Maintaining Dual Identity as Prescribing Psychologist at a Family Practice Clinic   By Stuart Kelter, Ph.D., Las Cruces
After starting my practicum at a family practice clinic and residency program, I wondered if it would be possible to retain my identity as an outpatient psychologist, while acquiring a new one as a prescriber of psychoactive medications. I had already faced a similar clash, when accepting a staff position at Las Cruces Public Schools as a school psychologist, after doctoral training and three years as a clinical psychologist in Chicago and Boston. In the schools, I found that I was able to provide parents and teachers with clinical insights, calling on my years of experience doing child and family therapy. It was gratifying to be able to provide clinical guidance to parents about the full range of their child’s issues, both at school and at home. Would I be able to do something similar in my new role as prescribing psychologist?   As a primary care setting, the family practice clinic is palpably different both from the schools and my private practice office. The atmosphere is undeniably medical. The examining rooms are spare, with medical posters on the walls, awash in the glare of fluorescent lighting. All students at the clinic, including the psychologists, are required to wear lab coats. Clearly, the shift of identity is, at least at first, from the outside in.    The family practice clinic is staffed by twelve residents, several nurses, and four attending physicians. Being at a learning institution insures that the physicians and supervisors are kept abreast of the latest information about psychoactive medications and their side-effects. We routinely consider the relationship between medical and psychiatric illnesses — which sometimes intensify and complicate each other, or even masquerade as one another.   Taking a careful medical history and review of systems becomes an exercise in sleuthing and puzzle-solving in a more direct way than psychologists ordinarily are used to. It is not easy to do this efficiently, while also allowing time for the patient to express the emotional overlay to the medical history and symptoms.   These kinds of conundrums become especially evident when trying to help patients with a dual diagnosis of psychiatric and pain disorders, which almost always brings in a third problem: sleep. Which piece of information determines the treatment — the self-report of the patient, the cutting edge research of the subtle effects of various sleep aides on the various stages of sleep, or the clinical experience of the supervisor with the medication options? In the face of multiple options and imperfect information, the gray area of uncertainty threatens to become a fog of indecision. In moments like these, I am grateful that the New Mexico prescribing psychologist law mandates a clinical practicum in which to make the transition from a closely supervised provider to a more independent one.   Although it is still early in the practicum, with some 20 hours of patient contact, I see an optimistic “prognosis” for my professional identity integration. I am not expected to make a diagnosis in the first session, and conferring with multiple professionals is highly encouraged. Before prescribing Ritalin for a hyperactive first grader, for example, I had the time to consult by phone not only with the boy’s teacher, but also with the school’s speech pathologist — to investigate whether a language disorder might underlie his poor attention at school. In addition, I could make full use of psychological questionnaires, such as the Parent Stress Inventory™, to investigate parenting problems as a potential cause and/or result of the ADHD. In this boy’s case, I decided to prescribe medication, but I can foresee others in which medication is not part of the solution.   Although the primary purpose of the practicum is to learn about applied psychopharmacology, psychotherapy can still be the most important component in helping patients at the clinic, particularly if a long-standing medication regimen is only managing symptoms, without facilitating needed life changes. Hour-long intakes and half-hour follow-up interviews are the norm — enough time to establish a therapeutic rapport, to learn about the patient’s life, and to explore issues in addition to medication efficacy.   Tensions of dual identity formation will undoubtedly intensify as my caseload fills up, and there are days where multiple walk-in patients will vie for my time. I anticipate that, at those moments, I will be reminded of the kind of doctor-patient relationship I want to avoid as a prescriber. Regardless of the pressures to see more patients, regardless of the financial enticements to spend less time per patient, I will not give up the most cherished part of my psychologist identity — i.e., giving the person who is coming to me for help an opportunity to a relate both to me and to him or herself in a deep, honest, and unhurried manner.   I cannot help noticing that, throughout this article, I have used the word “patient,” rather than “client.” While it is true that this is how people coming for help are referred to at the family practice clinic, am I obligated to refer to them as such, even here? Somehow, it would feel strange to do otherwise. Yet, I expect that, once back in my private office, I will dispense with the uniform and see my “clients,” as I have before, but with a valuable addition to my tool chest.   For now, it seems important to accommodate to the medical setting, at least on the outside. I need to learn as much as I can from doctors and nurses who already prescribe, and gain confidence in my new skills. In time, the public will become more fully acquainted with prescribing psychologists and no doubt discern that we offer an alternative to the prevailing culture of so much of the medical world, in which “patients” wait for long periods of time to speak to their doctors, who almost always end the five or ten minute encounter with the dispensing of a medication.