Psychiatrists fight blurring of line with psychologists
By Ellen Barry, Globe Staff, 6/1/2002 When Yale University tapped Alan Kazdin this spring to head its prestigious Child Study Center, organized psychiatry reacted with horror. The president of the American Psychiatric Association wrote of his ''deep disappointment'' with the choice and advised university president Richard Levin that ''Yale's stature in higher education will be markedly enhanced by a courageous acknowledgment of error.'' It wasn't that he had anything against Kazdin, who has written or edited 35 books and won a coveted 10-year research grant from the National Institutes of Health. The psychiatrists' complaint was this: Kazdin is a psychologist. These are uneasy days between psychiatry and psychology, which share a market and a mission but are divided by eight years of medical training. Once securely lodged atop the mental health care hierarchy, psychiatrists have increasingly found themselves forced to emphasize the differences between the professions. Psychiatrists interviewed said Kazdin's appointment felt like an insult to a prestigious medical tradition. Nerves were particularly raw for another reason, said two of the doctors who wrote in protest. In New Mexico, one of psychiatry's most central privileges was being questioned in a high-stakes debate: Should psychologists have the right to prescribe psychotropic drugs? ''There's always been some tension, but [the prescribing issue] has put them absolutely at each other's throats,'' said Dr. Jerry Weiner, a child psychiatrist and former president of the American Psychiatric Association. ''It's a fight for the identity of the profession, for the integrity of the profession.'' There are many close friendships and collaborations between individual psychiatrists and psychologists, many doctors interviewed pointed out. But the shrinking pool of money for mental health care has inflamed old differences between the guilds, which are distinct in their training: Although psychologists usually hold a doctorate, psychiatrists go through four years of medical school and four years of psychiatric training and go on to enjoy the privileges that go along with the MD degree. Psychiatrists have always had power over psychologists in many different ways, including the financial, because they make a lot more money,'' said Dr. Stephen Bergman, a professor of Psychiatry at Harvard Medical School, who under the pen name Samuel Shem documented his own experience as a psychiatry resident in the novel ''Mount Misery.'' The Yale appointment especially struck psychiatrists as a challenge to the profession. The Child Study Center has been led by psychiatrists, with one exception, for 50 years, and houses one of the handful of freestanding child psychiatry departments in the country. That the coveted post should be given to a psychologist stirred intense emotion among many psychiatrists, said Dr. David Fassler, a Vermont child psychiatrist who is chairman of the American Psychiatric Association's Council on Children, Adolescents and Families. Dr. David Kessler, the dean of Yale Medical School, said he had chosen the most distinguished candidate without regard to discipline. ''I have enormous admiration and respect for child psychiatrists,'' Kessler said. ''We have to get past this notion that there is only one discipline that can have leadership for the future of our children. If anything, that's the antithesis of what the child study center has stood for.'' Fassler said the letters of protest were a visceral reaction to a particular decision and should not be construed as a broad statement about the relationship of the two professions. ''This isn't really about divisions between psychology and psychiatry,'' Fassler said. ''I think it has more to do with people's personal and emotional connections to the Child Study Center.'' But Dr. Herb Sacks, who wrote his own letter of protest, said that when Yale announced the decision in early March, larger tensions were in the air. The appointment of a psychologist ''sent a frisson down the spines of American child psychiatrists and psychiatrists. We had just come away from the New Mexico situation,'' said Sacks, a clinical psychiatrist at the Yale Child Study Center and former president of the APA. ''There was great alarm, great concern. None of these letters obviously would effect a change, but it really put on the record the anguish of American psychiatry at the appointment of a psychologist.'' The New Mexico decision, which was made public on March 5, gave psychologists in that state a right enjoyed only by physicians: the right to prescribe medication. That role has grown only more important in recent years as medication has become a bigger part of mental health care. Governor Gary Johnson granted psychologists a limited right to prescribe after 450 hours of training and two years working under the supervision of physicians. The APA lobbied aggressively against the move, an effort that had failed in 14 states before it passed in New Mexico, according to the APA. Opposite them were state and national psychological associations. Harding called the bill ''the result of a cynical, economically motivated effort by some elements of organized psychology to achieve legislated authority without benefit of medical education and training.'' Although widespread prescribing rights for psychologists are still a distant prospect, such a change would severely limit psychiatrists' earnings, said John Klein, who edits Psychotherapy Finances, an independent newsletter for behavioral health practitioners. Psychiatrists are paid significantly more than psychotherapists; when paid out-of-pocket they get a median fee of $132 per 45-minute session for therapy, compared with psychologists' $100. When reimbursed by managed care they receive $95 an hour to psychologists' $70 an hour. In addition, licensed psychologists outnumber psychiatrists more than 2 to 1 in this country, numbering about 100,000 compared with 40,000, Klein said. If psychologists ever gain broad prescribing rights, ''it will render psychiatrists a kind of sideline boutique profession,'' Klein said. By eliminating referrals to psychiatrists for prescription purposes, psychologists are ''hoping they can be one-stop shopping for insurance and managed care professions.'' Psychological associations have predicted a domino effect, and eleven other states - among them Georgia, Louisiana, Illinois, Tennessee, Hawaii, Arizona, Alaska, and Tennessee - have put similar laws in the pipeline, said Marlin Hoover, president of the Illinois Psychological Association. Connecticut psychologists expect to have draft legislation by next year's legislative session, said Michael Schwarzchild, who heads the Connecticut Psychological Association. ''Prescribing is the last bastion, the last area in which psychiatrists have a monopoly in the mental health field,'' said Ray Fowler, former president of the American Psychological Association. ''They'll fight us on every front, because this is a life-and-death situation for them.'' Fowler has had front-row seats to previous skirmishes between the professions. In the 1980s, as president of the association, he met once a year for a weekend with his counterpart from psychiatry, as well as representatives from the nursing and social work fields. But toward the end of the decade, they saw their common ground shrinking away and canceled the weekend tradition. ''Finally the nurses and the social workers said, `We don't want to go to dinner with you people. It's too tense.''' This story ran on page A1 of the Boston Globe on 6/1/2002. � Copyright 2002 Globe Newspaper Company. http://www.boston.com/dailyglobe2/152/nation/Psychiatrists_fight_blurring_of_line_with_psychologists+.shtml __________________________________________________ Do You Yahoo!? Yahoo! - Official partner of 2002 FIFA World Cup http://fifaworldcup.yahoo.com
