The document discusses opening up the pipeline for prescriptive authority (RxP) training for psychologists. It notes that several post-master's degree programs in clinical psychopharmacology have closed, narrowing the pipeline for training. However, an Illinois law now permits predoctoral training in clinical psychopharmacology. The document argues that a predoctoral option is needed to appeal to stronger applicants and normalize RxP training earlier. Joint degree programs could help increase interest in RxP while producing psychologists prepared to support future legislative efforts to expand prescribing rights.
The document discusses opening up the pipeline for prescriptive authority (RxP) training for psychologists. It notes that several post-master's degree programs in clinical psychopharmacology have closed, narrowing the pipeline for training. However, an Illinois law now permits predoctoral training in clinical psychopharmacology. The document argues that a predoctoral option is needed to appeal to stronger applicants and normalize RxP training earlier. Joint degree programs could help increase interest in RxP while producing psychologists prepared to support future legislative efforts to expand prescribing rights.
The document discusses opening up the pipeline for prescriptive authority (RxP) training for psychologists. It notes that several post-master's degree programs in clinical psychopharmacology have closed, narrowing the pipeline for training. However, an Illinois law now permits predoctoral training in clinical psychopharmacology. The document argues that a predoctoral option is needed to appeal to stronger applicants and normalize RxP training earlier. Joint degree programs could help increase interest in RxP while producing psychologists prepared to support future legislative efforts to expand prescribing rights.
Opening Up the Prescriptive Authority (RxP) Pipeline
Robert K. Ax, Ph.D.
Submitted to the ASAP Listserv 10/3/14 Where should the pipeline to prescriptive authority (RxP) training begin? What capacity, or flow rate, must it have to sustain both the training and legislative components of the initiative? Post-masters degree programs in clinical psychopharmacology, as a group, have experienced a shakeout. Several, among them those at the Illinois School of Professional Psychology, the University of Georgia-Georgia State University, and the Massachusetts School of Professional Psychology have closed or gone dormant in the last decade. While viable programs remain, the pipeline to training and practice is narrower than it was. However, thanks to Dr. Beth Rom-Rymer and her colleagues, the amended Illinois Clinical Psychologist Licensing Act (Public Act 98-0668) affords the profession a great opportunity to support the RxP agenda in a way that has received too little attention up until now. The law permits predoctoral training in clinical psychopharmacology. And none too soon, because a college degree is becoming a dicey proposition in terms of return on investment: In 1989, the median income of families headed by young college graduates was twice that of similar families headed by high school graduates who never attended college. Now the difference is only 52 percent. There are more college graduates in the group, but those graduates have a lower real median income than their predecessors. (Norris, 2014; p. B3) After running the graduate school gauntlet, psychologists (clinical, counseling, school) mean income is $72, 210; better than that of social workers ($48,370), although the latter are out of school and earning money after two years, but not as good as physician assistants ($94,350), or nurse practitioners ($95,070)(U.S. Department of Labor, 2014). Are you an early-career psychologist hoping for a career in academia? Read the tenure and salary data and weep (Curtis & Thornton, 2013). Looking at the cost side of the equation, total student loan debt in the United States now exceeds 1 trillion dollars, and an increasing percentage of borrowers are delinquent in their repayments (DeSilver, 2014). Perhaps more disturbingly, some Americans now carry student debt into their 60s and 70s (Jeszeck, 2014). Data reported in the most recently available APA doctorate employment survey showed that about half of those with new doctorates owed more than $80,000 in student debt (mean student debt for new PsyDs was $118,327) related to their graduate educations, and almost 11% owed more than $160,000 in graduate student loan debt (Michalski et al., 2011). For graduate students in applied psychology, theres also the increasingly daunting prospect of finding an internship. This year, 22% of those who registered for the APPIC Match got skunked or withdrew (Keilin, 2014). So, if youre a bright, hardworking undergraduate today whos thinking about a doctorate in clinical, counseling or school psychology and you know all this, wouldnt you think twice about spending the next 4 to 7 years of your post-baccalaureate life accruing further debt, foregoing income, and then embarking on a career that might, in purely financial terms, be tantamount to indentured servitude? The simple answer, according to the most recently available figures, is that the customers keeping walking in the door. There were more than 35,000 applicants to APA-accredited Ph.D. programs in 2009-2010, with 1332 subsequently enrolled. (Kohout & Wicherski, 2010). Thats still a highly select bunch. Whos Entering the RxP Pipeline? But this begs the question: Are we getting the students we need for the future the best, the brightest, and the best fit with the profession as we desire it to be during the 21 st century? Rising generations will be the ones to fully realize our vision for psychology as a STEM and primary care profession, one whose members are integrated into multidisciplinary health care teams and organizations. Or not. In a field known for its intellectual and pedagogical pluralism, we have managed, despite the considerable financial and political capital expended on behalf of RxP over the past 20 years, to avoid normalizing the study of clinical psychopharmacology. It is still a marginal issue to most students and members of the profession. With the best of intentions, our profession formulated a model RxP curriculum that, being more or less entirely post-doctoral, raised the response cost prohibitively for too many. Survey data show that interest in RxP training decreases markedly as costs rise above $10,000 (Fagan et al., 2007). After all the time and effort expended and debt accumulated in obtaining a doctorate, the thought of pursuing another degree, particularly one offering uncertain return on investment, simply isnt very appealing. More to the point, we continue to recruit, for the most part, the same kinds of students to be trained in the same classes for the same journeyman-level scope of practice. APAs admonition that all providers in psychology need to have the basic knowledge in the area of clinical psychopharmacology represented by the entire knowledge base delineated in all the modules of the Level 1 curriculum (Kilbey et al., 1995, p. 2) has been ignored. No such requirement has ever been incorporated into the APA accreditation guidelines, whose most recent version (APA Office of Program Consultation and Accreditation, 2013), contains only a vague requirement that programs include biological aspects of behavior (p. 7). There isnt a mention of psychopharmacology in the entire document. Given this state of affairs, its hardly a surprise that graduate programs continue to attract applicants with suboptimal grounding in the natural sciences (deMayo, 2002), and turn out applied psychologists who, for the most part, have no personal interest or stake in RxP. Time has shown that attitude surveys showing wide interest in prescriptive authority (Ax, Forbes & Thompson, 1997; deMayo, 2002; Fagan et al., 2004; Fagan et al., 2007) do not predict enrollment in training programs or involvement in legislative activities. For more than a decade, members of Division 55 have been expressing their frustration over the ongoing and vocal opposition to RxP from within organized psychology. Yet given this self-perpetuating cycle, when we fail to address the source of the problem, why wouldnt opposition toward RxP endure within our ranks? Needed: Greater Pipeline Flow Rate As it is, too much time, money, and professional sacrifice continue to be required of too few in moving RxP forward. If we want psychologists who are, at a minimum, conversant with basic clinical psychopharmacology and see health care in terms of a biopsychosocial model, and if we want some reasonable number of them to seek RxP training and support related legislative initiatives, then we will need a predoctoral curriculum option that appeals to the prospective applicants with the best fit in terms of undergraduate preparation and career interests. Do we really want to stake the future of RxP entirely on continuing to retrofit a small percentage of mid-career psychologists with the requisite knowledge and skills? How will that serve the public interest the need for sufficient numbers of competent prescribers at the foundation of the RxP initiative? Is postdoc-only a viable business model, one that could sustain the extant training programs over the long term? Will those trainees be sufficient in number to advance new legislative initiatives expeditiously, or will it be another 10 years, or perhaps 20, before the next RxP law is enacted? Not every psychologist who sees patients will want to prescribe. Not every graduate program should offer the predoctoral joint-degree option (and the majority probably wont). Thats neither necessary nor desirable in a profession that celebrates diversity of all kinds. However, Barnett & Neel (2000) made a persuasive case, consistent with the recommendations of the APA Level 1 Task Force report (Kilbey et al., 1995), that all psychologists functioning as health care providers must have at least a basic knowledge of clinical psychopharmacology in order to work effectively and ethically with patients who may be taking, or benefit from taking, psychotropic medications as an adjunct to psychotherapy. Yet weve fallen short of meeting even this minimal criterion. This fact speaks to our abiding, self-defeating ambivalence regarding RxP. There must be sufficient flow through the educational pipeline to sustain the interdependent training and legislative initiatives if RxP is to remain viable. Beyond the content of their training, the curriculum impacts the types of students we recruit appealing to some prospects while dissuading others. We can proactively change the identity and course of the profession making it RxP-inclusive through the predoctoral curriculum. Joint-degree programs will help normalize RxP at the source of the pipeline the entrance to graduate school (although arguably it should begin even earlier), acculturating all graduate students, including those not enrolled in the psychopharmacology track (that is, matriculating only in the companion doctoral program), to the idea in their core curriculum classes. Those so desensitized will properly reject as hooey the notion that RxP will blur or tarnish professional psychologys identity. Lets face it: our identity, such as it is, is dynamic and multifaceted at best, and Balkanized at worst. Enlightened 21 st century practitioners will want to be part of an evolving, science-based profession and, not incidentally, one that allows them to make a decent living and get out of debt before retirement. Action Steps The RxP training and legislative initiatives are interdependent. They can be symbiotic or antagonistic. We should recruit more candidates into graduate programs who will seek clinical psychopharmacology training and will then actively support RxP legislative initiatives in their respective states and provinces. To do that, we must create the graduate programs that will attract them. At a minimum, this means implementing basic psychopharmacology course work (what used to be called Level 1) as a core curriculum requirement in applied psychology programs. But if we embrace the opportunity and the momentum Public Act 98-0668 has created, encouraging the development of joint-degree predoctoral RxP programs, inserting the appropriate authorizing language into RxP bills, and urging the APA RxP Designation Committee to recognize predoctoral training programs, we will recruit even more of the best-fit those candidates attuned to a biopsychosocial model of training and practice to the profession. And eventually we will quiet, or substantially dial down, the naysaying in our midst. And if we dont, too many of the best-fit graduate student prospects we need, seeking a better return on investment elsewhere, will never enter the RxP pipeline.
Authors note: The contributions of Thomas J. Fagan, Ph.D., Robert J. Resnick, Ph.D., ABPP, and David Nussbaum, Ph.D., to the ideas expressed here, many of them drawn from previous collaborations (Ax, Fagan & Resnick, 2009; Ax & Resnick, 2001; Resnick et al., 2012) are gratefully acknowledged. Errors of fact and other shortcomings are solely the present authors.
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