Since APA passed its resolution in support of prescriptive authority in 1995, organized psychology has achieved many successes in the legislative and training arenas. The United States Territory of Guam passed a RxP bill (1998) and at least a dozen programs now exist to train psychologists to provide psychotropic medications to their patients. More than half of the state psychological associations have RxP committees and 10 states have submitted RxP enabling legislation. The legislative battles will continue and proliferate. The first state bill should pass soon, perhaps by the time you read this.
However, psychology is not capitalizing on the training initiative to the extent we could. The various clinical psychopharmacology training programs are essentially autonomous. Therefore, they are less than maximally effective in promoting professional cohesiveness in support of a biopsychosocial model of practice. Perhaps the increased availability of the APA Practice Organization's College of Professional Psychology examination will serve as a catalyst for greater collaborative effort among these training programs.
That said, coordination at a more fundamental level is necessary. Of the three model curricula APA developed, the best known is Level 3, the template on which programs training students for prescription privileges are based. Level 2 appears to be vanishing into the ether as we speak. This level, in our view, never generated much enthusiasm, and was almost discarded by the original RxP Task Force. The collaborative practice model promulgated by Level 2 has generated little interest within the practitioner community and certainly has no champion.
The Level 1 curriculum, as its authors note (Kilbey et al., 1995), was designed to provide a fundamental knowledge in clinical psychopharmacology for all psychologists seeing patients: "all providers in psychology need to have basic knowledge in the area of clinical psychopharmacology represented by the entire knowledge base delineated in all the modules of the Level 1 curriculum" (p. ii).
With new psychopharmacological agents gaining FDA approval in an accelerated manner, there is increasing pressure on psychologists to understand how these drugs function. This knowledge is imperative in the application of psychological treatments and methods. Without it, patient care could be compromised. Unfortunately, there is no feasible way, given the heterogeneity of our various state continuing-education requirements, to ensure that psychologists will all receive this training at the postdoctoral level.
Accordingly, we immodestly propose that Level 1 training be made a criterion for accreditation for all doctoral programs in clinical, health, counseling and school psychology. It would be desirable to include such training in any human service doctoral programs, but the imperative remains: Level 1 training must be a part of the core curriculum for every doctoral student in applied psychology. Implementing this proposal would have several long-term advantages to the profession:
It would provide the knowledge foundation that will be vital for those psychologists who will practice in the next decades, when psychotropic medications will become increasingly effective, available and attractive to consumers/patients.
Psychologists will need such information in order to maximize the quality and effectiveness of their clinical care and be able to make better judgments about treatment approach: exclusively psychological versus integrated psychological/pharmacological versus exclusively pharmacological.
It would help provide the foundation for a biopsychosocial model of practice and promote a shift--which has already begun--in practitioner identity toward that of primary-care provider. It would help expand our scope of practice into prevention of health-care problems, augmenting our effectiveness in such areas as risky health behaviors, compliance with treatment regimes and stress reduction.
It would attract students to our profession, an additional cadre of the "best and the brightest," who have a greater interest in, and appreciation for, biopsychosocial practice (a model consistent with the nation's increased interest in holistic mental and physical health). This aspect of Level 1 training may be the least appreciated by graduate program faculty in particular and the profession in general.
Not forgotten are senior psychologists, including those with no interest in Level 3 training, who could take Level 1 training as nonmatriculated students and gain the knowledge that otherwise might be difficult to access. This would open a new revenue stream for graduate training programs. (Thanks to Dr. Cathy Rea, president of the Virginia Academy of Clinical Psychologists, for this suggestion.)
In addition, it would be desirable to reconfigure the Levels 1 and 3 curricula so as to be coordinated and compatible, so that Level 3 would be the logical extension of Level 1. As Level 3 training is lengthy and costly, why not integrate the two such that Level 1 training would comprise at least one of the modules (or a part of a module) of the Level 3 curriculum? The reduction in subsequent training costs would result in more students choosing to complete their Level 3 training after finishing their doctorates.
Remember, training and legislative initiatives are synergistic. Training grows the constituency for legislative efforts, which in turn show psychologists enrolled in Level 3 programs that their hard work will ultimately be rewarded. The more students who graduate with a working knowledge of clinical psychopharmacology, the more who will be motivated to continue their studies and join their respective state and provincial associations' legislative initiatives.
When we compare psychologists' quest for RxP with that of other professions, we must bear in mind that optometrists and nurses had a much more thorough grounding in clinical pharmacology at the pre-practice level than most of us psychologists did. Their professional identities as prescribing health-care professionals and, by extension, their legislative constituencies were formed at the journeyman level. Psychology's identity is evolving--whether we like it or not. Implementing Level 1 training as a core requirement at the predoctoral level would both shape our identity proactively as primary health-care providers and help create a stronger legislative constituency for Level 3 bills.
Robert K. Ax, PhD, is an APA Fellow and the President-elect of Div. 18 (Public Service). Robert J. Resnick, PhD, FAClinP, ABPP, is a Past-president of APA, and chair of the Committee for the Advancement of Professional Practice subcommittee on prescription privileges.
APA's Clinical Psychopharmacology Training Curricula
In 1992, APA's Ad Hoc Task Force on Psychopharmacology issued a recommendation for the development of three curricula that would provide psychologists with progressively greater clinical psychopharmacology knowledge and skills, culminating in preparation for prescriptive authority. The Level 1 and Level 2 models were developed by a Board of Educational Affairs working group, while the Level 3 curriculum originated with the Committee for the Advancement of Professional Practice Task Force on Prescription Privileges and was also based on other training models, including that of the Department of Defense Psychopharmacology Demonstration Project. These curricula are:
Level 1--Basic education in clinical psychopharmacology. This curriculum contains nine modules. Its framers suggested that it could be taught in a three-to four-credit, one-semester course at the doctoral level, or as separate continuing-education courses for applied psychologists.
Level 2--Collaborative practice. This curriculum incorporates a developmental perspective. The focus here is on educating practitioners for assisting in the management of disorders across the lifespan (child/adolescents, adults and older adults) with patients being treated with psychotropic medications.
Level 3--Training and education for prescriptive authority. Students take at least 300 contact hours of didactic instruction followed by a clinical practicum involving a minimum of 100 patients seen for medication. Several private vendors now offer this training.