Psychotherapies in current clinical psychology and psychiatry in Spain

BACKGROUND

The practice of psychotherapy in Spain (Europe) continues being a reason for doubts, uncertainty, controversy or confusion. The access to psychotherapy is also controversial. To contribute to clarify all this in order to improve quality and minimise risks is the aim of our work.

METHOD

Update of the regulations and legal rules which are applicable in psychotherapy to those graduated in both psychology and medicine.

RESULTS AND DISCUSSION

Neuroscience, clinical psychology and psychiatry develop in a parallel and convergent way. It is necessary to emphasise the risks of pseudotherapies, including pseudopsychotherapies, and pseudosciences in general. The practice of psychotherapy as a psychological treatment necessarily implies the healthcare field both for the private and public sectors. In order to practice as a psychotherapist in Spain, it is necessary to be a psychologist specialised in clinical psychology or a doctor specialised in psychiatry. The figure of the sanitary general psychologist is a regulated profession in Spain at present, but that is not equivalent to be a specialist. The former psychologists who have the required legal qualification are also allowed to act for the public sector in the healthcare field. Other doctors who are not psychiatrists, other psychologists or the nurses specialised in mental health are not allowed to name themselves or act as psychotherapists in any field or sector.

Clara Harrison Town and the origins of the first institutional commitment law for the "feebleminded": psychologists as expert diagnosticians

The first law providing for the commitment of "feeble-minded" individuals in the United States was passed in 1915, in the state of Illinois. House Bill 655 not only allowed for the permanent, involuntary institutionalization of feeble-minded individuals, but it shifted the commitment and discharge authority from the institution superintendents to the courts. Clara Harrison Town, a student of Lightner Witmer, and the state psychologist at the second largest institution for feeble-minded individuals in the country, was instrumental in this law passing and in ensuring that psychologists, for the first time, be viewed as court "experts" when testifying as to the feeble mindedness of individuals.

Practice guidelines regarding psychologists' involvement in pharmacological issues

The guidelines presented in this document are intended to provide a resource to psychologists interested in the issue of what represents optimal practice in relation to pharmacotherapy. They are not intended to apply to those psychologists who choose not to become directly or indirectly involved in medication management regardless of their level of competency. Some of the guidelines presented in this document are targeted specifically to the population of psychologists with prescriptive authority. Others are considered relevant in any case where the psychologist is actively involved in decision making, whether as a prescriber or collaborator. Still others are considered applicable any time a psychologist is involved in the practice of pharmacotherapy, whether as a prescriber, collaborator, or information provider. Given the unique elements of the population of psychologists who can prescribe on the one hand, and the frequency with which psychologists participate in collaborative and information-providing activities on the other, it was considered important to provide guidelines appropriate to each set of activities. However, it is also important to recognize that a principle of optimal practice may have different implications in the context of active participation versus providing information. In particular, the distinction between active participation and providing information can often be blurred in the practice setting, with a psychologist often playing different roles at different points in the treatment. Given the ambiguity that surrounds these activities, it is urged that these guidelines be read with the understanding that the clearest practice delineation occurs between those psychologists who possess prescriptive authority and those who do not, and that psychologists who do not possess prescriptive authority use critical judgment in determining which guidelines best inform their practice.

Contested jurisdictions: psychiatry, psychoanalysis, and clinical psychology in the United States, 1940-2010

American psychiatry on the eve of Pearl Harbor was a small, stigmatised, and isolated specialty, for the most part confined as surely inside the high walls of its barrack-asylums as the patients over whom it exercised near-autocratic powers. The number of mentally ill patients incarcerated in state and county mental hospitals had grown sharply, from 150,000 at the turn of the century to 445,000 in 1940. The fiscal crisis of the states that accompanied the Great Depression had produced a steady deterioration of conditions in these institutions, a deterioration that would intensify as a result of the exigencies of total war. In the immediate aftermath of that prolonged conflict, conditions had degenerated to such a parlous state that a number of outside observers compared America's asylums to Nazi death camps.

Teaching psychology to jurists: initiatives and reactions prior to World War I

This article deals with the kind of psychology suggested for jurists that was thought to be necessary training for their work. An analysis of the content of two textbooks by Otto Lipmann and Karl Marbe reveals that such teaching activity involves two different levels of historical analysis. On the one hand, it relates to experimental research done by psychologists on law-related issues; on the other, it concerns the professional experience psychologists accumulated by acting as expert witnesses in court. The paper investigates how psychologists presented psychology to jurists, which methods and theories they suggested as being essential for juristic training and professional performance, and whether jurists appreciated these materials and efforts. These inquiries are embedded in the debate on the history of criminal psychology, taking into account the European, particularly the German, context. The author shows how specific historical developments led to an increased exchange between experimental psychology and criminal law during the first decades of the 20th century.

Consent and confidentiality in clinical work with young people

Consent and confidentiality are increasingly important in clinical practice. However, the dilemmas faced by mental health practitioners can be highly complex and difficult to resolve. This difficulty is compounded by the fact that consent and confidentiality are subject to several different types of legislation based on different principles, and many of the policies which are formulated for general medical practice may not fit well with the mental healthcare context. The ethical principles, evidence base, legal context, developmental considerations and clinical context relevant to each situation must all be integrated, in consultation with children and adolescents and their parents, in order to arrive at a treatment plan which is sensitive to the views of all, developmentally appropriate for the children and adolescents, and responsive to changes in the situation or attitudes. We offer some practical approaches, including clinical practice algorithms, to consider the issues of consent and confidentiality in the child and adolescent mental healthcare setting.

Prescribing non-psychopharmacological agents: a new potential role for psychologists in primary care settings and specialty clinics

At least 10 years have passed since the Department of Defense Psychopharmacology Demonstration Project graduated its first class of psychologists. All graduates of that program were credentialed to prescribe and the program received promising external reviews and audits. The profession has since moved well beyond the initial question, "Can and should psychologists prescribe?" posed over two decades ago. A number of professional schools and training institutions have implemented postdoctoral psychopharmacology training programs and over 20 states are actively pursuing legislative agendas. Given recent initiatives to provide health psychology services within the primary care arena, the authors introduce a new role in the scope of psychology's prescribing activities. They propose that psychopharmacological agents are not the only medications psychologists should be trained to prescribe and psychopharmacology training should include course work and supervision related to treatment within a primary care patient setting in addition to a traditional psychiatric one. The authors provide the rationale for primary care clinical health psychology training as the appropriate mechanism for psychopharmacology education and practice. Public health needs and epidemiological data provide the rationale for health psychologists additionally prescribing non-psychopharmacological agents.

Prescription privileges for psychologists: a comprehensive review and critical analysis of current issues and controversies

The debate over whether clinical psychologists should be granted the right to prescribe psychoactive medications has received considerable attention over the past 2 decades in North America and, more recently, in the UK. Proponents of granting prescription privileges to clinical psychologists argue that mental healthcare services are in crisis and that the mental health needs of society are not being met. They attribute this crisis primarily to the inappropriate prescribing practices of general practitioners and a persistent shortage of psychiatrists. It is believed that, as they would increase the scope of the practice of psychology, prescription privileges for psychologists would enhance mental health services by increasing public access to qualified professionals who are able to prescribe. The profession of psychology remains divided on the issue, and opponents have been equally outspoken in their arguments. The purpose of the present article is to place the pursuit of prescription privileges for psychologists in context by discussing the historical antecedents and major forces driving the debate. The major arguments put forth for and against prescription privileges for psychologists are presented, followed by a critical analysis of the validity and coherence of those arguments. Through this analysis, the following question is addressed. Is there currently sufficient empirical support for the desirability, feasibility, safety and cost effectiveness of granting prescription privileges to psychologists? Although proponents of granting prescription privileges to psychologists present several compelling arguments in favour of this practice, there remains a consistent lack of empirical evidence for the desirability, feasibility, safety and cost effectiveness of this proposal. More research is needed before we can conclude that prescription privileges for psychologists are a safe and logical solution to the problems facing the mental healthcare system.

Risk management with suicidal patients

The patient who is at-risk for suicide is complex and is difficult to evaluate and treat effectively. Should suicidal behavior occur, the clinician faces the potential wrath of bereaved survivors and their externalized blame exercised through a malpractice suit. The clinician's duty of care to a patient is to act affirmatively to protect a patient from violent acts against self. A finding of malpractice is established if the court finds that this duty was breached, through an act of omission or commission relative to the standard of care, and that this breach was proximately related to the patient's suicidal behavior. This article discusses the standard of care and factors that determine liability in a suicide death of a patient. An extensive list of recommendations for competent caregiving for the at-risk patient and risk management guidelines are then presented.

Informed Consent and Clinical Research Involving Children and Adolescents: Implications of the Revised APA Ethics Code and HIPAA

In 2003, 2 new sets of rules and regulations affecting the conduct of clinical research involving children and adolescents went into effect: the revised American Psychological Association's (APA) Ethical Principles of Psychologists and Code of Conduct (APA, 2002; effective June 1, 2003) and the Privacy Rule (45 CFR Part 160 and A and E of Part 164; effective April; 14, 2003) of the Health Insurance Portability and Accountability Act (HIPAA: Public Law 104-191). This article highlights those APA ethical standards and HIPAA regulations relevant to clinical research involving children and adolescents and discusses how psychologists can apply these rules in ways that will ensure ethical and legal compliance.

The 2002 psychologist prescribing law in New Mexico: the psychiatrists' perspective

In March 2002 New Mexico passed the first state statute permitting the development of a process leading to prescriptive authority for doctoral level psychologists who obtain requisite training and certification. This article reviews the background of these events, the political processes by which this expanded scope of practice for psychologists evolved, the current state of regulatory discussions regarding this statute, forecasts of the practical impact of this legislation on practitioner patterns, and prospects for the future.

Providers issue brief: scope of practice and prescriptive authority: year end report-2002

Nonphysician providers continue to achieve enhanced stature, in part by gaining more autonomy in prescribing drugs. There is growing support for the concept that the public health is best served by the broadest access to primary care along with the safe use of pharmaceuticals. The states continue in their efforts to find ways to promote the use of less specialized and less costly providers to help serve the ever-growing population who have access to health care services.

Just say no to psychotropic drugs!

Prescribing drugs for mental disorders by psychologists means accepting an invalid model--the brain disease, biological-defect explanation of psychopathology--that is advanced by political conservatives and accepted by some naive, well-intentioned, but misinformed moderates who have not thought critically about the issue. Conservative psychiatry serves the ruling class by rejecting or ignoring the fact that most mental disorders are learned in the context of social and economic injustice, and familiar dysfunction. If we accept the fallacy of brain disease and genetic defect as the major causes of mental disorder and succeed in getting prescription privileges we will have sold our soul to the devil!

Prescribing privileges: grail for some practitioners, potential calamity for interprofessional collaboration in mental health

The focus of this article is the probable consequences, in the event psychologists aggressively pursue prescription privileges (RxP), upon collaboration between psychologists and physicians. The case for RxP is briefly and critically summarized and the current state of collaboration between psychologists and medical professionals is reviewed. Data are presented from a recent small survey of clinical psychologists that support the following hypotheses: (1) psychiatrists and other medical professional receive a consequential volume of referrals from psychologists which would be diminished by RxP; (2) psychologists receive referrals for psychosocial services from medical professionals which would be diminished by RxP; (3) psychologists anticipate an adverse effect upon collaboration from RxP; and (4) contrary to some claims, psychologists are at best divided over RxP. Implications of these findings upon interprofessional collaboration are discussed.

Responding to society's needs: prescription privileges for psychologists

The health care revolution has contributed to the natural evolution of the role of psychologists. This has led to the necessity for future psychologists to have the authority to prescribe psychotropic medications in order to offer the best-available, comprehensive treatment to the public. Psychologists' training gives them a unique role in addressing the psychosocial aspects of medical problems, in collaboration with primary-care physicians. Prescribing psychologists are cost-effective, many practice in rural areas where people have no other access to mental health care, and they will be able to treat other underserved populations such as the poor, the elderly, the chronically mentally ill, children, and prisoners in the criminal justice system. Prescribing psychologists will have an increasingly prominent role in future health care policy decisions and practice.

Opposition to prescriptive authority: is this a case of the tail wagging the dog?

This essay proposes that opposition to prescriptive authority (RxP) is not grounded in or based on any objective data. Opposition arguments fall into the category of ideology, opinion, and inappropriate economic beliefs. Moreover, what scant data does exist with respect to prescribing psychologists, the data disputes the main arguments in opposition to RxP. Major themes expressed by RxP opponents are analyzed, and counter-arguments are presented concluding that RxP opposition is not precedent-setting but part of the historical tension between academic and applied psychologists. The only precedent may be in the way the controversy is resolved.

The high cost of prescription privileges

This article presents some data regarding the costs in the augmentation of programs aimed at equipping psychologist to prescribe medications. Data are presented relative to the financial burden it will place on students, universities, internship sites, and the consumers of psychological services.

Prescription privileges for psychologists: constituencies and conflicts

The pros and cons of the proposal to link prescription privileges specifically to psychological training vary from the point of view of the constituencies involved. The present article analyzes those differences. Two surprising facts are noted. First, it is scientist-practitioners who are resisting the move toward prescription privileges, not so much the basic science organizations. Second, while the practice-based organizations have been avid in their support of prescription privileges, the same cannot be said for rank and file private practitioners. On closer examination, the costs, benefits, and views of the different constituencies make sense of these anomalies. The resistance to prescription privileges is not arbitrary or unreasonable and it is not likely to go away any time soon.

Should psychologists be granted prescription privileges? A review of the prescription privilege debate for psychiatrists

BACKGROUND

The debate over whether clinical psychologists should be granted the right to prescribe psychoactive medication has received considerable attention over the last 2 decades in the US, but there has been relatively little discussion of this controversial topic among Canadian mental health professionals, namely psychologists and psychiatrists. Proponents of prescription privileges (PPs), including the American Psychological Association (APA), argue that psychologists do not and cannot function as independent professionals because the medical profession places many restrictions on their practice. It is believed that PPs would help circumvent professional psychology's impending marginalization by increasing psychology's scope of practice. Proponents also argue that PPs would enhance mental health services by increasing public access to professionals who can prescribe.

OBJECTIVE

The purpose of this article is to inform psychiatrists about the major arguments presented for and against PPs for psychologists and to discuss the major implications of PPs for both professional psychology and psychiatry.

METHODS

We conducted a literature search of relevant articles published from 1980 to the present appearing on Psychlit and Medline databases, using "prescription privileges" and "psychologists" as search titles.

CONCLUSION

Although proponents present several compelling arguments in favour of PPs for psychologists, pilot projects relating to feasibility and efficacy are either sparse or incomplete. Thus, it is too soon to tell whether PPs could or should be pursued. Clearly, more research is needed before we conclude that PPs for psychologists are a safe and necessary solution to psychology's alleged impending marginalization.

Training for prescriptions vs. prescriptions for training: where are we now? Where should we be? How do we get there?

The proposal that state legislatures should grant prescription privileges to psychologists is examined critically, with particular attention to the proposal's implications for the future education and training of clinical psychologists. First, the current status of clinical psychology is described. Then, an alternative to the prescription privilege proposal is presented; this alternative prescribes a scientific approach to clinical psychology. Finally, a plan for achieving this alternative is outlined.

Concluding remarks on the debate about prescription privileges for psychologists

This article summarizes the six primary arguments for and against prescription privileges for psychologists (PPP or RxP) that were presented in this special issue. Four articles addressed points made in the testimony in favor of PPP by the American Psychological Association. Six articles addressed points in the testimony against PPP by the American Association of Applied and Preventive Psychology. It is concluded that the PPP debate reflects a deep schism in clinical psychology that represents a serious disunity in the field. The disunity is seen as a divide between those trained to be psychotherapists and those trained to be scientist-practitioners. It is argued that the former support PPP and are interested in the survival of professional schools, while the latter oppose PPP and are interested in the survival of university departments of psychology. For the discipline to survive there must be a rapprochement between these factions and alternatives to PPP for the retraining of psychotherapy practitioners.

Being ethical: more than obeying the law and avoiding harm

In this article, I provide the reader with a model for considering ethical dilemmas that arise in the settings in which assessors practice. The overarching set of principles necessary to consider to make an effective ethical decision are presented as well as a series of steps through which the assessor should proceed in considering a situation. The role of ethics codes in decision making is also described.

Psychiatrist-patient boundary issues following treatment termination

OBJECTIVE

Psychiatrist-patient relationships after termination of treatment are fraught with complexities and are the subject of ongoing debate. The authors discuss the issue of boundary violation allegations that arise after treatment has ended, with the goal of explicating how these issues have been handled in psychiatric discussions as well as in broader sociolegal settings.

METHOD

Clinical illustrations and legal cases are used to illustrate how legal and administrative bodies have dealt with posttermination boundary issues.

RESULTS

Courts and regulatory bodies have tended to use the psychoanalytic concept of transference to decide issues in which there has been a complaint of impropriety-be it romantic, financial, or social in nature-arising after termination of treatment. However, a multitude of treatment approaches are currently employed in psychiatry, and often their practitioners either do not use the concept of transference or deny its validity. If the concept is used, it is often present in many settings outside therapy.

CONCLUSIONS

The concept of transference is subject to continuing debate and modification within psychoanalysis, and its use in judicial or quasijudicial settings raises questions about whether it meets standards of scientific acceptance. Using the concept of transference to decide posttermination issues results not only in confusion but also has the potential for many adverse consequences for practitioners and the profession.

Applying our medicine to the psychopharmacology debate

Reasonable arguments can and should be made in favor of and in opposition to psychologists seeking prescription privileges. The debate presents psychology with the opportunity to converge rather than fractionate. An APA Task Force established in 1991 recognized that a number of preliminary issues would have to be addressed before the question of prescription privileges could be answered, and made recommendations for the types of training various psychologists would need. This article describes that training and discusses how psychologists in training may be affected by the current debate.

The dawn of a revolution in mental health

Issues surrounding the debate regarding psychologists' evolution as prescribers are discussed in a balanced format. Arguments against prescribing are challenged, such as the change in focus of psychological work and the potential harm to public welfare. Disruption of the process of psychotherapy, through employment of external prescribers, is also discussed, especially given the psychological meaning imbued to medicine by patients. It is concluded that psychologists have the opportunity and responsibility to improve the present models for the delivery of mental health services by obtaining the requisite training and legislative mandate to prescribe.

The case against prescription privileges for psychologists

The right to prescribe psychoactive medications could have major effects on the practice of psychology, on its education and training, on the marketing of psychological services, and on the public's perception of the field. This article presents the case against psychologists pursuing prescription privileges, including discussion of several arguments advanced by proponents of prescription privileges. Although APA has endorsed the effort to secure prescriptive authority, there is no requirement that states actually change their licensing laws so that their psychologists can prescribe. The costs (and potential risks) involved in pursuing prescription privileges are discussed.

Prescription privileges for psychologists

As the profession of psychology has matured, serious interest has surfaced over the past decade in obtaining prescription privileges within the practitioner community. Other nonphysician disciplines have exercised this clinical responsibility for years, significantly improving their ability to comprehensively serve current and new populations. Efforts are underway to develop appropriate and viable training modules. The primary objection expressed by medicine is once again that our practitioners will become "public health hazards." Not surprisingly, resistance to change exists within psychology's training programs. However, the power to prescribe represents the authority to ensure that psychotropic medications are appropriately utilized, if used at all, and will ensure that psychology's practitioners can address society's pressing needs.

The identity of psychoanalysis: the question of lay analysis

This article, besides being a general historical account of the nature and meaning of the almost century-long controversy over "the question of lay analysis," also had a specific context and purpose. The author was invited to give the plenary keynote address to the winter meeting of the American Academy of Psychoanalysis in Santa Barbara, California, on December 9, 1994. After the passage of the Gaskill Committee proposals by the American Psychoanalytic Association in 1986, the alteration of the Regional Association agreement between the American and the International Psychoanalytical Association in 1987, and the settlement of the class-action lawsuit by clinical psychologists against the American and the International in 1988, this controversy over lay analysis had finally been resolved within the International and all its component organizations, including the American. The American Academy of Psychoanalysis, however, is one organization (with some overlap of membership with the American Psychoanalytic Association) that continues to maintain a bar against any members except medically qualified psychoanalysts. The author agreed to give the plenary address with the stipulation, which was accepted, that he could use the occasion to review this long history of the struggle over lay analysis, and to ask the Academy to reconsider its long-standing policies that now make it a lonely holdout against the evolution and resolution that has taken place in the overwhelming balance of organized institutional psychoanalysis worldwide.

Clinical psychology training in Europe

Clinical psychology training in the United Kingdom (UK) and in the remainder of Europe differs in several respects; in particular, the latter allows for greater variability and clinical specialization with much more training taking place postqualification than in the UK; differences in content and in the balance between the supply of, and demand for, clinical psychologists also exist. These differences reflect employment arrangements and, to a lesser extent, the structure of higher education and legal regulation. Various current and predicted changes in health-care systems and in the legal and educational context will probably lead to training in the UK and elsewhere in Europe becoming more similar in the years after 1992.