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