Predictors of graduate student attitudes toward prescription privileges for psychologists

Predictors of Graduate Student Attitudes towardPrescription Privileges for Psychologists

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Kristen A. Luscher

University of Georgia

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William R. Corbin

University of Texas at Austin

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Jeffrey A. Bernat, Karen S. Calhoun, and Lily D. McNair

University of Georgia

The issue of gaining prescription privileges and its potential impact on thefield of clinical psychology has special relevance for graduate students.This study was designed to investigate clinical graduate students’ atti-tudes toward prescription authority, identify salient variables that contrib-ute to these attitudes, and ascertain preferred models of training. Only42.5% of respondents personally desired to obtain prescription privilege,although 61.8% of respondents favored efforts of the American Psycho-logical Association to acquire prescription authority. Proponents and oppo-nents were compared on their ratings of positive and negative aspects ofthe debate. There was strong agreement that the training should not bepredoctoral and that it should lead to board certification. The strongestpredictors of graduate students’ attitudes were concerns about fundamen-tal change to the field, malpractice premiums, and whether they consid-ered it a logical extension of the field. This study provides a framework forunderstanding important factors influencing the decision-making processamong clinical psychology graduate students. © 2002 Wiley Periodicals,Inc. J Clin Psychol 58: 783–792, 2002.

Keywords: prescription privileges; graduate students; attitudes

Correspondence concerning this article should be sent to: Kristen A. Luscher, LSUHSC Assessment Center,P.O. Box 97527, 15200 Scenic Highway, Baton Rouge, LA 70874.

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 58(7), 783–792 (2002) © 2002 Wiley Periodicals, Inc.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.2008

Increasingly, the issue of prescription privileges for psychologists has become the focusof national attention. The earliest study examining attitudes toward prescription privi-leges (Bascue & Zlotowski, 1981) found that the majority of clinicians surveyed did notpersonally desire the right to prescribe (58% against, 36% for, 6% unsure). However, amajority favored the right for younger psychologists, with younger psychologists express-ing more favorable attitudes than older ones. Subsequent studies have produced mixedresults, but have begun to show a trend toward favoring prescription privileges, withsupport ranging from 52 to 68% (American Psychological Association, 1995; Boswell &Litwin, 1992; Chatel, Lamberty, & Bieliauskas, 1991; Youngstrom, 1991). Moreover,Williams and Cantor (1998) reported that 52% of psychology interns would seek privi-leges if they were available whereas only 32% of internship directors would do the same.Although individuals may not personally desire the right to prescribe, there does appearto be a general trend supporting the attainment of prescription authority (Gutierrez &Silk, 1998).

Despite growing support for prescription authority, a clear consensus has yet to bereached about the direction the field should take on the issue. Arguments often cited byproponents include the natural evolution of the field (Brentar & McNamara, 1991; Fox,1988), improved mental health care for consumers (Adams, 1986; Fox, 1988; Pachman,1996), and the need for psychology to protect its market (DeLeon, 1992). Opponentsexpress concern about the redefinition of the profession (DeNelsky, 1991; Hayes &Heiby, 1996; Moyer, 1995), the difficulty associated with acquiring appropriate training(DeNelsky, 1996; Evans & Murphy, 1997; Riley, Elliot, & Thomas, 1992), and thesubstantial cost of acquiring these rights legally (Bell, Digman, & McKenna, 1995;DeNelsky, 1991, 1996).

In most cases, the average age of those responding to previous surveys was 40 yearsor older. However, the group most likely to be affected is future psychologists. Someevidence has emerged that younger psychologists may hold more favorable attitudes thendo older psychologists (e.g., Evans & Murphy, 1997). Ax, Forbes, and Thompson (1997)compared the attitudes of interns and directors of training and found that the majority ofinterns reported a willingness to seek training to prescribe whereas only one third ofdirectors would do so. To date, only a few studies investigating attitudes of graduatestudents have been published (Ax et al., 1997; Tatman, Peters, Greene, & Bongar, 1997;Williams & Cantor, 1998), with all reporting generally favorable attitudes. Taken together,studies of graduate students’ attitudes have not assessed their reasons for endorsing thistrend or what they would see as appropriate training models.

The present study attempts to further understand clinical psychology graduate stu-dents’ attitudes toward prescription authority. The purpose was threefold: to replicatestudies of general attitudes (with students expected to be generally favorable), to examinesalient variables that might predict graduate students’ attitudes, and to investigate atti-tudes toward future training in an effort to delineate the training model preferred bygraduate students.

Method

Participants

Questionnaires were mailed to 70 Directors of Clinical Training at American Psycholog-ical Association (APA)-accredited (full, provisional, or probationary) doctoral programsin clinical psychology, selected randomly from the APA Graduate Training Handbook.Fifty were Ph.D. programs, and 20 were Psy.D. programs. Each set of questionnaires was

784 Journal of Clinical Psychology, July 2002

accompanied by a letter explaining the purpose and voluntary nature of the survey, limitsof confidentiality, directions for administering the questionnaires to program students,and a stamped, addressed return envelope. Completed questionnaires were apparentlyreturned from 50% of total potential respondents (in 48 PhD and 8 PsyD programs).

Respondents were 421 graduate students who returned the questionnaire. The aver-age age was 28.6 (SD � 5.9) years; 68.9% were female and 31.1% were male; 88.4%were Caucasian, 4.5% were African American, and the remaining participants were ofAsian, Latino, or “other” ethnic status. The predominant theoretical orientation of re-spondents was cognitive-behavioral or behavioral (47.0%), followed by eclectic (22.1%),psychodynamic (17.8%), and systems or interpersonal (11.4%). A significantly greaternumber of females participated, consistent with the gender composition of current grad-uate school programs.

Measure

Participants were asked to complete a 16-item questionnaire assessing attitudes aboutprescription privileges for psychologists. Item creation was guided by issues currentlyraised in the field in an attempt to query participants on relevant aspects of the debate.Respondents were asked to indicate on a 5-point Likert scale their opinion regardingprescription privileges for psychologists in general as well as their personal desire toobtain these rights. (See Appendix 1 for questionnaire.)

Participants also were asked to evaluate four potential positive consequences andfour potential negative consequences of psychologists attaining prescription privileges.In addition, respondents were asked to rank order the four positive aspects of obtainingprescription privileges from 1 (most positive) to 4 (least positive) and the four negativeaspects of obtaining prescription rights from 1 (most negative) to 4 (least negative).

Finally, participants were asked to rank order five potential training methods thatmight be used if prescription rights were granted (i.e., predoctoral training, postdoctoraltraining, professional school training, specialized training leading to board certification,and combined medical and PhD degree) from 1 (most desirable) to 5 (least desirable).

Additional questions assessed students’ knowledge of the debate about prescriptionprivileges and knowledge of the position of the APA in this debate. Finally, several demo-graphic items assessed age, gender, race, type of degree, theoretical orientation, and yearin graduate school.

Results

Attitudes toward Prescription Privileges

With respect to psychologists’ right to prescribe, 55.1% agreed or strongly agreed thatpsychologists should have this right, 28.6% disagreed or strongly disagreed, and 15.7%expressed neutral opinions. With respect to whether clinical psychology students wouldpersonally desire the right to prescribe, 42.5% either agreed or strongly agreed, 38.5%either disagreed or strongly disagreed, and 18.3% expressed neutral opinions. When askedif APA should push for prescription privileges, 61.8% supported such action, 29.7%opposed such action, and 6.4% were undecided.

Subsequent analyses used percentages obtained from the question, “Should APAsupport the push for prescription privileges?” (yes or no) to identify proponents andopponents, as the endorsement of action on the part of the APA signifies a greater desireto promote change. Demographic analyses showed gender as the only significant variable

Attitudes toward Prescription Privileges 785

differentiating opponents from proponents, with men more likely to favor prescriptiverights than women, F(1,383) � 7.880, p � .01. No differences were found for age, race,year in school, theoretical orientation, or type of degree the student was working towardusing ANOVA or the Wilcoxon nonparametric test.

Respondents favoring prescription privileges generally believed that APA also favoredthe attainment of prescription authority whereas respondents opposed to prescriptionprivileges generally believed that APA did not favor such privileges, �2(4, n � 408) �55.95, p � .000. As such, it appears that respondents generally assumed that APA’s posi-tion on prescription privileges was congruent with their position.

To determine the basis of students’ opinions on prescription rights, participants wereasked to rank order the four fixed positive alternatives and four fixed negative alterna-tives. Among the four fixed positive alternatives, the belief that psychologists are bettertrained than other professionals in psychological theory was endorsed as the strongestpositive reason, with 44.9% of the total sample ranking it as the most positive reason.Among the four fixed negative alternatives, the belief that the field of psychology wouldbe fundamentally changed was cited as the strongest negative consequence of prescrip-tion privileges, with 56.3% of the total sample ranking it as the most negative alternative.

Table 1 summarizes the frequency responses for positive and negative alternativesrelated to prescription privileges. Proponents and opponents did not differ significantly inresponse to the most positive alternative, as both groups believed that psychologists arebetter trained than other professionals in psychological theory. An individual analysis ofeach additional fixed positive alternative revealed that a significantly greater proportionof proponents than opponents endorsed the belief that “prescription privileges are a log-ical extension of the field” as most positive, �2(3, n � 376) � 21.75, p � .001, whereas

Table 1Chi-Square Frequency Analyses of Positive Aspects, Negative Aspects,and Appropriate Training Models for Prescription Privileges

Position

Proponents Opponents Total Sample

Positive AspectsPsychological Training 44.7% 48.3% 376Logical Extension 38.9% 22.7%** 377Reduced Overprescription 13.6% 22.1%* 379Competition with Other Fields 5.8% 6.7% 376

Negative AspectsFundamental Changes 45.7% 75.0%** 382Malpractice Premiums 26.0% 10.5%** 382Proper Training Method 17.1% 14.5% 382AMA Opposition 9.3% 3.3% 381

Training MethodBoard Certification 54.8% 33.6%** 408Postdoctoral 27.0% 24.8% 407Professional School 2.3% 2.5% 407Predoctoral 14.3% 8.2%** 408M.D./Ph.D. 1.5% 32.5%** 406

*p � .01; **p � .001.


a significantly greater proportion of opponents than proponents endorsed “availability ofnon-medical approaches would make psychologists less likely to overprescribe” as beingthe most positive alternative, �2(3, n � 379) � 14.58, p � .01. Proponents and opponentsdid not differ on the belief that psychologists must gain prescription rights to competewith other fields. Both groups ranked this as least important.

Although both groups ranked the belief that prescription authority would fundamen-tally change the field of clinical psychology as the most important negative alternative, asignificantly greater proportion of opponents than proponents endorsed this reason as themost negative, �2(3, n � 382) � 33.66, p � .001. In addition, an individual analysis ofeach additional fixed negative alternative revealed that a significantly greater proportionof proponents than opponents endorsed that prescription privileges would lead to increasedmalpractice premiums, �2(3, n � 382) � 25.88, p � .001. Proponents and opponents didnot differ on the belief that prescription privileges would deplete APA resources to fightthe opposition by the American Medical Association or that selecting a proper trainingmodel would be difficult.

Attitudes toward Training Models for Prescription Privileges

Respondents were asked to rank order, from most to least desirable, five proposed mod-els for training psychologists to prescribe. These included specialization training lead-ing to board certification, postdoctoral training, professional school training, predoctoralspecialization, and MD/PhD training. The majority of respondents (47.3%) endorsedthe board certification process as the most desirable. Using frequency analyses, propo-nents and opponents were compared to determine whether differences in training pref-erences existed. Although both groups rated specialization training for board certificationas the most desirable training method, a significantly greater proportion of proponentsthan opponents endorsed this method as the most optimal, �2(8, n � 408) � 26.51, p �.001. A significantly greater proportion of opponents preferred the M.D./Ph.D. trainingmethod, �2(8, n � 408) � 120.74, p � .001. More proponents than opponents preferredthe predoctoral training method, �2(8, n � 408) � 54.76, p � .001, although this alter-native was endorsed by very few in either group. No other significant differences inpreferred training methods emerged. Overall, respondents supporting prescription priv-ileges indicated that board certification was most desirable, followed by postdoctoraltraining. Although not statistically significant, those opposed to prescription privilegestended to favor board certification as the most preferable training method, followedclosely by the M.D./Ph.D. option.

Predicting Prescription Privilege Attitudes

Five variables were entered in a backward logistic multiple regression procedure topredict prescription privilege attitudes among graduate students since the criterion vari-able was dichotomous in nature. Predictor variables included (a) gender, (b) responsesto the negative alternative regarding malpractice premium, (c) responses to the negativealternative regarding fundamental change to the field, (d) responses to the positive al-ternative regarding logical extension, and (e) responses to the positive alternative re-garding superior psychological training of psychologists. Given that gender was theonly demographic variable on which participants differed, it was included in the regres-sion model to determine whether it contributed significantly to students’ attitudes. Thepositive and negative variables were those alternatives endorsed most strongly. The cri-


terion variable used in this analysis was graduate students’ responses indicating theirposition on prescription authority.

Classification results for the regression model are reported in Table 2. Logistic regres-sion results yielded a significant model, �2(3, n � 376) � 53.352, p � .001, for theprediction of graduate students’ attitudes toward prescription privileges, with responsesto the logical extension to the field, responses regarding concerns about malpracticepremiums, and responses related to fundamental changes in the field as significant pre-dictors. Responses related to gender and to training in psychological theory and treatmentdid not contribute significantly to the prediction of graduate students’ attitudes towardprescription privileges.

Discussion

There does not appear to be a consensus regarding prescription privileges among clinicalpsychology graduate students. Although the majority of respondents indicated that theythought psychologists should be allowed to prescribe, less than half indicated that theypersonally desired these rights. In fact, nearly as many participants indicated that they didnot desire such privileges, and a relatively large proportion of respondents (15.0–18.3%)had yet to reach a conclusion on this issue. A possible explanation for the opposition orreluctance to support prescription authority may be related to the fact that such rightswould substantially change the current graduate curriculum, and possibly considerablylengthen graduate training.

Various questions have been raised in this ongoing debate, with several of theseissues examined in this study. The potential struggle with the medical profession, findingthe best training methods, increased malpractice premiums, concerns about the ability ofpsychologists to prescribe adequately, and the need for psychologists to remain compet-itive are examples of such issues. Though these pragmatic concerns raise many importantquestions that may need to be addressed in the future, they do not appear to be the mostimportant factors influencing participants’ attitudes toward prescription privileges. Theresults of this study suggest that the most central issue individuals considered in makinga decision was related to the impact prescription privileges would have on the professionof psychology. Both proponents and opponents appear to share similar views. Most par-ticipants believed that obtaining prescription rights would alter the direction of psychol-ogy and would lead to increased malpractice rates. However, most respondents also believedthat psychologists, who are better trained than other health care providers in psycholog-ical theory, have strong credentials that warrant the right to prescribe. Moreover, formany participants, the push for prescription privileges appears to be the next logical step

Table 2Summary of Logistic Backward Regression Analysis for Variable Predicting GraduateStudents’ Attitudes toward Prescription Privileges (n � 376)

Variable B SE Wald R Odds Ratio p

Fundamental Change .694 .189 13.48 .180 16.998 .001Logical Extension �.342 .156 4.79 �.089 4.853 .03Malpractice Premiums �.385 .149 6.63 �.114 6.796 .01

Note. Total Equation, �2 � 53.352, p � .001. Variables excluded in the final equation were Psychological Training and Gender.


toward the professional development of psychology (Brentar & McNamara, 1991; Fox,1988).

Although both proponents and opponents are concerned about the impact prescrip-tion privileges would have on the profession, they appear to hold different views on theunderlying reasons for seeking prescription authority. Proponents believe prescriptionprivileges are a logical extension of the field whereas opponents believe that psycholo-gists with prescription authority would be less likely to overprescribe.

In regard to opinions about the most appropriate training methods to equip psychol-ogists with the appropriate skills, there was agreement between opponents and propo-nents that board certification was best, with those supporting prescription privileges morestrongly in favor of this option. Opponents were split between board certification andM.D./Ph.D. training and were much more in favor of the latter option than were propo-nents. In fact, this may be related to their opposition—the concern that the requiredtraining would significantly alter clinical psychology training. It is clear that respondentsdid not favor extending predoctoral training to include prescription training. (Even amongproponents, fewer than 15% endorsed this option.) Regardless, the issue of appropriatetraining continues to remain under debate within the field.

Although many aspects of the debate were considered in the attempt to determinefactors underlying the opinions of graduate students, only limited conclusion about pre-dictors can be drawn. Factors that have been repeatedly cited as germane to the ongoingdebate were included in this study in an attempt to delineate significant contributors ingraduate students’ attitudes. However, other pertinent variables contributing to graduatestudents’ attitudes toward prescription privileges may not have been captured in the scopeof this study.

Considering that future psychologists will be significantly more affected by deci-sions made regarding prescription authority than currently practicing psychologists(Lorion, 1996) and that they are far from unanimous in their support, this population’sperspective is clearly important to consider. The field of psychology will no doubt con-tinue to be faced with this ongoing debate, with the implications having a particular effecton future psychological treatment regimens. This is, therefore, a timely matter that war-rants continued investigation.

Future research in this area should include a more detailed analysis of factors thathave influenced the attitudes of graduate students. For instance, Pimental, Stout, Hoover,and Kamen (1997) found that individuals who were given more information on the topicwere better able to formulate a conclusion about the issue of prescription rights. In thefinal analysis, however, the argument concerning prescription authority is based less onpragmatics and more on the history and tradition of psychology and the possibility ofmoving away from that tradition. These central issues warrant further examination aspsychologists consider the far-reaching implications of prescription privileges.

Appendix

Prescription Privileges QuestionnaireA. Respond to the following questions using this scale

1 2 3 4 5Strongly Agree Agree Neutral Disagree Strongly Disagree

Psychologists should have the legal right to prescribe medication. ________

I personally desire the legal right to prescribe medication. ________


B. There are advantages and disadvantages to psychologists obtaining prescriptionprivileges. In your opinion, which aspects do you consider to be the most positiveand the most negative.

Rank each list from 1 to 4.Positive Aspects: (1 � most positive; 4 � least positive)

_____ Prescription privileges are a logical extension of the field and in somecases psychologists may need drugs to properly treat their patients.

_____ Most psychologists are more intensively trained in psychological theoryand treatment psychiatrists, therefore, prescription privileges allow for more thor-ough treatment.

_____ Due to the other treatment approaches available to clinical psychologists,they may be less likely to overprescribe medication.

_____ In order to protect its market, psychology has no choice but to movetowards gaining the legal right to prescribe medication.

Negative Aspects: (1 � most negative; 4 � least negative)

_____ Malpractice premiums would increase dramatically for all psychologists,not just those prescribing medication.

_____ The field of psychology might take on fundamental changes, becoming amore medical field. Certain core concerns of psychology may be lost in thetransition.

_____ Deciding on a proper method of training would be difficult.

_____ It may not be worth using resources to fight the opposition of the AMAregarding prescription privileges when such resources might be used more effec-tively elsewhere.

C. What do you believe APA’s position is on prescription privileges for psychologists?________ For ________ Against

Should APA support the push for prescription privileges for psychologists?________ Yes _________ No

If you believe that psychologists should have the right to prescribe medica-tion, should psychologists have full prescription privileges, limited prescrip-tion privileges, or should the privileges be similar to the nurse practitionermodel (psychologist makes a diagnosis and has a physician sign the prescrip-tion)? _______________________

D. Rank order the following choices of training methods for prescription privilegesfrom 1 to 5 (1 � most desirable).

_____ A one- to two-year postdoctoral training program where clinical psychol-ogists can obtain intensive training in psychopharmacology.

_____ A professional school that focuses primarily on the clinical aspects oftraining. Included in this training would be didactic work and direct, supervisedexperience prescribing medication (Professional School).

_____ A specialization at the predoctoral level similar to that of Neuropsychol-ogy. The student would receive roughly one extra year of intensive study in psy-chopharmacology and one year of intensive internship focusing on prescribingmedication (Predoctoral).


_____ Psychopharmacological treatment, including course work and practica,should be handled as a subspecialty of clinical psychology, with training at anylevel (predoctoral, internship, postdoctoral). Completion of the program, intern-ship, and board certification would have to occur (Board Certification).

_____ Psychologists who want prescription privileges need to obtain both a Ph.D.in clinical psychology and a medical degree (M.D./Ph.D.).

References

Adams, D.B. (1986). A prescription for psychologists. Georgia Psychologist, 39, 13–15.

American Psychological Association. (1995). APA telephone survey of APA members. (Availablefrom Practice Directorate, APA, 750 First St., N.E., Washington, DC, 20002– 4242).

Ax, R.K., Forbes, M.R., & Thompson, D.D. (1997). Prescription privileges for psychologists: Asurvey of predoctoral interns and directors of training. Professional Psychology: Research andPractice, 28, 509–514.

Bascue, L.O., & Zlotowski, M. (1981). Psychologists’ attitudes about prescribing medication. Psy-chological Reports, 48, 645– 646.

Bell, P.F., Digman, R.H., & McKenna, J.P. (1995). Should psychologists obtain prescribing privi-leges? A survey of family physicians. Professional Psychology: Research and Practice, 26,371–376.

Boswell, D.L., & Litwin, W.J. (1992). Limited prescription privileges for psychologists: A 1-yearfollow-up. Professional Psychology: Research and Practice, 23, 108–113.

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Chatel, D.M., Lamberty, G.J., & Bieliauskas, L.A. (1991). Prescription privileges for psycholo-gists: A professional affairs committee survey of Division 40 members. The Clinical Neuro-psychologist, 7, 190–196.

DeLeon, P.H. (1992). Prescription privileges: An evolving consensus. The Independent Practi-tioner, 12, 169–171.

DeNelsky, G.Y. (1991). Prescription privileges for psychologists: The case against. ProfessionalPsychology: Research and Practice, 22, 188–193.

DeNelsky, G.Y. (1996). The case against prescription privileges for psychologists. American Psy-chologist, 51, 207–212.

Evans, G.D., & Murphy, M.J. (1997). The practicality of predoctoral prescription training for psy-chologists: A survey of directors of clinical training. Professional Psychology: Research andPractice, 28, 113–117.

Fox, R.E. (1988). Prescription privileges: Their implications for the practice of psychology. Psy-chotherapy, 25, 501–507.

Gutierrez, P.M., & Silk, K.R. (1998). Prescription privileges for psychologists: A review of thepsychological literature. Professional Psychology: Research and Practice, 29, 213–222.

Hayes, S.C., & Heiby, E. (1996). Psychology’s drug problem: Do we need a fix or should we justsay no? American Psychologist, 51, 198–206.

Lorion, R.P. (1996). Applying our medicine to the psychopharmacology debate. American Psychol-ogist, 15, 219–224.

Moyer, D.M. (1995). An opposing view on prescription privileges for psychologists. ProfessionalPsychology: Research and Practice, 26, 586–590.

Pachman, J.S. (1996). The dawn of a revolution in mental health. American Psychologist, 51,213–215.


Pimental, P.A., Stout, C.E., Hoover, M.C., & Kamen, G.B. (1997). Changing psychologists’ opin-ions about prescriptive authority: A little information goes a long way. Professional Psychol-ogy: Research and Practice, 28, 123–172.

Riley, W.T., Elliot, R.L., & Thomas, J.R. (1992). Impact of prescription privileging on psychologytraining: Training director’s survey. The Clinical Psychologist, 45, 63–70.

Tatman, S.M., Peters, D.B., Greene, A.L., & Bongar, B. (1997). Graduate students’ attitudes towardprescription privileges training. Professional Psychology: Research and Practice, 28, 515–517.

Williams, L.L., & Cantor, J. (1998). The right to prescribe: Important considerations and facts. TheAmerican Psychological Association of Graduate Students, 10, 16–18.

Youngtrom, N. (1991, March). Membership poll supports prescribing. APA Monitor, 22, 20.


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Predictors of graduate student attitudes toward prescription privileges for psychologists