Truth be told, I have only recently become an advocate for psychologists' prescriptive authority. I completed graduate school in 2001, earning my degree from the clinical studies program at the University of Hawaii, Manoa, and was content with the breadth of knowledge I had accumulated. My only question with regard to the prescriptive authority debate at that time was, "Why would anyone in their right mind want to do this?" I had taken nearly a decade to achieve my doctorate and could not fathom the need, nor want, for further training any time soon.
To date, my response has evolved, and I'll be the first to admit my own wonder and amazement. A Hawaiian proverb comes to mind that describes my transformation: Ma ka hana ka 'ike (In work, one learns). It was only when I began to work in rural communities providing primary-care psychology services in medically underserved areas that I learned there was value in prescriptive authority for psychologists.
My background as a Native Hawaiian Health Professions Scholarship recipient and postdoctoral health psychology fellow at Tripler Army Medical Center in Honolulu created training opportunities for an exciting, second wave of professional growth in health psychology and psychopharmacology. I have realized that sufficient psychopharmacology training can be attained and incorporated into a biopsychosocial-cultural model of conceptualization and treatment. The result: behavioral psychopharmacology. Psychologists are uniquely trained in ways that ultimately support the practice of prescribing. I now believe it is a necessary expansion of the scope of practice for psychologists, particularly those working in rural, medically underserved areas with minority groups, women and children.
I worked in Hana, Maui, for a year, and continue to work on the island of Molokai, where health-care needs and shortage issues abound. Mental health services in these areas have either been nonexistent, itinerant or too specialized to meet broad community health needs. A critical component of the primary-care psychology services I provide involves expanded knowledge of psychotropic medications, and the ability to consult with primary-care physicians and nurse practitioners regarding treatment interventions and overall effective management of mental health issues using combined drug and brief therapy treatments.
In my experience, this collaboration has been the most valued part of our services in rural settings, where availability and efficiency of service delivery speak volumes toward enhanced patient care. Toward this end, the primary-care psychology model has room for expansion and further improvement that begins with legislation enabling psychologists to prescribe.
Rural communities would benefit from psychologists' prescriptive authority in several ways. First, access to effective, representative and culturally sensitive mental health services would be increased. Psychologists are best trained to identify emotional and cultural barriers to physical health and to understand which behavioral markers indicate physiological mechanisms that may benefit from psychotropic medication, or which cultural markers indicate when a pharmaceutical intervention is inappropriate. Psychologists are able to provide biopsychosocial-cultural assessments that necessarily consider multiple determinants of health that define the problem and guide treatment recommendations. The answer is not always medication, and psychologists with an expanded knowledge base that includes cultural, behavioral and pharmacotherapeutic approaches could offer the "best of all worlds," so that more individuals receive treatment tailored to their needs and desires.
Second, provider productivity would be enhanced with less need for multiple consultations that can be time-consuming and disruptive. Consultation will always be a part of the working relationship; however, physicians would not have to be interrupted as often for writing and re-filling routine prescriptions for psychotropic regimens if psychologists could prescribe.
As psychologists, our role in a rural setting begins with an increased cultural awareness of the groups within the communities we serve, commitment to serving these communities and an expanded knowledge and practice base that includes talk therapies, drug therapies and cultural healing approaches that cover the broad range of community needs. I am not saying we alone can fix all problems, but we must prepare ourselves to do the best job we can by using the breadth and depth of training both received and available. The future generation of psychologists must ultimately realize the amazing impact psychologists can have on health-care access for minority populations that have gone underserved for far too long. The heart of the matter is this, and the time is now.
Jill Oliveira-Berry, PhD, is a clinical psychologist in the behavioral medicine department at Tripler Army Medical Center. The author's views are her own and not representative of either Tripler Army Medical Center or the Department of Defense.