A commentary: Canada is not that far north

Canadian Psychology, Nov 1995 by Deleon, Patrick H, Sammons, Morgan T

Abstract

The time has come for professional psychology to actively seek prescription privileges. Although the political gestalt in Canada may differ somewhat from that in the United States, the underlying policy issues are identical. Psychology has demonstrated that it can develop viable training modules and that by utilizing post - doctoral Fellowships, the profession will retain the basic integrity of its underlying scientific and behavioural knowledge base. The authors contend that Dozois and Dobson significantly overestimate the extent of psychology's internal opposition; underestimate psychiatry's historical hostility; and have given insufficient thought to potential new "market places" and scientific endeavours. As professional psychology systematically focusses upon society's real needs, all will substantially benefit.

The views expressed do not necessarily reflect those of the U.S. Navy or the Department of Defense.]

Most assuredly, we would not want to "second guess" the professional or political judgement of our colleagues in Canada regarding the timing of their eventual efforts to obtain prescription privileges. Although having been actively involved in the governance of the American Psychological Association (APA), we do not presume to fully appreciate the subtle nuances of the Canadian health delivery system, psychology's role therein, nor the impact of the historical "power" of the Canadian Medical Association over Canadian psychologists. To reiterate just one concrete example, the fact that various Canadian non - physician practitioners, particularly advanced practice nurses, apparently do not currently possess scope of practice acts that are comparable in autonomy with their American counterparts, does indeed suggest the existence of substantive (if not substantial) political and historical obstacles that must be overcome. But our sincere reluctance does not extend to the underlying policy issue of whether Canadian professional psychology should eventually obtain this clinical privilege/responsibility - and to this most basic question, we do respectfully disagree with our Canadian colleagues, Drs. Dozois and Dobson (1995).

PROFESSIONAL INTEREST

In all candor, we feel that Dozois and Dobson significantly underestimate the extent to which our professional colleagues are, in fact, interested in obtaining prescription privileges, and that they overestimate the extent to which there is internal opposition.

It is true that when the issue first surfaced in the mid - 1980's, only approximately one - third of psychologists (34%) strongly favoured obtaining this clinical privilege, while an almost equal percentage (27%) vigorously opposed it. However, as our colleagues became systematically exposed to the conceptual and clinical arguments, and most importantly to the relevant data - for example, that currently only 17.3% of psychotropic medications are, in fact, prescribed by physicians with substantial mental health training (i.e., by psychiatrists) - this profile has radically changed. The most recent report from Hawaii indicates that presently 70 - 75% of the HPA membership now favours obtaining prescription privileges. A 1990 APA Practice Directorate survey concluded that there is very strong support for prescription privileges and that there is nothing to suggest that APA is getting too far out in front of the troops on this issue. And, with the establishment of 25 state psychological association prescription privilege task forces, considerable "grass roots" support for the movement clearly exists. We would further note that this considerable enthusiasm has even developed prior to the availability of viable training modules which would allow our clinicians to feel comfortable that they are competently prescribing (DeLeon & Wiggins, in press).

We do not find our profession's initial skepticism at all surprising. The prescription privilege agenda is, after all, fundamentally a clinical training agenda, and yet one that at this time in our evolution is primarily being advanced by the practice community. As such, one must expect certain "glitches" that have to be overcome, not the least of which are the concerns of the training community as to where necessary training resources (i.e., faculty positions) will be obtained, as well as the very practical matter of how they as individuals are to obtain the necessary expertise to provide the required training, both didactic and clinical (i.e., "hands on").

Under our American legal system and Constitution, public agencies (such as, the Veterans Administration, the Indian Health Service, and the Department of Defense) are accorded considerable flexibility in providing necessary health care to their beneficiaries in the manner that they deem "appropriate", notwithstanding state laws (or scope of practice acts) to the contrary. During the past decade, we have become aware that many of our colleagues, particularly those within the federal sector, have been prescribing for years, with no reported "quality of care" problems. That is, our practitioners have already demonstrated the ability to utilize psychotropic medications "safely and effectively", and have done so within their appropriate "chains of command", even without formal intensive training. This has been reflected, for example, in modifications to relevant Indian Health Service (IHS) hospital by - laws (Burns, DeLeon, Chemtob, Welch, & Samuels, 1988; DeLeon, Folen, Jennings, Willis, & Wright, 1991).