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This is the fourth entry in a se...

Posted Sep 11 2008 5:08pm

This is the fourth entry in a series on the implications of psychologists pursuing prescription privileges. What those implications are exactly, is far from clear — they ought to bear close scrutiny. Others in the series include:

An important rule of thumb.
I started reading Cialdini’s Persuasion: Science and Practice, on a hunch that this might be relevant to prescriptive authority for psychologists (RxP). I was not disappointed. Dr. Cialdini’s writing is persuasive and grounded in a solid background of social psychology research. His focus is the irrational, emotional basis for many human decisions. Since RxP is an emotionally charged issue — for psychologists, for psychiatrists, for an informed public — how we make decisions is exceptionally pertinent.

The rule of thumb, then, is that people, more than ever before, rely on “rules of thumb”, cognitive shortcuts, in order to make judgements. This is an important, uniquely human activity. Human beings are meaning makers. Developmental pscyhologists note that inductive logic, the ability to make generalizations from information, is one of the hallmarks of what is called “formal operations.” Formal operations is reached is reached somewhere around ages 11 to 14. It makes algebra, and other manipulations of abstract principles, possible. (One curious sidenote: Not everyone reaches the formal operations stage.)

We are required to make decisions, daily, based on incomplete information. Why is this more relevant that ever before? Because we are constantly bombarded by more and more information. Given this assault, we rely on experts to delve issues we don’t have the time or inclination in which to become experts. Accountants, tax preparers, financial analysts, medical doctors, journalists, lawyers, psychologists. Cialdini calls this submission to overwhelming amounts of information “modern automaticity”. A typical statement:

Because technology can evolve much faster than we can, our natural capacity to process information is likely to be increasingly inadequate to handle the abundance of change, choice, and the challenge that is characteritic of modern life.

A small group of highly motivated people.
Recent historical events have underscored an old aphorism: One should never underestimate the power of a small group of highly motivated individuals to change the world. Within psychology, there is such a group. Health psychologists work in medical settings. They focus on behaviors that facilitate good medical outcomes. In fact, one such psychologist, presenting at the California Psychological Association, recently opined, “I don’t call what I do psychology, I call it behavioral medicine.” It would probably be overreaching to claim that health psychologists are in the majority of those seeking RxP, but they are certainly a group of highly motivated people.

And an important part of health psychologists do, is focus on compliance. Compliance to medical guidance is particularly critical in some diseases. Consider the role of behavior in: diabetes, heart disease, bipolar disorder. All the medication in the world is of little avail if the patient does not comply — watching blood sugar levels, keeping an eye on cholesterol intake, moderating sleeping habits, taking medications regularly — in many cases, thinking they are “all better”, people simply stop taking their medication. This state of events, a constant source of frustration to medical doctors, does not result in good outcomes.

The devaluation of primary care.
Alas, in our current health care system, medical doctors are not paid to ensure compliance. In fact, the salaries of primary care physicians, (e.g., pediatricians), who traditionally spend more time getting to know the patient as a whole person — are considerably lower than that of physicians who perform procedures. Procedures: surgery, radiology, anesthesiology, etc. Procedures are what pay. Procedures are what get reimbursed. And when faced with a choice to run two different procedures, guess what factor, empirical data demonstrates, has more influence on their choice than any other?

Taking stock of persuasive rhetoric.
So why even mention all this? Because this group of psychologists, health psychologists, are experts in compliance, experts in motivating people to act in their best interests. This is invaluable, honorable work. In essence, without stretching too far, it could be argued that they persuade. Since this is part of their stock-in-trade, it could be reasoned that if they want something bad enough, they might, intentionally or not, employ their persuasive powers. Cialdini has an evocative phrase, which he applies to salespersons, he calls them “compliance professionals”.

Lest some of my colleagues get the wrong impression, I am not suggesting that RxP supporters are intentionally manipulating other psychologists, or the public, in order to achieve their aims. But since even experts are human beings, and the stakes are so high, we need to scrutinize the RxP rhetoric. Since the power of persuasion is so well documented by social psychologists, we would be remiss if, as psychologists, we did not examine the arguments closely. So let’s look at what Cialdini says about the chief methods used by marketers to tap into largely unconscious decision-making processes. Let’s take a fine-toothed comb to the rhetoric.

Motivating decisions at a base level.
Even the New York Times, which seems to excel in presentating slanted, out-of-context, and incomplete information — when it comes to matters psychological, ran a story yesterday on the powerful influence of unconscious rules of thumb, sometimes referred to as heuristics. (Not long ago they were running stories disputing the very existence of unconscious processes, but the current fashions of scientific opinion have changed, and the Times, dutiful, themselves reliant on experts, follows suit.) If you’re really curious, you can read it here. Typically, the Times takes the popular perspective of biological determinism. Noting that the frontal lobes, where rationality, higher decision-making, formal operations are thought to reside, “can be one of the last neural areas to know when a decision is made.”

Applying models of persuasion to RxP rhetoric.
Well, this is already a long post, in the world of blogs. So I’ll concentrate on the strategies employed by ad agencies, marketing firms, political parties, grass roots organizations, in order to manip — shape your opinion, daily. Cialdini focuses on these cognitive stumbling blocks, rules that the human mind appears to be hardwired to follow. Particularly when information is complete.

Here are some of the areas that are very compelling for human beings:

    The need to appear consistent.
    The power of public commitment.
    The compelling nature of authority directives.
    The tendency to use social referencing to guide our own behavior.
    The need to reciprocate.
    The response to scarcity, and finally
    The lulling effects of feelings of liking or friendship

Kalea Chapman, Psy.D.

This is the fourth entry in a series on the implications of psychologists pursuing prescription privileges. Others in the series include:

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