Mental health counselors' perceptions regarding psychopharmacological prescriptive privileges. (Research).
Mental health counselors, one of the nonmedical mental health professionals (NMMHPs), are faced more than ever with a continually challenging client population. Psychotropic medications for the treatment of certain types of mental disorders have been improved, recognized, and accepted by medical and nonmedical mental health care providers. Often, the mental health counselor is more familiar with the client and the client's clinical issues than the prescribing physician. Therefore, the demand for mental health professionals to understand these medications' effects on patients with whom they work has become of paramount importance (Buelow & Hebert, 1995; Diamond, 1998; Hayes, 1997; Preston, O'Neal, & Talaga, 1997).
Ronald Koshes, a board-certified psychiatrist, believed that a cooperative approach to prescribing psychotropic medications would be in the best interests of the client (cited in Hayes, 1997, p. 8). He felt that most counselors were knowledgeable about their client's issues, including the possible benefits clients might receive from psychotropic medications. Legally and ethically, mental health counselors cannot prescribe medications, but they are often the ones to hear from their clients about the effects of medications.
Buelow and Hebert (1995) questioned whether it was ethical for the counselor to work with clients utilizing only counseling methods when pairing counseling with psychopharmacological interventions may be a more beneficial and efficient approach. Counselors need to be both educated and careful in their decisions to treat and refer clients who are in need of psychiatric medications. "The liability incurred in not referring a client for evaluation who needs psychiatric medication is certainly much higher than of referring a client who does not. Good faith referral of clients is the responsibility of counselors"(p. 107). Buelow and Hebert (1995) also indicated that mental health counselors are not receiving the training required to perform the collaborative work expected of them in clinical or hospital settings. They stated that many counselors are not prepared in psychopharmacology.
After examining the available literature relative to the current research, we did not find any existing survey of mental health counselors' perceptions about prescription privileges and requisite psychopharmacological training. Nevertheless, it was apparent from a review of the literature that the needs for further training and more involvement in the prescriptive process were emerging concerns. Therefore, a survey was developed to ascertain the perceptions of American Mental Health Counselors Association (AMHCA) members regarding their views of attaining independent and/or dependent privileges. The survey also addressed their perceptions about training needs and the extent of training they have already received.
There are several references related to training. From 1973-1986, Mount Zion Hospital in San Francisco, California, offered a doctorate in mental health that was intended to modify the shortcomings in the training of psychiatrists and psychologists to be able to work therapeutically and psychotropically with their patients (Wallerstein, 1992). A Prototype Educational Model for Training Psychologist Prescribers was developed in 1991 by the Department of Defense. This program initially offered post-doctoral training in psychopharmacology to clinical and counseling psychologists on active duty in the armed services (Sammons, Seton, & Meredith, 1996). Lott and Koshes (1997) developed a home-study program that was delivered through the American Counseling Association's (ACA) publications office. This program was to provide mental health professionals with information on the clinical use of psychoactive medications. The first specific information about requiring training for counselors was found in the 2001 draft of Standards for Accreditation submitted by the Council on Accreditation of Counseling and Related Educational Programs (CACREP). The two options that require didactic training in psychopharmacology were in Mental Health Counseling and Gerontological Counseling (ACA, 1999).
The literature pointed out that the American Psychological Association (APA) established a task force to determine the competence criteria necessary for the training of psychologists to secure psychopharmacological prescriptive privileges. The task force proposed three levels of education concerning psychopharmacology. The first level was described as basic knowledge, the second level stressed collaborative practice with physicians having oversight, and the third level of training proposed allowing prescriptive privileges (APA, 1992). Other studies explored proposed curricular training for prescriptive privileges for psychologists (APA, 1995; Fox, Schwelitz, & Barclay, 1992; Sammons et al., 1996; Seppa, 1998a, 1998b).
The major purpose of the exploratory study discussed in this article was to elicit mental health counselors' perceptions about attaining independent or dependent prescriptive privilege. A second purpose was to survey the beliefs of members regarding their needs for psychopharmacological training. Related to these major purposes was the intention to look at the relationship between agreement/disagreement with independent/dependent prescriptive privileges and perceived related training needs. The effect of securing psychopharmacological privileges on the profession was also explored briefly. A tertiary purpose was to delineate and compare selected characteristics of the random sample of members with their agreement/disagreement with independent/dependent prescription privileges. These characteristics included age, gender, years of experience, degree and training, geographic location, and job title. Previous related studies have included these variables (Barkely, 1990; Bell, Digman, & McKenna, 1995; Fox et al., 1992; Seppa, 1998a, 1998b; Youngstrom, 1991).
After piloting the survey, the authors sent it to 1,000 randomly selected AMHCA members. This number closely approximated a 20% sample geographically representative of the AMHCA membership. A return rate of 41% (410 usable surveys: from 262 females and 148 males) was achieved. Selected demographic characteristics of the survey sample were obtained and are described as follows.
The participants' age ranges were as follows: 144 (35.1%) were 51-60 years old; 115 (28%) were 41-50 years old; and 65 (15.9%) were 31-40 years old; 60 (14.6%) were 61 years old and over; and 23 (5.6%) were 24-30 years old. Three participants (.8%) did not respond.
The participants provided the following information about their years of experience: 151 (37%) participants had less than 10 years of experience; 116 (29%) participants had 11-20 years; 90 (22%) participants had more than 20 years. Forty-nine (11%) participants were not currently providing counseling services. (Thirty-five were retired mental health counselors; the remainder were currently students. Forty-three indicated they did not hold a current license or credential, see below). Four (1%) participants did not respond.
The participants indicated that they held the following state licenses and national credentials: 220 (53.7%) were licensed counselors, 85 (20.7%) had more than one license, 43 (10.5%) had no license/credential. Twenty-eight (6.8%) were licensed psychologists, 8 (2%) were licensed social workers, 7 (1.7%) were marriage/family therapists, 3 (.7%) were certified chemical dependency counselors, and 2 (.5%) were certified school counselors. Fourteen (3.4%) did not answer the item.
Some 195 (47.6%) participants indicated they had no classes in psychopharmacology in their training program; 96 (23.4%) had one class; 80 (19.5%) had two to three classes, and 24 (5.9%) had four or more classes. Fifteen (3.7%) did not respond.
There were 333 (81.2%) respondents who were not required to take a course at the master's and/or doctoral level and 67 (16.3%) who were required to take a course. Ten (2.4%) did not respond.
There were 366 (89.3%) participants currently working with clients who were taking psychotropic medication, and 37 (9%) who were not working with clients currently taking psychotropic medication. Seven (1.7%) did not respond
The lead author developed the survey. The 53 survey items were developed based on a review of literature concerning the role of psychotropic medication in client treatment, the possibilities of collaboration with medical personnel in the prescriptive process, and the changing role of mental health counselors as nonmedical members of the mental health care team. The items relative to the research question concerning attaining dependent or independent prescriptive privileges for mental health counselors were purely exploratory. They related to the proposed levels of training suggested by APA (1992) and other studies relative to psychologists attaining dependent and/or independent prescriptive privileges (Sammons et al., 1996; Wallerstein, 1992).
The items were developed to address the questions of the study. Two items asked members to respond with levels of agreement or disagreement (six levels from strongly disagree to strongly agree) to the query regarding mental health counselors attaining independent or dependent prescriptive privileges. Independent prescriptive privilege was defined on the survey as a type of privilege in which the mental health counselor is authorized to prescribe psychotropic medications without physician oversight (Cullen & Newman, 1997). Dependent prescriptive privilege was defined as a type of prescriptive privilege in which the mental health counselor has dependent authority to prescribe psychotropic medications, with oversight of a physician (Cullen & Newman, 1997). AMHCA members' perceptions regarding their training needs were addressed (nine items). The next category of items related to perceptions about attaining prescription privileges (30 items). Additionally, items relating to characteristics of the responding sample were included. (11 items addressed characteristics of age, gender, years of experience, degree and training, geographic location, and job title).
The main questions of the exploratory study and the results follow. Frequencies and logistic regression were methods used to describe the results. See Tables 1 and 2 for frequencies and Tables 3 and 4 for logistic regression.
Question 1: (Table 1)What are the perceptions of AMHCA members regarding independent or dependent prescriptive privileges in psychopharmacology? A majority of mental health counselors agreed with the attainment of dependent prescriptive privileges and disagreed with the attainment of independent prescriptive privileges. This may be related to their level of satisfaction with working with medical personnel in their current settings and continuing a dependent relationship in prescribing psychotropic medications rather than attaining independent prescriptive status. On the other hand, the results may be indicative of other variables such as perceived training needs in the area of psychopharmacology requisite to attainment of prescriptive privileges. When examining items related to the first question of the study, 243 (59.3%) agreed that advantages of attaining prescriptive privileges would outweigh the disadvantages. There were 300 (73.2%) who agreed that prescription privileges (either dependent or independent) would enable the mental health counselor to treat a broader range of clients. Further findings indicated that 250 (61%) agreed that clients would be better served if mental health counselors received independent or dependent prescription privileges for psychotropic medications.
Question 2: (Table 2) What are the beliefs of AMHCA members regarding psychopharmacological training prior to accurate referral of clients and requisite to gaining independent or dependent prescription privileges? There was overwhelming agreement on two points. First, mental health counselors agreed that they needed basic psychopharmacological training in order to accurately refer clients to medical personnel for psychotropic medication. Secondly, they perceived the need for inclusion of psychopharmacological education in core curriculum prior to attaining either independent or dependent prescription privilege. Other related results indicated they had preferences regarding the best arena in which to gain psychopharmacological education. Some 125 (30.5%) indicated that master's-level education with specialization in psychopharmacology would be the best training situation. Post-doctoral education with specialization in psychopharmacology was most desirable according to 115 (28%) respondents. Ninety-eight (23.9%) respondents indicated doctoral education with a cognate specialty in psychopharmacology provided the best situation, and 50 (12.2%) said that the pre-doctoral track with specialization in psychopharmacology was most desirable. Twenty-two (5.4%) did not respond.
When looking at perceptions about required didactic training prior to attaining independent prescription privilege, there were 119 (29%) of the mental health counselor respondents who believed that 2 years of post-doctoral didactic course work was necessary prior to attaining full prescription privilege; 107 (26.1%) indicated 1 year was necessary; 65 (15.9%) indicated 3 years; 37 (9%) indicated 5 years; 22 (5.4%) indicated less than 1 year; and 18 (4.4%) respondents indicated 4 years were necessary.
Concerning post-doctoral clinical residency with oversight of a psychiatrist and prior to attaining independent prescriptive privilege, 170 (41.5%) believed 1 year (2,000 hours) were necessary prior to attainment of independent prescription privilege; 164 (40%) believed that more than 1 year (3,000 hours) was necessary, 39 (9.5%) respondents indicated less than 1 year (1,000 hours), and 37 (9%) did not respond.
When looking at perceptions about required didactic training prior to attaining dependent prescription privilege, 173 (42.2%) indicated that 2 years (64 hours) of pre-doctoral didactic training was necessary; 122 (24.9%) indicated 1 year (32 hours) of pre-doctoral didactic training was necessary; and 48 (11.7%) believed that 1.5 years (48 hours) was necessary.
Regarding supervised clinical residency prior to attaining dependent prescriptive privilege, respondents favored a pre-doctoral clinical residency in excess of 1,000 hours. Specifically, 157 (38.3%) indicated more than 1 year was necessary; 153 (37.3%) indicated 1 year or 2,000 hours was a necessary requisite; and 62 (15.1%) believed 1,000 hours would be necessary.
Question 3: What are the most significant respondent characteristics relative to agreement/disagreement with independent and/or dependent prescriptive privilege? Selected characteristics--including age, gender, years of experience, degree and training, geographic location, and professional job title--were used to predict agreement/disagreement with attainment of independent or dependent prescriptive privilege for mental health counselors. Logistic regression was used to identify the effect of these selected characteristics of respondents, providing a model for the probability of two possible outcomes, in this case, agree or disagree. Logistic regression was chosen because it controls for multiple independent variables and allows classification of individuals based on predicted outcomes while allowing several characteristics to be examined. The standardized residual test was run for independent and dependent prescription privilege which indicated there were no outliers. Therefore, a sensitivity analysis was not conducted. Age and years of experience were the only two characteristics found to be significant (see Tables 3 and 4).
The Hosmer-Lemeshow test produced a fail-to-reject decision, a result consistent with the assumption that the specified logistic model was correct. Given the individualized nature of the survey, there was no reason to believe that there was any violation of the independence assumption. The odds of agreement for independent or dependent prescription privileges is defined as the ratio of probability of agreement to the probability of disagreement. The odds of agreement tended to increase with the younger population.
The estimated logistic regression model for independent prescription privilege indicated that age was the only one of the six characteristics, which was statistically significant at the p < .01 level (Table 3). For the independent and dependent prescription privilege assessment, the logistical regression was administered to 410 cases, 14 cases were rejected because of missing data, and so 396 cases were included in the analysis. The significant effects (p < .01) of the independent variables on independent and dependent prescription privilege indicated that age was the only significant variable. Specifically, the odds of agreeing with independent prescription privilege was estimated to be 2.04 times greater for AMHCA members who are 24-40 years old than for AMHCA members who are 41-50 years old, controlling for all other independent variables. The odds of agreeing with independent prescription privilege was estimated to be 2.45 times greater for AMHCA members who are 24-40 years old than for AMHCA members who are 51 years and over, controlling for all other independent variables.
For the dependent prescription privilege, it was observed that the odds of agreeing with dependent prescription privilege is estimated to be 2.97 times greater for AMHCA members who are 24-40 years of age than those AMHCA members who are 51 years and older. The odds of agreeing with dependent prescription privilege is estimated to be 1.76 times greater for AMHCA members who are 24-40 years of age than those AMHCA members who are 41-50 years and older. This was significant at the p<.10 level. The odds of agreeing with dependent prescription privilege was estimated to be 1.74 times greater for AMHCA members who are 41-50 years of age than those AMHCA members who are 51 years and older.
Experience was the other significant factor. The odds of agreeing with dependent prescription privilege was estimated to be 2.56 times greater for AMHCA members who have 11 to 20 years of experience than those AMHCA members who have less than 10 years of experience.
Because this was an exploratory study, further recommendations are offered based on some of the implications that may be derived from the more significant results of the study. A cautionary approach to interpretation of the results is warranted due to the 41% return rate as well as the exploratory nature of the survey. Reliability and validity of the survey have not been established. It was constructed based on questions that seemed to arise from a review of a limited amount of literature.
Concerning the first question of the study, it was observed that more mental health counselors agreed with attaining dependent prescription privilege than independent privilege. This may have been because they felt more secure with physician oversight when commencing this process. These results were also reflected in several of the most recent surveys (Barkely, 1990; Bell et al., 1995; Fox, Schwelitz, & Barclay, 1992; Seppa, 1998b; Youngstrom, 1991) However, these surveys did not differentiate between independent or dependent prescriptive privilege. These surveys were not about mental health counselors but focused on psychologists. An APA survey reported by Youngstrom (1991) found that "68% of practicing psychologists favor training for prescription privileges," (p. 20). Another survey found "65% favor such training in a survey of child psychologists" (Barkely, 1990, p. 1). A survey of clinical neuro-psychcologists revealed that "Slightly less than 60% favor it" (Fox et al., 1992, p.326). A similar view was indicated by family physicians, as there was 50% support for prescription privilege for psychologists from the female physician respondents and from those respondents, male and female, practicing in rural communities. Nearly 40% of the family physician respondents would sometimes refer patients to psychologists if they were granted prescription privileges especially for treatment of patients with such psychotropic drugs as antidepressants or anxiolytics (Bell et al., 1995). Another survey (Seppa, 1998b) revealed that: 58% of primary care physicians who were in the military supported psychologists' gaining prescribing privileges under the Pentagon's Psychopharmacology Demonstration Program (APA, 1995).
Sixty percent of the participants in this study agreed that the advantages of acquiring prescription privileges would outweigh the disadvantages. Eighty-seven percent indicated that prescription privileges would broaden the scope of the mental health counselors' practice.
The second question of the study was in the area of psychopharmacological training for mental health counselors. More than 90% of the participants agreed that basic psychopharmacological education was necessary for the mental health counselor to attain in order to accurately refer clients for medical evaluation. More than 90% of the participants believed that psychopharmacological training should be part of the required core curricular. Consistent with their belief in training, 65% indicated they would seek supervision necessary to utilize prescription privilege, and 68% said they would be willing to participate in professional development aimed at enhancing their understanding of prescriptive privilege.
A majority of respondents indicated they had not been required to take nor were they offered courses in psychopharmacology during their training programs. In spite of this, many participants said they had attended workshops, and many had gained knowledge in their workplace (87%). Because 89% said they worked with clients on psychotropic medication, it seems crucial that more attention should be given to requiring psychopharmacological education in master's and doctoral training programs for mental health counseling.
When asked about level of training necessary to obtain collaborative privilege at the pre-doctoral level, almost 79% believed they should have one year (approximately 32 credit hours) to 2 years (approximately 64 credit hours) of training in order to be adequately prepared for dependent prescriptive privilege. Additionally, 75.6% believed that supervised clinical residency in excess of 2,000 hours was necessary to be adequately prepared to exercise dependent prescriptive privilege. For independent prescriptive privilege, the survey asked participants to respond to two items regarding post-doctoral training. The responses indicated that 84% felt that one to 5 years of training was necessary, and almost 82% indicated that a clinical residency in excess of 2,000 hours was necessary to be adequately prepared to exercise independent prescription privilege.
Logistic regression was run to answer the third question of the study about significant characteristics of the sample relative to their agreement/disagreement with dependent/independent prescriptive privileges. The two significant characteristics relative to agreement with dependent and/or independent prescriptive privileges were age and years of experience. Age was the only significant independent variable with regard to the attainment of independent as well as dependent prescription privilege. The number of years of experience was related to the attainment of dependent prescriptive privilege. A survey of family physicians (Mauksch & Heldring, cited in Bell et al., 1995) regarding psychologist's privilege to prescribe medication indicates that the year of graduation from medical school was associated with respondents' likelihood to favor prescription privileges for psychologists. The authors speculated that younger respondents (graduates after 1977) may be favorable to granting prescriptive privileges because they were likely exposed during their family practice residencies to psychologists with expertise in psychopharmacology.
Recognizing the exploratory nature of the study, what implications can be logically drawn from the findings resulting from logistic regression analysis? First, it appears that younger mental health counselors in this sample are more interested in attaining independent or dependent prescriptive privilege. Second, the respondents' age range of 41 and above may have a more conservative outlook as a result of their training program. They may have been influenced by an era in which psychotropic medication was often viewed as somewhat sedating, and used only to control serious mental illness. Advancements in technology have taken psychotropic medication to a more respectable level in treating mental disorders, as there are fewer side effects and less sedation. Additionally, the age range of 41 and above may have come from training programs based on non-physical interventions developed on the premise that the mind and body were viewed as separate entities. Although we have no direct references, it's possible that persons in the age range of 24-40 may be in training programs which are paying more attention to the unity of mind and body. Treatment of a client with non-physical interventions alone may not be enough, especially since evidence seems to indicate that biomedical and behavioral factors are inextricably interwoven (Fox, 1988). Errors in clinical judgment as well as ethical issues arise when a mental health counselor fails to make a good faith referral for a client who needs psychotropic medication (Buelow & Hebert, 1995).
It seemed to be confusing that longevity of experience was somewhat counter to the finding regarding age, since those with 11-20 years of experience were more likely to agree with attaining dependent prescriptive privilege. Some of this confusion may have resulted from the necessity to collapse the age ranges as well as the years of experience range in order to run logistic regression. In other words, the upper part of the age range, 24-40, would have 11 or more years while the lower part of this age range would not. Possibly, the lack of significance between length of experience and independent privilege may accrue from their comfort level with already established collaborative relationships with general medical practitioners and/or psychiatrists and, therefore, see that obtaining dependent privilege would be an extension of this collaborative relationship.
Recommendations for Further Study
Since this was an exploratory study, further recommendations are offered based on some of the implications that may be derived from the results of the study:
* Investigate further whether needs of clients would be served more efficiently and effectively if mental health counselors were able to obtain independent and/or dependent prescriptive privilege. * Study more specifically the training needs of mental health counselors in psychopharmacology whether or not dependent or independent prescriptive privilege is obtained. * Assess the collaborative relationships mental health counselors now have with medical personnel relative to therapeutic success.
This exploratory survey was a first effort to hear the voice of mental health counselors. Mental health counselors are one of the groups of NMMHPs who heretofore have not been the focus of study concerning psychopharmacology and training needs. Yet, they are involved in providing services for clients who are on psychotropic medications. They are already involved in providing information to their clients on psychotropic medications, and they feel the need for formal training and recognize the ethical and legal dilemmas they may face if they do not have appropriate training and experience in the arena of psychopharmacology. There are abundant ad campaigns by the various pharmaceutical companies in the media. The public consumes the education these ads produce. This has increased awareness of the possibility of medications for psychological problems. It seems to follow that the mental health caregivers need to be well informed, allowing them to answer their clients' questions about medications and their utility. The authors hope that this study will serve to encourage further research and motivate training programs to broaden the curricular requirements. Mental health counselors should be encouraged to continue efforts toward serving clients with optimal tools within the legal and ethical dimensions of professional mental health practice. Hopefully, continued efforts will serve to increase the positive stature of mental health counselors and the standards of care for clients.
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Kari A. Scovel, Ph.D., is a licensed professional counselor of mental health with Steve Manlove Psychiatric Group, Rapid City, SD, and a post-doctoral resident/assistant adjunct professor. Orla J. Christensen, Ed.D., is a professor emerita of Counseling and Psychology in Education. Joan T. England, Ed. D., is a professor emerita of Counseling and Psychology in Education. All are with The University of South Dakota, Vermillion.
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|Author:||England, Joan T.|
|Publication:||Journal of Mental Health Counseling|
|Date:||Jan 1, 2002|
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