Prescribing Rights for UK Psychologists – Should We Be Cautious?

On October 2, 2019, the British Psychological Society (BPS) announced an internal consultation on giving psychologists prescribing rights which itself followed a longer consultation set in motion by NHS England. This project is led by Dr Rebecca Courtney-Walker, Chair of the British Psychological Society’s Prescribing Rights Task & Finish Group. A discussion paper was published in September 2019 following a year of consultation. As noted in the BPS discussion paper, the consultation was with “individuals and small focus groups of stakeholders including psychologists, medical doctors, pharmacists, psychiatrists, nurses and experts by experience.” The discussion paper strongly supports prescribing rights for psychologists.

According to the BPS, the purpose of the October 2 additional consultation was “to facilitate cross-society collaboration and expert input and to encourage members of Member Networks to comment on/contribute to draft documentation prior to its publication. This is an informal arrangement to support Member Networks in consulting with other Member Networks.”

As part of the informal consultation process, several professionals and those with lived experience submitted responses. It should be noted that the questions asked were presented very much as if prescribing rights were assumed to be the correct approach.

The questions asked were:

1. What do you think about psychologist prescribers working in contexts where the main emphasis would be to de-prescribe?
2. Do you think psychologist prescribers should be independent or supplementary prescribers or have the option for both?
3. Do you think psychologist prescribers should be able to administer medicines?
4. Can you think of any other contexts where psychologists being able to administer medicines may be useful or relevant?
5. Do you think that psychologist prescribers should have access to prescribe (1) licensed medications (2) licensed and unlicensed medications (3) licenced, unlicensed/off-label and controlled medications
6. Should psychologist prescribers follow the same framework as other Non-medical prescribers (NMPs)?
7. Do you think these pre-training requirements would be sufficiently robust to prevent inappropriate access to prescriber training for psychologists?
8. What do you think about this curriculum proposal?
9. Who do you think should mentor psychologist prescribers now and in the future?
10. Do you think the idea of using the developmental framework of (i) novice, (ii) experienced and (iii) expert is useful?
11. Are there any other settings where psychologist prescribers would be a benefit?
12. Do you have any other comments?

As the questions provided left little room for a response which disagreed with the original consultation premise, it became necessary to respond with more detailed observations under question 12.

A group of twelve professionals, service users and experts by experience provided a detailed reply which covered the main areas of disagreement with the question raised by the consultation process. The conclusion of this group is:

“We urge the BPS to consider the implications of the proposals in this discussion paper in much more detail, as we have suggested above, before proceeding any further. Specifically, we note that uncritical use of diagnostic language and assumptions in the field of mental health begs crucial questions about the nature of distress, while potentially contributing to the overuse and misuse of psychiatric drugs in the UK and across the globe. We are also very concerned about further restricting the right of service users to be offered a choice of understandings and approaches, especially in the field of mental health.”

The full response is provided below.

COMMENTS FOR THE ‘PRESCRIBING RIGHTS FOR PSYCHOLOGISTS’ PROJECT GROUP

We write to express our serious concerns, as psychologists, therapists and experts by experience, about the proposal to extend prescribing rights to psychologists. While we realise this is intended as a first step in what would be a long process, we believe this discussion paper is not adequate as an initial basis for informed discussion and decision-making on what would be a major shift in policy, with equally major implications for the BPS, for how psychologists are seen by the public, and for professional practice. In particular, the discussion paper either does not mention or does not engage with key issues raised by the proposals or with evidence relevant to them, and therefore risks misleading members, service users and other stakeholders. For these reasons, we believe that it is unlikely to lead to valid or constructive conclusions at any further stages of consultation. Our response is laid out below.

1. The proposals cover psychologists working in a variety of settings but do not sufficiently acknowledge that prescribing in different areas raises very different issues, especially in relation to mental health. Examples given of positive experiences of prescribing rights in general medical and non-medical settings are therefore very unlikely to apply in the same way in mental health settings, although it is likely that much, if not most, of psychologists’ prescribing would be in this sector.

2. Our concerns related to psychologists prescribing in mental health settings are as follows:

• The discussion paper notes that prescribing would need to be based on diagnostic categories. Decades of research-based critiques of the validity of psychiatric diagnostic systems from psychiatrists, service users and psychologists (summarised in Boyle, 2002; Bentall, 2010; Russo & Sweeney, 2016) have highlighted problems of such seriousness that major efforts are being directed towards developing entirely new approaches both within and outside the psychiatric system. These critiques formed the basis of the DCP’s Position Statement on Classification of behaviour and experience in relation to functional psychiatric diagnoses (2013) calling for ‘a paradigm shift ….towards a conceptual system which is no longer based on a “disease” model’ (p.1).
• Specifically, there is extensive research documenting that while psychiatric drugs have a role in relieving distress, diagnoses do not target ‘disease’ processes, or reliably predict drug effects or efficacy (Moncrieff, 2008.) This raises serious reservations about the way they are described, marketed, and explained to service users, including their misleading branding as ‘anti psychotics’, ‘mood stabilisers’ and so on. We are concerned that the language of the discussion paper (‘medications’; ‘treatment’; ‘antidepressants’ etc) suggests an uncritical acceptance of both the biomedical model of distress, and the disease-centred model of drug use.
• NICE guidelines as a basis for prescribing psychotropic drugs appear to be unquestioningly accepted by the discussion paper despite the fact that they have been the subject of several critiques (e.g. Moncrieff and Timimi, 2016; McPherson and Beresford, 2019). These, along with much other evidence, highlight the problems of basing guidelines on non-valid categories, and question the assumption that the majority of people who use mental health services are suffering from medical-type illnesses. In fact, there is a great deal of evidence that their experiences are best understood as the response to interpersonal and social adversities (www.acestoohigh.com). Thus, arguments drawn from the positive experiences of prescribing rights for non-medical prescribers such as chiropodists/podiatrists, nurses, optometrists, paramedics, pharmacists and dietitians as cited on page 15 of the discussion paper cannot simply be transferred to mental health settings, where the role of drugs is much more controversial. There is no straightforward analogy with, for example, a physiotherapist prescribing an inhaler for a patient with COPD, or a podiatrist prescribing antibiotics for an infection.
• Failure to appreciate these crucial conceptual issues has arguably contributed to the current widespread inappropriate prescribing of psychotropic drugs. It has also prevented an honest assessment of the limitations of these drugs. This includes both ‘side-effects,’ such as major impacts on bodily systems and quality of life, and severe potential withdrawal effects such as those documented for ‘anti depressants’ and ‘anti-psychotics’, especially if clinicians mistake these effects for a ‘return of the illness’ (Horwood, 2016; & Williams, 2018; Récalt and Cohen, 2019; Public Health England report, Taylor et al, 2019). More seriously, the rhetoric about ‘treatment’ for ‘illnesses’ has obscured the evidence that these drugs, on average and over the long term, reduce life expectancy and create rather than cure disability (Whitaker, 2010.) This could be seen as constituting a major public health problem, for which psychologists gaining prescribing rights in mental health is neither a timely nor an appropriate response.

3. The discussion paper suggests that psychologist prescribers would use formulation and diagnosis together in ‘formulation-informed prescribing’ (p.23), where it is noted that ‘At present, all medicines are licensed for use with a specific diagnosis, or list of diagnoses… psychologist prescribers would also need to utilise a diagnostic framework alongside formulation’ (p. 22). This overlooks the facts that:

• ‘Formulation-informed prescribing’ raises all the problems with the validity of diagnostic categories outlined above. In addition, the idea of ‘formulation-informed prescribing’ directly contradicts the DCP’s ‘Good practice guidelines on the use of psychological formulation’ (DCP, 2011) which clearly state that psychological formulation ‘Is not premised on a functional psychiatric diagnosis (eg schizophrenia, personality disorder)’ (p.29). The discussion paper, in contrast, is describing the very different process of ‘psychiatric formulation’ – that is, formulation as addition, not an alternative, to a functional psychiatric diagnosis, as described in Royal College of Psychiatrists guidelines (2010) and as discussed in the DCP Guidelines (p. 17.) Moreover, it also contradicts the DCP Position Statement ‘Classification of behaviour and experience in relation to functional psychiatric diagnosis’ (2013).  Prescribing rights would therefore conflict with and potentially undermine the stated position, core competency and role of clinical psychologists as outlined in their professional guidelines.
• In any case, the examples given in the discussion paper are not obviously formulation-informed. In the cases of both ‘John’ and ‘Carl’, the unique role of a psychologist would be to formulate the impact of, respectively, early trauma and combat experiences, as a basis for psychological intervention. In contrast, the case example suggests that the psychologist is now encouraged to conceptualise their distress as a ‘symptom’ and target it with drugs. Whatever the pros and cons of short term use of psychiatric drugs in such situations, this is not an example of psychological formulation, and the language used in the examples (‘treatment; disorder’) suggests a primarily medical not psychological model of distress.
• Service users have a range of views about psychiatric diagnosis, but many report a sense of shame, stigma and disempowerment, and a consequent failure to address what they see as the root causes of their distress in adverse life events. Ethnocentric bias is well-evidenced, increasing the risk of additional discrimination (eg Fernando, 2010). Prominent campaigners have reported that their recovery began with the rejection of their diagnostic label (eg May, 2000; Longden, 2010). The DCP leaflet ‘Understanding psychiatric diagnosis in adult mental health’ (2016) was written to offer SUs informed choice about how they understand their difficulties, as was the BPS report ‘Understanding psychosis and schizophrenia’ (BPS, 2017). The service user signatories are concerned about losing one of the few alternative, non-drug spaces available to them due to the expansion of applying diagnostic categories that is implied in ‘formulation-based prescribing’ by psychologists.

4. The discussion paper does not address the problem of psychologists, and potentially their employers, being targeted by pharmaceutical companies for incentivised prescribing and other ‘benefits’. This is mentioned by one of the psychologists in a group discussion, but not taken up in the discussion paper. Yet it is a significant problem in psychiatric and medical prescribing (Goldacre, 2014; www.nofreelunch.org). This wider context suggests that we do not need additional prescribers in the field, who, whatever their aims, are likely to come under pressure to comply with rather than question or challenge current prescribing trends. We do not share the optimism of the document that psychologists’ core training ‘may actually protect against over-reliance on medication’ (p.16), with the implication that they would be more resistant to these pressures.

5. The discussion paper does not address the issue of forced administration of psychotropic drugs and psychologists’ potential role in this. There is an extensive literature on the relevant debates and ethical considerations which has apparently not been considered (Pilgrim & Tomasini, 2012).

6. Most of the examples in the discussion paper involve psychologists’ potential role in reducing or changing inappropriate drug use. The feedback from service users also stresses the perception of psychologists as more responsible prescribers. All of this tacitly acknowledges that there are considerable problems of overprescribing, inappropriate prescribing, unwanted effects and lack of informed consent in the mental health field (Taylor et al, 2019), and yet the discussion paper does not openly describe or address these problems. These are systemic and structural problems within services and for society as a whole, which can only be addressed at those levels. While additional ‘de-prescribers’ would be useful, no one can be licensed simply to ‘de-prescribe’, and we do not understand what is meant by ‘contexts where the main emphasis would be to deprescribe’ in question 1. We believe it makes far more sense to train all professionals (including existing prescribers) in greater awareness of the overuse, misuse and possible damage of psychiatric drugs as recommended in the forthcoming All Party Parliamentary Group ‘Guidance for Psychological Therapists’ report (2019, in press).

We are similarly unconvinced by the argument for reduction and discontinuation of inappropriate prescribing in the related areas of LD, autism and Older Adults: ‘Should psychologists gain prescribing rights, this would significantly increase the capacity to work in this way and improve the lives of people with learning disability, autism and older people’ (p.13). We know that psychiatric drugs are routinely overused and misused in all these specialties (eg the STOMP project:  https://www.england.nhs.uk/learning-disabilities/improving-health/stomp). We do not understand the claim –for which no evidence is adduced – that giving prescribing rights to psychologists would fundamentally alter this situation, and nor do the language or arguments of the discussion paper persuade us that these crucial issues have been adequately appreciated or addressed.

7. A suggestion throughout the discussion paper is that prescribing would allow psychologists to offer more holistic, ‘biopsychosocial’ care. We do not agree that prescribing rights would fill a gap in psychologists’ attention to the ‘bio.’ Trauma-informed practice, for example, acknowledges the role of the body in threat responses such as fight/flight/freeze/dissociate, all of which can be ameliorated by psychological strategies. The mediating and enabling role of the body in this approach does not imply medical disorder or illness. ‘Biopsychosocial’ has various meanings within mental health settings, but it has frequently been observed that it is used to give primacy to the ‘bio’ such that it becomes the ‘bio-bio-bio’ model in practice (Sharfstein, 2005). This forms the basis of dissatisfaction with mental health services expressed by many service users over many years, as noted above. Psychologists at present have an essential role in offering interventions, at an individual and a team/service level, that counter the near-universal trend to focus on (speculative) biological causal factors at the expense of the psychosocial. The likely effect of expanding prescribing would not be to highlight the ‘bio’ – which already forms the dominant discourse – in any helpful way, but to water down a vital, and all too rare, balancing focus on  the ‘psychosocial.’

8. In summary, we are puzzled by the claim that prescribing could result in ‘a more holistic, primarily formulation-informed approach where alternatives to medication are considered as the primary intervention’ (p. 11) This is what psychologists already do. The proposals are, in our view, more likely to hinder than support this essential core role.

While many of our concerns also apply in the other areas of prescribing referenced in the discussion document, we believe that each area needs considering on its own merit, since each raises particular issues. They cannot and should not be treated simply as another possible arena for prescribing, subsumed under the general argument. We adduce some important specific considerations below.

Gender services

The prescription of hormone blockers for people who identify as transgender is a highly controversial trend, raising profound issues, both conceptual (about the validity of a diagnostic category of ‘gender dysphoria’; about the relationship between biological sex and gender roles, and so on) and ethical (the long-term effects of these drugs is untested and unknown).  We do not believe that prescribing rights should be extended to psychologists working in these areas unless and until these wider issues achieve some degree of resolution and consensus.

Pain clinics

Pain is a complex phenomenon, but medication clearly has a role in managing and relieving it. However, it is also important to be aware of the overuse and misuse of opioids, especially given the high risk of addiction (Taylor et al., 2019). We believe that the likely effect of prescribing rights in this area would be to marginalise the already scarce professional resources available for psychological strategies and approaches.

Addictions

Many medical approaches to addiction rely on the substitution of one psychoactive agent for another. As above, we contend that this is a matter for appropriately trained and experienced colleagues from pharmacy and medicine, while clinical psychologists are best employed to use their psychological skills.

General medicine and primary care

Most psychiatric drugs are prescribed in primary care, and there has been widespread concern about relatively low thresholds for prescription and loose monitoring of subsequent use. As we have said, there is no reason to suppose that psychologists will be immune to the pressures that have led to inappropriate practice by some GPs, many of whom are clear that what is needed is not more prescribers, but more non-drug options for the significant number of patients presenting with mental health difficulties (Taylor et al, 2019).

Conclusion

In conclusion, the question of prescriber rights raises many issues which go beyond the BPS and individual professions to society as a whole. We believe the BPS and psychologists must play a key role in research, public and professional debates and discussion on these issues, and in ensuring that psychologists are well-informed, and we look forward to the  All Party Parliamentary Group ‘Guidance for Psychological Therapists’ report (2019, in press) which will give further guidance in this area.  We welcome other recent developments which have, for example, highlighted the potential for withdrawal effects in ‘antidepressants’ and have recommended more awareness of the effects of psychiatric drugs for both prescribers and non-prescribers (Taylor et al, 2019 ). However, we are strongly opposed to extension of prescribing rights to psychologists in the field of mental health. We also believe that the issue needs more detailed and specific discussion in relation to gender clinics, pain clinics and other specialties identified in the discussion paper, each of which poses its own particular questions and challenges.

We see psychologists as having a crucial role in offering a critical perspective on these important public issues and in providing genuine alternatives to bio-medical approaches, and are concerned that the proposals as laid out would directly contradict the spirit and the letter of key DCP documents including the ‘Position Statement on Classification’ (2013) and the ‘Good practice guidelines on psychological formulation’ (2011).

We urge the BPS to consider the implications of the proposals in this discussion paper in much more detail, as we have suggested above, before proceeding any further. Specifically, we note that uncritical use of diagnostic language and assumptions in the field of mental health begs crucial questions about the nature of distress, while potentially contributing to the overuse and misuse of psychiatric drugs in the UK and across the globe. We are also very concerned about further restricting the right of service users to be offered a choice of understandings and approaches, especially in the field of mental health.

We also note that the feedback form does not offer an option for rejecting the proposals altogether – in their entirety, or in relation to particular specialties. This creates the worrying impression that the main issue has already been decided.

We are grateful for the opportunity to respond and would be happy to engage in further dialogue.

Signatories in alphabetical order:

Professor Mary Boyle, Professor Emeritus of Clinical Psychology, University of East London.

Dr James Davies, Psychotherapist and Reader in Social Anthropology and Mental Health, Roehampton University

Dr Jacqui Dillon, Independent Mental Health Consultant.

Amanda Griffiths, Service user

Professor David Harper, University of East London

Dr Lucy Johnstone, Consultant Clinical Psychologist and Independent Trainer

Professor Peter Kinderman,  University of Liverpool

James Moore, Service user

Professor David Pilgrim, Honorary Professor of Health and Social Policy, University of Liverpool

Dr Gary L. Sidley – Writer, trainer, retired clinical psychologist.

Gilli Watson, Chartered Clinical Psychologist, Trainer and Consultant

Jo Watson, Psychotherapist and trainer

References

All Party Parliamentary Group Guidance for Psychological Therapists: Enabling conversations with clients taking or withdrawing from prescribed psychiatric drugs (2019, in press)

Bentall, R.P. (2010). Doctoring the mind: Why psychiatric treatments fail. London: Penguin.

Boyle, M. (2002a). Schizophrenia: A scientific delusion? (2nd edn). London: Routledge.

British Psychological Society Division of Clinical Psychology (2017). Understanding psychosis and schizophrenia. Why people sometimes hear voices, believe things that others find strange, or appear out of touch with reality, and what can help (A. Cooke, Ed.). Leicester: Author

Division of Clinical Psychology (2011). Good practice guidelines on the use of psychological formulation. Leicester: British Psychological Society.

Division of Clinical Psychology, (2013). Classification of behaviour and experience in relation to functional psychiatric diagnosis: Time for a paradigm shift. Leicester: British Psychological Society

Division of Clinical Psychology (2016) Understanding psychiatric diagnosis in adult mental health.  Leicester: British Psychological Society.

Fernando, S. (2010). Mental health, race and culture (3rd edn.). Basingstoke: Palgrave.

Goldacre, B. (2014). Bad pharma: how drug companies mislead doctors and harm patients. Macmillan.

Horwood, F. (2016). Psychosis, antipsychotics and premature mortality: The elephant in the room. Clinical Psychology Forum, 284, 11-17.

Longden, E. (2010). Making sense of voices: A personal story of recovery. Psychosis: Psychological, Social and Integrative Approaches, 2, 255–259.

May, R (2000). Routes to recovery from psychosis: The roots of a clinical psychologist. Clinical Psychology Forum, 146, 6–10.

McPherson, S. and Beresford, P. (2019) Semantics of patient choice: how the UK national guideline for depression silences patients. Disability and Society  34  1-7.

Moncrieff, J. & Timimi, S. (2016) The social and cultural construction of psychiatric knowledge: an analysis of NICE guidelines on depression and ADHD. Anthropology and Medicine  20,  57-71.

Pilgrim, D. & Tomasini, F. (2012). On being unreasonable in modern society: Are mental health problems special? Disability and Society 27(5), 631-46.

Read, J., & Williams, J. (2018). Adverse Effects of Antidepressants Reported by 1,431 people from 38 Countries: Emotional Blunting, Suicidality, and Withdrawal Effects. Current Drug Safety, 13, 176-1863.

Récalt, A. & Cohen, D. (2019) Withdrawal confounding in randomised controlled trials of antipsychotics, antidepressant and stimulant drugs 2000-2017. Psychotherapy and Psychosomatics   88   105-113.

Royal College of Psychiatrists. (2010). A competency-based curriculum for specialist core trainingin psychiatry.www.rcpsych.ac.uk/training/curriculum2010.aspx

Russo, J. & Sweeney, A .(Eds.) (2016) Searching for a rose garden: Challenging psychiatry, fostering mad studies(pp.v-viii). Ross-on-Wye: PCCS Books.

Sharfstein, S. (2005) Big Pharma and American Psychiatry: The Good, the Bad, and the Ugly https://psychnews.psychiatryonline.org/doi/full/10.1176/pn.40.16.00400003

Stopping over medication of people with a learning disability, autism or both (STOMP)  https://www.england.nhs.uk/learning-disabilities/improving-health/stomp

Taylor S, Annand F, Burkinshaw P, Greaves F, Kelleher M, Knight J, Perkins C, Tran A, White M, Marsden J. (2019)Dependence and withdrawal associated with some prescribed medicines: an evidence review. Public Health England, London.

Whitaker, R. (2010). Anatomy of an epidemic. New York, NY: Broadway Paperbacks.