March 23, 1998
Over the last number of years there has been an increasing demand by many clinical psychologists for the right to prescribe psychotropic medications as a part of their clinical treatment. A typical argument in favor of prescription privileges takes the form of, "I am fully capable of understanding the effects of these medications and being able to prescribe will only enhance the effectiveness of my work with patients."
Another variation of the argument in favor is, "Are we not better suited to prescribe these types of medications for patients with whom we are doing therapy than a general or family practitioner or a psychiatrist who may only see the patient for a medication evaluation 15 minutes once a month?" My response to these type of questions is that of course clinical psychologists are at least as capable of prescribing these medications as M.D.'s.
Rationale
Besides the competence/effectiveness issue, another rationale for prescribing medications
deals with professional status and economic survival. These arguments, while considerably
less intellectually attractive than one based on competence and clinical effectiveness,
are quite understandable. All medical services in general, and psychotherapy in
particular, are under severe attack by the managed health care system. Being able to
prescribe medications would likely, for many psychologists, dramatically improve their
incomes. Being able to prescribe would also dramatically enhance the power status of
clinical psychologists as they would be seen by the public more like "real
doctors". Underlying the notion of being a "real doctor" is a
belief that only the physical sciences have legitimacy and as such all behavior (so called
mental illness) has an physiochemical etiology and cure.
Opposition
The essence of my opposition to prescription privileges for clinical psychologists is both
empirical and philosophical in nature. Prescribing medication
by psychologists is a complete acquiescence to a medical model view of mental
illness. The medical model with regards to mental disorders, as a subset of the natural
sciences, is primarily based on a physiochemical view of human behavior. Illness,
within this frame, is literally a structural dysfunction of the body determined by the
rules of the science of medical pathology.
These rules and observations are both repeatable and testable for a patient in Jakarta
as for a patient in Vancouver. While this view has fit within a given context (i.e.
the diagnoses and treatment of bodily diseases such as cancer, heart failure,
diabetes, etc.), I would contend this view is exactly the wrong one for psychology and
reflects an error in epistemology.
With so called mental illness there is by definition no structural disease. (Recent
research on schizophrenia has indicated observable differences in brain structure as
compared to non-schizophrenic patients. However, it is premature to conclude that this
brain difference is the cause of schizophrenia rather than the result of it. Future
research may occur that supports a causal mechanism).
For all intents and purposes with regards to the vast majority of what is designated as
mental illness, the observer observes what he or she determines to be functional problems
(i.e. based on reports of some form of suffering) in the person who has come to be
identified as a "patient" and then states this person to have some type of
mental disease. In using the "illness" metaphor we have confused the figurative
with the literal. With so called mental illness, there is no bodily disease and as such I
would contend that the application of the medical model (based on physical disease) in the
absence of physical disease makes no sense and is therefore wrong-headed.
How did this epistemological confusion come to be?
Psychology, in its long historical desire for acceptance as a real science by the natural sciences (physics), has struggled with the application of a linear mechanistic model (specific to the natural sciences) to the study of human behavior. Freud recognized this issue early on in his career and decided to accept the medical model even when his investigations of hysteria suggested otherwise.
Inventions
Within the medical model, physical/structural diseases are discovered following the
empirical process of the science of pathology. This is clearly not the case with so called
mental illness. Mental illness is invented by the observer not discovered
within the rules of medical science. The DSM-I had 60 categories and the DSM-IV has now
surpassed 300 different diagnoses. Interestingly, one might consider such expansionism as
an attempt to further justify and institutionalize power by the American Psychiatric
Association. I digress.
Homosexuality is a perfect example of a designated mental illness only to be undesignated
at later time (a move with which I am in total agreement). While a physical disease may be
eliminated (e.g. small pox), it will not be undesignated as a disease. Why? Because the
criteria for small pox, cancer, etc. are clear and identifiable and agreed to within the
rules of natural science. The behaviors as disease qua disease in the DSM are not so clear
and agreed upon (reliability diminishes with specificity).
I would submit that so called mental illnesses are interactional, moral, and ethical
problems in living, not diseases. The disease model ultimately does not fit and as such
medical interventions (prescriptions) would be an example of the wrong intervention
following the wrong model. The behaviors (not symptoms) presented by so called
patients are forms of communication and therapy is a form of meaning making and
co-constructing with the person a more useful reality ("the talking cure"). A
topic for a different time.
I am in no way denying the importance of genetics and/or physiochemical influences nor the
fact that some medications with some individuals in some instances would seem to be
effective. However effectiveness is open for discussion. Antonuccio and Danton
(1995) in a comprehensive review of research on antidepressants and psychotherapy report
that psychological interventions, particularly cognitive-behaviorally based therapies are
as effective as medication even if the depression is severe, with none of the negative
side effects of the medication.
In a recent meta analysis Kirsch and Sapirstein (in press) report the effect size for
active medications which are not depressants was a large as those classified as
depressants. They report that inactive placebos produced improvement that was 75% of
the effect of the active drug. They suggest that in fact the apparent drug effect
(the remaining 25% of the drug response) is actually and active placebo effect.
These studies, among others, suggest that medication is not what it is cracked up to be.
With the noted exception that there is a significant main effect for those who can
prescribe it, the effect of power, prestige and enhanced income. The claim that
psychologists who could prescribe can better help their clients is suspect.
As scientific investigations continue to advance there may be more so called mental
diseases determined to be organic in origin, in which case they would no longer be
classified as "mental". A classic example of this would be the causal
connection (within this narrative) between syphilis and general paresis discovered in the
19th century. Research on such disorders as bi-polar depression has shown some organic
basis for the disorder. Recent research on depression indicates very convincing evidence a
connection between depressed behaviors and over or under functioning of specific
neurotransmitters.
Regardless of whether such connections are correlation or causal physiochemical changes, the singular search for organic causes of behavior may be overly reductionistic (why not the atomic or sub-atomic levels of causality) and may not be completely useful for the study of human systems. Again, as a scientist, I do not deny the biological aspect of human existence. With regards to behavior, a primary emphasis on biology may be less productive than a conjoint perspective.
Summary
A demand for prescription privileges is tacit acceptance of the medical model which, as I
have argued, is both an philosophical and an perhaps an scientific error (based on
empirical research). To knowingly apply the wrong model to a given system is as unethical
as it would be to prolong psychotherapy because one's income depends on a fixed cash flow.
I do not believe that our (clinical psychology) economic survival is dependent upon our
acceptance of this frame. To accept this frame may in fact be participating in our decline
as clinical psychology would become medicalized and subsumed within psychiatry much in the
way that psychoanalysis was subsumed by psychiatry. While I hold no value for
psychoanalysis, I do for the field of psychology.
References
Antonuccio, D.O. & Danton, W.G.(1995) "Psychotherapy Versus Medication for
Depression: Challenging the Conventional Wisdom with Data." Professional
Psychology: Research and Practice, 6, 574-585.
Kirsch, I., & Sapirstein, G. (in press) "Listening to Prozac but Hearing Placebo:
A Meta-Analysis of Antidepressant Medication." Prevention and Treatment.
Copyright © 1998 by Dr. William Matthews.
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