Sunday, April 11, 2010

The Psychiatrists Whupped the Psychologists

For those who don't know, Oregon's Governor Kulongoski vetoed the psychology prescribing bill. I found this unfortunate, not because I'm particularly keen on psychologists prescribing, but because I think the bill would have put needed pressure on my profession to take a closer look at what psychiatrists are and where we should be headed.

In his veto letter, the Governor said he was concerned that the Oregon legislature approved the bill in a hurried fashion during a Special Session which included no public input. He proposed that the legislature come up with a pilot program in 2011 to help to gather more information about how to solve Oregon's crisis of access to mental health treatment. What this means is that in all likelihood we will again be treated to the spectable of America's new blood sport--the vicious turf wars between psychiatrists and psychologists. American Gladiator pales in comparison.

Truly, these last few weeks have not been pretty, and I'll plead guilty to my part in the fracas. I was the first "prominent" psychiatrist to publically proclaim that psychologists with extra medical training might actually be able to prescribe some medications safely.

In doing so, I felt a bit like Salman Rushdie, whose 1988 book, Satanic Verses, so unnerved the Islamic orthodoxy that the Ayatollah Khomeini issued Rushdie a fatwa (a death sentence). My own version of "Satanic Verses" is called Unhinged: The Trouble with Psychiatry (Simon and Schuster, due out May 18, but who's counting?). The book is not about psychologists prescribing, but rather about the loss of psychotherapy from psychiatry. Nonetheless, it
will likely enrage more than a few psychiatric jihadists, because in the last chapter I outline my prescription for reform, and it involves a fairly radical restructuring of psychiatric training. In this scheme, psychiatrists will be more competent than they are now, but they will unfortunately lose two crucial letters after their names: an "M" and a "D." I anticipate some resistance.

In the meantime, we are in a preposterous situation in which the two major organizations with expertise on the American mind are locked in mortal combat: the A.P.A. (psychiatric) vs. the A.P.A. (psychological). If they can't figure out how to resolve differences, God help us all.


FunPsych said...

Dr. Carlot,

I have tons of respect for you and the courage you've shown in taking your position, but don't you think it's a bit, well, dramatic to compare yourself to Salmon Rushdie? I mean, the guy had to go into hiding to avoid being murdered, whereas you probably stand to profit from this controversy leading to more book sales.

As someone who did not go into medical school with the intent of becoming a psychiatrist, I think the flaw in your prescription for fixing psychiatry is that it seems you believe that people who want to be psychiatrists (or psychotherapists) know this coming out of college. This may be true for clinical psychologists, but most of the people I know who have gone into psychiatry did not intend to do so when they started medical school. If you take out the MD training as the route to psychiatry, then there will be thousands of people who would never have the chance to fall in love with the specialty in medical school.

Perhaps I'm being hasty here, and maybe you've thought of this problem and have a solution for it in your book. If so, would you care to give us a quick preview?

-<a href=">Funpsych</a>

Cheryl Fuller, Ph.D. said...

I can't imagine the turf war between psychology and psychiatry ending soon or easily. I wish I could.

samir123xyz said...

Psychologist prescribing medication would hv been a disaster. U need to know not only psychiatry, but also whole body- anatomy/physiology/biochemistry/pharmacokinetics & pharmacodynamics, including drug interactions/internal medicine etc.
medical science is not so simple, so that anyone will start prescribing with a 6 month training.
its not about psychiatry -vs- psychology. only a doctor can & should be able to prescribe drugs.
there is a saying- "Half knowledge is more dangerous than no knowledge".
psychologist hv other important aspects to deal with. then, why they r trying to venture in unknown territory?? human life is at stake here !!
the Governor's decision was critical & he got it right !!
About dr. carlot- plz don't compare urself to the great Salman Rushdie. Ur silly suggestions can only be compared with "Muhammad bin Tughluq", the Turkic Sultan of Delhi from 1325 to 1351. !!! Link-

Anonymous said...

The cynic in me thinks you wrote these postings on psychiatrist vs. psychologist just to peddle your book.

Stuart Kelter, Psy.D. said...

Dr. Carlat,

While I applauded your endorsing prescribing psychologists' ability to prescribe safely, I am now dismayed that you are trying to belatedly distance yourself from this very position. You now say that you supported psychologists prescribing, "not because I'm particularly keen on psychologists prescribing, but because I think the bill would have put needed pressure on my profession to take a closer look at what psychiatrists are and where we should be headed."

I had thought that yours was the rare voice in the wilderness that is not afraid of speaking the truth. Now it turns out that you pull back from speaking the full force of your convictions because you are afraid of losing subscribers to your newsletter? As a credible critic of the psychiatric establishment (i.e., not simply anti-psychiatry), you are making a far more important name for yourself than any moral compromising is likely to do.

Daniel Carlat said...

Stuart--I hear what you are saying but in fact I haven't changed my tune here. If you look at my original posting on this, I made it clear that the reason I supported psychologist prescribing efforts is that this exerts pressure on psychiatry to reform its training model. Also, in that post I pointed out that the model of psychologists going to 5 to 7 years of graduate school, then another two years of a psychopharm masters program, is an inefficient training model, as is the current psychiatric model of medical school, internship, then residency.

Daniel Carlat said...

You are half right. I am certainly trying to peddle my book in any way I can. But that's not why I believe the things I believe, nor why I am publishing my beliefs. Both my book and my blog are reflections of my conviction that psychiatry needs to change in order to remain a relevant profession. And I appreciate your cynicism--you'd be crazy not to be cynical.

Daniel Carlat said...

FunPsych and Samir: All right, all right, I used a little poetic license in comparing myself to Rushdie. No, I am not in the same league as Rushdie, nor will I ever be. And death sentence? While some of my colleagues probably would like me to just go away, I don't think that a fatwa from the APA is in my future.

Anonymous said...

"As a credible critic of the psychiatric establishment (i.e., not simply anti-psychiatry), you are making a far more important name for yourself than any moral compromising is likely to do."

I feel like I keep hitting a brick wall in asking people on this blog to use more respectful language but I will keep trying. I find this ironic since the last anonymous psychiatrist talked about the last respect for psychiatry.

Anyway, why is it necessary to use the term anti psychiatry as that can mean so many things? And if the person is anti psychiatry, maybe there is a good reason for it such as a forced commitment which of course, we never hear about on psychiatry blogs like this.

As Steve M pointed out in a previous post, no one ever speaks out against excesses like this.

Remember Esmin Green, who died in a psych emergency room due to malpractice? Where was the outrage as there are many Esmin Greens we don't hear about.

I don't deny that there are people who are pretty extreme about psychiatry. I left an email list because of it. But just like you don't like being stereotyped for the third time on this blog, I am asking for the same respect in return.

As far as the point about Dr. Carlat being for psychologists being able to prescribe meds, you made a good point Dr. Kelter that his reasons seem questionable. I had totally missed that so I thank yo for point that out about the bill putting pressure on psychiatry to change.

Dr. Carlat, you don't need a bill as it simply takes a willingness to think outside the box and look at how you are viewing issues. I am not optimistic this will happen but of course, I would love to be proven wrong.

SteveM said...

Re: Dr. Carlat

I don't think that a fatwa from the APA is in my future.

On the contrary, I'm guessing that the long knives of the APA cognoscenti are being drawn. BTW, they are usually thrust into the back with much collegiality. The assaulted is then allowed to bleed to death from pronounced indifference.

About ”anti-psychiatry”. That’s people talking past each other, which really muddies the conversational waters. Few are anti-psychiatry in an absolute sense. Many labeled as anti-psychiatry are really anti-the-normative-psychiatric-practice-model.

Using that definition, so is Dr. Carlat, perhaps Dr. Frances. Dr. Pies meanwhile, pretends to be on the edges. But he’s not very good at it.

Buddha said...

Hold it you want the person I spend the most time with to prescribe me medication? You want the person who listens to me and writes down all kinds of little notes about me to prescribe me medication? You want someone who may just think medication is only a temporary solution to prescribe me medication? I'm a paranoid psychotic schizoid but yeah I would trust my psychologist more than my psychiatrist to prescribe me medication. I think the mental health system is a really a bad joke but yeah that would be a improvement from this consumers point of view.

caduceus said...

This debate seems silly, when there are clear, well established, safe options for non-MD prescribing. Nurse practitioners and physician assistants receive adequate training to prescribe under supervision of an MD, and I don't know why these options are so removed from the debate. I don't believe psychologists are qualified to give medications - not without a clinical internship in a hospital or acute medical setting, but NPs and PAs would be an easy option.

Ronald Pies MD said...

The use of psychiatric nurse practitioners (PNPs)is indeed a partial solution to the shortage of psychiatrists in some under-served areas. Readers interested in the extensive differences in preparation between PNPs and those enrolled in masters programs for "prescribing psychologists" may find the following article of interest (my response to James Quillan).--Ronald Pies MD

Anonymous said...

"About ”anti-psychiatry”. That’s people talking past each other, which really muddies the conversational waters. Few are anti-psychiatry in an absolute sense. Many labeled as anti-psychiatry are really anti-the-normative-psychiatric-practice-model."

Great point Steve M as you are always right on target.

Thinking about this some more, this could apply to physicians in non psych areas. As one who has a psych med history, I feel I have received inferior treatment in the past due to that. Obviously, I can't prove it but judging from various postings on different internet boards, my experience is not unique.

Anyway, psychologists who are given prescription privileges need to work to eliminate this stigma. Sadly, I don't see many psychiatrists doing this.


Anonymous said...

"Many labeled as anti-psychiatry are really anti-the-normative-psychiatric-practice-model."

Wow! That is seriously profound. You just changed the way I describe how I feel about psychiatry and psychiatrists. Wow. (I'm being serious, although it probably sounds sarcastic. This really was profound). And here I had been generalizing and calling the entire thing a farce... I clearly was taking a less-than-nuanced view of it all.

Anonymous said...

I'm glad it wasn't approved as well. My two cents are that Psychiatrists need to do a more comprehensive job and spend more time on clients. Perhaps back to the extensive psychosocial interview done decades previous.

I want MD's to actually know about their clients, and spend more than 15minutes with them--and have a keen sense of their lifestyle/health issues rather than rubber stamping prescriptions b/c clients/parents/schools want them--or its just the way to make money.

Since MD's that are non Psychiatrists are doing most of the medicating--why not have them do additional training and limit the scope of what they can do without at least consulting with a therapist working with the patients/or a Psychiatrist. Although, I see the 15minute--prescribe 3 different drugs to help compensate for each symptom cluster, then go on your merry way version of 'medicine' all the time, overall Family doctors basically giving patients drugs--because lets be honest most of the people out there are self-diagnosing off of hear say from friends, or the ever pervasive TV Pharm Ads.

Anonymous said...

Sad thing, is nearly all of the theorist that have informed my conceptualization and primary treatment modalities were Psychiatrists.

Alfred Adler, Carl Whitaker to name two prominent MD's which fewer and fewer Psychotherapists are familiar with--and likely even fewer Psychiatrists given that many MD programs no longer include even one class on psychotherapy. I doubt many Psychiatrists will be seen as founders of schools of psychotherapy ever again, unless we create a biological reductionism school--where we just tell people that they have burnt out receptor sites and abnormal 'balances' of neurotransmitters and thus to their horrible lifestyle, choices, and history of abuse are just side-notes. Some may view this as advancement--so people don't feel some sort of stigma, but isn't it dehumanizing to the majority of people who don't have primary biological causation issues, but rather their neurochemistry is a result of past and ongoing neuroplasticity?

I suppose i would rather trained Psychologists/therapists be allowed some minimal medication ability--rather than many primary care physicians--which only some seem to know what they are talking about--I've seen some of the worse medicating from MD's that aren't psychiatrists.

I once had a client who was given massive amounts of ADHD meds, to the point he was jittery and was skinny as a rale--and then given Ambien as a "mood stablizer" to knock him out and help his parents manage his anger and anxiety. He was a clear example IMO of where the "cure" mad a bad situation worse--but the parents did enjoy having him fall asleep--no behavior problems then. Perhaps we should just put kids to sleep from now on, eh?

Herb said...

When I was in medical school in the late 1950’s, a visiting professor (a psychiatrist from Yale, I think, whose name I have forgotten) gave a talk advocating a restructuring of training that would lead to a degree of “Doctor of Medical Psychology.” I think that it was an idea much like yours, even then, before the current split between talk therapy and pharmacological therapy. I infer that you are advocating training that plays up the essentials and does away with the nonessentials, and I agree wholeheartedly. I have ordered your book and am eagerly awaiting it. It seems to me that some authority will have to be persuaded to license people trained in that manner. In another of your blogs, I suggested that a possibly promising route would be the military (i.e. the Uniformed Services University of the Health Sciences). What do you think?

Jack Walsh said...

Perhaps a merger of two threads might be helpful -- this thread, and the thread commenting on your Times article.

The Times thread, repeatedly, reports that psychiatrists do NOT use their med training. They see someone for 15 minutes, scribble, and don't even do the lab work and follow up that the medication requires. This is the current standard of care; whether we like it or not, it is the current standard. I live and work in Massachusetts, which has more psychiatrists on the ground than anywhere -- and, believe me, this is the standard of care. I've seen it maybe a thousand times.

So, this is what the psychiatrists don't want to give up? Aw, c'mon; let the rest of us see someone for 15.....well, you get the point. Let the rest of us mess things up to the point of killing folks. We deserve a shot, too.

And, further, we now want to have two pretty important parts of med practice -- the psychiatrists and the family practice folks -- do med school for 3 years? I have an idea: change the reimbursement patterns. Or, let's do it this way: there is a shortage of neurosurgeons in, say, Montana?? Great, let the dentists do brain surgery. They have almost been to med school.

Sometimes I wonder if I'm on the same planet with everyone else.

Anonymous said...

I joined this a bit late. I wanted to add that when I was seeing a psychologist during a period of "bereavement" of sorts, she had me get a prescription for Xanax from someone who had the legal license to do that. I'm sure she's not the only one that done that.

I think the problem is complex. On one hand you have the overmedication of children in particular. Something that I'm sure the drug companies don't mind seeing. On the other hand, you have a medical system in which adequate medical care is somewhat lacking for those who don't have the right insurance or are stuck with a Medicaid HMO. This compounds the problem for physicians as well as patients.

That being said, I think that ethics within both those professions as well in the neurosciences is becoming a relevant issue that needs to be addressed first. A degree or training does not guarantee quality of service for patients, academic arrogance does not make for good sciences, and the intrusion of a financial factor usually is ruinous for everyone except the companies.

I say this as a victim of nonconsensual experimentation involving stress, anxiety, trauma. And, no, I'm not delusional. I'm not sure who's involved. Certainly the psychologists are getting a bad name thanks to Guantanamo. The particulars of my case point to something along the lines of neuropsychiatry/cognitive neurosciences as the culprits. What's the point of all the arguing when what really matters is the adherence to human rights - of those who have been labeled "mentally ill," of those who are victimized by "mentally ill" people and of those who are victimized by people who probably don't have labels but have no respect for ethics or human rights.