It's a dynamic, perhaps pivotal, time for psychopharmacology training for psychologists.

Although there is currently no official list of training programs and no mechanism for accrediting them, there are at least 11 such programs across the country (see list on page 44), with a variety of modes of training.

Most programs have started in the last two years and at least five have formed in just the last few months. And some of the schools with a year or two experience are making plans to expand.

"There is a high demand for this training," says Ron Fox, PhD, chair of APA's Committee for the Advancement of Professional Practice. "The programs don't have any trouble getting people to participate."

Others involved with the training estimate that more than 500 psychologists have now completed a training course, most of them through the Prescribing Psychologists Register (PPR), which offers its program through seminars around the country.

In addition, last summer the program sponsored by the Louisiana Psychological Association became the first associated with a state association to graduate students, with a class of 35.

Those numbers are likely to increase regularly over the next few years as the other schools begin graduating classes.

At the same time, several developments are further shaping the future of psychopharmacology training. For one, APA's College of Professional Psychology will launch in April a standardized test for use by state licensing boards in assessing an individual's knowledge in psychopharmacology. Meanwhile, the Association of State and Provincial Psy- chology Boards (ASPPB) is drafting a set of suggested guidelines for psychopharmacology education and licensing.

All of the developments are tied to an increased demand for training. Fox and other observers agree that demand is one of the best indications that many people believe that some states will pass laws to allow psychologists to prescribe in the next few years. The state psychological associations in Louisiana and Georgia believe they have a significant chance of passing legislation in the near future. According to a recent APA survey 28 states have some type of prescription privilege activity planned or underway and 23 of those have an actual task force on the issue. The U.S. Territory of Guam actually passed a law for prescription privileges at the end of 1998. However, says Fox, "I think the first state law could happen any time and it may happen in a state that we are not even thinking about."

In 1996 the APA Council of Representatives endorsed a model for state legislation that calls for psychologists to be given prescriptive authority "within the scope of practice of psychology" governed by state boards of psychology regulations.

Most of the training programs, say people familiar with the field, are following APA's recommended curriculum for psychopharmacology training. That model, adopted by the APA Council of Representatives in 1996, calls for 300 contact hours of didactic instruction in five core content areas: neurosciences, pharmacology and psychopharmacology, physiology and pathophysiology; physical and laboratory assessment and clinical pharmacotherapeutics.

However, each program differs in its approach to teaching. Some programs hold classes in traditional classroom settings on weekends. Others instruct over the Internet or in continuing-education seminars held in various places. Some programs offer a postdoctoral master's degree and others offer a certificate of completion. This year Forest Institute in Missouri is offering a psychopharmacology specialty as part of its regular doctoral program, as well as a postdoctoral program.

The shape of the programs is guided by what people think their state legislatures and licensing boards will consider legitimate, when and if state laws are passed, says John Bolter, PhD, who helped develop the psychopharmacology training program for the Louisiana Psychological Association.

Ronald Levant, EdD, who has developed a training program at Nova Southeastern University in Florida, contends that many psychologists need this training to understand what is happening with their patients, since so many are on medication. He also makes the point that, "the power to prescribe is the power to unprescribe."

Tests and guidelines

A landmark event for the training will happen in the next few weeks with the release of the APA College of Professional Psychology's psychopharmacology test, being offered primarily for use by state licensing boards. There is increasing interest in the exam by individual psychologists who have completed training in programs consistent with APA's model curriculum. Although the exam is not connected to any certification, APA President Pat DeLeon, PhD, JD, says, "It will give the training a credibility that will encourage other people to undertake it."

An exam with APA's imprimatur will also make it easier to answer state legislators' questions about quality control when they consider voting for prescribing privileges, says Levant. Advocates for the privileges can now point to a rigorous exam, he says, that could be part of the licensure requirements for psychologists who will be prescribing powerful drugs.

The computer-based test will be given at Sylvan Prometrics testing centers across the United States. For psychologists who take the test now, the scores will be banked and kept on file in the event any states decide to make passage of this test a requirement for prescription licensing.

The Louisiana state board has become the first to request access to the exam for graduates of that state's psychopharmacology training program in advance of an actual prescription privilege law. The college will report the scores at the examinee's request to the state licensing board.

To take the exam, a person must be a licensed psychologist who provides health services and has completed a didactic study program in psychopharmacology consistent with APA's model curriculum.

When enough scores are compiled, APA's College will publish the average scores for graduates from each of the training programs. That could also influence training by indicating which schools prepare graduates better and how strong the individual schools are in the 10 content areas on the test.

And in another development, ASPPB's education committee recently set to work to quickly create regulatory guidelines on licensure issues, including training and testing, for consideration by state boards in case state laws are passed. The committee believes passage of the first state law is apt to happen fairly soon, says the association's Director of Professional Affairs Asher R. Pacht, PhD.

"We see this as a priority for guidelines," he says, indicating that the purpose is to protect consumers by suggesting effective state licensing practices. He expects the guidelines may be ready this year or early next year.

The decision on whether to use the guidelines will be made by each licensing board, as would a decision about using the College's exam.

Nevertheless, the guidelines' release will be considered an important point, since the licensing boards are likely to be the critical decision-makers after state laws are passed.

Practical experience

The next couple of years will also be important to the development of the second part of the training, practical experience.

APA guidelines call for students to have a clinical practicum with a minimum of 100 patients seen for medication, with a mix of inpatient and outpatient placements, and at least two hours of weekly individual supervision.

Russ Newman, PhD, JD, APA executive director for practice, notes that "the practical experience component needs to be as carefully organized and planned as the didactic portion. It's the combination of the didactic and supervised clinical experience that will provide quality training for actual prescribing."

Bolter says the Louisiana program has a subcommittee looking at how to ensure the practicum is a good experience with good supervision. They will be exploring the types of disorders to treat, the settings and length of the training, and accommodations for students since most already work. They'll also be determining who will do the supervision, particularly since some psychiatrists may refuse.

Levant believes his program, which started last fall with 17 students, will be the first to offer a practicum as a part of the training course. The practical experience will be done in association with a community mental health center operated by the university. The training will take place over a few weeks each summer, for two summers.

He notes, however, that the program is already getting inquiries from people in other parts of the country who are completing the didactic training and need a place to take the practicum. The program is considering collaborating with local hospitals to create more of the practicum slots for both the trainees from other programs and the expanded classes Levant expects in his own program.

Matthew Nessetti, PhD, says the new program he heads, The Psychopharmacology Institute, will have the didactic training in seminars around the country but will offer the practical training in six clinics in Nebraska.

A graduate of the Prescribing Psychologists' Register, Nessetti notes that program simply has students arrange their own preceptorships and then get them approved, a system he says worked well for him.

In the end, state licensing boards will also likely write rules on what a practicum should be, according to those in the field. The upcoming ASPPB committee guidelines will address this issue also.

First law

Meanwhile, the growing number of psychologists trained in this area is creating greater credibility for the privilege as well as a cadre of professionals motivated to push for the laws.

Once the first state law is passed, "It will be kind of like the dam that broke," says Nessetti. It will create a tremendous impetus both for the passage of other state laws and for psychologists to seek the psychopharmacology training, he and others predict.

After that, if two or three states give unambiguous prescription authority, that "will just light a match under the training programs," says Levant.

That first law may also be looked to as a model for other state laws. Indeed, cautions Nessetti, the psychology community needs to be careful what it asks for or accepts with the first law. He points out that licensing requirements that are too strict or too loose could cause problems.

APA President DeLeon comments, "The prescription privileges agenda represents the best of psychology. It involves practice, education and science. It is in the public interest since it will allow psychologists to ensure people have medications or not have them, as appropriate. And now the training programs themselves are evolving nicely and it is good to have variation in the programs."