An Interview with William Robiner, Ph.D. ABPP on Prescription Privileges for Psychologists
In this edition of the Wise Counsel Podcast, Dr. Van Nuys interviews William Robiner, Ph.D., ABPP, on the topic of prescription privileges for psychologists. Dr. Robiner is a health psychologist who has worked most of his career in medical settings, including direct work in primary care clinics where he closely coordinates with physicians. He has been interested in and involved with the debate over prescription privileges for psychologists throughout the 20 or so years that the proposal has been kicking around.
To orient the listener, the American Psychological Association (APA) has for some years now promoted the idea that Professional Psychologists who have completed additional training and certifications in the area of psychopharmacology (e.g., prescription drugs for mental illness) above and beyond their standard psychology credentials ought to be able to prescribe psychoactive medications to their patients in addition to other treatments such as psychotherapy they might provide. The issue is contentious both within and outside of the clinical psychology field and no clear position has come to dominate the debate (as to whether prescription privileges is a good/workable idea or not) despite the many years of discussion.
In the 1990s, the Department of Defense authorized psychopharmacological training of a small group of military psychologists and tracked their efficacy as prescribers. These test case psychologists were offered one year of classes and then an additional year of supervised clinical practicum prior to gaining prescription privileges According to Dr. Robiner, the results from this study (summarizing the performance of the psychologists) were mixed. Respondents (Patients?, physicians?, I'm not clear on who was judging) were impressed with the abilities of the psychologists as prescribers, but also apparently concerned that their abilities were "weaker" and more student-like than would otherwise be expected of a professional. I (Mark Dombeck) have not read this study and am paraphrasing Dr. Robiner's summary of the results.
Subsequent to the DOD study, state level governments in Guam (a US territory), New Mexico and Louisiana have authorized psychologists who have passed through approved additional psychopharmacological training programs to prescribe. Each year numerous other state legislatures take up the issue. The debate happens at the level of state government as all professional licenses are regulated by state law in the United States.
Currently, the exact nature of what constitutes adequate training and certification in psychopharmacology necessary to achieve prior to gaining the prescription privilege remains in question. The current APA recommendations fall short of the requirements that the original military psychologists were held to. Presently there is something like 400 hours of coursework required, and the passage of a national examination, the "Psychopharmacology Examination for Psychologists". There is no residency requirement, apparently. Again, this information is a paraphrasing of Dr. Robiner's statements in the interview.
Dr. Robiner is staunchly opposed to the idea that prescription privileges for psychologists is a good idea. He is a member of Psychologists Opposed to Prescription Privileges for Psychologists, a group of psychologists who (obviously) think prescription privileges for psychologists is a bad idea. He describes his early career decision to become a psychologist in the first place as having involved an affirmative decision to not pursue medical training, and as an embrace of the psychological and bio-psycho-social diagnostic models instead of the medical model. Keeping this firmly in mind, Dr. Van Nuys asks Dr. Robiner to talk about what the arguments in favor of prescription privileges for psychologists are.
The first argument in favor of psychologist's prescription privileges is that psychologists are already highly trained healthcare professionals who have a detailed knowledge of mental illness treatment. Granting them license to prescribe (when adequately trained to take up this responsibility) is in the interests of society as psychologists will be able to offer their patients a greater and more integrated range of services than is otherwise possible. Dr. Robiner points out that some 70% of psychoactive medications are prescribed by medical professionals who have little or no specialized knowledge of mental illness (General Practitioners, Family Medicine physicians, etc.)
The second argument involves the idea that the nation as a whole but rural areas in particular suffer from a shortage of qualified psychiatrists, a situation which creates a public health care risk. Training, certifying and licensing psychologists to provide psychopharmacology services in addition to their other psychotherapy duties can help ease this shortage.
A third argument is less a public health one than a guild one and more about the internal debate within the field of clinical psychology than something all that relevant to outsiders. At issue is the nature of psychologist's identity within a shifting professional landscape. In recent years, other fields besides psychologists have entered the business of providing psychotherapy (including social workers, professional counselors of various stripes, psychiatric nurses, and marriage and family therapists). The sole remaining exclusive province of Clinical Psychology is now psychological assessment, and that is not as reimbursable as it used to be due to healthcare payment reforms (AKA managed care), or as valued (given improvements in brain imaging technologies). Some within the field of Clinical Psychology argue that prescription privileges are an essential direction for the field to go in so as to secure the future of the profession in an increasingly medicalized world. A related "guild" argument has to do with reimbursement rates for professional services. Take-home pay for psychologists has dropped as the flood of masters level practitioners has entered the field, and, some argue, prescription privileges might be one way to stem the tide and differentiate doctoral level psychologists from their masters level counterparts.
Dr. Robiner has responses to these issues, of course. With regard to the first argument that psychologists, who are already mental health specialists, should gain prescription rights to round out and integrate their service potential for patients, he suggests that most psychologists simply lack the foundational education in chemistry and biology necessary to understand the higher level psychopharmacology they would be taught as preparation for prescription privilege He believes that the preparatory programs as they currently exist are inadequate in terms of classroom time and subjects covered, and that a period of "residency" (e.g., full time supervised practice in a hospital setting) is necessary before any responsible independent practice might occur. He respects psychologists' specialized mental health knowledge but suggests that responsible psychopharmacology is far more about understanding the liver and the kidneys than the mind. He does not think it a good idea that psychologists prescribe until and unless psychologists go through training as rigorous at least as what nurse practitioners or physician's assistants go through. To do less, he suggests, is to create a public health problem.
He rejects the second argument as based on false premises. He suggests that just as there are few psychiatrists living in rural areas, the same is true of psychologists. Both professional groups like to live in bigger cities. He suggests that the healthcare needs of rural areas can be handled through a variety of creative means, including tele-health (e.g., remote visitation using video conferencing), and rethinking the role of psychiatry. Psychiatry should be thought of more as a consulting service (like radiology), rather than as the doctor you go to for regular monitoring, which general practitioners can generally handle, in his opinion. Patients like visiting with their general practitioners as well, as they more often have a relationship with those GPs than with psychiatrists.
Because of Dr. Robiner's career working within primary care clinics and hospitals Dr. Van Nuys wonders if he maybe has been influenced by these employers, or has actually been paid (e.g., has become a lobbyist) to speak on his anti-prescription views. Dr. Robiner reports that the issue of prescription privilege is unimportant to his employers who think he is weird for spending time on it. He denies that he has ever taken money for speaking and writing on this subject. He reports he has never felt condescended to or controlled by physicians he has worked with. Conversely, he asserts, the forces who promote prescription privileges for psychologists may be financially motivated. He wonders out loud whether the APA, which is apparently the largest publisher of mental health professional journals in the world, would like to gain significant revenue from psychiatric medication advertisements which might one day run within journal pages. Dr. Van Nuys suggests that is quite a conspiracy theory.
As the interview winds down, Dr. Van Nuys tries to summarize Dr. Robiner's position by suggesting that it is not so much that psychologists should never ever be allowed to prescribe as that the present day guidelines and educational requirements and standards are inadequate (in Robiner's opinion), and that psychologists should not gain the right to prescribe until such a time when they have to meet the same stringent training requirements (including all prerequisites of those requirements) required of other professions which have privileges. Robiner basically agrees with this position, adding that there are more efficient means for society to meet the need for more prescribers than to put resources into clinical psychology for this purpose.
Via email communication, Dr. Robiner has supplied the following additional comments:
The URL for the APA recommended training is: http://www.apa.org/ed/rx_pmodcurri.pdf. They do not call it a "residency". Rather it is called a "clinical practicum" with the following requirements:
- Minimum of 100 patients seen for medication
- Inpatient and outpatient placements
- Inclusion of appropriate didactic instruction
- Minimum of 2 hours weekly of individual supervision
What I meant to say about the residency is that in the evaluation of the DoD, the graduates of the DOD thought more training was important. The ACNP report (which is attached) included, "Virtually all graduates of the PDP considered the "short-cut" programs proposed in various quarters to be ill-advised. Most, in fact, said they favored a 2-year program much like the PDP program conducted at Walter Reed Army Medical Center, but with somewhat more tailoring of the didactic training courses to the special needs, and skills of clinical psychologists. Most said an intensive full-time year of clinical experience, particularly with inpatients, was indispensable."
That type of comment is absent from the APA's efforts to promote RxP with more abbreviated training, including online opportunities. There is currently no "full-time year of clinical experience, particularly with inpatients."
My comments about the liver and kidneys is actually a paraphrase from Kingsbury, S.J. (1992). Some effects of prescribing privileges. Professional Psychology: Research and Practice, 23, 3-5. In describing the differences in the training for physicians and psychologists, he stated, "Studying the effects of medications on the kidney, the heart, and so forth is important for the use of many medications. Managing these effects is often crucial and has more to do with biochemistry and physiology than with psychology. I was surprised to discover how little about medication use has to do with psychological principles and how much of it is just medical" (p. 60).
Links Relevant To This Podcast:
About William Robiner, Ph.D.
William Robiner, Ph.D., A.B.P.P. is Professor in the Department of Medicine and Director of Health Psychology and the Psychology Internship at the University of Minnesota Medical School. He also is the Chair of University of Minnesota Medical Center, Fairview Psychology Standards Committee. He received his Ph.D. in clinical psychology from Washington University and is board-certified as a clinical health psychologist. He has been on the Minnesota Board of Psychology and is a Fellow of the Association of State and Provincial Psychology Boards. He was on the Committee that drafted the ASPPB (2001) Guidelines for Prescriptive Authority. He has numerous publications related to the education, training, supervision and workforce of psychologists, and has authored peer-reviewed articles that address problems related to psychologist prescribing.