RxP and the Federal Bureau of Prisons: The time is right
By Robert K. Ax, PhD
In 1982, during our first week at Norristown State Hospital, my fellow interns and I were given a tour of the grounds. Particularly memorable were a number of vacant buildings, mute testimony to the continued downsizing of the nation's public mental health system. Our guide pointed out one structure in which fires were periodically set so the local fire department could practice. The year after I finished, the residential substance abuse treatment program was closed, despite its impressive treatment record. Several years after that, the internship program itself was terminated. Such was deinstitutionalization.
Meanwhile, the prison business was booming. In particular, the Federal Bureau of Prisons (BOP), once home to a select group of criminals (traitors, kidnappers, bank robbers, interstate-flighters), was becoming the single largest prison system in the country as street crime was federalized and the total prison-jail census approached 2 million. After all, drug addicts and seriously mentally ill persons still needed a place to go.
I went to work for the BOP, saw the light, i.e., the potential public health benefits of prescriptive authority (RxP) for prisoner and other underserved patient populations, and became a proponent. By 1995, the movement was gathering momentum: The Department of Defense (DoD) had a cadre of prescribing psychologists, several states had started legislative initiatives, and the APA Council of Representatives was soon to endorse RxP as policy. As an internship training director, I got curious about what interns and my counterparts in other programs thought of the issue. They were, respectively, individuals whose futures might be largely bound up with RxP, and mentors who would presumably have an impact on how their trainees viewed the prospect. So with approval from the agency's IRB, a group of us sent out a Likert-scale survey inquiring about interns' and DODs' attitudes toward prescriptive authority: Support or not? Why or why not? Personally interested or not? Fairly tame stuff, we thought. Not so.
Melvin Sabshin, MD, then the Medical Director of the American Psychiatric Association, in a letter dated Dec. 21, 1995 and addressed to U.S. Attorney General Janet Reno, objected to the survey on behalf of his organization, and requested “your review of the matter and the termination of any such activities related to psychologist prescribing.”
Yet prospects for the survey remained surprisingly bright. In responding (letter of Feb. 21, 1996), Thomas R. Kane, assistant director of the BOP for Information, Policy and Public Affairs, noted, “We have reviewed the project and find no cause to terminate it ... We, as an agency, must proactively think through just how limited prescription privileges would impact current Bureau policies, procedures, and training.”
They soon found a cause. According to the AAP Advance (1996), Sabshin wrote a second letter (which I have never seen), and shortly thereafter the agency reversed its position. Our group was ordered to cease and desist from all activities related to the survey on agency time and strip the raw data from the department computer. Long story short, we finished the project on our own time and with a home computer, and eventually published the results (Ax, Forbes, & Thompson, 1997) without agency affiliation. The BOP has not gone near RxP in any meaningful way since then, despite its growing inmate census: 3.6 percent annual growth rate from 2000-12, down just 0.9 percent from 2012 to 2013 (Glaze & Kaeble, 2014).
To put all this in perspective, understand that government agencies are largely reactive entities. They have limited latitude to shape their missions, set their budgets, or write the rules and regulations under which they operate. Over the last several decades, prisons and jails have been tasked with accommodating increasing numbers of individuals with a range of health problems for longer periods of time. Accordingly, this is not a criticism of the BOP, whose attempt, however tentative, at an affirmative approach to patient health care fell victim to guild interests.
Rather, it is a call to our professional organization to take action. The BOP needs organized psychology's functional support — not mere cheerleading — to authorize prescribing psychologist positions in their facilities. It cannot simply depend on grassroots advocacy from within the agency, in the face of predictable pushback from the usual suspects, including some of our own colleagues. APA, and not just the Practice Directorate, should lead on the issue. All oars must get in the water: the other directorates, APAGS, the Council of Representatives and APAPO. Just as Heather Kelly, PhD, of the APA staff has admirably collaborated with Rep. Beto O'Rourke to craft a bill implementing RxP in the Department of Veterans Affairs, another staffer should be tasked with identifying one of our elected “mass incarceration” reducers willing to introduce a similar bill on Capitol Hill. Even a DoD-type demonstration project would be welcome. (I would further note, in the spirit of collaborative health care and optimizing human resources, that I also support the appropriate expansion of other nonphysician providers' scopes of practice, including nurse practitioners and physician assistants.) Yeah, it's a big wish list. So what?
It's also a great opportunity for organized psychology to help address an ongoing public health concern. The BOP continues to employ large numbers of doctoral-level psychologists. The agency wants good psychologists: It has 13 internship programs, 11 of which are APA-accredited. These programs were set up as recruitment vehicles. I believe some of those in the BOP Central Office — and many more in the field — would like to see RxP become a reality in the agency, but don't feel they can touch what they see as a political third rail. (I would bet similar pressures have contributed to skittishness among the VA psychologist ranks, too.) From all indications, RxP will soon be implemented on a large scale in the Illinois Department of Corrections, subsequent to the passage of the law in 2014. The time is right for RxP in the BOP and other American prison systems and jails. It has been the right time for 20 years.
AAP Advance. (1996, Summer). Psychiatry continues to meddle in psychology's internal affairs, p. 7. Colorado Springs, CO: Author.
Ax, R. K., Forbes, M. R., & Thompson, D. D. (1997). Attitudes of psychology interns and directors of internship training toward prescription privileges for psychologists. Professional Psychology: Research and Practice, 28, 509-514.
Glaze, L. E., & Kaeble, D. (2014, December). Correctional populations in the United States, 2013 (Bureau of Justice Statistics Special Report, NCJRS 248479). Retrieved from: http://www.bjs.gov/content/pub/pdf/cpus13.pdf