Prescription Privileges for Psychologists: An Intro to “Pro” Arguments

This is the second entry in a series on the implications of psychologists pursuing prescription privileges. What those implications are exactly, is far from clear — they ought to be examined very closely. Others in the series include:

Preamble to a thorny issue.
Before launching into the positive side to psychologists gaining prescriptive privileges, I would like to tip my hat, once again, to John Norcross, Ph.D. He makes exceedingly level-headed arguments. He knows his stuff. In making his argument for prescription privileges for psychologists (RxP), he does one thing that I have not seen anyone else do — he outlines the weaker of the “pro” arguments that only confuse issues further.

“Could” does not equal “should.”
Norcross observes that “could” arguments ought not be treated as “should” arguments. The logic: We could do that, so we should do it. Of course, this is silly — a version “monkey see, monkey do.” Norcross has the confidence in his real arguments to toss the silly ones aside.

The weak arguments:

    Psychologist competence: With additional training, we will be able to safely and effectively prescribe psychoactive medications and therefore we should prescribe.Psychologist affluence: Psychologists in the United States are losing money, patients, and positions due to managed care, which favors subdoctoral-level providers and medications. Prescription privileges will reclaim some of our losses.

    Non-physician precedents: Numerous non-physician health care professionals have acquired prescription privileges in recent years and so can we.

    Organizational support: The American Psychological Association, in a rare demonstration of convergence between the scientist and practitioner factions, is wholeheartedly supporting prescription privileges.

    Practitioner preference: The robust majority of practicing psychologists, graduate students, and predoctoral interns now support prescription privileges so we should pursue and obtain them.

I was particularly relieved and amused to see what Dr. Norcross had to say about the first argument:

But why we should acquire privileges is not addressed by the finding that we can do it. Psychologists with additional training, I submit, could safely and effectively extract teeth, construct skyscrapers, harvest green beans, remove appendices, draft legal briefs, and perform all sorts of complicated professional activities. But that misses the point of why we should acquire prescription privileges.

Next post, finally, the substantial arguments for RxP.

Kalea Chapman, Psy.D.

This is one entry in a series on the implications of psychologists pursuing prescription privileges. Other articles in the series include:

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Psychology and “Big Pharma”

This is the first entry in a series on the implications of psychologists pursuing prescription privileges. What those implications are exactly, is far from clear — they ought to be examined very closely. Others in the series include:

Here’s a draft I wrote for a professional newsletter.
In the editing down, one part that got lost was how difficult it is to consider the topic of Big Pharma and prescription privileges rationally. It’s a hot-button issue for psychologists. The opposition can easily fall into “the-sky-is-falling” type arguments — prescribing privileges will ruin the profession, and so on. Those in favor, however, appear to see what they want to see.

Stopping time, turning back the clock.
Within the profession, if you are staunchly opposed to presriptive authority, you risk coming off as being opposed to change, which might seem like being opposed to growth. An awkward and untenable position. History shows us that people that try to “stop time” fail miserably. But progress and growth are two different things.

The upside.
There are a number of potential benefits to prescription privileges for psychologists (rural access to care, the potential to prescribe more conservatively, the right to unprescribe, and so on), which I will cover more fully in another post, however, here I address my concerns that the profession is stepping into some very dicey territory. This is a complex issue.

Anyway, here’s the piece proper:

The potential for undue influence by pharmaceutical companies is considerable. Influence, and how it will effect patients’ best interests, is a key ethical issue in prescriptive authority for psychologists (RxP). The recent SGVPA workshop on RxP was enlightening and thought provoking, soothing and quite balanced. Dr. Doris Penman and Dr. Jarline Ketola did a very nice job of sorting through the issues and keeping the discussion civil. For all that, on RxP, particularly on the question of undue influence of monied interests, I remain unconvinced.

Building a firewall between science and marketing.
Elaine Levine, Ph.D., current president of APA division 55, the American Society for the Advancement of Pharmacotherapy (ASAP), directed me to the watershed article on the challenges related to RxP, Antonuccio (2004) Psychology in the Prescription Era: Building a Firewall Between Marketing and Science. It is well worth reading. It contains a number of useful proposals, none of which address how to limit the influence of marketing on practitioners. There is no credible strategy for doing this. “Big Pharma” will be courting us, and in a big way.

Experts on influence.
Social psychologists are experts on influence. Potential prescribing psychologists need to educate themselves, and quickly, about the powerful influence of Big Pharma. The epithet generally refers to pharmaceutical companies with annual profits upwards of $3 billion. There are thirty such companies. Each year, it is estimated, they spend $54 billion on marketing. For perspective on what corporate marketers are reading, take a look at psychologist Robert Cialdini’s Influence: Science and Practice (2001). The book has sold over a million copies and has been published in twenty languages.

Compromising judgment.
Phil Zimbardo, Ph.D., known for the Stanford prison experiment, has written extensively on influence and social pressure: “When information is systematically hidden, withheld or distorted it is impossible to make unbiased decisions. … people may be subtly led to believe they are ‘freely’ choosing to act…we come to believe in those attitudes and actions for which we have generated our own justifications.” Even small gifts compromise people’s judgment.

Conflicts of interest.
The APA ethics code is quite rigorous in addressing conflicts of interest. But enforcing the ethics code will be challenging, at best. A group of physicians have put together an informative website called No Free Lunch (link below). The site addresses the many ways in which drug companies have successfully influenced the practice of medicine, to its detriment. The site offers practical suggestions for sidestepping influence tactics. Some offer that psychologists are different. We will not let Big Pharma subsidize 97% of our continuing education, as psychiatry has, according to Dr. Penman. Perhaps the latter part is true.

Evolving professional identities.
Big Pharma will approach psychologists differently. The idea that psychologists are somehow inherently different from other prescribers is hubris, regardless of how well established our professional identity. The small group of psychologists working toward RxP strike me as dedicated, competent professionals – often experienced in medical settings – who will probably be thoughtful, judicious prescribers.

I am less convinced about how the larger group of early-career psychologists will prescribe, and how that prescribing will affect their professional identities. Many of them have the time and inclination to pursue RxP. Their curricula are steeped in biological bases of behavior, pharmacology, and evidence-based treatments. Consequently, the professional identity of these psychologists will be different, and more subject to influence.

The role of managed care.
If all this strikes you as reactionary and overblown, take a look at a July 16, 2007 article run on United Press International (UPI), by senior science writer Lidia Wasowicz: “When it comes to treating children with mental, behavioral and/or emotional problems, the cards seem stacked against giving the non-pharmaceutical way a chance, some U.S. Specialists say. ‘Managed-care organizations are less likely to pay for psychotherapy and family interventions,’ said Peter Conrad, professor of sociology at Brandeis University in Waltham, Mass.” There will be many unintended consequences to RxP, and we need to proceed thoughtfully.

Kalea Chapman, Psy.D.

This is the first entry in a series on the implications of psychologists pursuing prescription privileges. Others in the series include:

Recommended Reading

Anderson, S. and Zimbardo, P. (1979). “On Resisting Social Influence.” (Technical report). Stanford University Department of Psychology.

Angell, M. (2004). “The Truth About Drug Companies.” In The New York Review of Books. Retrieved at http://www.nybooks.com/articles/17244 on July 14, 2007.

Cialdini, R. (2001). Influence: Science and Practice (4th ed.) Boston: Allyn & Bacon.

Katz, D. (2003). “All Gifts Large and Small: Toward an Understanding of the Ethics of Pharmaceutical Industry Gift Giving.” The American Journal of Bioethics – Volume 3, Number 3, Summer 2003, pp. 39-46. Retrieved at http://muse.jhu.edu/login?uri=/journals/american_journal_of_bioethics/v003/3.3katz.html

Wall, L. L. and Brown, D. B. (2007). “The High Cost of Free Lunch.” In Obstetrics & Gynecology. Retrieved at http://www.greenjournal.org/cgi/content/abstract/110/1/169
July 14, 2007.

Wasowicz, L. (2007). “Ped Med: Non-drug options slighted?” In Science Daily. Retrieved at http://www.sciencedaily.com/upi/index.php?feed=Science&article=UPI-1-20070716-09132900-bc-pedmed-drugs-options.xml July17, 2007.

Zucker, A. (2004). “When Your Doctor Goes to the Beach, You May Get Burned.” In The New York Times. Retrieved at http://www.nytimes.com/2004/02/24/health/policy/24ESSA.html July 14, 2007.

Website:

Cialdini. Website: http://www.influenceatwork.com/

Tantrum: How to Deal with My Child

451090111_9afd98e135_zphoto by jennifer woodward maderazo (creative commons)

My child has lost it. I’m about to lose it.
This is related to how to praise a child. Here’s a typical scenario: The child, being a 3-and-a-half-year old is extremely frustrated because it can’t have what it wants. Your last nerve was worn out an hour ago, and truth be told, you are starting to dislike your little darling. You are tempted to raise your voice. You are tempted to give the kid a time-out. You are tempted to tap the kid on the side of the head. So what should you do at this point?

A common parenting dilemma.
Some would say that talking to the child at this point is giving the child attention for having a tantrum and this is bad. I disagree, partially. It is true, you don’t want to reinforce bad behavior. But let’s be clear on two points. First, a tantrum at 3-and-a-half is not bad behavior. It is age-appropriate behavior. Nevertheless, you don’t want to encourage the tantrum. Nor do you want to reinforce it with rewards. Second, and more important, you do want to show the child that you understand he is frustrated, or whatever the experience he is having.

But that sounds like a contradiction!
It is, in a way. Here’s what you do. Remembering that you are the adult and the other person is 3-and-a-half, you gather together all the self-composure you can. You get down to his level, so that you are speaking eye-to-eye (that’s important). You let the child know, in a calm voice, that you understand what he is going through: “I’m sorry little Johnny, I can see that this is very hard. I know you really want to eat ice cream right now, but we’re not going to do that today.” You make sure that the child heard you, and you set a limit. You comfort the child a little. You have shown the child two important things: that you are sympathetic to his frustration, and that you are not going to give in to a tantrum. For a child being heard is very important. Being the boss is not. Being in control of situations is actually disturbing for children. It makes them test even more to find out what the limits are.

The tantrum continues.
If the child continues with the meltdown. Now, in the calmest, non-punitive voice you can manage (this takes practice!) you tell the child, “Johnny, I see that this is very hard for you, but if you are going to keep screaming and hitting then you are going to have to have a time-out. Do you understand?” The child may calm down. More likely he will continue full blast with the ear-splitting behavior. Then you gently take the child to its room and close the door. You do this in a very matter-of-fact manner.

Note: Below age 3 or so, a time-out is probably not a good idea. Really kids just cannot self-regulate that young. From age 3 up, an appropriate length of time is a roughly a minute per year of age. So for a three-year-old: three minutes. For a four-year-old: four minutes. And so on.

But what if I’m in public?
Parenting is not for the faint of heart. It is not easy to have people staring at you, as if you have just done something horrendous to your child — and people will stare. Mostly because it is difficult for anyone to hear a child screaming. Possibly because, sadly, people will take any chance they can to feel superior. So, back to the kid. You need to find a consequence for the child that fits the outburst. You might try telling the child that if they don’t stop making this noise that we are going to have to: a) go sit in the car until he’s done, or perhaps b) not visit his friend later in the day, or even c) go straight home. You do not want to overreact. You want to show the child that you are in control, and that the child’s choice has an impact on the situation.

It all succeeds or fails on one critical point.
This cannot be overemphasized. You absolutely must follow up with any consequence you have stated. So from the outset, have it clear in your mind that you are ready to carry out the the consequence. Even if it is inconvenient. Even if it means a change in plans. Even if it makes you feel bad. Otherwise you will not be taken seriously. In fact, the child will have taken one step toward being in charge. Not only is this important because of the message it sends: when mommy or daddy says they are going to do something then they do it. That’s what makes it a limit.

Setting limits, establishing authority.
But also, every time a child sees that he can get away with something it means you will make it much, much harder to establish a limit in the future. Roughly speaking, if a tantrum is reinforced once, it’s going to take roughly 10-15 more tantrums before you’ve re-established authority. Think about that very carefully before you give in to your child. Sometimes it is convenient to give in. Especially when people are staring. But just stop yourself and really think — do I want to go through this ten more times?? In a moment of weakness, this may give you strength.

In summary.
Setting limits with a child can be very difficult. Perhaps your parents didn’t set firm limits? Perhaps there were no limits. Perhaps your parents were too controlling. Nobody wants to repeat the mistakes of their parents. But we need to be able to separate our experience from the experience of our child. We are not our parents. Our child is not us. Here’s a brief recap regarding how to deal with tantrums:

  1. At eye-level, acknowledge the child.
  2. Use a calm voice. This says, “I’m in control.”
  3. Offer a consequence if the behavior continues. Take a deep breath and use a calm voice.
  4. If necessary follow through with the consequence. You’ll be saving yourself a lot of energy in the long run.
  5. If the child is able to calm himself down, then you might even praise him for doing such a good job. It is no small accomplishment for young children to learn to self-regulate difficult emotions.

A final word of caution.
There is no cookie-cutter approach to parenting. You will find that what works for one child does not work for another, even within a family. You will have to find out what works for each child, and it will take time. You will also have to experiment to learn what is comfortable for you as a parent. Each parent, even within a family, may have different abilities to stay calm, acknowledge the child, deliver consequences. Parents do not develop bottomless patience over night. It takes practice. Don’t be too hard on yourself if things go wrong. Simply take a look at what went wrong, and what you can learn from the situation. In this way, we learn not to make the same mistakes over and over.

Kalea Chapman, Psy.D.

Parenting Books: Hazards and Fortunes

The hazards of parenting books.
If you’ve ever sat down in your local bookstore and started reading parenting books, you find that there’s one for just about every point of view. If you are looking for definitive answers you will be disappointed and confused. Authors take stances as varied as “spare the rod, spoil the child” (spank when appropriate) to advocating “family bed” (where parents and kids share a bed). So you can buy a book that appeals to you, go home feeling that your style of parenting is right, will result in successful children, admission to ivy league schools, or, for the less ambitious — well adjusted children.

Why so many parenting books?
You might also notice that there are a lot of these books. The reason? One reason is that people are unsure how to parent. New parents are hungry for advice. Somewhere along the way in our fast-paced, mobile culture, some basics of parenting stopped being held down from generation to generation. Many parents suffered through inadequate parenting themselves, and despite the best intentions, simply don’t know what good parenting is. As a result, new parents are vulnerable to claims that “this is the correct way to raise your child, help her sleep through the night, get her to eat” — whatever the claim may be.

There’s gold in them books — the fortunes.
Another reason is that there are so many of these books — they are big sellers. Publishers are not overly concerned about whether the parenting approaches are valid or not — they are interested in selling books. So marketing, rather than the well being of children, takes a front-and-center role in the flood of information that parents confront. As I’ve said before, parenting books are a part of the self-help market, and that’s a very lucrative market.

Who knows your child?
In the end, none of these authors knows your child, nor do they know you. If you are an anxious new parent having a difficult time with your child, you are not alone. Often, your pediatrician will be able to help you with your questions. If your child seems to be having a behavioral problem, then how you approach the problem needs to be tailored to both you and your child.

For instance, if you are letting your child cry himself to sleep, but find it very anxiety provoking to do so, then that is probably the wrong approach for your family. Your child will pick up on that anxiety. New parents are generally anxious enough as it is. Difficult emotional and behavioral problems can become entrenched, creating a tremendous amount of anxiety for a family. And anxiety is contagious — more on that another time.

Kalea Chapman, Psy.D.

Parenting: Heading Off the Tantrum

3766009204_8721a00dde_zphoto by mindaugas danys (creative commons)

Here are two simple tactics for heading off tantrums — giving choices and verbally preparing the child — both are remarkably effective. You give the child a choice. What the choices are is much less important than the fact of offering choices. For example:

  • Would you like to clean your room or would you like to take a nap now?
  • Do you want to finish your dinner and have some ice cream, or are you ready to brush teeth?

As you can see, often the questions can be quite leading, and the child will have no problem making the choice. In offering a choice the child feels a sense of some control and agency. And in this first move toward independence (the second being adolescence) having a sense of agency, the ability to do what you want, is very important. Offering choices also conveys respect. I’ve seen offering choices in action, and it is very effective. Try it sometime. You prepare the child. If you know that the child is not going to like doing something, then give the kid a “heads up.” For instance, if you’re going to a dental appointment, let the child know a day or two in advance. If you forget, even an hour before is helpful. And keep reminding the child.

You know we’re going to the dentist tomorrow. I don’t like the dentist. Why’s that? It’s scary. I know it’s scary. I’ll be there with you. I know you don’t like going to the dentist that much, but we’re going to go tomorrow.

The child may react positively or negatively, either way you’ll have a chance to discuss it with her. You will also be showing the child respect. You are not going to ambush her with a trip to the dentist. Imagine if someone told you out of nowhere, “I’m taking you to the dentist.” Or, worse yet, imagine if someone took you for a drive and then pulled into the dentist’s parking lot. How would you feel? Kalea Chapman, Psy.D.

My Teenager, My Three-Year-Old

Declarations of Independence.
Three years old (give or take a few months), is the child’s first statement of independence. This is a good thing. But it’s not so easy on parents. It is important, at this age, to find a good balance in how you set limits. One thing to keep in mind is that this is boot camp for the second statement of independence.

Add ten years. That’s right, you guessed it, adolescence. One day your chubby little monkey is going to be a teenager. If you’ve established a comfortable way of setting limits, listening to your child, and following through with consequences you will have your child’s respect. They will know that when you say, “no,” you mean it. They will also know that you will listen to them, not just dictate how it’s going to be.

I’m not your friend anymore!

That’s okay, sweetheart. I’m your daddy, and sometimes daddies do things their children don’t like.

I’m still not your friend! I hate you!

It sounds like you’re very angry and frustrated, but don’t talk to daddy that way. Do you need a time-out, or can you calm yourself down?

Observe the dance that you and your 3-year-old do together now. Do you like the way that you resolve conflicts? If not, then you have some time to make changes. Otherwise, this is a preview for what’s ahead — but instead of ice cream and sticker books, the stakes will be higher, a night out with the boyfriend, a loan of the family car, an iPhone. Will your teenager have learned to tolerate frustration? Or will she descend into a mood so foul you could hardly have imagined it?

When those teenage years arrive, you will have laid a nice foundation. And let’s face it, you will have made things a whole lot easier for yourself. It won’t be easy, but it does not have to be a nightmare.

Kalea Chapman, Psy.D.

Parenting Styles: Strict, Lax, Flexible

Parenting Posts: I’ve got quite a few of these lined up. Here’s one theorist’s view on different parenting styles.

Strict, lax, and flexible.
In psychology, we say authoritarian, permissive, and authoritative. These terms based on the research of Baumrind (1971). Sharon Jablon, Ph.D., who runs a test prep workshop for the national licensing exam in psychology (EPPP), has a nice summary of these parenting styles, which I’m going to quote from:

Authoritarian parents expect unquestioned obedience, are demanding, controlling, threatening and punishing. [They] tend to be more detached and less warm than other parents. Children exposed to this parenting style are frequently moody, irritable, discontented, withdrawn, distrustful, and aggressive and tend to have more behavior disorders. …This parenting style was termed “conflicted-irritable” and led to children who were also termed “conflicted-irritable”.

Permissive parents value self-expression and self-regulation. [They] are either permissive-indifferent or permissive indulgent.

Permissive-indifferent parents set few limits, provide little monitoring, and are generally detached and uninvolved. Their children have poor self-control, are demanding, minimally compliant, and have poor interpersonal skills. [Apparently, Baumrind didn’t have a label for this sub-type of permissive parenting.]

Permissive-indulgent parents are loving and emotionally available, yet set few limits, demands or controls. Their children tend to be impulsive, immature, and out of control. …The permissive-indulgent parenting style was termed “impulsive” and led to children who were termed “impulsive-aggressive”.

Authoritative parents are caring and emotionally available, yet firm, fair, and reasonable. They set appropriate limits, and provide structure and reasonable expectations. Children with authoritative parents are usually competent, confident, independent, cooperative, and at ease in social situations. …This parenting style was termed “energetic-friendly” and led to children who were termed “energetic-friendly-self-reliant”.

What have you observed?
Safe to say, you have observed or participated in parenting that resembles one of these categories more than the others. Reflect upon your own upbringing. Does one of these fit? Do the outcomes of these parenting styles described fit with your own experience?

Striving to be the parent you want to be.
If you are a parent, do you fall under one of the categories? Most of us would prefer to be to be in the “authoritative” camp. But most of us tend to veer into one of the other styles, if left to our own devices. In other words, some of us struggle with being a little lax, while others struggle with being a little strict. This has to do with how we were raised. By default, we raise our kids how we were raised; or, quite often, we raise our kids in reaction to how we were raised. Many of us struggle with being inconsistent, one of the most difficult battles of parenting.

Just another set of labels.
Remember, these are just labels. People love to categorize the world and say, “There, that’s how it is.” When we do this we blind ourselves to other possibilities. Reality is usually much more complicated. Perhaps this scheme does not fit with your own experience. As with any system of thought, take it with a grain of salt. These things have their day, are useful for a time, are often replaced by more useful ways of thinking. Take what you can use. If you’re interested in reading more about this scheme, click here.

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