PRESCRIPTION RIGHTS: The Evolution of Psychologists?

This could be one of the biggest evolutionary milestones the field of psychology has encountered in recent times.

Since the early 2000’s American psychologists have been able to prescribe medications to their service users following a movement which originated in the 1960’s (APA Services Inc., 2014); this ability has never been granted to UK psychologists.

In 2018, the BPS set up a task and finish group, in response to an NHS review in 2016, regarding whether psychologists should be added to the list of professions that have the right to prescribe medications (Courtney-Walker, 2019). Originally the BPS did not have enough information or insight on the matter, so were unable to hold a viewpoint. Therefore, research and debate has been ongoing since, with professional contributions ending on the 2nd of October 2020 (Courtney-Walker, 2020). At this time no stance has been taken as the process of deliberation continues.

As a psychology student with the ambition to pursue a career in clinical psychology, this is a hot topic that could shape the professional world I aspire to be part of. Moreover, it could change the very definition of psychologist, as well as shaping future service user experiences. Having attended BPS webinars on the matter (Courtney-Walker, 2020), and conducted reading around the issue; I believe it is one of the biggest evolutionary milestones the field has encountered in recent times. The debate in question does not only relate to clinical psychologists, but also those in other denominations of the practising psychology professions; though, this article will mostly stand from the consideration of clinical practise.

It is important to gain insight into some of the context relating to what proposals are being deliberated, and to summarise some of the viewpoints from both sides of the debate.

Key Points of Consideration

The debate at hand consists of much more than the granting of prescription rights to psychologists - it relates to what this new model of practise would look like down to the working components. The BPS have worked to consider many points raised by professionals and research; a summary of the main considerations can be found below:

Should psychologists as a profession gain prescribing rights, the choice of an individual psychologist to train and prescribe would be optional.
A programme of training, mentoring and post qualification governance would have to be agreed to meet the regulations and standards set out by the Royal Pharmaceutical Society and the Health and Care Professions Council to ensure that psychologists have the appropriate competencies to fulfil the role.
Should psychologists gain prescribing rights, it would be expected that they would be working within a multidisciplinary team or practice network that would enable seamless access to medical support to meet the physical health needs of service users; they would not be working in isolation in private practice.
(Courtney-Walker, 2020)

From these pointers we can visualise the future of psychological practise if prescription rights were to be granted. Each of these pointers comes with a chain of questions and issues. For example…

If training and obtaining prescriptions rights is optional, what would the cost incurred be through making that choice?
Is it for the individual psychologist to absorb the monetary burden that comes with facilitating training? And if so, will they be rewarded with a greater pay grade post-prescription?
Following from this, if better salaries are offered to those that choose to pursue prescription powers, would there be a monetary incentive to engage with the medicalisation of psychology (which could be argued as ethically questionable)?

The task of navigating these hurdles is no small order - hence the BPS have had to work diligently over a series of years to acquire necessary information and professional opinion.

As another indication of what the world of psychology may look like with prescription rights granted, inferences can be made from the recent development of physiotherapist’s prescription rights in the UK. It is acknowledgeable that there are professional differences between physiotherapy and psychology, though parallels can be drawn in the sense that prescription rights were not granted until 2013 (Chartered Society of Physiotherapy, 2018); since which additional control measures have been introduced, as of 2015. Therefore, being granted prescription rights does not mean professionals have free reign, there are accountabilities and limits that can be imposed; an example being only certain relevant medications are enabled. This highlights how a non-medical profession, often working within medical settings or teams, with clients whom may be using or in need of medication, can evolve to work with prescription rights.

Opening The Door to Over-medicalisation: Biobio

With a potential change as far reaching as the granting of prescription rights, there is a diverse array of opinions and arguments in opposition; some of which feature on the BPS webinar accessible online (Courtney-Walker, 2020). Here I will unpick and summarise a crucially reoccurring point: prescriptions relate to medications, do we run the great risk of overmedicalising our psychological professions?

Medication has provided a branch of treatment for mental health conditions for many years, with antidepressant medications (ADMs), rising through their accidental discovery in the 1950’s (see Antidepressants and The Biopsychosocial Approach for more on ADMs), alongside the development of antipsychotics from malaria medication (Ramachandraiah, 2009). As a standalone issue, medication is a heavily debated option when it comes to psychology, particularly so in-relation to mental health. For example, some argue that medications only provide treatment for the symptoms of psychological issues, as opposed to a means of recovery (see Antidepressants and The Biopsychosocial Approach). Through increasing the ease of access to medications with prescription rights, there is a concern that there will become a greater reliance on this branch of treatment. Under the current way of working, access to medication is harder because multiple professionals must be liaised with and seen - therefore the chain is longer to navigate. This is not to say that every service user would be prescribed medication, but where there is easier access, there is potential for increased supply.

Why would increasing prescriptions be an issue? Well, the principle underpinnings of utilising medication for the treatment of psychological issues, relates to a biological understanding and approach to psychology. At a basic level, medications work by altering our biochemistry, and thus impacting the way our bodies function, and relationally altering the way we feel. Whilst clinical psychologists traditionally work to acknowledge this aspect of mental experiences, they predominantly approach from a psychological and social understanding with intervention in-relation to therapies. However, by granting psychologists the right to prescribe, and entering a greater biological dominance, there is a risk that a Bio-Bio model of understanding would be favoured.

Biobio understanding refers to the fact that a biological treatment would be utilised (medications), in addressing a biological underpinning of psychological experience. Yes, we are biological organisms, it is important that this element of our experiences is acknowledged; however, we are so much more besides this. If psychologists were to transition from providing therapies and interventions, to filling out a prescription, individual’s experiences would be reduced to their biological components. For example, experiences of depression are associated with lower levels of some neurochemicals (chemicals in the brain that pass information), such as serotonin. Thus, there is a whole arena of medications that aim to boost serotonin levels. However, this association between serotonin and depression is not necessarily causal, nor do we know the direction of interaction; depression may elicit lower levels of serotonin, as opposed to serotonin levels initiating depression. Aside from the neurochemical, an individual could be experiencing social circumstance such as a relational breakdown and psychological experiences such as negative thought patterns - medication would not address these contributory factors. Therefore, increased medication would not necessarily mean increased treatment, nor recovery.

Of course, this standpoint is a rather stark hypotheses regarding what could happen post-prescription rights, as it insinuates that psychologists will run with the opportunity to prescribe. This may not be the case, but nonetheless it is an argument that deserves to be acknowledged and considered in depth.

A Necessary Step in Professional Progression: Biopsychosocial

Within the last decade, a predominant movement within psychology has been the Bio-Psycho-Social approach to human experiences; the holistic opposite of the previously mentioned Bio-Bio standpoint. Biopsychosocial understanding outlines that biological, psychological and social factors are individual yet interactive components, each a key cog of an overarching system that influences how we think, feel and behave (Toates, 2010). Following from this, psychological assessment in mental health utilises formulation, in which each of these components may be considered before a diagnosis or action plan is decided. A formulation can include gathering information on family history, biological conditions, contextual information (such as relational), and so on. The structure of formulation can vary with therapeutic approach i.e. CBT or systemic, but the principle of encompassing information remains. As opposed to a medical diagnosis such as with physiological illnesses. This model is one outlined and referenced within the BPS webinar, (Courtney-Walker, 2020), and one of the arguments raised is that granting prescription rights does not lend to biological domination, but biological incorporation within the biopsychosocial framework.

There is an argument for the increased training and education of psychologists in-relation to medications, through granting prescription rights, as this could help to approach service user support from a holistic viewpoint. The granting of prescription rights would come with career development and medical insight through education, providing knowledge to psychologists that they may have not accessed otherwise. Even though psychologists currently work daily with service users whom use medication, some may not have the necessary knowledge to gage how the medications are having an impact. For example, serotonin-based medications (such as SSRIs), are sometimes deemed symptom reducers as opposed to depression treaters, as they lessen symptoms such as regulating sleep patterns and appetite. If a psychologist was working with a client utilising this prescription, but had no underlying knowledge of their impact, it may be deemed that the reduction in symptoms is due to therapeutic intervention and this misinformation could lead to poor decisions for future therapeutic work. Through the necessary training that psychologists would engage with, it is arguable they will not only hear, but understand client’s medical experiences as well as their therapeutic. Thus, prescription rights do not necessarily mean over-medication, but increased education; ensuring that a biopsychosocial formulated approach, can truly be taken.

Moreover, enabling a singular professional to knowledgably adjust service user prescriptions, whilst working with the client on a consistent and regular basis through therapy, creates a stable and supportive system through which the service user can be monitored effectively. Psychological medications are associated with side effects and can be misused by service users. These crucial drawbacks can be missed by medical professionals who only see clients briefly and infrequently, such as GPs. On the other hand, psychologists work to build therapeutic relationships with service users, through continued and consistent interaction. Their professional circumstance could be ideal to ensure that medication related situations are monitored and promptly acted upon. Furthermore, psychologists could utilise prescription rights to safely reduce existing medications, and support individuals throughout the process with regular check-ins and therapeutic interventions; as opposed to service users having to go through the chain of medical professionals. Likewise, some service users that have been spoken with the BPS, have reported positive feelings towards prescription rights, one reason being the simplified chain of communication (Courtney-Walker, 2020).

There is much to be said for supporting prescribing rights, the overarching theme being that granting this extension to the professional role of psychologists, would be a key steppingstone in the evolution of the field.

Of course, there are endless stances one could take on either side of the table and merit should be given to each of the research findings, judgements, and professional contributions. Through a collective effort, an encompassed and substantially evidenced viewpoint can be offered by the BPS.

Though, even after the official stance is communicated to the NHS and the government, it could still be years to come before prescription rights are enacted as legislation. However, it has been a long time since such a drastic legal change has been made in terms of defining the role of professional psychologists (see Mental Health Through Time for more on the history of legislation). Therefore, it is important that people engage with this debate, watch it as it forms, and learn from this as it develops; we are watching history unfold before our eyes.

References

APA Services Inc. (2014), ‘About Prescribing Psychologists’, American Psychological Association Services, Inc. [Online]. Available at https://www.apaservices.org/practice/advocacy/authority/prescribing-psychologists#:~:text=The%20movement%20to%20grant%20psychologists,as%20a%20discipline%20of%20psychology (Accessed 13th October 2020).

Chartered Society of Physiotherapy (2018), ‘NHS gives green light to consultation on drugs physios can prescribe’ [Online]. Available at https://www.csp.org.uk/news/2018-02-19-nhs-gives-green-light-consultation-drugs-physios-can-prescribe (Accessed 13th October 2020).

Courtney-Walker, R. (2019), ‘A role for psychologists on prescription?’, The Psychologist: The British Psychology Society, vol. 32, pp. 2 [Online]. Available at https://thepsychologist.bps.org.uk/volume-32/march-2019/role-psychologists-prescription (Accessed 13th October 2020).

Courtney-Walker, R. (2020), ‘Prescribing Rights for Psychologists’, The British Psychology Society [Online]. Available at https://www.bps.org.uk/who-we-are/practice-board/prescribing-rights (Accessed 13th October 2020).

Ramachandraiah, C., Subramaniam, N. and Tancer, M. (2009), ‘The story of antipsychotics: Past and Present’, Indian Journal of Psychiatry, vol. 51, no. 4, pp. 324-326 [Online]. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2802385/ (Accessed 16th October 2020).

Toates, F. (2010) Book 1: Core Concepts in Mental Health, SDK228 Module Team (eds), ‘Chapter 1: Explanations in mental health’, Milton Keynes, The Open University, pp. 1-27