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.

References:
American Psychological Association. (1995). Council resolution on prescription
privileges for psychologists. Retrieved
from:http://www.apa.org/about/policy/chapter-10.aspx#prescription-privileges
APA Office of Program Consultation and Accreditation, (2013). Guidelines and
principles for accreditation of programs in professional psychology. Retrieved
from: http://www.apa.org/ed/accreditation/about/policies/guiding-principles.pdf
Ax, R. K., Fagan, T. J., & Resnick, R. J. (2009). Predoctoral training for prescriptive
authority: The rationale and a combined model. Psychological Services, 6, 85-95.
Ax, R. K., Forbes, M. R., & Thompson, D. D. (1997). Attitudes of psychology interns
and directors of internship training toward prescription privileges for
psychologists. Professional Psychology: Research and Practice, 28, 509-514.
Ax, R. K., & Resnick, R. J. (2001, March). Prescription privileges: An immodest
proposal. The APA Monitor, 53-54.
The Clinical Psychologist Licensing Act/SB 2187. (2014). Retrieved
from:http://www.ilga.gov/legislation/publicacts/98/PDF/098-0668.pdf
Curtis, J. W., & Thornton, S. (2013, March. Heres the news: The annual report on the
economic status of the profession 2012-2013. Academe. Retrieved
from: http://www.aaup.org/file/2012-13Economic-Status-Report.pdf
deMayo, R. (2002). Academic interest and experiences of doctoral students in clinical
psychology: Implications for prescription privilege training. Professional
Psychology: Research and Practice, 33, 499-501
DeSilver, D. (2014, May 15). By many measures, more student borrowers struggling with
student-loan debts. Pew Research Center. Retrieved
from: http://www.pewresearch.org/fact-tank/2014/05/15/by-many-measures-
more-borrowers-struggling-with-student-loan-payments/
Fagan, T. J., Ax, R. K., Liss, M., Resnick, R. J., & Moody, W. (2007). Prescriptive
authority and preferences for training.Professional Psychology: Research and
Practice, 38, 104-111.
Fagan, T.J., Resnick, R.J., Ax, R.K. [joint first authors], Liss, M., Johnson, R., & Forbes,
M.R. (2004). Attitudes among interns and directors of training: Who wants to
prescribe, who doesnt, and why. Professional Psychology: Research and
Practice, 35), 345-356.
Jeszeck, T. (2014, September, 14). Older Americans: Inability to repay student loans may
affect financial security of a small percentage of retirees. U.S. Government
Accounting Office, (GAO-14-866T). Retrieved
from:http://www.gao.gov/assets/670/665709.pdf
Keilin, G. (2014, March 24). 2014 APPIC match statistics, combined results: Phase I and
Phase II. Association of Psychology Postdoctoral and
Internship Centers. Retrieved
from:http://www.appic.org/Match/MatchStatistics/MatchStatistics2014Combined.
aspx
Kilbey, M. M., Brown, R. T., Coursey, R. D., Eisdorfer, C., France, C., Johnson, D. L., et
al. (1995, December). Report of the BEA Working Group to develop a Level 1
curriculum for psychopharmacology education and training. Washington, DC:
American Psychological Association.
Kohout, J., & Wicherski, M. (2010, October). 2009-10: Applications, acceptances,
enrollments, and degrees awarded to masters and doctoral-level students in U.S.
and Canadian graduate departments of psychology [Table 12]. APA Center for
Workforce Studies. Retrieved
from: http://www.apa.org/workforce/publications/11-grad-study/table-12.pdf
Michalski, D., Kohout, J., Wicherski, M., & Hart, B. (2011, June). 2009: Doctoral
employment survey. APA Center for Workforce Studies. Retrieved
from: http://apa.org/workforce/publications/09-doc-empl/index.aspx
Norris, F. (2014, September 13.) Young households, even educated ones, lose ground on
income. New York Times, p. B3.
Resnick, R. J., Ax, R. K., Fagan, T. J., & Nussbaum, D. (2012). Predoctoral prescriptive
authority Ph.D. curriculums: A training option. Journal of Clinical Psychology,
68, 246-252.
U.S. Department of Labor, Bureau of Labor Statistics. (2014, April 1). May 2013
national occupational employment and wage estimates, United States. Retrieved
from: http://www.bls.gov/oes/current/oes_nat.htm#00-0000