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 firstname.lastname@example.org 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. email@example.com May 4, 1998
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