time. In a 1995 article in Canadian Psychology, he argued that prescription privileges would increase "psychology's market share," and boost its public image by recognizing the specialized advanced training required by those able to prescribe drugs.
He argues that registered psychologists, who are generally trained to the PhD level, are better educated regarding mental health matters than other professionals, such as general physicians, who can prescribe drugs. Indeed, he suggests that allowing less-trained professionals to prescribe drugs is actually a danger to public health.
"No other profession is better prepared academically to prescribe drugs. Most physicians are pretty poor prescribers because they don't have the training in pharmacology. Psychologists won't fall pray to the drug company salesmen. Our people are scientists first, and clinicians seconds."
Critics of the prescription privileges idea aren't so sure. "With prescribing privileges and without medical training, psychologists may become legal drug dealers, pushing pills as the solution, the quick fix, to everything that is unpleasant or unacceptable in life," says Ms. Dineen.
Keith Dobson, a psychologist at the University of Calgary and a past president of the Canadian Psychological Association, also worries about "the corruption of the field."
"Prescription privileges don't fall within the realm of psychology," he says.
In particular, he fears that many psychologists will tend to prescribe drugs as a way of getting quick results, sliding away from the hard work of psychotherapy. As well, psychologists would be sorely tempted to see a lot more patients -- and make a lot more money -- if they had prescription privileges. What's the choice going to be, he asks, for a psychologist who can either see five patients for 10 minutes each at $50 each if he can justifiably prescribe a pill for their condition, or charge, say, $150 for 50 minutes with one patient, which is what the average psychotherapy session involves?
More broadly, he and Ms. Dineen are concerned that psychology would be forced down the same path as psychiatry, resulting in the "medicalization" of psychology and its talk-therapy methods in favour of pharmatherapy, or drug-therapy. They say that would mean psychologists abandoning the search for psychological causes to mental problems in favour of biological causes. Psychologists, in Mr. Dobson's words, would become "junior physicians."
The debate over prescription privileges is not just a matter of professional interest for psychologists. The issue also touches the public interest.
Proponents of prescription privileges say psychologists would be better able to meet the needs of underserved groups such as the elderly, the mentally handicapped and those living in rural areas who lack access to psychological services. "Having prescription privileges is going to help Canadians have more access to comprehensive mental health care services," says Mr. Pagliaro.
Opponents, however, say those who seek prescription privileges are avoiding the question of the essential nature of psychology in favour of the pragmatics of how to get those privileges, which smacks more of self-interest than of concern for the public. There's little evidence, they say, to suggest that psychologists with prescription privileges would be any more inclined toward underserved groups or areas than, say, physicians.
The opponents maintain that instead of giving psychologists prescribing powers, psychologists would do better to cooperate with other prescribing professionals and even educate physicians in mental health.
What is behind the debate over prescription privileges, in part at least, are recent developments in medical science showing increasing evidence for the role of biological factors in mental illness and disorders.
Proponents of prescription privileges argue there is unequivocal evidence that certain mental disorders such as schizophrenia and depression are best treated with drugs. But they also suggest there may be a biological base to other disorders -- everything from overeating and anorexia to panic attacks, nicotine addiction and even gambling addiction -- that justifies using drugs.
A combination of drugs and psychotherapy may be the most effective treatment for mental health problems, says Mr. Pagliaro. Drug medication would be just another tool psychologists can use much like behaviour modification therapy and biofeedback. Indeed, a drug treatment program might be able to help a patient gain enough control of his life to allow him to undertake psychotherapy.
Opponents question that view. Psychology, they say, aims to help people change their thinking and behaviour through psychological methods aimed at developing self-awareness, emotional control and intellectual insight, along with problem-solving and coping strategies. Resorting to drugs undermines the patient's self-efficacy by increasing their dependency on the external agency of a drug.
"Instead of dealing with life, its ups and downs, its complexities and frustrations," says Ms. Dineen, "people will rely on this new breed of Dr. Feel-Goods to prescribe a pill to make it all better."