Commentary on Sanua's "Prescription Privileges," Journal of
Universal Peer Review, May 4, 1998
[From The Journal of Universal Peer Review [on-line], May 4, 1998,
St. John's University, Jamaica, New York. Invited response to
"Prescription Privileges" versus Psychologists' Authority:
Psychologists Do Better Without Drugs by Victor D. Sanua, Ph.D.
To subscribe send command below to listserv@maelstrom.stjohns.edu
subscribe jupr yourfirstname yourlastname]
COMMENTARY ON SANUA'S "PRESCRIPTION PRIVILEGES"
by
Jeffrey A. Schaler, Ph.D.
Professor Victor Sanua argues against state licensure of psychologists
to prescribe drugs for behavioral disorders. He asserts that
prescribing drugs by psychologists is a "category error." Dr. Sanua
cites evidence of the harmful physiological side-effects of drugs used
to control behavior. He describes political maneuverings of
influential persons in the American Psychological Association to
secure prescription privileges for psychologists. He predicts that
the licensure of psychologists to prescribe psychoactive drugs will
harm those seeking help from psychologists, as well as the profession
of psychology itself.
I will limit my comments on Dr. Sanua's article to three areas:
The first concerns the "category error" -- the confusion of behavior
and disease. The second concerns the admission of ineffectiveness by
psychologists who are psychotherapists and wish to be licensed to
prescribe drugs. The third concerns the right to prescription drugs
as property.
THE CATEGORY ERROR
I agree with Dr. Sanua's assertion that psychologists should not
prescribe drugs for clients because the focus of study and practice
for psychologists is behavior, not disease. Psychologists should
neither diagnose or treat persons for disease. Physicians are the
properly trained professionals for this activity. If psychologists
wish to develop expertise in the diagnosis and treatment of disease
they should also become physicians.
By definition, psychologists (_psyche_, soul, mind and _logos_,
study) observe behaviors. In contrast, pathologists (_pathos_,
suffering, disease and logos, study) examine the nature of diseases.
There are reasons for behaviors. Diseases are caused. Psychotherapists
(including psychiatrists, psychologists, social workers, nurse
practitioners, pastoral counselors, lay counselors, etc.) analyze what
their patients or clients say and do and converse with them to
influence their conduct. Rhetoric is the tool of their trade.
Physicians (including neurologists, cardiologists, dermatologists,
ophthalmologists, urologists, endocrinologists, gastroenterologists,
etc.) study what people say (symptoms) and the signs of disease
(ascertained through objective tests) and dispense drugs to patients
to influence their physical bodies. Drugs are the tools of their
trade.
Psychologists and psychotherapists focus on what persons do -- their
attention is on "mind" and ethics -- the moral choices people make in
relationship with others. Pathologists and physicians focus on what
persons have -- their attention is on the body and physical
health -- their goal is optimal physiological function free of
disease. Psychotherapists and physicians may focus on the
relationship between behavior and disease, however, the primary focus
and expertise of each is different.
When psychotherapists focus their attention on physiological
processes, i.e. the "realm" of physicians, and vice versa, they commit
a "category error" or mistake. When psychotherapists practice beyond
the boundaries of their profession, they perceive mental activity as
physical. Behavior ceases to be the central focus of the
psychologist. The person as moral agent is disregarded, and
responsibility for behavior is "removed." Likewise, when physicians
act like psychotherapists, they attribute physical processes with
moral agency. Responsibility for disease is "assigned."
Behavior refers to the activity of a moral agent. Behaviors are
described through symptoms, or subjective signs. Behavior involves
choice. Disease refers to the presence of physiological
lesions -- something strictly physical. Epilepsy, for example, is
not behavior. Diseases are described through signs, or objective
symptoms. Disease do not "choose" to invade the body. Something
causes a physiological change.
Psychotherapists act like physicians when they say they are diagnosing
and treating disease -- the basis upon which they claim the right to
prescribe psychopharmaceuticals. Physicians act like psychotherapists
when they make moral judgments and influence behavior -- a basis upon
which some "holistic" physicians operate. Since drugs are the tool of
physicians, psychotherapists who wish to use drugs, wish to act as
physicians. Since rhetoric is the tool of psychotherapists,
physicians who wish to talk to patients (instead of dispensing drugs),
wish to act as psychotherapists.
THE FAILURE OF PSYCHOTHERAPISTS
When psychotherapists wish to prescribe psychopharmacological agents,
they tacitly admit that they are failures in their own profession (1).
Psychiatrists have painted themselves into a corner. Those arguing
that behavioral disorders are caused by neurological dysfunctions have
made poor professional investments. Instead of training in neurology,
they have trained in psychiatry. Now they seem to regret their choice
of professions. In the guise of neurologists, they have convinced
insurance companies that behavior is rooted in biology. As a result,
they can't make a living conversing with people anymore. They are
neither fish nor fowl, neurologists nor psychotherapists.
Understandably they try to protect the professional "turf" they still
enjoy -- thus fighting against prescription privileges for
psychologists (while retaining these privileges for themselves).
Psychologists arguing for the right to prescribe drugs are painting
themselves into a similar professional corner. Aspiring to be
psychiatrists, they are trying to convince insurance companies and
state legislators that behavior has biological causes, not reasons.
Perhaps this is also because they too can't make a living talking to
people anymore. In other words, if they could help people by talking
to them, they would not be interested in prescribing drugs. Their
desire to prescribe drugs for behavior is an admission of failure.
How have they failed as psychotherapists? I suspect the fact that
they have confused behaviors with diseases has had a lot to do with
this. Psychologists who wish to prescribe drugs to control behaviors
probably subscribe to the myth of mental illness (whether they believe
in it or not). They fail to differentiate between metaphorical and
literal disease. Since metaphorical disease cannot be treated
literally, they've created an impossible situation for themselves. By
describing metaphorical diseases as literal ones, psychologists have
rendered themselves impotent and incompetent.
ANYONE SHOULD BE FREE TO PRESCRIBE AND PURCHASE ANY DRUG
Although I agree with Dr. Sauna about the discrete functions of the
professions, I disagree with him about the _right_ of psychologists to
prescribe drugs. I believe anyone should have the right to prescribe
or purchase any drug -- not just physicians and now psychologists.
Licensure of physicians and psychologists to prescribe drugs is an
attempt to protect the economic interests of both trade professions
under the guise of protecting the public welfare.
Should psychologists be able to write prescriptions for drugs? Of
course. Should they be licensed by the state to prescribe drugs?
Absolutely not. Are physicians more qualified to prescribe drugs for
physical illness? Most likely. Should they be licensed by the state
to prescribe drugs? Absolutely not. People should be free to
purchase and consume any drug they wish to without being coerced by a
trade profession or the state to consult with anyone in particular.
The sanctioning of prescription privileges by the state for any trade
profession establishes monopoly. People should be able to purchase
any substance they wish, e.g. antibiotics, select serotonin re-uptake
inhibitors (SSRI) and even heroin if they want to. They would
probably benefit a great deal by seeing a physician for guidance in
taking drugs. However, if they decline to visit a physician, they
should still be free to purchase and ingest drugs as they choose. And
if they prefer to see someone who is not a physician for guidance in
how to use drugs, they should be free to do so as well. Heroin users
prefer not to see a physician.
Many people in countries where antibiotics are available without a
prescription purchase these drugs without the advice of a physician.
Moreover, according to a study appearing in a recent issue of _Journal
of the American Medical Association_, (April 15, 1998, Volume 279, No.
15, pp. 1200-1205) "[m]ore than 2 million Americans become seriously
ill every year because of toxic reactions to _correctly_ [emphasis
added] prescribed medicines taken properly, and 106,000 die from
those reactions...That surprisingly high number makes drug side
effects at least the sixth, and perhaps even the fourth, most common
cause of death in this country" (2).
And this is Dr. Sanua's scotoma: If psychologists prescribe drugs
inappropriately, consumers will cease to go to them for prescriptions
or will hold them accountable for harm they cause by prescribing
drugs. If psychologists prescribe drugs, a new area of liability may
emerge as a result of their negligence and malpractice. The economic
curb on inappropriate dispension of drugs by psychologists will be the
threat of malpractice litigation. Consumers harmed by psychologists,
as well as their lawyers, will make lots of money in malpractice
suits.
If prescription laws protecting the psychiatric profession are
repealed, consumers will have free access to "Prozac," for example, as
an over-the-counter drug. Pharmaceutical companies will benefit by
eliminating the middle man, i.e. the psychiatrist or psychologist.
They will sell greater quantities of Prozac at lower prices because
insurance companies won't have to pay exorbitant fees to psychiatrists
and prescribing psychologists. Insurance rates will drop as a result
because consumers won't have to go to psychiatrists or psychologists
in order to acquire drugs. People who don't wish to ingest Prozac
will benefit because their insurance premiums will drop as well. If
psychologists fail to give consumers what they want, consumers will
simply stop going to them. If psychologists give consumers what they
want, consumers will continue to go to them -- licensure has nothing
to do with it.
Psychologists have a right to prescribe drugs if they wish to, just as
psychiatrists do. However, non-psychologists and non-psychiatrists
also have a right to ingest (and prescribe) any drug they wish. At
the same time, they alone will be responsible for the consequences of
their actions. There is a difference between rights and
responsibilities. The right to choose does not guarantee that choices
will be made wisely.
The consumer's right to drugs as "property" is completely overlooked
by Dr. Sanua and other psychologists arguing against prescription
privileges. By arguing that psychopharmaceuticals are "dangerous,"
and that psychologists aren't "qualified" to prescribe them, he argues
that people need to be protected from their own choices. That's the
same kind of "reasoning" drug warriors use. In other words, Dr. Sanua
and those psychologists arguing against prescription privileges are
supporting a form of paternalism. And paternalism sanctioned by
government is far more destructive to liberty than any drug (or
psychologist) could ever be. (3)
NOTES.
(1) The idea of admission of failure is from Amos M. Gunsberg.
(2) Weiss, R. (1998). Correctly prescribed drugs take heavy toll.
_The Washington Post_, A1, April 15.
(3) See "Is Depression A Disease?," Show #235, with Thomas S. Szasz,
M.D., Donald F. Klein, M.D., Jeffrey A. Schaler, Ph.D.,
Frederick K. Goodwin, M.D. Ron Leifer, M.D., and Peter Kramer, M.D.;
and "Do We Need Prescription Drugs?," Show #238, with
Thomas S. Szasz, M.D., Charles A. Sanders, M.D., Jeffrey A. Schaler,
Ph.D., Ron Leifer, M.D., and Tia Powell, M.D., both shows taped March
31, 1998, from debatesdebates, Warren Steibel Producer,
http://www.debatesdebates.com. (Videotapes available for $35.00
each, includes shipping and handling, at (212) 849-2851.
Jeffrey A. Schaler, Ph.D., teaches psychology at Johns Hopkins
University and is an adjunct professor of justice, law, and society at
American University's School of Public Affairs. jschale@american.edu
May 4, 1998
|
|