Current Controversies in Clinical

Psychology
 Prescription Privileges
• Historically been one of the primary distinctions between psychiatrists and
psychologists
– Within the general public, it is a defining difference
• Recent years have seen some clinical psychologists actively pursue prescription
privileges
– Roots of the movement were established in the 1980s
– The 1990s and 2000s saw high-profile, high stakes debates
• The APA has published numerous articles
– Endorsing prescription privileges
– Offering suggestions for training of psychologists to become proficient in prescribing
safely and effectively
• Several prominent psychologists have promoted the movement towards
prescribing
– Patrick H. DeLeon
– Morgan T. Sammons
– Robert McGrath
 Prescription Privileges
• Three states have granted prescription
privileges to trained psychologists
– New Mexico in 2002
– Louisiana in 2004
– Illinois in 2014
– Others have given serious consideration
• Several psychopharmacology training programs
are available for psychologists in the US military
Why Clinical Psychologists Should Prescribe

• Shortage of psychiatrists
• Clinical psychologists are more expert than primary care
physicians
• Other nonphysician professionals already have
prescription privileges
• Convenience for clients
• Professional autonomy
• Professional identification
• Evolution of the profession
• Revenue for the profession
Why Clinical Psychologists Should Prescribe

• Shortage of Psychiatrists
– Low ratio of those who can prescribe medications
and those who need them
– Underserved segments of society would benefit
from a higher ratio of prescribers to patients
• The lobbying for privileges in New Mexico and
Louisiana
– The low number of psychiatrists per capita was a
cornerstone of the (successful) argument
Why Clinical Psychologists Should Prescribe

• Clinical Psychologists are More Expert Than Primary

Care Physicians
– Psychiatrists have specialized training in mental health
issues
• However, they aren’t the only ones prescribing psychoactive
medications
– More than 80% of prescriptions come from primary care
physicians
• Clinical psychologists’ training is more extensive and specialized
than a physicians’
– Thus, clinical psychologists could be better able to diagnose problems
correctly and select effective medications
Why Clinical Psychologists Should Prescribe

• Other Nonphysician Professionals Already Have

Prescription Privileges
– These include dentists, podiatrists, optometrists, and
advanced practice nurses
– This sets a precedent for specially trained clinical
psychologists to do the same
Why Clinical Psychologists Should Prescribe

• Convenience for Clients

– Many patients could benefit from both nonpharmacological
interventions (i.e. psychotherapy) and prescription medications
• A psychotherapist
– Can provide psychotherapy
– Can’t provide the medication
• A primary care physician or psychiatrist
– Can provide medication
– Can’t provide psychotherapy
– Inconvenient for both the patient and provider
• Increases the time and money that patients spend on appointments
• Requires two busy treatment providers to be in communication
Why Clinical Psychologists Should Prescribe

• Professional Autonomy
– Clinicians may feel restricted in what they can do
– With prescription privileges, clinicians provide a
wider range of services to clients
Why Clinical Psychologists Should Prescribe

• Professional Identification
– It might be difficult for the general public to distinguish
between psychologists and other non-prescribing
therapists or counselors
– The ability to prescribe would set psychologists apart
(and above) other professions
Why Clinical Psychologists Should Prescribe

• Evolution of the Profession

– Clinical psychologist has undergone many changes in its brief
history
• Many were initially unfamiliar
• These changes have allowed the profession to thrive
– Many see prescription privileges as the next step in the
evolution of the profession
• They argue that to stop this would impede growth
– Prescription privileges could open multiple doors
• Direct pharmaceutical treatment of clients
• Consultation with physicians about psychoactive medications for
patients
Why Clinical Psychologists Should Prescribe

• Revenue for the Profession

– Financial benefit for the profession and its members
• Salaries have decreased as a result of managed care
• Prescription privileges could offset this
– Some psychiatrist organizations strongly oppose
prescription privileges of clinical psychologists
• Members stand to lose business if psychologists can prescribe
– Could be huge
» In the 1990s, the percentage of those on antidepressants doubled
from 37% to 74%
» Antidepressants were the most commonly prescribed category of
drug in the US in 2011
 Why Clinical Psychologists Should Not
Prescribe
• Training issues
• Threats to psychotherapy
• Identity confusion
• The potential influence of the pharmaceutical
industry
 Why Clinical Psychologists Should Not
Prescribe
• Training Issues
– Good questions
• What kind of education should clinical psychologists receive before they are licensed to
prescribe?
• What should it cover?
• Who should teach them?
• When should it take place?
– Early in graduate school?
– During the predoctoral internship?
– As specialized training after the doctoral degree?
– Some argue for a comprehensive understanding of everything involved in a
prescription decision
• The only way to appreciate the impact of the drug on
– Multiple systems of the body
– The interactions with other medications
– All other medical factors
– Others argue for just a basic competence in psychopharmacology
– Most fall in the middle…
 Why Clinical Psychologists Should Not
Prescribe
• Threats to Psychotherapy
– If clinical psychologists can prescribe, what will become of
psychotherapy?
• Some worry that it will drift from “talk therapy” to pharmacological
intervention
• Clients may come to expect medication from clinical psychologists
• Clinical psychologist might discover that prescribing is more profitable
– Cummings (2007)
• “Undoubtedly, the acquisition of prescription authority… would
significantly expand the economic base of the psychological practice.
When that day comes, it remains to be seen, however, whether they
abandon the hard work of psychotherapy for the expediency of the
prescription pad.”
 Why Clinical Psychologists Should Not
Prescribe
• Identity Confusion
– Until/Unless all psychologists prescribed, an
identity crisis could emerge
• Some clinical psychologists will prescribe, some won’t
• Training
– Some will have trained during graduate school
– Others will have specialized training long after earning their
doctoral degrees
– The public could become genuinely confused
about the role that a clinical psychologist plays
 Why Clinical Psychologists Should Not
Prescribe
• The Potential Influence of the Pharmaceutical Industry
– Drug companies attempt to increase profits by offering
gifts, funding research, controlling the publication of
research results, etc.
– Some have concerns that psychologists might be targeted in
these ways
• This could result in biasing a clinician to make decisions that are
not solely based on the client’s welfare
– In response, some psychologists have called for formal
guidelines on how psychologists should interact with drug
companies
Evidence-Based Practice/Manualized Therapy

• The movement in favor of evidence-based and

manualized therapy has intensified in recent
decades
• First, we have to pose a question…
– Does psychotherapy work?!?
• How do we know?
• If it does, what makes it work?
• If it doesn’t, is it ethical to charge?
• What if it works only as a placebo?
– Is it ethical to charge for a placebo?
Evidence-Based Practice/Manualized Therapy
• Hans Eysenck (1952)
– Stated that psychotherapy had no proof of positive outcomes
– Sparked a huge debate within the field
• Early wave of research proved Eysenck to be wrong
– Psychotherapy was found to be quite efficacious
• Smith and Glass (1977)
• Smith, Glass, and Miller (1980)
– Much of this work was on the effectiveness
• Of any type of psychotherapy
• On any diagnosis
• Recent waves of research have targeted
– Specific psychotherapeutic interventions
– Specific diagnoses
• Waves went from
– “Does therapy work?” to
– “Which forms of therapy work best for which disorders?”
Evidence-Based Practice/Manualized Therapy

• Two research designs

– Does therapy work?
• Therapists can be assigned clients and instructed to provide therapy for them
– No further instructions are given
– Therapy can differ widely
» Between therapists
» Between patients
• Lack of uniformity isn’t a problem for this research design
– Which forms of therapy work best for which disorders?
• Here, you need to make absolutely sure that therapy is the same
– Across therapists
– Across patients
• In order to do this, you need a therapy manual
– The purpose of the manual is to keep variability among therapists to a minimum
– If the technique is effective, it can then be shared with others in exact, unambiguous
terms
Evidence-Based Practice/Manualized Therapy

• There have been many, many research studies on manualized

treatments, for example…
– Exposure and response prevention
• A specific form of behavior therapy for the treatment of OCD
– Dialectical Behavior Therapy (DBT)
• For the treatment of Borderline Personality Disorder
– Cognitive Behavioral Therapy (CBT)
• For the treatment of depression and anxiety
• Each of these treatments
– Have shown to be effective in the treatment of the specific disorder
– Have had their results published in professional journals
• This is extremely important because this is how we know that
treatments work
– Without these studies, would treatment be ethical?
Evidence-Based Practice/Manualized Therapy

• Division 12 (Clinical Psychology) of the American

Psychological Association
– Created a task force to compile a list as a reference for
therapists who sought the most proven therapies for
particular disorders
• Was originally called “empirically validated” and then “empirically
supported”
• Now called “evidence-based practice”
– This term incorporates
» The treatment itself
» Factors related to the people providing and receiving it
– “The integration of the best available research with clinical expertise in the
context of patient characteristics, culture, and preferences”
» “APA Presidential Task Force on Evidence-Based Practice, 2006, p. 273
Evidence-Based Practice/Manualized Therapy

• Reviews the latest

research on
pharmacological and
psychosocial treatments
that work for the full range
of psychological disorders
– 26 of the 28 chapters
review the evidence base
for 17 major syndromes
– This most recent version
was released in 2015
Evidence-Based Practice/Manualized Therapy

• Advantages of Evidence-Based Practice/Manualized Therapy

– Scientific legitimacy
– Establishing minimal levels of competence
– Training improvements
– Decreased reliance on clinical judgement
• Disadvantages of Evidence-Based Practice/Manualized
Therapy
– Threats to the psychotherapy relationship
– Diagnostic complications
– Restrictions on practice
– Debatable criteria for empirical evidence
 Advantages of Evidence-Based
Practice/Manualized Therapy
• Scientific Legitimacy
– Before manualized therapies, a critic could describe clinical
psychology as a “cottage industry” of sorts
• A depressed patient who saw Dr. A might get one form of therapy
• Another depressed patient who saw Dr. B might get another
– A scientific approach to treatment requires a beneficial
treatment that all members of the discipline uniformly
practice
• We expect such standards from medical doctors treating a
physical disease
• If clinical psychology subscribes to the medical model of diagnosis
and treatment, the same expectation should apply to them
 Advantages of Evidence-Based
Practice/Manualized Therapy
• If clinical psychologists were allowed to practice their own
unique brand of therapy…
– A few of them would be ineffective or even harmful
• As evidence-based treatments are disseminated and used…
– Ensures that potentially incompetent or detrimental therapists
will be educated in effective treatments
– As treatments evolve into professional standards, psychologists
will be obligated to follow them
– The public will receive a more consistent, proven brand of
treatment for each disorder
– Psychologists can be held to a greater standard of accountability
 Advantages of Evidence-Based
Practice/Manualized Therapy
• Training Improvements
– These manualized treatments can be incorporated
into graduate programs
– The APA considers criteria related to training in
evidence-based treatments when making
accreditation decisions
– Upcoming generations of psychologists will have
been educated in evidence-based therapy
 Advantages of Evidence-Based
Practice/Manualized Therapy
• Decreased Reliance on Clinical Judgement
– Clinical judgements are susceptible to bias and are quite flawed
• This can compromise therapy decisions and clinical outcome
– Surveys suggest that clinicians rely more on their on clinical
judgement than mechanical or actuarial judgements based on
empirical evidence
• This is a problem
 Disadvantages of Evidence-Based
Practice/Manualized Therapy
• Threats to the Psychotherapy Relationship
– What aspects of therapy are effective?
• Some of “what works” in therapy is attributable to specific techniques
• A greater proportion is due to the therapeutic alliance
– The relationship between the therapist and patient
– Therapy manuals typically don’t emphasize the therapeutic
alliance
• Overlook “how” therapists relate to their clients
• Favor “what” therapists do with (or to) their clients
– A therapist operating as a technician carrying out an algorithm
could be a disservice to those seeking a meaningful human
connection
• Some psychologists argue that it should be the relationship, not the
technique, that is manualized
 Disadvantages of Evidence-Based
Practice/Manualized Therapy
• Diagnostic Complications
– Evidence based treatments target specific disorders
• When tested in clinical trials, the clients are of that target
disorder – typically without any other diagnosis
– This isn’t generalizable to clinical settings in which
comorbidity is the norm
• It’s possible that the therapy could be useful for “clean” (i.e.
uncomplicated) disorders but not useful in more “messy”
diagnostic features commonly seen in real world settings.
– Some work focuses specifically on this issue
 Disadvantages of Evidence-Based
Practice/Manualized Therapy
• Restrictions on Practice
– Some suggest that empirically supported
treatments are the only therapies worth practicing
– Some psychologists have used the term
malpractice in reference to using a therapy that
lacks empirical support
– Managed-care and Health Insurance Companies
• May use empirical support to argue that psychologists
should practice certain treatments exclusively
– This could further limit the psychologists autonomy
 Disadvantages of Evidence-Based
Practice/Manualized Therapy
• Restrictions on Practice (cont.)
– Proponents of manualized therapy often think it gets a bad rap:
• “We believe that manuals are mischaracterized when they are described
as rigid… specifying the components of the therapy does not have to
deprive a therapy of its lifeblood. At best, it can help everyone involved
come to understand what that lifeblood actually is (Spokas, Rodebaugh, &
Heimburg, 2008, p. 322).
 Disadvantages of Evidence-Based
Practice/Manualized Therapy
• Restrictions on Practice (cont.)
– Does strict adherence to manualized therapy
produce better outcomes?
 Disadvantages of Evidence-Based
Practice/Manualized Therapy
• Restrictions on Practice (cont.)
– Does strict adherence to manualized therapy produce better
outcomes?
• Therapists who demonstrate flexibility while using manuals are more
successful in comparison to therapists who follow manuals rigidly
– Chu & Kendall, 2009
• The option of flexibility, as opposed to the requirement of rigid
adherence, helps clinicians accept manualized treatments as a form of
practice
– Forehand, Dorsey, Jones, Long, & McMahon, 2010
– Curry (2009)
• Sees manuals as training in musical instruments…
– It requires the learning of standard techniques, but also allows for (or even
encourages) improvisation
 Disadvantages of Evidence-Based
Practice/Manualized Therapy
• Debatable Criteria for Empirical Evidence
– What should it take for a manualized therapy to
make the “empirically supported” or “evidence-
based” list?
• Some argue that the current criteria are questionable,
or do not account for failed trials of a treatment
• Others argue that the criteria are biased
– Favor the more empirically oriented therapies
» e.g., behavioral and cognitive
– Shut out therapies that produce less easily quantifiable results
» e.g., psychodynamic or humanistic
Overexpansion of Mental Disorders
• Size and scope of the DSM has
vastly increased over time
– The number of people with mental
disorders has climbed with it…
• 50% of the U.S. population is diagnosable
at some point in their lifetime
• 11% of the U.S. population is currently
taking antidepressant medication
– Many different names for the increase
rates of mental disorders
• Overdiagnosis, diagnostic expansion,
diagnostic inflation, diagnostic creep,
medicalization of everyday problems,
false positives, false epidemics, etc.
Overexpansion of Mental Disorders
• Some critiques of DSM-5 overdiagnosis
– “There has been no real epidemic of mental illness, just a much looser
definition of sickness, making it harder for people to be considered well.
The people remain the same; the diagnostic labels have changed and are
too elastic. Problems that used to be an expected and tolerated part of
life are now diagnosed and treated as mental disorder.”
• Frances, 2013, p. 82
– “The danger of DSM-5 ideology is that it extends the scope of mental
disorder to a point where almost anyone can be diagnosed with one.”
• Paris, 2013, p. 41
– “The more that psychiatric diagnoses appear to encroach on the
boundaries of normal behavior, the more psychiatry opens itself to
criticisms that there is no validity to the concept of mental disorders
(e.g., there’s no such thing as mental illness – it’s a ‘myth’).”
• Pierre, 2013, p. 109