Prescribing and Primary Care Psychology: Complementary Paths for Professional Psychology

Abstract

Two paths have been suggested for the future evolution of professional psychology. Prescribing psychology has already been legally authorized in two states, the military, and the Indian Health Service. Primary care psychology does not require legal recognition and has been slowly growing as a career option for psychologists across the nation. Both paths have their obstacles and limitations, but both are also associated with great potential. This article provides a brief summary of the strengths and weaknesses of each path and suggests an integrated perspective for planning the future of the profession. Each is seen as complementary to the other and providing a basis for pursuing the other. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

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Prescribing and Primary Care Psychology:
Complementary Paths for Professional Psychology
Robert E. McGrath
Fairleigh Dickinson University
Morgan Sammons
Alliant University
Two paths have been suggested for the future evolution of professional psychology. Prescribing
psychology has already been legally authorized in two states, the military, and the Indian Health Service.
Primary care psychology does not require legal recognition and has been slowly growing as a career
option for psychologists across the nation. Both paths have their obstacles and limitations, but both are
also associated with great potential. This article provides a brief summary of the strengths and
weaknesses of each path and suggests an integrated perspective for planning the future of the profession.
Each is seen as complementary to the other and providing a basis for pursuing the other.
Keywords: primary care, integrated primary care, prescriptive authority, healthcare systems
Doctoral-level healthcare psychology faces several serious
threats to its status quo and perhaps even its survival. The first
comes from the pressures all healthcare professions are experienc-
ing from managed care and other third-party reimbursement sys-
tems. Involvement in managed care has been associated in psy-
chologists with longer working hours, larger caseloads, less
participation in supervision, greater stress, higher rates of prema-
ture termination, reduced flexibility, and greater pressure to com-
promise quality of care (Chambliss, Pinto, & McGuigan, 1997;
Cohen, Marecek, & Gillham, 2006; Gold & Shapiro, 1995; Mur-
phy, DeBernardo, & Shoemaker, 1998; Rothbaum, Bernstein,
Haller, Phelps, & Kohout, 1998; Rupert & Baird, 2004). Although
some of this literature can be criticized as potentially out of date,
revelations in the past year about conflicts of interest in the setting
of usual and customary fees for providers (Hakim & Abelson,
2009), and recent revelations of substantial increases in health
insurance premiums in the face of record profits by certain man-
aged care entities (Department of Health and Human Services,
2010), suggest psychologists will experience continuing pressure
from third-party payers attempting to improve profit margins.
The second threat is the growing number of masters-level pro-
viders of psychotherapy. According to the Occupational Outlook
Handbook (2008 –2009; http://www.bls.gov/oco), there were over
200,000 counselors in 2006 in the fields of mental health, sub-
stance abuse and behavioral disorders, and marriage and family
therapy, as well as more than 120,000 social workers in mental
health and substance abuse. Manderscheid and Henderson (2004)
estimated in 2002 that there were approximately 18,269 psychiat-
ric nurses. The number of nondoctoral mental health workers is
expected to grow another 30% by 2016. In contrast, the 150,000
school, clinical, and counseling psychologists are expected to grow
by only half that much (U.S. Department of Labor, 2008). The
rapid growth in the number of masters-level providers partly
reflects the creation of new professional identities in response to
increased demand for mental health services. It also reflects the
preference in managed care organizations for the cheapest pro-
vider, a preference reinforced by a lack of evidence suggesting that
doctoral-level providers are associated with better psychotherapy
outcomes than masters-level providers (Bickman, 1999; Lambert
& Ogles, 2004; Seligman, 1995). This failure to find consistent
evidence of an advantage for doctoral-level care could be a gen-
erally valid finding for traditional psychosocial mental health
services, but it may also reflect the more restricted range of
pathology commonly seen by professionals in private practice
settings.
Finally, the model of the solo independent practitioner that has
defined much of mental health practice for the last 40 years has
come under closer scrutiny. This model emerged out of a fee-for-
service system of reimbursement that rewarded specialty services
and maximizing the level of care provided. There are at least two
initiatives in progress that challenge the existing fee-for-service
system. Pilot testing has begun evaluating an episode-based alter-
native in which a treatment team receives bundled payment for the
complete treatment of a condition (Robert Wood Johnson Foun-
dation, 2009). Unlike traditional service-based fee-for-service or
population-based capitation, a diagnosis-based system allows the
ROBERT E. MCGRATH received his PhD in clinical psychology from Auburn
University. He is a Professor of Psychology, Director of the PhD Program
in Clinical Psychology, and Director of the MS Program in Clinical
Psychopharmacology at Fairleigh Dickinson University. His areas of re-
search include psychological assessment and measurement and profes-
sional issues in healthcare psychology.
MORGAN T. SAMMONS received his PhD in clinical psychology from
Arizona State University. He is a retired Captain in the US Navy and is one
of the first graduates of the U. S. Department of Defense’s Psychophar-
macology Project. He is currently the Dean of the California School of
Professional Psychology at Alliant International University and is a dip-
lomate of the American Board of Professional Psychology (Clinical). He
contributes frequently to the professional literature. He is an associate
editor of the APA journal Psychological Services. He lectures and contrib-
utes to the professional literature on issues pertaining to prescriptive
authority and the professional practice of psychology.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Robert
E. McGrath, School of Psychology T-WH1-01, Fairleigh Dickinson Uni-
versity, Teaneck, NJ 07666. E-mail: mcgrath@fdu.edu
Professional Psychology: Research and Practice © 2011 American Psychological Association
2011, Vol. 42, No. 2, 113–120 0735-7028/11/$12.00 DOI: 10.1037/a0022649
113

insurer greater precision in the projection of costs per episode. This
is a feature likely to make episodic reimbursement very attractive
to insurers.
The second factor is growing interest in the concept of a medical
home (American Academy of Family Physicians, American Acad-
emy of Pediatrics, American College of Physicians, American
Osteopathic Association, 2007), in which a personal primary-care
physician becomes responsible for the coordination and integration
of care across specialists and ancillary care providers. There is
growing interest in establishing the medical home as the focus of
healthcare services. This interest is demonstrated in the develop-
ment of standards for the medical home by the National Commit-
tee for Quality Assurance (www.ncqa.org/tabid/1034/Default.a-
spx); the formation of an organization dedicated to the topic, the
Patient Centered Primary Care Collaborative (www.pcpcc.net),
which enrolled over 500 member organizations in 5 years; and
extensive discussion of the topic in other organizations devoted to
healthcare policy such as the Collaborative Family Healthcare
Association (www.cfha.net). The recently enacted Patient Protec-
tion and Affordable Care Act includes several sections demon-
strating a preference for the development of integrated healthcare
practices, e.g., in awarding of loans for the establishment of
nonprofit health insurers and in various demonstration projects.
Episodic reimbursement and collaborative healthcare are clearly
complementary initiatives (de Brantes, Gosfield, Emery, Rastogi,
& D’Andrea, 2009), and the widespread adoption of either would
dramatically increase pressure for psychologists to join multidis-
ciplinary teams, usually under the control of physicians.
Other healthcare professions have responded to the flux in the
system by pursuing expansion in their scope of practice and
enhancement of their status. Nurses are attempting to expand the
roles of specialty practitioners such as advanced practice nurses
and nurse anesthetists. A recent survey finds the latter group is
attracting higher salaries than primary care physicians (Kavilanz,
2010). Nurses are also pursuing independent practice as primary
care providers (PCPs) through the Doctor of Nursing Practice
degree. Optometrists are similarly expanding their formulary in
some states, and in others they are pursuing the authority to
perform surgical procedures (see Fox et al., 2009, for a review of
advances by nonphysician health care providers relative to psy-
chologists). Masters-level mental health providers are vigorously
pursuing authorization to engage in activities that were previously
considered doctoral-level such as independent diagnosis and as-
sessment.
The challenge professional psychology faces is whether to
maintain its current stance within the healthcare system or whether
to move aggressively into new markets. The former option must be
seriously considered. It is clear there remains a tremendous need
for traditional mental health services. Mental disorders have joined
the list of the five most costly conditions (Soni, 2009), and it has
been argued that the growing number of masters-level providers
involved in the treatment of mental health issues is required to fill
the unmet need (Annapolis Coalition on the Behavioral Health
Workforce, 2007). Furthermore, there is growing evidence that
psychotherapy is effective as an alternative or adjunct to medica-
tions (e.g., Hollon et al., 2005; Jensen et al., 2007; Kennard, Silva,
Vitiello, Curry, & Kratochvil, 2009). It is therefore possible that
the market for psychotherapy services will continue to grow for
quite some time and provide enough opportunity for all.
At the same time, some worrisome statistics can be noted.
Olfson and Marcus (2009, 2010) presented evidence that although
the number of individuals receiving psychotherapy since the late
1990s has increased, the role of psychotherapy in the treatment of
mental disorders is declining, resulting in a net decline in total
expenditures for psychotherapy. Although the proportion of gross
domestic product devoted to healthcare more than doubled in the
period from 1970 to 2003, the proportion devoted to mental health
care remained flat at less than 1% (Frank & Glied, 2006). Trou-
bling findings specific to psychology indicate it was the only one
of four professions (psychiatrists, nurses, and counselors being the
other three) in which the number working in community mental
health centers was declining (Cypres, Landsberg, & Spellmann,
1997), suggesting a growing emphasis on medication management
concurrent with a shift in therapy services to masters-level pro-
viders. So long as the healthcare system is largely governed by
professions based in biomedicine, there is the danger that psycho-
therapy will continue to be treated as a secondary alternative to
biological interventions regardless of the evidence. The increasing
reliance on masters-level therapists could further undermine the
status of psychosocial interventions relative to medical procedures
that continue to be offered primarily by doctoral-level providers. A
recent statistical analysis concluded that only 18% of U.S. counties
needed additional nonprescribing mental health providers
(Thomas, Ellis, Konrad, Holzer, & Morrissey, 2009). Finally, data
from the Occupational Outlook Handbook (Bureau of Labor Sta-
tistics, 2010) reveals that psychologists have the lowest median
income of any of the doctoral-level healthcare professions. In-
creased competition from masters-level providers can only
dampen those salaries further.
If simply maintaining the status quo is not an option, or does not
adequately ensure the future of the profession, then psychologists
should aggressively pursue new professional opportunities. Two
such opportunities have been discussed, involving increased par-
ticipation in primary care and acquiring prescriptive authority. So
far, these initiatives have been pursued in relative isolation from
each other. The purpose of this article is to suggest primary care
psychology and prescribing psychology as complementary ap-
proaches to the future of the profession and to describe how they
can be combined to create a flexible model of advocacy for the
future of the profession. The next two sections will briefly review
key issues in primary care and prescribing psychology.
Primary Care Psychology
Primary care represents the most common site of treatment for
individuals with mental disorders (Kessler et al., 2005). Between
the years 1998 and 2003, the percentage of patients receiving
mental health care only in medical settings increased 154%, and
the number of patients treated in community health centers for
mental health or substance abuse issues increased from 210,000 to
800,000 annually (Mauer & Druss, 2009, April 2). Among people
who successfully committed suicide, far more saw a PCP in the
year before their deaths than saw a mental health professional
(Luoma, Martin, & Pearson, 2002), and some studies suggest more
than 50% of patients seen in primary care settings meet criteria for
a mental disorder (Spitzer et al., 1994; Toft et al., 2005). At the
same time, a survey of PCPs indicated that the barriers to accessing
mental health care for their patients exceed those for other spe-
114 MCGRATH AND SAMMONS

cialty services, for a variety of reasons (Cunningham, 2009). As a
result, various governmental agencies are encouraging greater
sensitivity to behavioral and mental health issues in the primary
care setting (e.g., Kates, Ackerman, Crustolo, & Mach, 2006;
Kirkcaldy & Tynes, 2006; Power & Chawla, 2008).
Blount (2003) offered three dimensions for characterizing col-
laborative activities between psychologists and PCPs. The first
dimension has to do with the relationship between providers, and
he described three types of relationship. Coordinated care occurs
when the psychologist and PCP operate independently of each
other but share information, colocated care when the psychologist
and PCP share physical space, and integrated care when the
psychologist and PCP serve together as part of a team responsible
for treatment planning. The second dimension has to do with
the population being treated. A targeted population means cases
are preselected for collaborative treatment, usually because of the
presence of a specific diagnosis or problem. The population is
nontargeted when collaborative care is offered to any patient for
whom initial evaluation suggests behavioral or mental health ser-
vices would contribute to outcome. The third dimension has to do
with the type of treatment offered by the psychologist through the
collaboration. A specified treatment program means a pre-
established treatment program is offered to all patients, whereas an
unspecified treatment program involves an individualized decision
about what form of behavioral intervention would be most helpful.
In traditional mental health practice, psychologists’ collabora-
tion with PCPs is usually restricted to coordinated or in some
cases, colocated care. That is, the patient is seen by both the
psychologist and a PCP who share information as necessary.
Colocation can offer some advantages over coordination in terms
of ease of referral and information-sharing, but the primary care
and mental health treatments proceed in relative isolation from
each other.
The emergence of health psychology created the potential for
integrated care models combining psychologists and PCPs. How-
ever, the health psychology model has often involved a specified
treatment (e.g, relaxation training for individuals with various
medical diagnoses), a targeted population (e.g., individuals with
sleep disorders), or both (e.g., a structured program for the treat-
ment of chronic pain).
Primary care psychology is distinct from the mental health and
health psychology models in that it involves integrated care (psy-
chologists and PCPs determining care together) using an unspec-
ified treatment (whatever clinical tools are appropriate for a pa-
tient) for a nontargeted population (any patient for which
psychological interventions could be helpful). Gruber (2010) in-
dicated that primary care psychology can be further distinguished
from more traditional psychological models by a relatively greater
emphasis on the treatment of individuals with acute problems. To
summarize, the primary care psychologist is a full participant in
the primary medical care, providing varying interventions for
patients with various types of problems including acute medical
conditions.
Given the frequency of psychological, interpersonal, or behav-
ioral difficulties in the primary care patient, the primary care
psychologist has the potential to become an integral element of the
primary care practice. However, successful integration into the
primary care setting will in part require demonstration that this
integration results in cost reductions, clear improvements in
healthcare outcomes, or both. Although some research suggests
that the cost of incorporating behavioral interventions into primary
care is more than offset by reduced healthcare use (Chiles, Lam-
bert, & Hatch, 2002), there is still insufficient data available to
conclude that the integration of psychologists into primary care is
cost effective.
The medical home model also implicitly acknowledges the
importance of integrating psychological and behavioral services
into the primary care setting. Although the statement of principles
developed to describe the medical home refers to whole person
care, the document does not mention that achieving such a level of
care would require a broad range of evaluation and treatment
options including behavioral, mental health, and substance abuse
services. For example, as part of its efforts to integrate the medical
home model into its primary care services, a Health Behavior
Coordinator will be hired for every one of the Department of
Veterans Affairs’ 153 medical centers. This will likely have a
significant impact on the implementation of the medical home in
other settings as well.
A brief list of functions the primary care psychologist can fill
includes the following (see also McDaniel & Fogarty, 2009), many
of which combine the traditional skills of the psychologist with
new skills relevant to the primary care setting:
1. Identifying and addressing emotional concomitants to medi-
cal disorders.
2. Consulting to the PCP about how best to interact with the
medical patient who is difficult to manage because of, for example,
severe mental illness or personality-based resistance.
3. Determining whether the patient’s emotional needs exceed
the services available at the site and overseeing referral for spe-
cialty services in psychopharmacotherapy, psychotherapy, or
health psychology.
4. Screening for depression, substance abuse, cognitive impair-
ment, personality disorders, and other psychobiosocial disorders
that are potentially overlooked in primary care evaluations.
5. Providing supportive services to patients who are finding it
difficult to participate in their care effectively.
6. Offering specialized treatments for smoking, obesity, and
other common behavioral disorders in the general primary care
population.
7. Offering behavioral interventions for individuals whose pri-
mary medical diagnosis calls for a treatment with a substantial
behavioral component. Examples would include individuals with
diabetes, asthma, chronic infectious disease, and heart disease.
8. Developing outcomes assessment and program evaluation
systems as called for by outside agencies.
9. Aiding in the design of research protocols.
These activities require that the psychologist become embedded
within the primary care practice, although it is possible in the
future that some of this embedding will be accomplished through
telehealth options.
The work regimen of the primary care psychologist is quite
different than that of the psychologist providing psychotherapy.
The primary care psychologist often serves as a consultant to PCPs
as well as a direct care provider. Treatment is often time limited
both in duration and in length of sessions: a patient may be seen for
no more than 15 min at a time with long intervals between
contacts. The primary care psychologist needs the flexibility to
handle cases immediately when the PCP concludes a behavioral or
115
PRESCRIBING AND PRIMARY CARE

psychological consult is warranted. Psychotherapy is a specialty
activity, much like a medical specialty, for which the primary care
psychologist serves as the coordinator and referral source rather
than as the therapist.
Despite the potential opportunities for integrating psychologists
into primary care settings, achieving this integration can be diffi-
cult for several reasons. A very important one is the current
character of the training received by psychologists, which is often
singularly focused on the traditional weekly 50-min hour of psy-
chotherapy. Admittedly, this is universally acknowledged among
psychologists as a difficult skill to master. However, the degree of
focus on this single activity leaves little additional time for mastery
of nontraditional skill sets. As a result, few psychologists have
much understanding of the knowledge and skills needed in the
primary care setting (O’Donohue, Cummings, & Cummings,
2009). For example, many psychologists are largely unaware of
the economics of healthcare in systems that traditionally do not
tend to incorporate mental health services, such as large capitated
practices and community health centers. In fact, many psycholo-
gists have never heard of community health centers, although they
provide primary healthcare services for 19 million Americans.
Psychologists also receive little training in basic medical concepts,
in healthcare terminology outside the mental health arena, in
providing consultation to and collaborating with other profession-
als, and in basic clinical medicine. In response to this gap, various
authors have provided lists of the core competencies needed for
psychologists to practice effectively in primary care (e.g., Robin-
son & Reiter, 2007) and have described elements of training
programs of varying lengths (McDaniel, Hargrove, Belar, Schroe-
der, & Freeman, 2004; O’Donohue, 2009), although few psychol-
ogists currently pursue this training.
Another factor that will slow the process of integration into
primary care is the lack of coordination between healthcare entities
in the United States. Convincing healthcare agencies to hire psy-
chologists must be accomplished one primary care agency at a
time.
There are also reimbursement barriers to successful integration
of psychologists into primary care. These include restrictions on
billing for multiple professionals in a single day, a policy that
reinforces the role of nonphysicians in primary care either as
physician extenders or as ancillary service providers who require a
separate contact. There are also restrictions on the Current Proce-
dural Terminology codes accessible by psychologists working in
settings that rely on insurance reimbursement. The existence of the
health and behavior codes acknowledges the role psychologists
can play in the treatment of individuals with primary physical
illnesses, but insurers vary in their willingness to reimburse these
codes. Psychologists also remain unable to use evaluation and
management codes, a policy that institutionalizes their distinction
from primary treatment coordinators in healthcare settings.
Other economic factors create obstacles to the growth of pri-
mary care psychology. Medical cost offset can be perceived as a
long-term, and therefore only potential, gain when compared with
the immediate increase in cost resulting from treatment by multiple
providers. Furthermore, the case for offset is clearest for those
patients with the highest rate of medical service use. More nor-
mative integrated care, such as expanded screening for mental
health problems, the dissemination of treatment guidelines, and the
colocation of mental health specialists in primary care settings
have not resulted in desired improvements in care (Thielke, Van-
noy, & Unutzer, 2007). Accordingly, psychologists should be
selective in their assertions about the cost savings resulting from
psychologists’ integration into primary care or risk outcomes that
undermine the enterprise in the future.
One final and extremely important barrier is the competition
psychologists face from other mental health providers who have
also indicated interest in increasing their presence in the primary
care setting (e.g., Claiborne & Vandenburgh, 2001; Schneider &
Levenson, 2008). This competition is particularly acute with
masters-level providers, who tend to be cheaper alternatives to
psychologists.
In offering a rationale for psychologists in particular as psycho-
social partners in primary care, two factors stand out. One is that
psychological treatments are not restricted to psychotherapy or
even the treatment of psychological disorders but encompass a
variety of interventions that are relevant to treatment of individuals
seen in primary care settings (Barlow, 2004). Increasingly, psy-
chologists join the workforce with an understanding of behavioral
medicine and/or neuropsychology that sets them apart from other
providers whose training is restricted to mental health. The second
factor that can potentially play an important role in identifying the
psychologist as a desirable alternative to the masters-level provider
or to the more expensive psychiatrist in the primary care setting is
prescriptive authority.
Prescribing Psychology
A great deal of progress has been made toward establishing an
infrastructure for prescribing psychology over the last 10 years,
primarily because of the efforts of the American Psychological
Association. This has included the development of education and
training standards, the creation of a system for designating pro-
grams consistent with those standards, and the underwriting of a
competency examination called the Psychopharmacology Exami-
nation for Psychologists (McGrath, 2010). It is estimated that
approximately 1500 psychologists have already completed post-
doctoral didactic coursework in preparation for prescribing (Ax,
Fagan, & Resnick, 2009), whereas approximately 60 psychologists
were prescribing in New Mexico and Louisiana as of Fall 2008
(LeVine & Wiggins, 2010). Psychologists are also prescribing in
all three branches of the military with healthcare services and in
the Public and Indian Health Services.
Even in the absence of prescriptive authority, increased training
in the use of psychopharmacological agents will inevitably influ-
ence the practice of pharmacotherapy. A recent study found that
approximately 60% of prescriptions for a psychotropic medication
are written by primary care physicians (Mark, Levit, & Buck,
2009), even though more than 60% of family medicine residencies
offer no formal training in clinical pharmacology let alone clinical
psychopharmacology (Bazaldua et al., 2005). Psychologists with
little formal training are already called upon to provide advice to
PCPs on an appropriate medication regimen; psychologists with
advanced training in pharmacotherapy will increasingly find phy-
sicians using their expertise.
So far, 14 states have explicitly defined consultation with pre-
scribers on medication decision-making as within the scope of
practice of psychology (McGrath, 2010). The appropriateness of
psychologists with advanced training in pharmacotherapy serving
116 MCGRATH AND SAMMONS

as medication consultants in other states is uncertain. Even when
the authority to engage in this type of collaboration has not been
explicitly defined, however, psychologists with advanced training
will find themselves in situations where they believe they are
ethically obliged to advise physicians who have little or no formal
training in either psychopharmacology or psychodiagnosis.
Given the central role awarded to medication in the treatment of
mental disorders in the current healthcare system, even if large
numbers of psychologists start to prescribe, they are likely to have
little effect on the rate at which the services of psychiatrists are
accessed. Where psychologists will probably have their greatest
impact is on the use of psychotropic medications in primary care.
Current laws authorizing psychologists to prescribe in New Mex-
ico and Louisiana actually contribute to the creation of stable
relationships with PCPs by mandating collaborative relationships,
at least under certain circumstances.
The psychologist with prescriptive authority represents the only
mental health professional who has received extensive training in
all modalities appropriate to the amelioration of mental conditions.
Familiarity with both psychosocial and biological interventions,
combined with training in the critical evaluation of research, can
potentially help psychologists resist excessive reliance on medica-
tions and use of medications without consideration of its interper-
sonal and experiential context. The prescribing psychologist
should also be more effective than the general practitioner at
determining when psychosocial versus biological interventions are
warranted and at informing the patient about the potential benefits
of psychosocial intervention. In this way, the prescribing psychol-
ogist can actually enhance participation in psychotherapy.
Prescriptive authority allows psychologists to address a compel-
ling and demonstrable need. The same analysis that concluded
most counties across the nation have enough nonprescribing men-
tal health professionals also found that 96% of counties face a
shortage of prescribers competent to address psychological and
behavioral disorders (Thomas et al., 2009). In those states where
psychologists can prescribe, the shape of clinical practice has
already started to change. Among the roles prescribing psycholo-
gists are now filling, or are filling in ways very different than in the
past, are the following (Ally, 2009):
1. Sharing on-call duties with psychiatrists in both agency and
private practice settings.
2. Contracting for difficult-to-fill positions formerly reserved for
psychiatrists.
3. Providing voluntary care to the indigent.
4. Providing administrative services in state agencies.
5. Serving as officers and even owners in hospitals.
6. Becoming involved in policy making at the state level.
7. Participating in pharmaceutical research.
As was true for primary care psychology, the traditional skills of
the psychologist contribute to the quality of care offered by the
prescribing psychologist in various ways. Training in the critical
analysis of research, assessment and psychodiagnosis that includes
contextual and cultural considerations, complex multidimensional
disorders, outcomes assessment, research design, and understand-
ing the psychosocial aspects of the interpersonal relationships, all
of these will contribute to psychologists’ effectiveness at develop-
ing a model of prescriptive practice that can distinguish psychol-
ogy from the other prescribing professions.
Prescribing psychology is also similar to primary care psychol-
ogy in its increasing the likelihood of brief intermittent interactions
with patients, some of whom are not intimately familiar to the
psychologist. The practice of pharmacotherapy also means a
greater emphasis in sessions on the biological as well as psycho-
social, on clinical medicine as well as clinical psychology. How-
ever, conversations with prescribing psychologists indicate pa-
tients adapt well to the seamless transition between one and the
other. The sharp distinction providers draw between pharmaco-
therapy and psychotherapy services has more to do with the reality
of the provider, who is traditionally trained almost exclusively in
one or the other, than with that of the patient.
The most serious obstacle to the advance of prescriptive author-
ity is opposition both within and outside the profession. Psychol-
ogists opposed to prescriptive authority have raised concerns about
whether prescribing will undermine the traditional psychosocial
roots of the discipline, whether the additional training is sufficient,
whether prescribing psychologists in the long run will be able to
resist pressures to become medication managers, and whether
prescriptive authority as an advanced authority will create two tiers
of psychologists (e.g., Robiner et al., 2002). McGrath (2010)
provided responses to many of these arguments, noting that the
creation of advanced practice nursing has not undermined the
traditional identity of the nurse, the greater focus on psychosocial
factors in the undergraduate and graduate preparation of psychol-
ogists, and the continuing critical analysis of medications by
psychologists who are not prescribing (McGrath, 2005) as poten-
tial protective factors.
Psychiatrists see prescriptive authority for psychologists as a
potential threat to the survival of their profession, so it is not
surprising to find they are adamantly opposed. As a result, physi-
cians have mounted aggressive resistance to enabling legislation
across the country. It took 30 years to achieve licensure for
psychologists in every U.S. state and 30 years to achieve licensure
in every Canadian province (Reaves, 2006), so it is reasonable to
anticipate that prescriptive authority for all appropriately trained
psychologists may not be achieved until at least 2030 in the United
States.
Complementary Agendas
Prescribing psychology and primary care psychology represent
complementary paths to re-engineering the future of professional
healthcare practice in psychology. The greatest advantage of pri-
mary care psychology over prescribing psychology as a goal is its
reliance on the traditional tools of the psychologist as a psychos-
ocial care provider, making it more palatable to key audiences
within psychology and medicine. Furthermore, it requires no leg-
islative action.
On the other hand, prescriptive authority involves service to the
same patient population that is most familiar to psychologists.
Although the legislative barriers can be daunting, once overcome,
the shift in psychologists’ roles is inevitable. There is an existing
funding stream for medication management that becomes available
to psychologists through third-party payers so that the authorized
prescribers can quickly create practice opportunities.
Both paths would substantially enhance the reach of psychology
in terms of patient populations and potential for enhancing public
health. Each can also be treated as a stepping stone to the other.
117
PRESCRIBING AND PRIMARY CARE

This complementarity creates an opportunity for a flexible ap-
proach to advancing the profession.
The optimal balance between the two agendas will vary from
state to state. In some cases, a vigorous effort to achieve prescrip-
tive authority has already emerged. If the number of states autho-
rizing psychologists to prescribe reaches a critical mass, and if
research demonstrates that prescribing psychologists reduce costs
and are safe and effective as has been the case with other nonphy-
sician prescribers (Lenz, Mundinger, Kane, Hopkins, & Lin, 2004;
Speer & Bess, 2003), these efforts are likely to become more
successful. Given the inevitable outcomes once legislation is en-
acted, pursuit of prescriptive authority represents the most efficient
option for enhancing clinical practice.
Even so, once prescriptive authority is achieved, there are good
reasons to pursue increased involvement in primary care as the
next phase in the evolution of the profession. First, the exclusive
biological focus in psychiatry in part emerged in response to
external pressures such as managed care (Luhrmann, 2000). De-
spite the protective factors noted earlier, it is reasonable to assume
prescribing psychologists will eventually be confronted with the
same pressures. One potential offshoot of psychologists’ becoming
involved in integrated primary care is enhanced status for psycho-
social interventions in healthcare in general.
Involvement in primary care also opens access to new popula-
tions of patients. This has potential economic benefits. It also has
implications for the profession’s contribution to the public good
through the enhancement of services for individuals with emo-
tional and behavioral concomitants to their physical disorders.
Finally, the combination of prescriptive authority, an under-
standing of psychosocial diagnosis and intervention, and behav-
ioral management skills will enhance the attractiveness of psychol-
ogists as partners to PCPs. The ability to prescribe will allow the
PCP to feel comfortable transferring more of the care for individ-
uals with concomitant psychological disorders to the psychologist,
whether the psychologist ultimately prescribes medication or not.
Furthermore, psychologists with expertise in neuropsychology,
treatment of substance abuse, and/or behavioral medicine can
contribute to the establishment of true integrated care for primarily
medical patients as well as better care for primarily mental health
patients.
In other states where it is not deemed realistic to achieve
passage of authorizing legislation in the foreseeable future, psy-
chologists may be better served by turning their attentions to
enhanced integration into primary care. This process begins by
educating primary care entities such as the state primary care
association about the roles the psychologist can fill. In the case of
psychologists with advanced training in pharmacotherapy, those
roles can include collaboration with PCPs on medication decision-
making. However, conversations with psychologists involved in
primary care around the country suggest this role has to be ad-
dressed with some sensitivity because reactions have been quite
mixed. Some report they found primary care organizations very
interested in the opportunity, whereas other organizations have
rejected this option to avoid involvement in the debate over pre-
scriptive authority for psychologists.
In some cases, offering traditional colocated mental health ser-
vices in primary care settings may provide the foot in the door
from which psychologists can move to discussing integrated
healthcare services. This approach may be particularly effective in
training settings where there is a preference for the use of doctoral-
level mental health providers or in communities where there are
few alternative mental health resources. In others, psychologists
may find that primary care entities are more interested in employ-
ing masters-level providers to provide mental health services, in
which case psychologists must make their case for integration
directly on the basis of their behavioral services for patients with
traditional medical disorders.
Once psychologists are participating in primary care, the con-
tribution they can make to the medication management of patients
will start to emerge. Through improved diagnosis of mental health
conditions, comprehensive treatment planning, and direct advice
on appropriate medication management by psychologists who
have also received postdoctoral training in psychopharmacology,
PCPs can learn about the value of allowing psychologists a greater
role in this arena. This strategy has been used to great effect in
Hawaii and several other states where the placement of psychol-
ogists knowledgeable in pharmacotherapy in primary care settings
has been ongoing for a number of years.
Whichever approach psychologists pursue, both prescribing and
primary care psychology will have predictable effects on the field.
Psychologists will be working with sicker, more medically com-
plex, needier, and more culturally diverse populations than they
have in the past. Although medicine is likely to remain the dom-
inant profession in primary care settings, psychologists can adopt
greater leadership in the management and design of healthcare
systems. This will be particularly true for psychologists who
combine prescriptive authority with work in a primary care setting.
This role will allow psychologists to advocate more effectively for
the increased use of psychosocial intervention even as traditional
weekly psychotherapy becomes more of a specialty service; for
enhanced use of assessment and psychological principles to predict
treatment adherence and to identify the emotional and behavioral
concomitants of medical illness; and for the development of treat-
ment plans that truly considers the needs of the whole person.
Preparing psychologists to pursue these opportunities will re-
quire creating additional educational opportunities for psycholo-
gists. Doctoral-level training will need to evolve if it is to remain
relevant to the survival of the practitioner. It is noteworthy that the
current accreditation documents in doctoral-level psychology do
not even mention several topics that are essential to behavioral
healthcare, including training in substance abuse, psychopharma-
cology, or clinical medicine.
Even in the absence of change in the curriculum, there are
opportunities for preparing students through practica. Advanced-
level practicum experiences in primary care settings provide a
cost-effective method for both preparing psychologists in primary
care psychology and exposing PCPs to the roles psychologists can
fill in those settings. The main obstacle slowing the progress of
such placements (beyond lack of awareness among psychologists)
is a shortage of psychologists who can supervise in the primary-
care setting. This is slowly changing, but in the meantime, some
training programs are providing the supervision services them-
selves to make the opportunity available. At the same time, super-
visors for all levels of psychology students should be discussing
medication in any case where it is a consideration or where the
patient is currently receiving medication. Students in healthcare
psychology are rarely encouraged to consider the extent to which
their patients’ medications are actually working because this is
118 MCGRATH AND SAMMONS

considered the task of the prescriber. Such reflections can contrib-
ute to a more objective evaluation of the appropriate role for
medication in clinical practice. Primary care placements will en-
hance these opportunities to discuss medication issues. At the same
time, postdoctoral programs in pharmacotherapy for psychologists
should acknowledge and prepare their students for a future involv-
ing greater collaboration with PCPs.
Conclusions
The profession of psychology must evolve or risks withering. The
healthcare system can benefit from the emergence of a discipline with
a strong empiricist tradition that examines health from a psychobio-
social rather than a biopsychosocial model (LeVine & Foster, 2010).
Psychologists will help identify circumstances in which biological
interventions should be ancillary to the psychosocial rather than vice
versa, teach patients to advocate for themselves, and understand why
this patient behaved this way in this situation and how the doctor can
behave differently to achieve the desired end.
The pressures identified at the beginning of this article created a
troubling picture for the future of psychology. With lower-cost pro-
viders competing effectively with psychologists, psychology could
well become increasingly marginalized, a profession perhaps re-
spected by other healthcare providers but offering a boutique service.
Alternatively, psychology can work to redefine what is meant by
doctoral-level psychological care. Doing so will require formidable
effort. To summarize the various actions mentioned in this article, it
will require addressing limitations in same-day billing, educating
stakeholders in the primary care community about the role psychol-
ogists can play in the medical home, training psychologists to work in
these settings, increasing the number of psychologists collaborating
with physicians on medication decision-making, and convincing leg-
islators that psychologists can prescribe. Psychologists will have to
get used to dealing with medically complex patients and more se-
verely mentally ill individuals, working collaboratively with other
professionals, and understanding the practices of primary care. We
believe these changes are necessary if we are to secure the future of
our profession.
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