Article archive / November 1, 2014
Originally published: . Volume 5, No. 15. Source pages: 8, 9.
Dr. Sean Ransom, Louisiana Medical Psychologist from the Cognitive Behavioral Therapy Center of New Orleans and faculty associate at Tulane University School of Medicine, provides a candid and down-to-earth view about being a prescriber in Louisiana for the recent issue of the Behavior Therapist. His article was one of a select group for a Special Issue of the publication for the prestigious Association for Cognitive and Behavior Therapies.
“I can testify that RxP offers important, sometimes shockingly positive advantages for patients and for a psychologist’s ability to care for them,” Ransom writes in “The RxP Conundrum: How Prescriptive Authority Makes (Some of) My Patients Better and My Practice Worse.”
But he writes, “… despite these positives and despite my own early enthusiasm for the opportunity to become a prescriber, I have found that RxP has an inescapable dark side for psychologists individually, for our profession, and for some patients as well.”
In an intriguing account of his own career path he writes about his training, what it feels like to work collaboratively with physicians, and the conflicting issues that can arise with psychiatrists. He talks about the benefits of working with primary care physicians and provides a sobering anecdote about braving it out without medical support when something goes awry with one of his medically treated patient.
“This article is written in the hope,” says Dr. Ransom, “that my experience may help inform the broader population of psychologists who are forming their views of what the direction our field should take and perhaps to provide an additional perspective for those who are considering the lengthy pathway to making RxP a part of their own practice,” he writes.
Ransom explains that he decided to obtain his prescribing certificate while running a psycho-onology program in a New Orleans medical center where the lack of psychiatric coverage was a “gaping hole.” The oncologists welcomed him and considered his training in psychopharmacology stronger than their own.
“From the onset,” Ransom says, “this appeared to be a fulfillment of what RxP advocates claim as a prime motivator––to open up access to care for a population without easy access.”
Unlike New Mexico and now Illinois, Louisiana does not require a practicum. “So with the postdoctoral master’s degree and the PEP passed,” he explains, “you’re ready to roll. If you become a Louisiana prescribing psychologist, it is perfectly within the realm of possibility that your first experience evaluating a patient for a medication is when you, by yourself, unsupervised, sit down with your very own patient and prepare to write your first live prescription.”
Ransom writes that the online training was conducive to learning, invigorating, and the faculty was well-informed. “I was impressed that the program was strongly invested in creating a model of prescribing that stayed true to the role and mission of the clinical psychologist,” he writes. “Time after time, faculty would emphasize that the gold- standard treatment for various disorders was psychotherapy, particularly cognitive behavioral therapy.
He was less impressed with the exams. “Exams universally consisted of a few dozen multiple-choice questions, open- book, open-note, unproctored, untimed,” he said.
As he moved from the oncology clinic and the luxury of a “tightly integrated medical setting with strong medical oversight,” things became more complicated after he opened a stand-alone, specialized Cognitive Behavioral Therapy clinic.
Ransom explains the process of deciding when to prescribe and when to refer to a psychiatrist, linking up with the primary care physicians, and experiencing some very successful cases where his patients benefited greatly from medicine and evidence-based psychotherapy.
“But these experiences are exceptional for a reason,” he writes. “Most cases have less clear-cut successes and there are regular treatment failures. Collaborating primary care physicians who are amenable to initiating a patient on a medication can become squeamish when they are asked to approve yet another augmentation strategy, or medication switch, or dosage adjustment.”
He describes the difficulties of navigating relationships with psychiatrists, who sometimes stopped referring when they discovered he was a prescriber, and the frustrations with insurers reimbursing for his psychopharmacology add-on codes.
However, he notes the benefits with primary care physicians. “… becoming a prescriber has pushed me to create a series of highly collaborative relationships with nonpsychiatrist physicians (particularly PCPs) as I work with them to develop treatment plans for our joint patients.”
“The benefit ends, however, not necessarily at the end of your expertise but at the end of the expertise of the physician you collaborate with,” he say, “who, it must be eternally emphasized, is not a psychiatrist and will sometimes not know as much as you, which is chilling because you won’t know much yourself.”
He tells about a nerve-wracking incident when a patient developed a rash, in this case a potentially serious side effect. He was without full medical support because of Mardi Gras. While his decisions were right, it was still sobering. A psychiatrist colleague said he would have handled the situation the same way, but added, “The only difference is that if something goes wrong, I have the whole American Medical Association behind me.”
“RxP gives us a tool to use for patient care, and it’s a good one,” Dr. Sean Ransom says. However, for those who want to stay focused on psychotherapy, the “cost of that tool is too high…” Among his reasons––the loss of professional autonomy, the time needed to become a competent prescriber takes time away from other competencies, and the lower quality of work life. Also he notes the loss of genuine collaboration with the most skillful psychopharmacologists, the highly competent psychiatrists.
Instead, “We should have found better ways to build better bridges between our field and the medical community, including the psychiatric community,” he says. “We should have formed alliances to ensure that the work of psychologists is honored and that a well-defined, well- coordinated collaboration between individuals across disciplines is promoted as the standard of mental health care.”
Dr. Ransom launched the Cognitive Behavioral Therapy Center of New Orleans and works with colleagues Drs. Urmi Jani, Missy Bonell, Laura Niditch, Lisa-Ann Cuccurullo and Ms. Carly LeBlanc, LCSW. Their website is http://cbtnola.com
The Behavior Therapist is available at the Association for Behavioral and Cognitive Therapies website, at http://www.abct.org/Journals/?m= mJournal&fa=TBT
This article is part of a historical newspaper archive. Read the original issue for its original layout, photographs and graphics.