Wednesday, June 06, 2007


Hawaii and Guantanamo -- combat zones for psychologists' wars

Hawaii and Guantanamo would seem to be polar opposites--one is a dream destination with pristine beaches and sunshine offering endless leisure opportunities, while the other is despised worldwide as the site of indefinite detention, sensory deprivation and illegal torture.

There is one area of overlap, however--both places are battlefields for psychologists' professional turf wars. In Hawaii, psychologists have struggled for several years to pass a bill giving them prescriptive authority--the right to prescribe psychotropic drugs. This year, with the aid of high-powered lobbying, a bill passed the state legislature for the first time and awaits the governor's signature or veto. In Guantanamo, it appears that psychologists may be assisting in the administration of mind-control medications and aiding the torture conducted by the US Government on detainees held there indefinitely.

The connection is scary. Psychologists are attempting to advance their profession as a scientific discipline in both places. Over a six-year period in the 1990s the military granted what psychologists and the American Psychological Association had long hoped for--the same prescriptive authority as psychiatrists. Perhaps in return, and casting the entire profession in an ethical cloud, psychologists have assisted the military with their interrogation program at Guantanamo and perhaps elsewhere.

Both the American Medical Association and the American Psychiatric Association have prohibited their members from participating in military interrogations. The APA has not. This should concern those who favor the Hawaii bill and are willing to overlook the lengths that the APA and many in the profession will go to in order to advance into fields that properly belong to medical science.

From last Friday's Democracy Now broadcast:

In 2005, the American Psychological Association convened a Presidential Task Force on Psychological Ethics and National Security that concluded psychologists' participation in military interrogations was "consistent with the APA Code of Ethics."

A February 2007 article in In These Times, Interrogations Behind Barbed Wire: Who’s to blame for America’s new torture techniques? describes the reaction of the APA to criticism:

The APA passed a resolution condemning torture last August, but pointed to the U.S. government’s reservations about the U.N. Convention Against Torture in their resolution. Those reservations claim that, “in order to constitute torture, an act must be specifically intended to inflict severe physical or mental pain or suffering.”

The article mentions also:

A leaked interrogation log, reported by Time magazine two years ago, reveals that a psychologist was present during an interrogation where the prisoner was made to perform dog tricks and given intravenous fluids to force him to urinate on himself.

More from the Democracy Now program:

Last year the Pentagon reportedly moved to only using psychologists, and not psychiatrists, to help in interrogations. Why? Because the American Psychiatric Association had adopted a new policy discouraging its members from participating in military interrogations. As did the American Medical Association. But their counterpart, the American Psychological Association, did not.

Who is administering drugs in Guantanamo? Why are the licenses of psychologists participating in torture and involuntary drugging not being pulled? Several Guantanamo detainees have described being drugged or finding drugs in their food. The reports are considered credible.

What's incredible is that if Hawaii allows psychologists to prescribe medications (only two states at present allow this), we will be complicit in enhancing the case that psychologists are prepared with training and ethical strength, to handle prescriptive authority. It's clear, from their role in Guantanamo and the stance of their professional organization, that this would be a mistake.

The suffering of Guantanamo prisoners may seem remote to Hawaii residents, but the effects of giving prescriptive authority to psychologists will be first felt right here, and we should work to prevent this from happening. The APA ethical standards would govern how Hawaii psychologists behave, and these standards appear to favor professional advancement over patient concerns.

After many unsuccessful years trying to push a bill through the Legislature, psychologists hired Alex Santiago as their lobbyist. Santiago served as the chairman of the Hawaii Democratic Party From April 2003 to June 2004. Clearly, he still wields some power with long-term legislators. As reported here in Disappeared News in April, HB 1456, the House version of the psychologist bill, was heard by the Senate CPH committee and failed on a vote, as in the past. A tipster reported that Santiago begged Senators to schedule the bill for another vote, and they complied, blindsiding the public by scheduling the vote with less than the required 48-hour notice, and perhaps even less than 24-hours notice. And this time it passed. A bill that died was thus resurrected. It should not have happened. Santiago seems to have earned his pay.

One person who testified at legislative committee hearings claimed that there were no complications after 10,000 prescriptions written by psychologists in the military program (paraphrase). I found that claim to be incredible. In that many prescriptions, regardless of who writes them, it would seem that some are likely to run into trouble. Drug therapy simply isn't that safe. I don't have data to back this up, but it was up to legislators to ask for the evidence and to challenge claims that were made for the military program and its relationship to the very different proposal for Hawaii.

Hawaii has a shortage of psychiatrists on Neighbor Islands. The problem is likely not going to be solved unless the issue of reimbursements for all physicians in rural areas is solved. We should not look upon psychologist's drive for prescriptive authority as a band-aid to cover up our health care problems in rural areas. Every citizen of the state deserves equal access to quality medical care, and the band-aid simply allows the wound to fester underneath. It also could put our elderly at risk.

The governor should veto this bill. It would condemn some Hawaii patients to second-class status, deserving only a lower level of medical care. Since psychologists would be allowed to prescribe from a very limited formulary, it would deprive those who  need different drugs of the opportunity to be treated properly. It splits citizens according to ability to pay--those who live in Hawaii Kai, for example, won't be affected--they'll continue to have their medications prescribed by physicians.

Let's face it--"when your only tool is a hammer," that is, when you are only allowed to prescribe certain drugs, we can be sure that those drugs will be applied instead of the more expensive, newer, or more appropriate drugs that are not in the formulary. That is why mental health advocates and others oppose the use of restrictive formularies in any setting. Most states now have laws requiring managed care organizations to disclose if they impose a restrictive formulary and to describe the procedure necessary to obtain non-formulary drugs. Hawaii, on the other hand, if this bill becomes law, would be imposing restrictions on the treatment of its poorest residents, and there would be no alternative procedures for them to get the prescriptions they might need.

Worse, since geriatric patients often have multiple drug needs and complicated interactions to their medications, this bill would, simply put, place them at risk of life-threatening complications. Would you want your elderly parents or grandparents to be seen by someone with limited training, no geriatric training at all, and without access to proper medicines? I don't think so.

Sometimes patients show up in emergency rooms, for example, presenting symptoms that might be mistaken for psychiatric illnesses, such as disorientation. It takes the skill of a doctor to recognize that the problem might be a physical, not mental, situation, such as a diabetic reaction, and to apply the appropriate care to save the patient's life. In the elderly also, physical problems may be dismissed as mental, with disastrous results. Doctors understand this. The limited training proposed in the bill now before the governor does not prepare psychologists to care for the elderly or to recognize physical ailments.

On the other hand, multi-disciplinary teams with psychologists, physicians, social workers and others are highly effective and widely used. Prescriptions are written by the doctors in consultation with the mental health professionals.

While the APA remains ethically challenged, Hawaii should not put patients at risk in order to advance professional aspirations of psychologists. Should the governor sign the bill, the APA will use our example to push for prescriptive authority in other states. Our citizens should not be made into pawns in this struggle.

Call the governor at 808-586-0034 or fax her at 808-586-0006 and ask her to veto SB1004, the bill granting psychologists prescriptive authority.


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