Collaborative Prescribing Rights for Psychologists: The ...

John Fitzgerald & Karma Galyer

Collaborative Prescribing Rights
for Psychologists:

The New Zealand Perspective

John Fitzgerald & Karma Galyer, The Psychology Centre, Hamilton

The circulation in 2007 of a Ministry of Health consultation paper focusing on communities, but have at least entered
the extension of collaborative prescribing rights to non-medical professionals into the debate (e.g., Lavoie & Barone,
has again brought the issue of psychologist prescribing into sharp relief. 2006). Apart from a survey of 36 New
In the context of mental health workforce shortfalls there has been a slow Zealand psychologists published in
expansion of psychologists prescribing in America. Closer to home, the 1995 by the NZ Clinical Psychologist,
Australian Psychological Society has recently completed a survey amongst little attention has been given to the
members and developed a proposal for psychologists to prescribe. In light arguments for and against collaborative
of these developments, and the Ministry of Health initiated discussion of prescribing in New Zealand.
collaborative prescribing, it seemed pertinent that New Zealand psychologists
review their position on this issue. A survey of New Zealand psychologists Meeting mental health needs is a
was undertaken to obtain local perspectives of collaborative prescribing. key consideration for all communities
A small majority of the 571 respondents indicated that they supported the currently introducing or considering
idea of collaborative prescribing, and saw a need for it at least in some introducing prescribing psychologists
areas of health care. Psychologists providing clinical services indicated (Lavoie & Barone, 2006; Norfleet,
that collaborative prescribing could be potentially useful in their practice. 2002; Price, 2008; Westra, Eastwood,
Several arguments for and against prescribing were considered important, Bouffard, & Gerritsen, 2006). A
but the impact of collaborative prescribing on the nature of psychology as a potential shortage of psychiatry services
profession raised the most concern. prompted the APS to investigate the
views of their membership on this topic
Keywords: psychology, prescribing, medication, collaboration, survey (APS Prescription Rights Working
Group, 2007). APS respondents ranked
The issue of non-medical professionals to psychologists have been conducted “increased access to prescribing
in New Zealand undertaking within the United States over the last professional, particularly in areas with
prescribing activities has recently three decades (Baird, 2007; Fagan, Ax, currently poor access to psychiatrists”
became more salient with the Ministry of Liss, Resnick, & Moody, 2007; Fagan as the number one reason for training
Health (MoH) circulating a consultation et al., 2004; Grandin & Blackmore, prescribing psychologists. Second to
paper entitled, Enabling the Therapeutic 2006; Sammons, Gorny, Zinner, & this was the argument that prescribing
Products and Medicines Bill to Allow Allen, 2000; Walters, 2001). Legislation psychologists could provide more
for the Development of Collaborative supporting psychologists prescribing effective assessment, treatment, and
Prescribing (Ministry of Health, 2006). has been introduced in New Mexico and continuity of care than was currently
This paper invited consideration of Louisiana, and is under consideration available. As can be seen, the focus
the need for collaborative prescribing, in several other states. The Australian was not on increasing the number of
potential models/systems, and what Psychological Society (APS, 2007) has prescribers per se, but increasing the
skills practitioners might require. also conducted a survey of its members. number of clinicians with a combination
These are difficult questions for the Finding that the majority of respondents of specialist mental health skills and
New Zealand psychology community supported prescribing in principle, the the ability to prescribe psychoactive
to answer as we are somewhat behind APS is now developing a proposal medication. The possibility that
our international counterparts in for the training and registration of prescribing psychologists could
developing a position on collaborative prescribing psychologists. The United improve mental health care for
prescribing. Multiple surveys regarding Kingdom and Canada have yet to certain groups within society is also
the extension of prescribing privileges canvas the views of their psychology consistently endorsed by the majority
of respondents in surveys of North

• 44 • New Zealand Journal of Psychology Vol. 37, No. 3, November 2008

Prescribing Rights

American psychologists (Baird, 2007; the second survey the overall proportion or will not train, may be dependant on
Fagan et al., 2007; Fagan et al., 2004; of psychologists for, undecided, and the current the socio-economic context
Grandin & Blackmore, 2006; Sammons against prescribing was the same as of individual communities, the current
et al., 2000). Evaluation of the work the baseline survey. However 35% of status of their health care services, current
of the single prescribing psychologist practitioners had changed their opinion training models, and the advancement
working within the Indian Nations over the intervening period. There was of our understanding of mental health
in the USA found the work to be no pattern to this with equal numbers (Levine & Pedhazur Schelkin, 2006).
both safe and effective (Fox, 2003). moving between the three groupings. It would be remiss to assume that the
Similarly, a US Department of Defence Similarly, Fagan et al. (2007) found views of the psychology communities
evaluation found that having prescribing that the reasons US psychologists described above necessarily coincide
psychologists improved mental health give for wanting prescribing rights with the views of New Zealand’s
services to military personnel and their has changed over time. In their 2004 psychologists. The current survey was
families during peacetime (Alpert et survey psychologists saw prescribing undertaken with the aim of determining
al., 2000). The impact on prescribing as meeting a need, providing a better New Zealand psychologists’ views on
psychologists in more typical mental service, and as essential to the economic collaborative prescribing. It also aimed
health setting has yet to be evaluated. survival of the profession. In 2007 to compare the New Zealand perspective
Possibly the experiences of prescribing economic reasons were not raised, and with views expressed in the American
psychologists in New Mexico and instead the respondents emphasized that and Australian surveys on prescribing.
Louisiana will eventually be able to prescribing was seen as consistent with
provide this information. other tasks in their routine clinical work Method
and was in keeping with a bio-psycho-
The question of how prescribing social model of health. Survey Development
might impact on the nature of psychology
as a profession also elicits strong and Although the majority of The topic areas and content of the
emotive argument, from both those in psychologists supported prescribing survey items was primarily taken from
support and those against (Heiby, 2002; in Walters’ (2001) meta-analysis, and the APS Prescription Rights Working
Lavoie & Barone, 2006; Norfleet, 2002; several subsequent surveys (Baird, Group survey (2007) and the questions
Robiner et al., 2002). Would prescribing 2007; Fagan et al., 2007; Fagan et raised by the New Zealand Collaborative
medicalize psychology, or vice versa? al., 2004; Grandin & Blackmore, Prescribing consultation document
Levine and Pedhazur Schelkin’s (2006) 2006) the proportion who indicated (MoH, 2006). Demographic questions
survey found a weak relationship that they would take up training was were taken from the Health Workforce
between psychologist’s endorsement of considerably smaller. This raises an Annual Survey information collected as
a biological component in mental health important question - even if prescribing part of the New Zealand Psychologists
models and support for prescribing. The was found to be a desirable and viable Board registration process (NZHIS,
authors note that psycho-social models option, would enough psychologists 2006). This was to determine if the
were equally valued by those for and undertake it? Walters found that survey respondents were representative
against prescribing, suggesting that psychologists in training were more of registered psychologists as a whole.
medication was seen by the respondents likely to want prescription privileges The survey consisted of three substantive
as an additional skill rather than as a than senior staff. Fagan and colleagues sections.
replacement of current psychological found that willingness to take up
approaches. Other commonly cited training was related to the respondent’s Professional perspectives on
areas of disagreement in the prescribing age, job type, degree type, and current prescribing. General items asked for
debate include the relevance of other level of educational debt (Fagan et the respondents’ overall opinion on the
non-medical prescribers as establishing al., 2007; Fagan et al., 2004). The desirability of appropriately trained
a precedent for psychology, the impact survey conducted by VandenBos psychologists prescribing, if it was
on training psychologists, the negative and Williams (2000) identified that needed in New Zealand, and to what
impact on collegial relationships, the psychologists valued knowledge and degree our professional organisations
risks involved for both practitioners skills related to psychoactive drugs, should prioritise this issue. Respondents
and their clients. Substantial arguments and had already acquired these after were also asked to consider many of
have been presented by professionals on post-graduate training. Information the commonly stated arguments for
both sides (see Heiby, 2002 or Lavoie & was gained via their medical and and against prescribing and indicate
Barone, 2006 for review). non-medical colleagues, conferences how strongly they agreed or disagreed
and other professional meetings, and with each one. Qualitative information
The American survey data to date through reading relevant journal articles was requested on any other issues the
shows that psychologists are divided on and psychopharmalogical texts. Half respondent considered to be relevant to
whether or not prescribing is desirable of the psychologists surveyed had prescribing.
for our discipline. However, it appears attended formal training such a course
that opinions on this topic are not or seminar. Usefulness of prescribing. More
static. Boswell and Litwin, (1992) specifically, the perceived usefulness
repeated a survey of hospital-affiliated The endorsement of arguments for (or not) of being able to prescribe
psychologists over a 12 month period. In and against prescribing, and who will in respondents' own practice was of
interest. Psychologists were also asked

New Zealand Journal of Psychology Vol. 37, No. 3, November 2008 • 45 •

John Fitzgerald & Karma Galyer

to indicate what medications (if any) to members of NZPsS and NZCCP, of settings was consistent with the 2006
may be of use them. these 535 (33%) were returned. A further NZHIS survey. Forty-eight percent
36 were returned by non-members or worked in a private practice setting, 41%
Training and supervision for respondents who did not answer the in a District Health Board setting, and
prescribing. A section on training and question regarding membership of a 16% in university/polytechnic. Group
supervision was included, particularly professional organisation, giving a Special Education employees (4%) were
for those respondents who supported total of 571 surveys for analysis. As the under represented compared with the
prescribing. The aim was to determine number of non-member psychologists NZHIS survey.
what training areas New Zealand who received the invitation to participate
psychologists thought were important, is unknown, the return rate from this Forty-eight percent of respondents
and how long they would anticipate group cannot be calculated. Nineteen indicated three or more areas of practice.
it would take to acquire those skills. surveys were returned unopened with The most common area was clinical
Consequently participants were asked unknown or incorrect address. Ten work (75%). Counselling (20%),
to put their own ideas forward rather were received after the closing date, and research (17%), child youth and family
than commenting on overseas models. were not included. Twenty percent of psychology (18%), training activities
Psychologists were also asked what they respondents completed their survey on- (16%), neuro-psychology (15%), and
might expect in terms of supervision and line, and eighty percent were returned forensic (15%), were the next most
ongoing training for prescribing. in the mail. Ten respondents did not common areas of work. There were
complete all of the required sections fewer respondents working in addictions
Both pen/paper and on-line versions on the desirability of prescribing, and than would have been expected given
of the survey were constructed. Each arguments for/against. What information the results of the NZHIS survey.
version was trialled by clinical staff they did give has been included in the Eighty-five percent of respondents were
at The Psychology Centre, Hamilton analysis. providing health services to people.
to ensure it could be easy read and Most indicated they work with a range
understood. The answer format of Respondent Demographics of difficulties (66% indicated 3 or more).
the on-line version was adjusted in The most common areas of difficulties
accordance with the options available The distribution of age, gender, for clients were mood disorders (82%),
for formatting the survey. The on- and ethnicity of the survey respondents anxiety disorders (81%), and personality
line administration of the survey was is consistent with the 2006 NZHIS disorders (44%).
hosted by Survey Monkey (www. workforce survey, the most recent date
surveymonkey.com). for which figures are available. There Professional Perspectives on
were equal numbers of respondents in Prescribing
Data Collection each 5-year incremental age bracket
between 30 and 60+. In contrast, there In your opinion, is it desirable
All members of the New Zealand were substantially fewer respondents that New Zealand psychologists with
Psychological Society (n=1,030), and in the youngest age bracket (9.5% of appropriate training and supervision
the New Zealand College of Clinical the total sample). Sixty-six percent of be permitted to prescribe psycho-active
Psychologists (n=603) were mailed respondents were female and thirty- medications? Half of the respondents
an information letter and survey. one percent were male. The majority of indicated support for psychologists
Respondents were asked to either mail respondents (81%) were NZ European. prescribing (see Figure 1), although the
the survey back to The Psychology Four percent identified as Māori, and majority of this group had reservations.
Centre in a freepost envelope, or less than 1% identified as a Pacific Twenty-two percent had too many
to complete the on-line version by people. “Other” ethnicities (11%) were reservations to support prescribing
following the Survey Monkey address mainly European, South African, Indian, at this time. A minority (8%) were
given. An attempt was also made to and Asian. absolutely opposed to psychologist
include psychologists who were not gaining prescribing rights.
members of these professional groups. Ninety-seven percent of respondents
Psychology Advisors for District were registered, of these 19% were Eighteen percent of respondents
Health Boards were asked to forward solely in the general scope, 62% were in indicated they were uncertain or that
an email to their staff with options clinical scope, 3% in educational scope. they needed more information. The most
to download a paper version of the Trainee and intern psychologists made frequent need was for information about
survey or to complete it online. The up the rest of the respondents. Those what the training to become a prescribing
Head of Psychology for all University who were not registered included people psychologist would entail. Other areas
departments in New Zealand was also in managerial roles, academic roles, and of information noted as desirable were
contacted with a request to forward the retired psychologists. any conditions that would be applied to
survey information on to their staff. The prescribing, including any limitations to
number of psychologists who received There were respondents from all of particular scopes of practice. To a lesser
these emails is unknown. the 21 District Health Board areas. The extent, evidence supporting the pros and
highest number of respondents in any cons of prescribing, and possible risks
Results one region was Auckland (30%), then was mentioned.
Canterbury (12%), Waikato (11%), and
Response Rate Capital & Coast (10%). The proportion In response to the question, “At this
of respondents in most employment time do you think there is a need for New
In total 1,633 surveys were sent out

• 46 • New Zealand Journal of Psychology Vol. 37, No. 3, November 2008

Prescribing Rights

Figure 1. Is it desirable for New Zealand psychologists to gain prescribing rights?% of Respondentshad a higher proportion of respondents
who disagreed than agreed, ranging
35 between 51% and 72% of the group
across items.
Yes absolutely
For the group of psychologists
30 who indicated that prescribing was
not desirable, the strongest argument
25 Yes with against was that “prescribing would
reservations change the nature of the psychology
as a profession”. Qualitative answers
20 gave some indication as to how these
respondents thought that the profession
No too many would change. The most common
15 reservations concern expressed was that psychology
would become “medicalized”, thus
No absolutely not losing its unique identity and core
strengths. Prescribing psychologists
10 were predicted to start working within
a medical model, not consider systemic
5 Uncertain/more issues in assessments, locate causal
information factors in psychological disorders
within the biology of the individual,
0 and prefer medical treatments over
psychological therapies due to the
Zealand psychologists to gain privileges Specific Arguments Against ease of prescribing. These concerns
to prescribe psychoactive medications?” Prescribing extended to research undertaken by
19% said yes, and 34% said yes, but in psychologists where it was expected
some areas only. Thirty-three percent did Table 1 shows all of the arguments that there would be a reduction in
not think there was a need, and twelve against prescribing that were presented efforts to develop better psychological
percent were unsure. Respondents within the survey. They are listed in therapies in favour of medical options.
were also asked the degree of priority the rank order of their endorsement by Prescribing psychologists were also
our professional organisations should respondents, from strongest to weakest likely to be perceived differently by
place on undertaking an advocacy role support. The first two arguments other health professions. For example,
in support of prescribing. High priority “insurance costs for psychology would it was envisaged that psychologists
was endorsed by 23%, medium priority rise” and “prescribing would change would become an alternative or
by 30%, and low priority by 37%. A the nature of the psychology as a “cheap” psychiatrist, thus turning a
few respondents qualified their answer profession” were the most frequently
by saying that because prescribing was endorsed concerns. Twenty percent of
undesirable, it should not be given any psychologists “strongly agreed” with
attention by psychology’s professional each of these statements. For all other
organisations. items the proportion of respondents who
“strongly agreed” was between 2% and
9%. Most arguments against prescribing

Table 1 The number of respondents who agreed vs disagreed with arguments against prescribing.

Argument Agree Unsure Disagree

Insurance costs for psychology practice would rise 67% 27% 4.8%
Allowing psychologists to prescribe changes the fundamental nature of psychology
as a profession 43% 10% 46%
Psychologists would not gain adequate training to prescribe 28% 20% 51%
Training psychologists would unnecessarily duplicate current services 27% 14% 58%
Psychologists are more likely to mis-prescribe, increasing risk to clients 16% 20% 64%
Prescribing psychologists would reduce consumer choices of treatment modalities 16% 11% 72%
Non-prescribing psychologists would be ‘phased out’ 15% 24% 60%
Psychologists would favour prescription over psychotherapy 15% 14% 71%
Training psychologists to prescribe would be too expensive for taxpayers 10% 26% 64%

Notes
1) Some rows do not sum to 100% due to missing answers for that item.
2) For ease of presentation the Strongly Agree and Agree categories have been combined, as have the Strongly
Disagree and Disagree categories.

New Zealand Journal of Psychology Vol. 37, No. 3, November 2008 • 47 •

John Fitzgerald & Karma Galyer

potentially collaborative relationship not solve the problems such as access a psychologist could not conduct the
into a conflictual and competitive one. to specialists, limited supervision for physical assessments necessary to
Psychologists would be under pressure psychiatric registrars, and lack of mental determine if there were contraindications
to prescribe from many quarters (e.g., health training for General Practitioners. to the type of medication they were
colleagues, pharmaceutical companies Instead improved collaboration between considering prescribing. From the
and the clients themselves); pressures medical and psychology staff was qualitative comments made it appeared
which those arguing against prescribing seen as a better direction to focus on that risk could be somewhat mitigated
did not think would be well managed. than psychologists gaining prescribing by “appropriate” training.
rights.
Some respondents who put Specific Arguments For Prescribing
forward their own arguments against Another commonly raised objection
prescribing said that the costs of training was that clients would not benefit from a Table 2 shows all of the arguments
psychologists to prescribe outweighed prescribing psychologist. For example, put forward in support of prescribing
the benefits that could be derived it was suggested that clients get better in order of those with the strongest to
from it. The time and cost of adequate service when at least two professionals weakest support from respondents. For
training to prescribe was considered an are working together on their case, all items there were more respondents
unacceptable addition the already high which was not predicted to happen who agreed than disagreed, but the
demands that current training placed if a psychologist prescribed. Some items with the highest proportion who
on the individual psychologist. Those respondents did not think that clients “strongly agreed” were “psychologists
arguing against prescribing hypothesised benefited from medications whoever have extensive biopsychosocial training”
that this would result in a reduction in was prescribing them, and thus did not (29% strongly agreed), “psychologists
the psychology training components, see the use in psychologists taking up often provide monitoring of medication
particularly in psychological therapies. this task. prescribed elsewhere” (28%), and
Adequate training was considered to “increased collaboration between
be a duplicate of psychiatrist training. Possible risk to clients, and to psychologist and doctors” (26%). The
Because this service is already provided, the psychologist themselves if a items predicting increased quality of care
this was regarded as a wasted resource. prescribing error occurred, were raised as an outcome of prescribing received
The current deficits in the medical but this issue was not in the top half “strongly agree” endorsements from
system were noted, but with the caveat of arguments against prescribing. The approximately 20% of respondents.
that having psychologist prescribe would most commonly raised risk was that

Table 2 The number of respondents who agreed vs disagreed with arguments supporting prescribing.

Argument Agree Unsure Disagree

Psychologists often provide monitoring of effectiveness and side-effects of medications 84% 10% 5%
prescribed elsewhere
76% 9% 14%
Psychologists have extensive training in biopsychosocial assessment and treatment of
psychological disorders 74% 12% 13%

Knowledge of psychoactive medications would increase collaboration between 71% 12% 14%
psychologists and doctors 70% 11% 17%
64% 26% 8%
Prescribing psychologists will increase public access to professionals able to
prescribe psychoactive medications, particularly in areas with limited access 62% 12% 24%
60% 22% 16%
Psychologists could work more consistently with the client on adherence to medications
59% 14% 26%
Psychologists would be able to reduce or stop medications to the benefit of the client 45% 37% 16%

Psychologists have more time to explain effects and side-effects, and to gain 45% 28% 25%
informed consent from the client 32% 62% 5%

Psychologists could provide more effective assessment and prescription than GPs

Allowing psychologists to prescribe would increase the quality of treatment from
psychologists by increasing their options and providing greater continuity of care
Many other professions are able to prescribe with little or no psychopharmacological
training

Many non-psychiatric professions (especially GPs) are currently prescribing
psychoactive medications and prefer to refer to psychologists for advice

Psychologists are already prescribing safely and effectively in other countries

Notes

1) Some rows do not sum to 100% due to missing answers for that item.

2) For ease of presentation the Strongly Agree and Agree categories have been combined, as have the Strongly Disagree
and Disagree categories.

• 48 • New Zealand Journal of Psychology Vol. 37, No. 3, November 2008

Prescribing Rights

The arguments that respondents respondents that quoted the “holistic” (n=272) of respondents to this question
were the most uncertain about were model of mental health as supporting saying antidepressants and/or mood
those pertaining to prescribing in their perspective. To some, being stabilisers would be useful. Medication
other professions and other countries. holistic meant giving consideration for anxiety was thought to be useful by
The qualitative responses suggest to all of the relevant aspects of care, 61% (n=183). Although anti-psychotic
that many respondents were unaware including biology. To others, being medications had the most caveats noted,
that this was happening. The fact that holistic meant considering dimensions this group was still thought to be useful
other professions prescribed was not of health other than biological or by 27% (n=81). Medications for sleep
considered to be an adequate indication medical perspectives. were the next most frequently reported
that psychologists could safely prescribe group (24%). Methylphenidate was
by those arguing against prescribing. Common reservations from those specifically noted by 19% of the group.
Common concerns were that other non- in support of prescribing were that Other medications mentioned were
medical professions who prescribe have adequate administration, training and those used in specialist areas of physical
more basic training in physiology than supervision would be essential for safe health and addictions services.
psychologists, less complex medications, practice. Also, that the option to take up
and less complex clients. Prescribing in training to prescribe should be restricted, What Training Is Important
these professions was also not thought with access granted based on the To Become a Prescribing
to have been adequately monitored and psychologist’s area of practice. Several Psychologist?
reviewed. respondents proposed that prescribing
privileges be restricted to those with The questions for training were
Similar to respondents arguing training in clinical psychology, and/or optional for those people who did
against prescribing, proponents of those employed in a workplace or with not think prescribing was desirable,
prescribing saw training as pivotal. a particular client group that had an and consequently were competed
The key differences between the two identified need for prescribing. Further by 75% (n=431) of the total sample.
groups was that those arguing for evidence for the potential benefits The following analysis applies to this
prescribing saw psychologists as able of prescribing was also considered group of respondents only. A frequent
to complete any necessary training, necessary. qualitative response noted in this section
and that adequate standardisation, was that training should be consistent
monitoring and evaluation within the What Kinds Of Medication Would with the content, timing and standards
profession is possible. Evidence cited to Psychologists Find Useful? of other prescribing professionals (e.g.,
support this view was that psychologists overseas prescribing psychologist, GP’s,
already have good academic standards, In response to the question “How and Nurse Practitioners). This also
emphasis on evidence-based approaches, useful would it be to prescribe in your applied to ongoing education/training
as well as the use of supervision and practice?” 20% said “very useful”, 35% and supervision.
reflective practice. said “somewhat useful”, and 6% were
unsure. Medication was not considered As Figure 2 shows, 59% of
Those who generally supported the to be useful in the practice of 36% of participants who answered these
extension of prescribing privileges to respondents. questions indicated they would possibly
psychologists described ways in which take up training (46% of the whole
the profession would be enhanced by Fifty-two percent (n=298) of survey). Twenty-percent indicated that
this, rather than changed for the worse. respondents listed at least one medication they would not, and eleven-percent had
For example, they noted there was no that would be of assistance. The most yet to decide.
evidence that prescribing psychologists frequently noted group of medications
in other countries have changed their were for mood disorders with 91% The most common reasons endorsed
approach to psychological assessment by those who were unlikely to take up
and treatment. This group predicted
that with prescribing knowledge, Figure 2. Would you be likely to undertake additional training to become a
psychologists would be more influential prescribing psychologist?
in team decisions about whether
medication, therapy, or both were an 25
appropriate choice for clients. There
was a keen emphasis on medication Yes absolutely
being part of a holistic approach that
is intrinsic to psychological models 20
of care. Overall those in support of
prescribing felt that psychological % of Respondents Yes it's possible
principles could positively influence
the use of medication, rather than 15
psychology becoming corrupted by
“medicalization”. In both the groups Unsure
for and against prescribing there were
10

Not likely

5

No absolutely not

0

New Zealand Journal of Psychology Vol. 37, No. 3, November 2008 • 49 •

John Fitzgerald & Karma Galyer

training (n=135) were “I do not believe checks (e.g., blood pressure) to screen desirable by 48%. An internship was
it would be relevant to my work as a for contraindications and monitor side thought appropriate by 42%, group
psychologist” (50%) and “I am not effects. Recognition of addiction and supervision by 21%, and a set time for
interested in including medications as drug seeking behaviour was another each client by 14%.
part of the treatment option I can offer” initial assessment skill. The need for
(46%). Of those that would not train, psychologist to understand the treatment Prescribing Opinions and
37% still noted that it was desirable outcome studies for medications was Demographic Characteristics of
for psychologists to have prescribing emphasised by several respondents. This Respondents.
rights. included having an awareness of the
pros and cons of combining medication Whether or not prescribing
Respondents indicated multiple and psychotherapy, and preferable was considered desirable was not
psychology streams as being possible alternatives to medication. Finally, significantly related to respondents’
pre-requisites for prescribing training, respondents noted process issues in age, gender, ethnicity, geographical
of which clinical psychology (97%) the broader context of health care that place of work, or employer. Because
was the most frequently endorsed. a prescribing psychologist would need some of the qualitative responses put
Also considered important was clinical to be cognizant of. These included the forward by respondents suggested
neuropsychology (63%) and health ethics, legalities, and cross-cultural that psychologists working in the area
psychology (43%). The minimum level issues related to prescribing. The of clinical psychology would have a
of qualification to be achieved before influence of pharmaceutical companies different perspective from other groups
starting prescribing training was a on research and practice was of particular a comparison between clinical and non-
Masters or higher for the majority of concern to some. clinical participants was undertaken. No
respondents. A postgraduate diploma differences in responses to the questions
was endorsed by 48%, and a DClinPsy The time anticipated to complete regarding desirability, need, training,
or PhD by 21%. The majority (66%) also training for prescribing varied greatly. and prioritisation of advocacy were
opted for a required minimum number Fifty-nine percent of those who found. The only significant difference
of years of professional practice before specified a time period indicated that was that a higher proportion of clinical
training (m = 4 years, SD = 1.8). 12 months or less would be enough psychologists indicated collaborative
time, 25% thought up to 2 years, and prescribing would be useful in their
Specific training areas for 11% thought up to three years. Both work than was found for non-clinical
prescribing were put forward by full time and part time training options psychologists (χ2 = 34.12, df = 4,
many respondents. The most common were desirable. The ongoing training/ p<0.001).
area was pharmacology skills. This education arrangement preferred by
included knowledge of drug types, the majority of respondents (76%) was Discussion
mechanisms of action, common uses a set number of hours of professional
and guidelines, expected effects, side development. Respondents were asked The good response rate and often
effects over short and long term, effects to indicate a desirable number of hours lengthy qualitative information provided
of discontinuation, contraindications, of professional development. Answers by the participants for this survey
indications of toxicity and/or allergy, ranged from 1 to 60 hours per year (m indicate that New Zealand psychologists
and possible interactions with other = 15 hours, SD = 12). appear to have considerable interest in
prescription and non-prescription the debate about prescribing. Overall
drugs. Areas of learning to support Participants were asked to indicate there were more psychologists than
pharmacology were also recommended. their preferred supervision arrangements. not who indicated that prescribing was
These included physiology/anatomy, Seventy-four percent preferred a desirable, that there was a need for it, and
biology, neurology, and the biological psychiatrist, 33% another prescribing that it would be useful in their day to day
basis for behaviour. psychologist, 19% any physician. Some work. This is consistent with both the
people specifically identified GP’s and Australian and North American findings.
As well as pharmacology, pharmacists as possible supervisors Compared to the APS survey, the New
respondents noted several other for prescribing. Forty-one percent of Zealand respondents included more
assessment and treatment skill sets participants identified more than one psychologists who had reservations or
that were desirable in a prescribing professional group. A psychiatrist were uncertain about prescribing, and
psychologist. Overall these skills and prescribing psychologist was the more respondents who did not see
were aimed at ensuring safe and most frequent combined response for prescribing as a priority for professional
effective practice. For example, a preferred supervisor. Similarly, many organisations.
good prescribing psychologist would people (42%) identified more than
recognise the limitations of his/her one suitable supervision style. The Arguments For And Against
ability and know when to consult with most commonly rated style was an Prescribing.
a medical professional. They would individual supervision arrangement
have the ability to work collaboratively (48%), typically for an hour each week. Australian and New Zealand
with a team or a specific doctor. They Seeking consultation with a medical respondents had different reasons
would know how to stay up to date with professional regarding the treatment for supporting prescribing. The most
developments in medications. Important plan for each client was also considered salient arguments for the Australian
clinical skills included physical health group were primarily client based,
including increased access to prescribing

• 50 • New Zealand Journal of Psychology Vol. 37, No. 3, November 2008

Prescribing Rights

professionals, increased quality of care workforce. It would be particularly address, for example, mood disorders,
with more effective assessment and pertinent to ascertain the views of GP’s often include medications as part of the
treatment than what General Practitioners as they current do the bulk of mental treatment.
currently provide. New Zealand health prescribing in New Zealand.
participants also strongly endorsed What Potential Models Of
these, but gave more weight to items A question only asked of the New Collaborative Prescribing Could
about psychologists’skill sets, including Zealand psychologists was whether Work And What Skills Might
working from a biopsychosocial model prescribing would be useful, and if so, Practitioners Require?
and monitoring medications currently. what medications would be relevant to
The New Zealand view found here is their work? Over half of the New Zealand The Ministry of Health’s
more consistent with that found in the sample indicated that prescribing would collaborative prescribing consultation
survey conducted in America by Fagan be useful, and this seemed to apply document (MoH, 2006) requested
et al. (2007), who also found a shift particularly to the anti-depressant group consideration of potential models of how
from the client needs-based perspective of medications. Unfortunately the survey such prescribing could work. Ideas for
endorsed by the APS group to the did not ask why respondents would find education, training and supervision put
professional-based perspective endorsed prescribing particular medications forward by New Zealand psychologists
by the New Zealand respondents. useful. Tasks such as psychologist- were not inconsistent with other
physician collaboration, recommending proposed and currently operational
Qualms about prescribing were medication, providing drug-related models overseas. Both New Zealand
similar across North American, APS information for clients, monitoring and APS psychologists endorsed
and New Zealand respondents. Forced ongoing adherence with drug regime, specialised post graduate training in
choice items and qualitative answers monitoring effects and side-effects pharmacology. These components
highlighted issues to do with the impact on are all examples of clinical issues that are also part of the proposed training
psychology as a profession, particularly psychologists report managing in their schemes for American states currently
the question of medicalization. No routine clinical work (VandenBos & considering psychologists prescribing,
respondent in this survey indicated a Williams, 2000). In Sammons et al.’s and the current training scheme in New
preference for medical intervention (2000) survey of US psychologists in Mexico. The current training scheme in
or medical models of health over a Maryland, respondents highlighted Louisiana does not have the same clinical
psychological approach. Some insight common problems they encountered with practicum component. The American
as to how psychology and prescribing the prescribing of medical practitioners. course work is set at 300 hours, and
might combine in practice comes from Sixty-two percent indicated that their clinical training at 100 cases with two
a survey of American psychologists client’s drug regime was insufficiently hour supervision sessions each week.
who are also qualified nursing staff, monitored by prescribers, and 46% Half of the APS respondents approved
meaning they could prescribe if they indicated that their clients had been this as a suitable training scheme. There
wished. Wiggins and Wedding (2004) over-prescribed medication. It may be was no particular trend on what needed
did not find a preference for a medical those psychologists see themselves as to change to satisfy those who did not,
approach over a psychological approach able to take more control of medication- but only 9% wanted less training than
in this sample. Only 5% of respondents related clinical tasks with prescribing the North American models.
were using their prescription privileges rights.
in their psychological practice, primarily Current prescribing practice in New
to treat anxiety and mood difficulties. Individual Differences In Mexico and Louisiana is based on close
Prescribing Opinions. and ongoing collaboration with a medical
The APS found that respondents professional. The supervisor in these
were concerned that prescribing would Levine and Pedhazur Schelkin schemes is usually a psychiatrist, but
result in a deterioration in relationships (2006) noted that prescribing opinions can be another medical practitioner (i.e.,
with their medical colleagues, whereas are likely to be influenced by individual general practioner), which is consistent
the majority of the New Zealand differences such as a respondent’s socio- with the majority of New Zealand
respondents, and those in the Fagan et al. economic context, health care context, respondent’s preferred supervisory
(2007) survey anticipated the opposite. and the dominant training model at arrangements. Broadening collaboration
The relationship between psychologists the time. This survey did not find any beyond psychiatry as suggested by
and doctors is paramount as the type particular pattern of responses across many of the New Zealand survey
of prescribing under consideration demographic groups. It could be argued respondents could potentially make the
in the MOH document is limited and (and some did) that prescribing is only model of collaborative prescribing more
dependant, meaning doctors have a viewed positively by those working applicable to primary care. Ongoing
pivotal role. The majority of New in the area of clinical psychology; education was considered to be important
Zealand respondents saw doctors, however this was not the case. The by APS and New Zealand psychologists,
particularly psychiatrists, as providing only difference between clinical and who both preferred to have a set number
the bulk of regular supervision. As yet non-clinical psychologists was that of hours of professional development for
there is no information on the opinions more of the clinical group reported that this. The APS also had a wide range of
of New Zealand’s medical professionals they would find being able to prescribe hours proposed. Many of the suggestions
about having a prescribing psychology useful. This is likely to be because the are consistent with how psychologists
mental health difficulties that this group informally develop their knowledge and

New Zealand Journal of Psychology Vol. 37, No. 3, November 2008 • 51 •

John Fitzgerald & Karma Galyer

skills in psychoactive medications at Boswell, D. L., & Litwin, W. J. (1992). Norfleet, M. A. (2002). Responding to
present (Sammons et al., 2000) Despite Limited prescription privileges for society’s needs: Prescription privileges
the uncertainty of what training would psychologists: A 1-year follow up. for psychologists. Journal of Clinical
entail, approximately half of the New Professional Psychology: Research & Psychology, 58, 599-610.
Zealand survey respondents would at Practice, 23, 108-113.
least consider undertaking it. This is Price, M. (2008). The American Society for
more than found in North America, but Fagan, T. J., Ax, R. K., Liss, M., Resnick, the Advancement of Pharmacotherapy
less than APS survey participants. R. J., & Moody, S. (2007). Prescriptive pushes for prescriptive authority through
authority and preferences for training. training and advocacy. Monitor on
At present there is still much that Professional Psychology: Research & Psychology, 39, 58-60.
needs to occur before a formal decision Practice, 38, 104-111.
about extending prescribing rights Robiner, W. N., Bearman, D. L., Berman,
to psychologists could possibly be Fagan, T. J., Ax, R. K., Resnick, R. J., M., Grove, W. M., Colón, E., Armstrong,
made. In particular, there is the need Liss, M., Johnson, R. T., & Forbes, J., et al. (2002). Prescriptive authority
to review evidence relating to one of M. R. (2004). Attitudes among interns for psychologists: despite deficits in
the big questions in the prescribing and directors of training: Who wants education and knowledge? Journal of
debate: Is there is a need for prescribing to prescribe, who doesn’t and why. Clinical Psychology, 58, 211-221.
psychologists in New Zealand? If this is Professional Psychology: Research &
the case, do we as a profession want this, Practice, 35, 345-356. Sammons, M. T., Gorny, S. W., Zinner, E.
and what do our potential “collaborators” S., & Allen, R. P. (2000). Prescriptive
in the medical professions think? Fox, R. E. (2003). Early efforts by authority for psychologists: A consensus
Whatever our personal views may be psychologists to obtain prescriptive of support. Professional Psychology:
we owe it to our community to consider authority. In M.T. Sammons, R.F. Levant, Research & Practice, 31, 604-609.
their changing needs, and weigh these & R. Ullman Paige (Eds), Prescriptive
against any additional risk/demands that authority for psychologists: A history VandenBos, G. R., & Williams, S. (2000).
may accrue. We also need to bear in and guide (pp. 33-58). Washington, DC: Is psychologists’ involvement in the
mind that the margins of our discipline American Psychological Association. prescribing of psychotropic medication
are not cast in stone. While most really a new activity? Professional
issues that challenge our professional Grandin, L. D. & Blackmore, M. A. Psychology: Research & Practice, 31,
boundaries are either ignored until they (2006). Clinical psychology graduate 615-618.
ebb away, or are passively managed, the students’ opinions about prescriptive
issue of prescribing for psychologists authority: A discussion of medical versus Walters, G. D. (2001). A meta-analysis of
may be an issue that we want to manage psychological training models. Journal of opinion data on the prescription privilege
more actively. Clinical Psychology in Medical Settings, debate. Canadian Psychology, 42, 119-
13, 407-414. 125.
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Dr John Fitzgerald
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• 52 • New Zealand Journal of Psychology Vol. 37, No. 3, November 2008