Progress Notes: Earning the Right to Prescribe

Deborah C. Baker, JD, is the director of Legal & Regulatory Policy in the Office of Legal & Regulatory Affairs of the American Psychological Association's Practice Directorate. Since joining APA in 2004, she has worked with state psychological associations, APA leadership and members, and regulatory bodies on a variety of issues involving scope of practice/licensure, testing, telehealth, prescriptive authority, HIPAA compliance as well as other legal and regulatory issues. Ms. Baker works with APA governance groups, such as the Committee for the Advancement of Professional Practice and the Board of Professional Affairs on legal/regulatory issues affecting professional practice. She has also provided support to several APA task forces, including the joint APA-ASPPB-APAIT Task Force on Telepsychology, which developed the APA Guidelines on the Practice of Telepsychology as well as task forces established to review and revise APA policies on prescriptive authority and designation of psychopharmacology training programs. She represents APA Practice in several outside organizations, including the Coalition for Patients' Rights and the American Telemedicine Association. She has made numerous presentations at the APA Annual Convention, state psychological association meetings and conferences as well as outside organizations on the issues of telehealth and scope of practice issues.

Susan Farber, PhD, has run a private practice in Boise, Idaho since 1983. She specializes in individual therapy work with children, adolescents and adults. She’s also assisted in the development of various conferences on topics such as autism, epilepsy and behavioral aspects of neurologic disorders. Dr. Farber has served as president of the Idaho Psychological Association and chair of IPA’s Continuing Education Committee. She is currently co-chair of IPA’s Advocacy Committee, taking the lead on prescriptive authority legislative initiatives for the last four years. Dr. Farber was also appointed to the advisory board on prescriptive authority issues serving the Idaho Board of Psychologist Examiners. In 2017, Dr. Farber won the Karl F. Heiser APA Presidential Award for Advocacy. The award honors psychologists who are at the forefront of advocating for the profession.

Dr. Farber received her undergraduate degree in English from the University of Chicago in 1967 and her doctorate in clinical psychology from Columbia University in 1973. Before returning to Idaho, her home state, she ran a private practice in New York and taught clinical psychology at New York University.

Steven D. Hollon, PhD, is the Gertrude Conaway Vanderbilt Professor of Psychology at Vanderbilt University. His research focuses on the nature and treatment of depression with a particular emphasis on the enduring effects of psychosocial treatments. He is the past president of the Association for Behavioral and Cognitive Therapies and the Society for a Science of Clinical Psychology and the recipient of awards for both Distinguished Scientific and Professional Contributions to Clinical Psychology from the Society of Clinical Psychology. He chaired the steering committee advising the American Psychological Association on the generation of clinical practice guidelines.

Marlin Hoover, PhD, is a licensed psychologist in Illinois and New Mexico. He is also the clinical director, founder and owner of Hoover and Associates, a group practice comprised of highly qualified, licensed mental health professionals. Dr. Hoover is board certified in clinical psychology by the American Board of Professional Psychology, and in medical psychology by the American Board of Medical Psychology. Dr. Hoover is a fellow of the Academy of Clinical Psychology and a fellow of the Academy of Medical Psychology.

Currently, he is an instructor of doctoral clinical psychologists, who are studying to obtain prescription privileges through the New Mexico State University/Southwestern Institute for the Advancement of Psychotherapy Cooperative and through Fairleigh Dickinson University. He has prescription privileges in New Mexico, where he works two days per week. He is a member of the faculty of the Southern New Mexico Family Medicine Residency at Memorial Medical Center in Las Cruces. Additionally, he sees patients for psychotherapy and medication at the Center Through the Looking Glass.

While starting a private practice in the Chicago area in 1985, he was a faculty member at Saint Xavier University for 20 years, and chair of the department of psychology of Saint Xavier University at Chicago. Dr. Hoover has done research and publications on the relationship between personality and heart disease, training of psychologists and validation of personality tests.

He earned a PhD in behavioral sciences from the University of Chicago and a postdoctoral master’s in clinical psychopharmacology from Fairleigh Dickinson University.

Jewel Edwards-Ashman: One thing that sets licensed psychologists apart from other health care providers is their extensive training in the assessment, diagnosis and treatment of mental disorders. Patients are drawn to them because of their expertise in those areas. But are patients also looking to their psychologist to prescribe and manage psychotropic medications, tasks that are sometimes left to physicians or psychiatrists? In this episode of Progress Notes, we’ll look at what it means for practicing psychologists to have prescriptive authority. 

I attended a session on psychopharmacology training at APA’s 2017 convention. When the panelists finished giving an overview of the psychopharmacology programs at various universities, they asked the audience of psychologists and psychology grad students a question. How many of them were planning to enroll in one of these trainings to learn more about medications? Only about three people in an audience of maybe 20 raised their hand. Right now, most psychologists don’t enter practice so that they can write prescriptions, and that includes prescribing psychotropic medications used to treat mental disorders. Dr. Susan Farber, a clinical psychologist from Idaho, can attest to that.

Susan Farber: I love doing therapy. I like doing advocacy. I have absolutely no interest in prescribing. None.

Jewel Edwards-Ashman: Dr. Farber is a proud non-prescribing psychologist and plans to remain that way. But her career choices haven’t kept her from taking the reins on getting prescription privileges, or RxP, for psychologists in her state.

Susan Farber: I, for three almost 4 years, have been the lead on the Idaho prescriptive authority legislation. I don’t prescribe. I’ve never had an interest in prescribing and I don’t intend to do the training. I simply think that this is something that is good for this profession and I know with certainty that it’s something we need in my state. My personal belief is that prescriptive authority should simply be one of the branches of psychology.  In whatever environment psychologists find themselves, I think that that should be one option if they get the proper training. 

Jewel Edwards-Ashman:  Deborah Baker, director of legal and regulatory policy at the Practice Organization, works with state psychological associations and advocacy leaders like Dr. Farber to craft legislation that defines prescriptive authority for psychologists and outlines what training is needed.

Deborah Baker:  So, prescriptive authority the way we envision it here at APA and APA practice organization, is that it’s a doctoral-level licensed psychologist who has attained additional postdoctoral training in clinical psychopharmacology with the focus being eventually the ability to prescribe or modify prescriptions for the patients they see and those prescriptions would be for mental and behavioral health issues. It wouldn’t involve medical issues like endocrinology or other type of specialty medical issues. A lot of patients have difficulty seeing a psychiatrist. And a number of patients have their mental and behavioral health medications prescribed by their primary care provider, who are often quite busy and don’t have the time to devote to ensuring medication compliance or being able to really drill down about side effects.  

Jewel Edwards-Ashman:  APA has historically supported prescriptive authority for appropriately trained psychologists. In the early 90s, APA worked with the Department of Defense to create the psychopharmacology demonstration project. This was the first dedicated effort to train licensed psychologists in psychopharmacology. Today trained psychologists continue to prescribe for DOD and other federal agencies, and the Practice Organization works with state associations to help enact laws allowing psychologists to prescribe at the state level.

Deborah Baker: Currently, there are five states that have passed laws allowing appropriately trained psychologists to prescribe. That would be in New Mexico, Louisiana, Illinois, Iowa, and more recently Idaho passed its law earlier this year.

Jewel Edwards-Ashman:  Dr. Farber, a fourth generation Idahoan, was instrumental in making this happen. She sees supporting the RxP agenda as one way that she can give back to people in her state.

Susan Farber: Actually, one of the reasons that I think rural states are the first states to enact this is because the need is so desperate. In my state, we have the worst ratio of psychiatrists to patient population in the entire United States. There are more than 20 counties in my state that don’t even have a physician, much less a psychiatrist. The wait times in northern Idaho, for child patients are just over a year, for adult patients just under a year. Near one of the northern Native American reservations the wait is 18 months. In southern Idaho which is more populated, wait times is several months. I know there is one university with many of thousands of students that has a psychiatrist come through for half a day every week or so and they have to triage their students. All of us know that this is dangerous. All of us know that our patients are not being well served.

Jewel Edwards-Ashman: Dr. Farber and the Idaho Psychological Association decided to work on getting prescribing rights for psychologists, and the state legislature ended up passing a bill in three years.

Susan Farber: Three years is probably not that unusual in Idaho. The first year, in retrospect, was everybody becoming educated.  The legislators had to become educated. One of the ways we talked to our very conservative legislators was that this really is a free market issue. That it is not good economics to have guilds prohibiting other groups from providing services if those services are based on good training. And a real free market would say remove the barriers, take down the artificial bumps in the road give us a level playing field, we will prove our competency or we won’t. And in my state, that worked very well. Our state organization had to become educated.  Our smaller RxP committee had to become educated. And from then on it became a matter of convincing people that the training was sufficient for it to be safe. The medical association would not even talk to us for almost three years. They wouldn’t even sit down for discussions. We similarly couldn’t get discussions going with any of the other providing professions. We spoke to our colleagues in the profession. We spoke to our physician friends, such as our own private doctors and anybody we could basically talk to and I think what finally happened is that by the third year, people were educated well enough about the benefits of this and about the adequacy of the training that they decide that they were willing to give it a try. And I do believe one of the major turning points was when the medical association, not the psychiatrists at that the point, but the medical association began liking the idea because they have no place to send their patients. They simply do not have providers to whom they can send their patients particularly on Medicaid or Medicare. And I think some of them realized that this was going to be very helpful to them, and they prevailed then on the psychiatrists to sit down at the table with us. 

Jewel Edwards-Ashman: With a law in place, Dr. Farber says the psychologists who do want to prescribe in Idaho are eager to learn how.

Susan Farber: I hear interest from younger psychologists, I hear interest from older psychologists in my state who say they want to go back and get the training interestingly enough.

Jewel Edwards-Ashman: One psychologist who ended up going back to school to study psychopharmacology is Dr. Marlin Hoover.

Marlin Hoover: I didn’t go back to seek this training until I was, 53 years old. My goal was to write a prescription by the time I was 60. I beat it by two months. And now I’ve been prescribing for 10 years. So, I hit the big 7-0.

Jewel Edwards-Ashman: Dr. Hoover is a Behavioral Science Faculty member at the Southern New Mexico Family Medicine Residency in Las Cruces New Mexico where he teaches family physicians to manage psychotropic medications and other forms of brief psychological treatments.

Marlin Hoover: Well, I became convinced that I wanted to know more about how medications worked fairly early in my career as a clinical psychologist, because I had training as a psychotherapist. A client center therapist, and then cognitive behavioral therapy with some dynamic supervision. And I noticed that although many patients did better and seemed to improve significantly in psychotherapy that there were a few patients who simply didn’t seem to improve until they were placed on psychotropic medications. I really, really do spend a lot more time taking people off medications than I do putting them on. And because I’m a prescribing psychologist that gives me a kind of traction or credibility to assist the physicians in the management of things like opiate medication. So, because of being a prescribing psychologist and because of the issue of dependence on opiates I ended up being the person who started our controlled substances committee that then set the policies for the management of narcotic medications and other controlled substances, and we put together protocols for titrating people off of benzodiazepines, for instance, as well as what a physician would need to do to re-prescribe or to continue opioid- type medications for patients.

Jewel Edwards-Ashman: Promoting better medication management and preventing overmedication, are worthy reasons for psychologists to seek prescribing rights, according to Dr. Steve Hollon. Dr. Hollon is a clinical psychologist and on the faculty at Vanderbilt University. His stance is that he is not opposed to psychologists having prescriptive authority. But he would like to see more emphasis placed on using psychological interventions over medications for nonpsychotic disorders, like depression for example.

Steve Hollon: I don’t think there is any question, psychologists can prescribe safely competently and I think there’s pretty good evidence of that. My problem if I have any problem at all is not with psychologists prescribing medications, having prescriptive authority, I just think many medications are overprescribed in this country. For the non-psychotic disorders, there is nothing that you can treat pharmacologically that you can’t treat at least as effectively and with longer lasting effects with the absence of side effects with psychological interventions. So, I think we’ve become overly reliant on medications in this country.

One of the things that not all psychologists do but many psychologists is do is psychological interventions. And the empirically supported psychological interventions, for example, for depression the empirically supporting treatments are every bit as efficacious as medication, but they have longer lasting effects. You don’t get that from medications. You also don’t get side effects from psychological interventions and nobody’s overdosed from a behavioral activity schedule. There are things that psychologists are particularly good at doing that work better than medications.

Jewel Edwards-Ashman: Dr. Hollon was an original member of the Advisory Steering Committee for Development of APA’s Clinical Practice Guideline.  He references the APA guideline on treating posttraumatic stress disorder as an example of psychological treatments versus medicinal.

Steve Hollon: If you look at the recommendations there for folks who have been through trauma or other things, the most strongly recommended interventions are psychosocial. And medications can be used and they get weaker recommendations. It’s not clear to me that there’s any particular literature that suggests that putting the two together is better than the psychosocial intervention alone.

Jewel Edwards-Ashman: So, he agrees that psychologists can prescribe. But still I had to ask if he would ever enter that world.

Steve Hollon: If I prescribe, I own the constipation. I don’t particularly want to talk to my clients about constipation.  And I do like getting them back to work and I do like getting them into new relationships but there are a whole host of things. I’ve spent most of my career working closely with psychiatrists.  And working alongside them. I was trained. My mentor was a psychiatrist. I went through a psychiatric residency program for my internship. Thirty to 40 years ago, when I went through training, psychiatrists were as well-trained at doing psychosocial interventions. They’ve stopped doing that. They’ve become plumbers over the last two or three decades. And it is not a happy profession. The notion that we would choose to go down that line because it’s somehow going to do better things for us, I’m a little skeptical of that. If we choose to go down that line because it allows us to cut back on unnecessary prescriptions, to not overmedicate patients, to provide necessary services for people in underserved areas then I think that’s quite reasonable. 

Jewel Edwards-Ashman: Primary care providers don’t always have referrals for patients for psychosocial care and evidence-based therapies.  As a result, they often end up writing prescriptions for mental health conditions.

As the health care industry transitions to paying providers based on patient outcomes and quality, many believe that physicians and psychologists can work alongside each other to provide the best possible care for their patients.

Susan Farber: I do believe that one of the movements of the future is for the mental health professions and really the health care professions to interact much more with each other there are much more grave dangers to the health care professions combined than fighting with each other. And I think that we need to join together and form teams, and utilize our strengths and not compartmentalize abilities.

Marlin Hoover: The fact that I’m a prescribing psychologist and can look at the behavioral aspects of what brings a patient to be dependent on medication and all of the psychological complications associated with the act of giving a pill and the placebo effect, and to really address that helps me help the physicians and the physician faculty working with the residents to help them not over rely on psychotropic medications. 

Jewel Edwards-Ashman: During that psychopharmacology session I attended at convention, the panelists reassured the psychologists and future psychologists in the audience that learning to prescribe would not change their identity as a psychologist.  And Dr. Hoover agrees.

Marlin Hoover: The more challenging and subtle skill is the psychologist part, is being a psychologist. And that that is a very, very, rewarding and wonderful thing to be able to be is to be trained and learn to address people as a psychologically sensitive and attentive person.

Jewel Edwards-Ashman: This episode of Progress Notes, produced by me, Jewel Edwards-Ashman, with help from Hannah Calkins and Luana Bossolo.  Next month, we’ll hear about the pitfalls and benefits of using social media.  You don’t want to miss it.  Subscribe to this podcast on iTunes, or listen on our website at apapracticecentral.org.