Professional Point

The battle for prescription privileges often focuses on the ability of appropriately trained psychologists to prescribe safely and effectively, as physicians presumably do. What often gets lost, however, is the capacity of prescribing psychologists to use medications in a qualitatively different manner than psychiatrists. Simply put, it is anticipated that psychologists will use pharmacotherapy based on a psychological model of treatment in contrast to a medical model. The implications of this difference may be quite profound.

Training for psychologists

During deliberations of the Army Surgeon General's Blue Ribbon Panel, convened to make curriculum recommendations to the Department of Defense Psychopharmacology Demonstration Project (PDP), one particular source of debate was the issue of tailoring coursework. That is, what specific courses and training were necessary to ensure that psychologists already licensed could prescribe medication safely and effectively? Not surprisingly, the psychiatrists argued that psychologists wanting to prescribe should simply attend medical school. We psychologists on the panel, however, argued that the training should be customized and focused to provide just enough knowledge and skill to enable psychologists to prescribe. Our objective was not to transform psychologists into physicians.

A good case in point was the series of medical school courses in the history, philosophy and ethics of medical practice. Such coursework seemed unnecessary for health-care professionals already trained in the history, philosophy and ethics of psychological practice. Our goal was to teach psychologists enough medicine to prescribe without indoctrinating them in the medical model. Ultimately, the PDP did not include such courses, although it used many "off-the-shelf" medical school courses and a few customized courses. Other later psychopharmacology programs are more tailored to practicing psychologists' training needs.

Medical v. psychological

Training psychologists to prescribe offers an alternative to a medical model approach. How, then, should the medical and psychological models be differentiated? One operational definition of the medical model is diagnosing a "defect or disease" and then intervening to remove it surgically or medicate it away chemically. Further, this model presumes the reductionistic presence of a discrete illness, equates health with the absence of disease, and insofar as surgery is not appropriate, assumes medication is the intervention. The "psychological model" of treatment, by contrast, can be described as a systems-oriented, holistic, integrative approach. It presumes a continuum of function and dysfunction, equates health with integrity of function and adaptability and, to the extent that medication is appropriate, assumes it is but one aspect of treatment.

Another difference between models is the role of the patient/client. In the traditional medical model, the patient is, by and large, a passive recipient of care and of a "Dr. knows best" approach to treatment. A good patient is a compliant patient. By contrast, a psychological model maximizes client/patient empowerment. Treatment anticipates an active, problem-solving approach by the client. Collaboration between the health-care professional and the consumer of services (and, where appropriate, the client's family) is the norm, not the exception.

These differences in the two models are expected to create practical differences in how medication is used. For example, in the medical model, there is often no alternative treatment other than medication. In a psychological model where medication is only one of a number of possible interventions, pharmacotherapy is more likely to be combined with other interventions. Relatedly, collaboration between prescriber and client may lead to more discussion, explanation and psychoeducation supporting the use of medication than in the medical model. Also, when other treatments are available, with a psychological model, the power to prescribe is also the power to not prescribe.

Another important practical difference concerns how each treatment model conceptualizes symptoms. The medical model often presumes that the severity of a patient's symptoms is an indicator of disease severity. Therefore, if mental health-related symptoms increase, so does the likelihood that medication will be prescribed. In the psychological model, symptom increase does not on its own mean that the disorder is worsening. In fact, as treatment works to help patients better confront problems, symptoms may be exacerbated. When symptoms interfere with psychotherapeutic work, medication would help. But if symptoms are not interfering with psychotherapy, medication may not be a necessary or appropriate intervention. The actual use of medication differs depending upon whether a psychological or medical model is adopted.

There are likely many other differences in prescribing practice beyond this column's scope. In short, important qualitative differences in medication use may result from training psychologists to prescribe and should not be overlooked among the benefits of prescribing by nonphysicians.