by William J. Matthews, Ph.D.
Over the last number of years there has been an increasing demand by many clinical psychologists for the right to prescribe psychotropic medications as a part of their clinical treatment. A typical argument in favor of prescription privileges takes the form of, “I am fully capable of understanding the effects of these medications and being able to prescribe will only enhance the effectiveness of my work with patients.”
Another variation of the argument in favor is, “Are we not better suited to prescribe these types of medications for patients with whom we are doing therapy than a general or family practitioner or a psychiatrist who may only see the patient for a medication evaluation 15 minutes once a month?” My response to these type of questions is that of course clinical psychologists are at least as capable of prescribing these medications as M.D.’s.
Besides the competence/effectiveness issue, another rationale for prescribing medications deals with professional status and economic survival. These arguments, while considerably less intellectually attractive than one based on competence and clinical effectiveness, are quite understandable. All medical services in general, and psychotherapy in particular, are under severe attack by the managed health care system. Being able to prescribe medications would likely, for many psychologists, dramatically improve their incomes. Being able to prescribe would also dramatically enhance the power status of clinical psychologists as they would be seen by the public more like “real doctors”. Underlying the notion of being a “real doctor” is a belief that only the physical sciences have legitimacy and as such all behavior (so called mental illness) has an physiochemical etiology and cure.
The essence of my opposition to prescription privileges for clinical psychologists is both empirical and philosophical in nature. Prescribing medication by psychologists is a complete acquiescence to a medical model view of mental illness. The medical model with regards to mental disorders, as a subset of the natural sciences, is primarily based on a physiochemical view of human behavior. Illness, within this frame, is literally a structural dysfunction of the body determined by the rules of the science of medical pathology.
These rules and observations are both repeatable and testable for a patient in Jakarta as for a patient in Vancouver. While this view has fit within a given context (i.e. the diagnoses and treatment of bodily diseases such as cancer, heart failure, diabetes, etc.), I would contend this view is exactly the wrong one for psychology and reflects an error in epistemology.
With so called mental illness there is by definition no structural disease. (Recent research on schizophrenia has indicated observable differences in brain structure as compared to non-schizophrenic patients. However, it is premature to conclude that this brain difference is the cause of schizophrenia rather than the result of it. Future research may occur that supports a causal mechanism).
For all intents and purposes with regards to the vast majority of what is designated as mental illness, the observer observes what he or she determines to be functional problems (i.e. based on reports of some form of suffering) in the person who has come to be identified as a “patient” and then states this person to have some type of mental disease. In using the “illness” metaphor we have confused the figurative with the literal. With so called mental illness, there is no bodily disease and as such I would contend that the application of the medical model (based on physical disease) in the absence of physical disease makes no sense and is therefore wrong-headed.
How did this epistemological confusion come to be?
Psychology, in its long historical desire for acceptance as a real science by the natural sciences (physics), has struggled with the application of a linear mechanistic model (specific to the natural sciences) to the study of human behavior. Freud recognized this issue early on in his career and decided to accept the medical model even when his investigations of hysteria suggested otherwise.
Within the medical model, physical/structural diseases are discovered following the empirical process of the science of pathology. This is clearly not the case with so called mental illness. Mental illness is invented by the observer not discovered within the rules of medical science. The DSM-I had 60 categories and the DSM-IV has now surpassed 300 different diagnoses. Interestingly, one might consider such expansionism as an attempt to further justify and institutionalize power by the American Psychiatric Association. I digress.
Homosexuality is a perfect example of a designated mental illness only to be undesignated at later time (a move with which I am in total agreement). While a physical disease may be eliminated (e.g. small pox), it will not be undesignated as a disease. Why? Because the criteria for small pox, cancer, etc. are clear and identifiable and agreed to within the rules of natural science. The behaviors as disease qua disease in the DSM are not so clear and agreed upon (reliability diminishes with specificity).
I would submit that so called mental illnesses are interactional, moral, and ethical problems in living, not diseases. The disease model ultimately does not fit and as such medical interventions (prescriptions) would be an example of the wrong intervention following the wrong model. The behaviors (not symptoms) presented by so called patients are forms of communication and therapy is a form of meaning making and co-constructing with the person a more useful reality (“the talking cure”). A topic for a different time.
I am in no way denying the importance of genetics and/or physiochemical influences nor the fact that some medications with some individuals in some instances would seem to be effective. However effectiveness is open for discussion. Antonuccio and Danton (1995) in a comprehensive review of research on antidepressants and psychotherapy report that psychological interventions, particularly cognitive-behaviorally based therapies are as effective as medication even if the depression is severe, with none of the negative side effects of the medication.
In a recent meta analysis Kirsch and Sapirstein (in press) report the effect size for active medications which are not depressants was a large as those classified as depressants. They report that inactive placebos produced improvement that was 75% of the effect of the active drug. They suggest that in fact the apparent drug effect (the remaining 25% of the drug response) is actually and active placebo effect. These studies, among others, suggest that medication is not what it is cracked up to be. With the noted exception that there is a significant main effect for those who can prescribe it, the effect of power, prestige and enhanced income. The claim that psychologists who could prescribe can better help their clients is suspect.
As scientific investigations continue to advance there may be more so called mental diseases determined to be organic in origin, in which case they would no longer be classified as “mental”. A classic example of this would be the causal connection (within this narrative) between syphilis and general paresis discovered in the 19th century. Research on such disorders as bi-polar depression has shown some organic basis for the disorder. Recent research on depression indicates very convincing evidence a connection between depressed behaviors and over or under functioning of specific neurotransmitters.
Regardless of whether such connections are correlation or causal physiochemical changes, the singular search for organic causes of behavior may be overly reductionistic (why not the atomic or sub-atomic levels of causality) and may not be completely useful for the study of human systems. Again, as a scientist, I do not deny the biological aspect of human existence. With regards to behavior, a primary emphasis on biology may be less productive than a conjoint perspective.
A demand for prescription privileges is tacit acceptance of the medical model which, as I have argued, is both an philosophical and an perhaps an scientific error (based on empirical research). To knowingly apply the wrong model to a given system is as unethical as it would be to prolong psychotherapy because one’s income depends on a fixed cash flow.
I do not believe that our (clinical psychology) economic survival is dependent upon our acceptance of this frame. To accept this frame may in fact be participating in our decline as clinical psychology would become medicalized and subsumed within psychiatry much in the way that psychoanalysis was subsumed by psychiatry. While I hold no value for psychoanalysis, I do for the field of psychology.
Antonuccio, D.O. & Danton, W.G.(1995) “Psychotherapy Versus Medication for Depression: Challenging the Conventional Wisdom with Data.” Professional Psychology: Research and Practice, 6, 574-585.
Kirsch, I., & Sapirstein, G. (in press) “Listening to Prozac but Hearing Placebo: A Meta-Analysis of Antidepressant Medication.” Prevention and Treatment.