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Over the last 2 decades, in both the US and Canada, an important
debate has emerged within professional psychology about whether
clinical psychologists should be granted the legal right to prescribe
psychotropic medications. The American Psychological Association
(APA) and both American and Canadian psychologists argue that psychologists
cannot function as independent professionals, due to the many restrictions
placed on their practice by the medical profession (1–3). Proponents
argue that prescription privileges (PPs) may significantly improve
patient care and are in the best interests of the profession. Despite
receiving considerable attention throughout the US, there has been
relatively little discussion of this important debate among Canadian
mental health professionals and professional legislative bodies.
Throughout the course of this paper, we present the major arguments
for and against PPs for psychologists, followed by a discussion
of the potential impact of PPs on both the professions of psychology
and psychiatry. Given that psychiatrists will likely be consulted,
we hope this article will help inform them about the major issues
surrounding this debate.
Lightner Witmer, who established the first American psychology
clinic in 1896, originally founded clinical psychology. At that
time, the practice of clinical psychology was conceived as the application
of psychological principles to the study of the individual (4),
but it remained a largely academic discipline until World War II.
During and after the Second World War, the demand for mental health
services to treat the victims of war increased dramatically, and
the Veteran’s Administration (VA) was forced to expand the
role of psychologists to include psychometrics, interpretation of
aptitude, intelligence, and personality tests, diagnostic interviewing,
and psychiatrist-supervised psychotherapy (5). Interestingly, the
APA’s Committee on Training in Clinical Psychology (CTCP) (6)
did not envision psychotherapy as a central activity for clinical
psychologists. Training programs were designed to produce psychological
scientists by emphasizing research, psychodiagnostics, and general
psychology principles. Training clinicians was secondary in importance.
Despite the intentions of the CTCP, many clinical psychologists
wanted psychotherapy to be their central activity and no longer
wanted psychiatrist supervision. Although psychiatry claimed psychologists
lacked proper training, psychologists ended psychiatry’s monopoly
on psychotherapy by the end of the 1950s (7).
While psychologists were battling psychiatrists for the right to
conduct psychotherapy, modern psychopharmacology emerged as a major
force in mental health care. Between 1950 and 1960, many of the
psychotropic medications in use today were introduced (for example,
chlorpromazine, tricyclic antidepressants, and benzodiazepines)
(8). At the time, clinical psychologists criticized their efficacy
by arguing that they only treated the symptoms of a disorder, not
the underlying psychological disturbance (9). Psychology’s
theoretical approach to mental illness, unlike psychiatry’s,
did not promote a disease model of mental illness, but rather emphasized
applying psychological-based theories to the understanding and treatment
of mental disorders (10). Consequently, the APA expended little
effort at the time to obtain PPs for clinical psychologists, and
licenced physicians retained sole right to prescribe medication.
In the US, determining the practitioners with the authority to
prescribe medication generally occurs at the state level. Through
their respective pharmacy and medical practice acts, each state
determines which professions are authorized to prescribe (11). In
Canada, the Federal Bureau of Human Prescription Drugs decides how
drugs are sold, and provincial legislatures determine which professions
may prescribe. A 2-factor classification scheme for PPs was established
to specify the degree of prescriptive authority held by a particular
profession. The first dimension (independent vs dependent) pertains
to whether physician supervision is required to prescribe. The second
dimension (limited vs unlimited) concerns what categories of drugs
may be prescribed (12). Only physicians have independent and unlimited
PPs in the US, but Canada grants independent and unlimited privileges
to both physicians and dentists. Over the years, various professions
have been granted limited PPs in the US, such as dentists, optometrists,
and podiatrists. Prescriptive authority for these professions is
limited typically to medications that affect body parts in their
area of practice (11). The APA is currently advocating for independent
privileges, which would be limited to prescribing psychoactive medications.
Other nonphysicians who may be granted some degree of prescriptive
authority are called “physician extenders.” Professions
that fall into this category include nurse practitioners, pharmacists,
and physician assistants, whose prescriptive authority depends on
physician supervision and is limited to specific drugs or drug formularies
(13). Note that in Canada, however, that although podiatrists have
limited PPs in the province of Alberta, no other nonphysician disciplines
may prescribe medication in this country.
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Understanding the nature and timing of the PP debate involves recognizing
that it is occurring in a larger context of change within and around
the practice of professional psychology. For years, psychologists
have devoted time and energy to making psychotherapy their central
activity, perhaps to the detriment of equally important activities
such as research and developing preventive interventions. Now, psychologists
face the possibility that they are no longer required to fulfill
their psychotherapeutic role. Research shows that in most circumstances,
a doctoral-level psychologist need not deliver psychotherapy to
be effective (14,15). Presently, the field includes master’s-level
psychologists, doctorate-level psychologists, and ever-expanding
groups of mental health professionals who also conduct psychotherapy,
namely social workers, nurses, marriage and family counsellors,
occupational therapists, and sex therapists (10).
Economic factors are also fuelling the debate. Since the end of
the 1980s, the governing force in mental health services in both
Canada and the US has been cost containment. Although Canada’s
health care system has been managed publicly for decades, the need
to reduce health care costs in the US has contributed to the creation
of health maintenance organizations (HMOs) (16). Canada’s publicly
operated system and the rise of managed care systems in the US are
essentially leading to the replacement of doctoral-level psychotherapists
with less costly psychotherapists, whenever possible (17,18). Although
doctoral-level psychologists may still be required for training
and supervision, there is no longer a reason to use them as front-line
service providers. From a cost-containment perspective, we expect
that this situation will continue as long as third-party payers
decide who conducts psychotherapy.
Similarly, the rising importance of mental health to pharmaceutical
companies, who have a clear financial interest in the expansion
of prescription authority, is stimulating the debate. Psychoactive
medications now occupy a significant portion of the drug portfolios
of major pharmaceutical firms, and drug companies are eager to see
the use of such drugs expand (18). Not surprisingly, the APA’s
Division of Psychologists in Independent Practice has been sustaining
relations with the pharmaceutical industry over the past few years
(19), and there has been a dramatic increase in drug company-sponsored
symposia for psychologists and training grants for research “with
a strong psychopharmacology emphasis” (20).
The following section reviews the major arguments of APA representatives
and both Canadian and American psychologists in favour of PPs, followed
by a section discussing the weaknesses of those arguments. Further,
we discuss the implications of PPs for professional psychology and
psychology.
One of the most popular arguments put forth by PP advocates is
that psychologists do not and cannot function as independent professionals
because the medical profession places many restrictions on their
practice in such areas as hospital privileges, insurance reimbursement,
and PPs (1,2). Advocates assert that obtaining PPs would help increase
the scope of psychological practice by helping psychologists expand
their practice into settings that are traditionally dominated by
physicians, such as nursing homes, long-term care facilities, and
hospital-inpatient services (3,21).
To support this argument, advocates assert that because doctoral-level
psychologists have more education than do other professionals who
have secured various degrees of prescriptive authority (for example,
nurse practitioners and pharmacists), psychologists should qualify
for privileges (22,23). In fact, it is generally accepted by both
proponents and opponents of PPs, that with the proper curriculum,
psychologists could be trained to prescribe psychoactive medication
(2,18,24). Evidence emanating from both the Department of Defence
Psychopharmacology Demonstration Project (PDP) and the Indian Health
Service (IHS) shows that psychologists have been trained successfully
to prescribe psychoactive medication (11,24–26).
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