Jeffrey A. Schaler, Ph.D.

        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.
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     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.

     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

     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.

     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.

     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

     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)

     (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,  (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.
May 4, 1998