Psychology and Pharmacology: Not So Strange Bedfellows.
In March 2002, the Governor of New Mexico (USA) approved the proposal qualifying the psychologists in the state to prescribe psychotropics.
The criteria to be certified, have been outlined as follows:
- Completion of a four hundred and fifty hrs course in basic sciences.
- Four hundreds hrs of clinical experience under the supervision of a Medical Doctor, (not necessarily a psychiatrist).
- Positive outcome on a test of clinical pharmacology.
This model has already been tested by the Department Of Defense, which few years ago sponsored a training program for several psychologists, still practicing within the ranks of the military system with a high degree of competence, according to official sources (1).
Further, the psychologists in the state of Guam (territory under the jurisdiction of the USA), have already acquired prescribing rights in
1999.Similar proposals are also being evaluated in other states. The American Psychological Association has explained the event as a necessary consequence of the lack of appropriate psychiatric care in the rural areas of New Mexico, and by the fact that it could help in filling the gaps. A study sponsored by the New Mexico chapter of the American Psychological Association, revealed that the number of psychiatrists in the rural areas, is a very modest eighteen (2): Far inferior to the needs of a population of approximately one million. But, while the psychologists are confident that the proposed training is more than adequate, the psychiatrists (represented by the local chapter of the American Psychiatric Association) disagree, stating that the only way to be competent in pharmacology is the completion of a formal medical education. The two positions have become crystallized under the impetus of economic interests, elegantly ignored by both sides, during the public debate. The focus on the effectiveness of the training has also obscured the importance of the historical factors contributing to this development. In order to understand these underlying forces, it is necessary to go back in time. This retrospective panorama will glide through the eighties, period witnessing a radicalization of American medicine in its biological and technocratic tendencies, and reach back to the first period of the twentieth century, when they first manifested.
At the beginning of last century, American medicine changed radically: Its pluralistic paradigm, encompassing traditional and folkloristic approaches, shifted into a reductive model, based on biological causation (3). This change was due primarily to the influence of the corporate world, represented emblematically by the magnate Rockefeller who sponsored a study (the Flexner report), with the goal of identifying and closing down schools not based on a biological orientation (3).
The new trend moved the control of the medical profession from the physicians office to the general quarters of the big corporations, the only entities with the necessary capital to manage the emergent technology (4).
The growth of this system required also an expansion of the health care system, which was extremely limited. This resulted from the establishment of the Medicare and Medicaid systems in the sixties, which broadened health care coverage, and allowed for a diffusion of technologic medicine, with a consequential skyrocketing of expenditures (5). The issue of universal coverage, however, was not seriously addressed, and it is still an issue debated at the present. The considerable increase in the health care budget could not go unnoticed for a long time. In fact, in the seventies, under the Nixon administration, the goal of cost containment became a priority that led to the development of the Managed Care concept, fully applied later in the eighties. This model, now well known, is based on the principle that the Health Care Provider is the "Guardian" of the resources: His role is strongly devoted to containment of health care utilization and costs. However, the results are not consistent with a decrease in medical expenditures; on the contrary, and paradoxically, we have witnessed a" beefing up" of the administrative apparatus and a phenomenal increment in the salaries of the various manager and CEOs, factors depleting resources for clinical care (6).
In this context, psychiatric practice has been sacrificed thru two principal mechanisms: 1) Progressive reduction of psychiatric services, which have been focused mainly on prevention of emergencies, especially suicide (7); 2) The encouraging response by American psychiatry to the biological orientation, sponsored by health care organizations and pharmacological companies, for pure reasons of profit.
Unfortunately the unrealistic optimism towards the biological trend, contributed to ignore that the strong economic influences propelling it would have eventually followed the path of profit and not of science.
A careful attention to the past would have shown that psychology, psychiatry, and the whole field of medicine, have been historically vulnerable to the economic, social, and cultural tenets of the consumerist/ corporative ideology.
Indeed, The influence of this culture, contributed, from the beginning of the 20th century, to the creation of a concept of identity based on the principles pf autonomy and economic individualism.
Melanie Kleins work, by focusing on the inner intrapsychic processes, at the expense of the "cultural" and "social"(8), symbolizes this trend strongly influential on the practice of psychotherapy up to the 60s, and still part of our paradigm.
In contrast, the "ecological" approach propounded by Sullivan, viewing the individual as a by-product of societal, and cultural influences, was totally ignored (8).
We could actually propose that the corporative ideology of the first three quarters of the past century was related to the intrapsychic and decontextualized turn in psychotherapy, as it has been, in the last twenty-five or thirty years, to the radical biological model.
With the emphasis directed towards the mind and not the brain, psychology experienced a restriction of its market capability. Therefore an expansion of its role became necessary for pure survival reasons.
The broadening of the scope has included: Marketing, business consultation, behavioral therapy for chronic medical problems, and, why not, the prescription of pharmacological agents (9): Psychology and pharmacology not so strange bedfellows, after all!
Another negative aspect, which has been totally neglected so far, is implied in the view that psychologists will remedy to the lack of rural psychiatric services by merely prescribing medicines. The results will consist in an approach removed from the cultural and social aspect of areas mainly populated by low-income populations, particularly Minorities (10).
The huge literature on this topic, which would be difficult to cite even partially, reveals eloquently the inefficiency of therapeutic modalities
not consistent with specific cultures and traditional views.
One of the essential findings from this substantial body of work is that minority populations, not only have insufficient access to treatment, but also tend to drop out from it at much higher rate than whites (10).
In conclusion, the new development is not just the result of market hunting by the psychological profession; it goes deeper than that: More correctly, is the inevitable result of insufficient awareness of the economic, cultural, and social forces rooted in the practice of biological psychiatry.
The lesson is therefore obvious.
Maybe it would be sufficient to be cognizant of the teachings of Virchow, the famous pathologist and pioneer of cellular studies. He used to repeat incessantly, that beyond the biological implications, medicine is essentially a social science.
- New Mexico Governor signs landmark decision on prescription privileges for Psychologists; APA On Line,3/6/02; web site:http;//www./apa.org/practice/nmrxp.html,viewed:7/8/02.
- Arnet, N, How the Psychologists prescribing bill passed, Psychiatric Medical Association of New Mexico, July 2002
- Brown, E.R, Rockefeller Medicine Men, Medicine and Capitalism in America, Berkley, CA: University of California Press,1979.
- Rodberg, L., Stevenson, G, The Health Care Industry in Advanced Capitalism, Radical Political Economies, 1977, 9:104-105.
- Stevens, R, American Medicine and Public Interest, New Heaven CT: Yale University Press, 1971.
- Anders, G, Health against Wealth: HMOs and the Breakdown of Medical Trust, Boston, MA: Mariner Books, 1996.
- Boyle, P, Callahan, D, Managed Care in Mental Health, Health Affairs,1995.
- Cushman, P, Constructing America, a Cultural History of Psychotherapy, Reading, MA: Addison-Wesley,1955.
- Clay, R., Mental Health Professions vie for positions in the next decade, APA Monitor, Sept. 1998,volume 29, #9;web site: http://www.apa.org/momitor/Sept98/htlm,viewed:7/8/02.
- Sue, S ,Allen, D ,Connoway, L, The Responsiveness and Equality of Mental Health Care to Chicanos and Native Americans, American Journal of Community Psychology,1975,45:111-118.
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