Lieutenant Commander Michael R. Tilus, PsyD, MSCP
U S Public Health Service
Director, Social Services & Mental Health Programs
Spirit Lake Health Center
Fort Totten, ND 58335

DISCLAIMER: The opinions expressed in this article do not necessarily reflect the official position of the U.S. Public Health Service or the Indian Health Service.

U S Public Health Service Prescribing Psychologist: Responding to the Grassroots Need for Access to Quality Mental Health Care

Prescribing psychologists (PP) have an opportunity to answer the call to support America’s health responders through the U.S. Public Health Service (USPHS) Commissioned Corps. Driven by the grass roots emergence of the social shift in primary care, a growing number of psychologists within both the USPHS Corps Officers and federal civilians are gaining prescriptive authority while serving their various state and federal service regions.

Prescribing psychologists are doctoral level psychologists with certified post-doctoral training programs, or a completed Masters of Science degree in Clinical Psychopharmacology. New Mexico and Louisiana state statues differ, but generally, requirements include a medical practicum of 80-hours, passing a national norm based test, completing a physician supervised one year long 100-patient preceptorship, before applying for state license. Prescriptive psychologists embed their independent psychotropic prescriptive authority within a psychologically based treatment model.

Psychologists with prescriptive authority increase access to the highest quality care for all Americans, including isolated, remote, medically underserved or unserved populations. Prescribing psychologists are highly trained behavioral scientists and practitioners who potentially bring a wider array of therapeutic “tools” for health and wellbeing than other behavioral health disciplines. Appropriately trained and licensed prescribing psychologists, working in a collaborative fashion with physicians and other medical and behavioral health professionals, act as a “combat mission multipliers” (an apropos military metaphor meaning to provide increased help and support).

The USPHS Commissioned Corps is an elite, specially qualified team of more than 6,000 highly trained, discipline-driven, public health professionals dedicated to the mission of protecting, promoting, and advancing the health and safety of our Nation. Many of these officer clinicians and their families have chosen to devote their personal and professional life to service with isolated, remote, and medically underserved populations. Such a mission demands steadfastness, heart, courage, and tenacity. As any veteran will tell you after serving on the front lines (behavioral health included), the Marine Corp pragmatic motto of “improvise, adapt, and overcome” is more than a slogan for military operations. It is an unwritten but operant axiom for providing clinical services in isolated areas or disaster responses with few resources. In such places, a psychologist with prescriptive authority can especially be a critical Mission Resource Multiplier. Such an important resource supports a military commander or medical director’s efforts to maintain a high standard of patient care despite limited infrastructure assets, funding, and perennial personnel shortages.

Force Multipliers: The Bottom Line!

What’s the bottom line? Properly trained and licensed prescribing psychologists are valuable, professional personnel resources that increase the availability of comprehensive, quality mental health services. Indeed, this is force multiplication “on the front lines” of rural mental health care.

Indian Health Service Prescribing Psychology Precedent for Prescribing Non-Physician Health Care Provider

Currently, to practice as a psychologist within either a USPHS health facility or other federally managed facility, one must have an unrestricted, state issued, psychology license. To practice as a prescribing psychologist, one must also obtain a State Certificate of Prescriptive Authority, and a U.S. Drug Enforcement Administration Controlled Substances Registration Certificate.

For the Indian Health Service (IHS), prescriptive authority for psychology has already been established. In the mid-1980s, a clinical psychologist Dr. Floyd Jennings legally prescribed at the Indian Health Service’s (IHS) Santa Fe Indian Hospital. The Santa Fe IHS hospital’s authorization was granted to doctoral level clinical or counseling psychologists who had completed an internship, one year postdoctoral supervision, relevant training and experience with psychopharmacology, direct hands-on clinical case supervision with documented physician oversight. Of the 378 patients that Dr. Jennings treated with psychotropics in the first year (under a collaborative physician arrangement), no adverse experiences were encountered. The grassroots need in this particular Indian community drove this kind of approach. As a result, the IHS medical community already has a precedent for this kind of practice.

In fact, opportunities exist today for prescribing psychologists within the Aberdeen Area Indian Health Service behavioral health program as either a Commissioned Corps or civil service psychologist. The Aberdeen Area Indian Health Service Behavioral Health Division is actively recruiting for this specialty.

Legal Opinion on Scope of Practice of Federal Prescribing Psychologist

The following references illuminate federal law regarding the practice of prescribing/medical psychologists in federal practice settings:

“…regarding the first bullet, see 42 U.S.C. § 254f(e):

"(e) Practice within State by Corps member

Notwithstanding any other law, any member of the Corps licensed to practice medicine, osteopathic medicine, dentistry, or any other health profession in any State shall, while serving in the Corps, be allowed to practice such profession in any State.”

This statement also appears in this Instruction from the Office of General Counsel Secretary HHS.

“CCPM, Book 2, Chapter 5, § 1, Inst.251.01 (Old CC26.1, INSTRUCTION 4, §A.)

Section A. Purpose and Scope

The prevailing community standard requires that healthcare providers be licensed, certified, and/or registered in their specific areas of practice. The Public Health Service (PHS) requires such license/certification/registration as an indicator of competence.”

Senior USPHS Psychologists Opinions on Prescribing Psychology Opportunities, Recruitment, and Billet Structure

In other discussions between senior USPHS psychologists, the following points have been made:

• Current law and regulations permit those medical/prescribing psychologists to practice in the USPHS Commissioned Corps so long as they have an appropriate license from one State.
  
• Privileging remains a local process.
  
• The New Mexico (NM) Board of Pharmacy and the NM Board of Psychologist Examiners in association with the NM Attorney General's office has indicated, in the case of CAPT Kevin McGuinness, that the State cannot interfere in the practice of a USPHS Medical Psychologist licensed in another state (not NM). CAPT Kevin McGuinness has also practiced as a Medical Psychologist in South Dakota, on the Rosebud Sioux Reservation.
  
• Officials in the Indian Health Service have indicated that there already is a privileging pathway for prescribing psychologists. It’s just like any other specialty. One practices within one’s scope of practice and is privileged as such. What is different is the credentialing committee’s familiarity with a prescribing psychologist, not the process itself.
  
• Efforts are being made at providing appropriate medical practicum and preceptorship training within select Indian Health Service Units for prescribers.
• We do have one actively prescribing USPHS medical psychologist practicing in NM with a LA license.
  
• We likely have several USPHS officers prescribing within the next year and other IHS federal service psychologists who will likely be prescribing soon as well.
  
• The USPHS is actively recruiting mental health officers (in the hundreds), to include prescribing psychologists, clinical psychologists, psychiatrists, psychiatric nurse practitioners, and social workers. This is a wonderful opportunity for medical psychologists and clinical psychologists in training for prescriptive authority to practice.
  
• The USPHS would be very happy to provide recruitment presentations to universities and professional schools who would like to have us.
  
• The USPHS is undergoing significant Transformation. There is an effort to have new prescribing psychologist billets (job descriptions) written into a number of new force structures so that licensed, prescribing psychologists may seek an appointment as an officer within the USPHS.

Aberdeen Area Indian Health Service Behavioral Health Strategic Initiative

For any Indian Health Service, or tribal, prescribing psychologist position, there are normal governmental application procedures. With regard to prescriptive authority, the prescribing psychologist must submit credentials and licenses to the Clinical Director and Medical Staff for review and recommendation. Credentials are accepted with delineated clinical privileges. A recommendation report from the recommending body (local IHS Service Unit) is submitted to the Area Level IHS for final approval. So, the Service Unit directly authorizes all medical privileges, with the Area Headquarters administratively approving.

Recruiting psychiatrists to come to the upper prairies has been particularly challenging, with almost all of them located in the few, larger settled towns of the upper prairies- far from the reservations. Further, there is little likelihood this will change in the future. This combined with the pressing mental health needs, substance use, poverty, lack of medical funding, and limited infrastructure resources, makes providing services in these circumstances extremely difficult. The Aberdeen Area IHS and Dr. Vickie Claymore-Lahammer PhD, the Director of the Division of Behavioral Health for the Aberdeen Area IHS, saw this potential mission impact of having prescribing psychologists in the small Service Units providing both psychotherapy and prescriptive clinical services. She thus spearheaded and supported the prescriptive training for seven psychologists as a part of her division’s Strategic Behavioral Health Initiatives. This support included the direct funding of the cohort’s program, fees, and books. As a “lead by example” director, Dr. Claymore-Lahammer joined this cohort and also began formal prescriptive training. At the time of this writing this Aberdeen Area cohort was advancing in the didactic portion of their formal prescriptive training. (This is another example of the successful precedent of prescriptive authority for psychology in the IHS established by Dr. Floyd Jennings in Santa Fe).

To date, the Aberdeen Area Behavioral Health Division has seven openings for psychologists, with hopes of placing prescribing psychologists in each. The current openings are in Belcourt, ND, Rapid City, SD, Rosebud, SD, Pine Ridge, SD, Ft. Thompson, SD, Sisseton, SD, and Standing Rock, SD. (The Billings Indian Health Service Area also has a prescribing psychologist position open at Ft. Peck, MT.) Six of these seven currently open psychologist positions rank high on the list of the IHS Loan Repayment Program which assists in repaying a practitioner’s school loans for their service in these communities. All six positions are posted at a GS-12 or 13 levels. Like many small Service Units, funding is difficult so many IHS positions are not advertised on the web or in national magazines, but are usually listed on usajobs.gov or ihs.gov. Word of mouth is still the norm. Prescribing psychologists who still need to complete either their 100-patient preceptorship or 80-hour medical internship are welcome to apply. Most of these sites have practicing internists or family practice physicians available for collaboration with the independent prescribing psychologist, and in the case of the training prescribing psychologist, medical supervision is also available.

Should you be interested in these sites in particular, please feel free to contact LCDR Michael Tilus (contact information at end of article). Working in the upper prairies with populations in need, extreme poverty, and austere conditions demands inner fortitude, humility and grit. It is not work for the faint of heart. However, it is a rare opportunity where your daily clinical work can support an entire community and serve the Greater Good in ways only a handful can ever say they were so privileged to do.

Prescribing psychologists who are interested in consultation work, part time practice, or wishing to utilize their full scope of practice, should contact their local reservations’ Clinical Director, Behavioral Health Director, or resident Psychologist to discuss their professional interests and IHS needs. Such practice would fall under the normal government contact procedures for “outside contract services,” that is, you would be applying to be an outside contractor for the local IHS service unit, providing your full scope of practice.

However, simply having another “tool” of prescribing authority is insufficient for access. How you approach your reservation leaders and Indian Health Service Area personnel will communicate more than the fact that you have a prescription pad. Applicants are encouraged to come to their job, their patients (especially in this cross-cultural setting) as a learner. Assuming a humble position may allow you the opportunity to exercise your full range of psychological skill, to include the prescription pad.

Prescribing and ingesting a substance has both psychological and spiritual meanings. For many Indian people, separating culture, church, family, spirituality, and health is incompatible. Western empiricism does that. Reservation mental health works to integrate all aspects of Native life into a spiritual balance. As such, the prescriber and the prescribed both have cultural and spiritual significance. So, along with your prescription pad, bring some positive spirituality. In the words of my Mom and Dad who were both South Dakota Pentecostal preachers, “Son, how’s your faith?” This work requires “faith”! Prescribing psychologists who have faith!

What’s the bottom line? To practice in a federal site or program you must have a state-issued, unrestricted, independent practice license, and practice within your scope of practice. Local Indian Health Service Units privilege practitioners with final administrative approval from Area IHS. This includes a prescribing psychologist with a license from either Louisiana or New Mexico. Such privileging allows you to practice anywhere within the tribal or Service Unit area that granted the privileges.

So, you may be working and licensed in California, but also have a NM or LA license. This would allow you to practice anywhere in Indian land, in any state, with your free, unrestricted, independent license, with the local Service Unit and Area support.

Department of Defense Memorandum of Understanding (MOU) with the USPHS, to include Prescribing Psychologists

A second opportunity for prescribing psychologists within the USPHS involves the new Memorandum of Understanding recently signed with the Department of Defense (DoD). This joint agency agreement will place USPHS mental health professionals (prescribing psychologists, clinical psychologists, psychiatrists, psychiatric nurse practitioners, and clinical social workers) at DoD facilities to provide assistance, coordination, and direct care for of our returning and deploying personnel, and their families. Prescribing USPHS psychologists who are stationed at DoD sites will be eligible to request prescriptive privileges across their full scope of practice (as reported by officials in the Navy and Air Force). While potential opportunities may exist at Army facilities, these opportunities are currently much more restrictive for prescribing psychologists.

Psychologists with previous military duty who are prescription qualified are highly encouraged to contact Captain O’Neal Walker or LCDR Michael Tilus (contact information at end of article).

Civilian prescribing psychologists may wish to contact their local Department of Defense installation and talk to the Chief Psychologist, Chief Medical Officer, or personnel office. Many military installations contract with private parties for clinical duties, and as a prescribing psychologist, you may find an opportunity for full time or part time work as a civilian, working on a military installation.

The Psychologist Professional Advisory Group (PSYPAG) is made up of USPHS Psychologists who provide ongoing collaboration, consultation, support, recruitment, and career mentoring to any psychologist. This is a strong network of actively engaged, highly motivated, PHS psychologists that any applicant can tap into for news on vacancies in federal agencies (Bureau of Prison, Immigration and Naturalization, Indian Health Service, and Department of Defense, among others). To access this group, contact LCDR Michael Tilus, Sub-Committee Chair for “Prescribing Psychologists” and Associate recruiter for the USPHS, or CAPT Jon Perez, 2008 PSYPAG Chair.

If you are interested in exploring the available positions as either a PHS or civil service psychologist in the Aberdeen Area Indian Health Service, please feel free to contact LCDR Michael R. Tilus or Dr. Claymore-Lahammer. You may also consult with LCDR Tilus concerning possibilities with federal and tribal programs near you, or you may go to usajobs.gov, or the IHS web site and contact the Behavioral Health Director of the Region in which you are interested.

If you wish to discuss the application process to become a U S Public Health Service
prescribing psychologist and are interested in the Department of Defense positions, or other federal agencies, please contact LCDR Michael Tilus, CAPT Kevin McGuinness, or CAPT O’Neal Walker. Please follow this web address for further information: www.usphs.gov/profession/behavioral/default.aspx.

Answer the Call! And, bring some good long underwear!

Points-of-Contact for Further Information

LCDR Michael R. Tilus, PsyD, MSCP
Director, Social Services & Mental Health Programs
Spirit Lake Health Center
3883 74th Ave, NE
Fort Totten, ND 58335
701.766.1613
Michael.tilus@ihs.gov

CAPT O’Neal Walker, PhD
Director, Division of Commissioned Corps Recruitment
U S Public Health Service
1101 Wootton Pkwy, Tower Building
Plaza Level
Rockville, MD 20852
240.453.6058
oneal.walker@hhs.gov

CAPT Kevin McGuinness, PhD, MP
Team Leader, USPHS Mental Health Team 4
Chair, USPHS Mental Health Functional Advisory Committee
c/o National Health Service Corps Field Site
1600 Thorpe Road
Las Cruces, NM 88012
kmcguinness@hrsa.gov

CAPT Jon Perez, PhD
National Behavioral Health Consultant
Indian Health Service
Team Leader, USPHS Mental Health Team 2
Chair, USPHS Psychologist Professional Advisory Group (PSYPAG)
jon.perez@ihs.gov

Dr. Vickie Claymore-Lahammer, PhD
Director, Division of Behavioral Health-AAO
Aberdeen Area Indian Health Service
115 4th Ave, SE
Aberdeen, SD 57401
605.226.7341
vickie.claymore-lahammer@ihs.gov