Psy.D. Programs 10 Years From Now

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Originally Posted by 4410

the moderators have informed me that I will be banned if I continue on with my support for PsyD programs.

Originally Posted by Therapist4Chnge

The issue is probably that you post a great deal of misinformation and parade it as fact...

Oh boy. I was thinking, why would they ban you for supporting PsyD programs?? Did they really say that??? But, yeah, I realized it was 4410 and it probably didn't go down like that. T4C called it!

I'm really surprised that my thinking has changed so dramatically over the past 7 years, but looking back on my Psy.D. experience and program, I am more and more leaning towards the Boulder model as the more comprehensive of the two. I went to one of the relatively smaller professional schools -at least it was relatively smaller when I started in 2005, but has now grown in leaps and bounds, recently into an institution that I don't even recognize. I was dead set on a Psy.D. out of undergrad, but honestly, I wasn't that well informed and didn't go in with the knowledge I have now about debt, class size, etc. My Psy.D. program was my first choice and my years in class and practica were invaluable. However, I chose to buck the system and pursue a specialty area that my school could not accommodate. I found my own practicum sites at top university hospitals and was one of the few students who applied for, and got, an APA internship. My internship included a primary neuropsychology rotation and I went on to complete a 2 year, APA approved postdoc in neuropsych as well. Now, my career has taken an amazing course and I am sub-specializing within the field of neuropsychology with some of the best and brightest in the field.

However, THIS IS NOT NORMAL!!! Not for my program at least. I have supervised practicum (2nd year) students from my program that have NO intention of doing an APA internship. Ok, fine, your choice, but my program does not have comps (which I never fully understood the significance of), so it is extremely difficult to weed out those who don't belong. Internship becomes somewhat of a natural selection process and when programs (and state boards for that matter) eliminate the need for an internship, anyone who is still hanging in there is going to graduate with a Psy.D. This model is inherently flawed and, while I enjoyed my experience, seems now to me to be one of financial opportunity for the school. I have been struggling with this a lot lately and it saddens me that programs choose to move in this direction. I, too, have wondered about the significance of the Psy.D. and I do plan to seek ABPP status to protect against any future backlash, but it's too bad that even the larger programs can't put in some sort of safeguard against handing out Psy.D. degrees like candy.

Quite the shift for you, Flutter.

Originally Posted by Flutterbyu

it is extremely difficult to weed out those who don't belong. Internship becomes somewhat of a natural selection process and when programs (and state boards for that matter) eliminate the need for an internship, anyone who is still hanging in there is going to graduate with a Psy.D. This model is inherently flawed and, while I enjoyed my experience, seems now to me to be one of financial opportunity for the school.

I know this has been brought up before (probably in the internship/occupy thread), but it really is true, isn't it? I have a friend who is in a FSPS PsyD program, with a cohort of close to 100, according to posted disclosure stats, and who will soon be dismissed from the program after being put on academic probation. I'm not sure of the details, but I believe it's a combination of work overload due to being ineligible for high loan amounts, resulting in the need to work excessive hours on top of school (in order to pay for it)--so grades suffered. This is nuts! I can't imagine spending a year in school, being at least $20k in debt, and being done (and likely blacklisted from entering any psych doctoral program ever again), let alone being $100k+ in debt and not matching for internship! I have another colleague who created his own internship, graduated, putzed his way through a "postdoc" (it wasn't one), and is now seeking licensure--for what? To do therapy in private practice, when he already has a masters license?? In. Freaking. Sane.

This is why I get MAAAD when I hear people saying things like, "I want to be a Dr." or "Either program will call me Doctor when I'm done." I cannot believe that this silly title is so important to people, that they will ruin so many parts of their lives in pursuit of it. This culture of chasing "dreams" is ridiculous!! Rant over.

Originally Posted by Psychadelic2012

This is why I get MAAAD when I hear people saying things like, "I want to be a Dr." or "Either program will call me Doctor when I'm done." I cannot believe that this silly title is so important to people, that they will ruin so many parts of their lives in pursuit of it. This culture of chasing "dreams" is ridiculous!! Rant over.

Preeeetty sure you're referring to a thread I made in which I said "either way they'll call me doctor," and so's we're clear, I was being facetious.

The MD and DO shows some similarities with PhD and PsyD and now there are some PsyD programs that are actually administered by Osteopathic medicine schools. In this date in time there is not any difference between MD and DO programs and a DO is considered to be equivalent to the MD degree. With RxP legislation in the next 20 years most psychologists will be licensed by the State Board of Medical Examiners or rather the psychology board will be merged with the medical board. LPC's will take over the more traditional mental health treatment and psychologists will be considered a medical specialty and readily be accepted in Hospital and medical settings. I could see psychologists training having the degree designation of MD or DO with training being provided in medical schools with the designation of MD or DO degree psychologists and the PhD and PsyD degree will become something such as MD-PhD psychologists or DO-PsyD psychologists but we will have either the MD or DO degree designation.

Originally Posted by 4410

The MD and DO shows some similarities with PhD and PsyD and now there are some PsyD programs that are actually administered by Osteopathic medicine schools. In this date in time there is not any difference between MD and DO programs and a DO is considered to be equivalent to the MD degree. With RxP legislation in the next 20 years most psychologists will be licensed by the State Board of Medical Examiners or rather the psychology board will be merged with the medical board. LPC's will take over the more traditional mental health treatment and psychologists will be considered a medical specialty and readily be accepted in Hospital and medical settings. I could see psychologists training having the degree designation of MD or DO with training being provided in medical schools with the designation of MD or DO degree psychologists and the PhD and PsyD degree will become something such as MD-PhD psychologists or DO-PsyD psychologists but we will have either the MD or DO degree designation.

It's obviously conjecture on all our parts, but I personally don't see this happening. RxP has been in the works for years already; it's only been pushed through in two states (and still receives fairly significant resistance from some physicians in at least one of those two states), and has failed for years in probably three times as many places. I also don't know that I see a merging of psych and medicine boards. I could certainly see there being a significant push to have psychology more-consistently included in primary care settings, but the training models are far too different for the licensing boards to merge and for one profession to have a significant say in the licensing practices of the other.

As for the Psy.D. degree, with many Ph.D. programs seemingly now offering a much more balanced approach to training than in decades past (backed up by numbers of clients and treatment hours reported by internship applicants per APPIC stats), and thereby offering comparable amounts of clinical exposure to Psy.D. programs, I honestly do struggle to see the rationale for continuing to offer both degrees for much longer. But that's just me.

I agree. That's not going to happen. More likely, meaningful doctoral level mental health will require an MD. At some point, there will be a push back against the dumbing down of education.

Originally Posted by Veit

Preeeetty sure you're referring to a thread I made in which I said "either way they'll call me doctor," and so's we're clear, I was being facetious.

I can't remember if you said that. Honestly, so many people say those things that it is impossible to point a finger in only one direction. Interesting that everyone also says that they are joking when confronted--there is an element of truth in humor. That's my point.

Originally Posted by Veit

Preeeetty sure you're referring to a thread I made in which I said "either way they'll call me doctor," and so's we're clear, I was being facetious.

Originally Posted by Psychadelic2012

I can't remember if you said that. Honestly, so many people say those things that it is impossible to point a finger in only one direction. Interesting that everyone also says that they are joking when confronted--there is an element of truth in humor. That's my point.

+1. I personally know people who think this way. They don't care what they have to do or where they end up as long as someone calls them doctor in the end. We had a prof confront one of these individuals and ask why she didn't just drop and get a master's degree because it would save her a lot of time, stress, money, etc., since her end goal was to "do therapy." She attempted to explain that only folks with PhDs are allowed to work in CMHCs/hospital settings, which is where she wants to work. In reality, she simply wants folks to call her doctor.

Originally Posted by paramour

She attempted to explain that only folks with PhDs are allowed to work in CMHCs/hospital settings,

Uhh..has this person actually been in a hospital or CMHC before?

Originally Posted by paramour

+1. I personally know people who think this way. They don't care what they have to do or where they end up as long as someone calls them doctor in the end. We had a prof confront one of these individuals and ask why she didn't just drop and get a master's degree because it would save her a lot of time, stress, money, etc., since her end goal was to "do therapy." She attempted to explain that only folks with PhDs are allowed to work in CMHCs/hospital settings, which is where she wants to work. In reality, she simply wants folks to call her doctor.

Look no further than the posters' usernames and signatures on this forum. It's important to them that they be called doctors regardless of how they get there.

Originally Posted by zzzz2

Look no further than the posters' usernames and signatures on this forum. It's important to them that they be called doctors regardless of how they get there.

To be honest, I could care less. Whenever it is appropriate, I don't use the title. For example, I use the title on inpatient consults because I think it puts patients at ease. The last thing they need is an explanation of what doctorate training in psychology is and how it compares to medical training when they are in a delirium. But otherwise I use my first name, which helps build rapport, especially with older patients.

"Doctor" isn't really descriptive of what we are given the general public understanding of what a "doctor" is (i.e., medical doctor). I prefer the "Ph.D." after my name.

Originally Posted by erg923

Uhh..has this person actually been in a hospital or CMHC before?

This line of questioning was attempted. But in the student's specialized experience, because she is an expert on anything & everything, she could not possibly land the job of her dreams without a PhD. Because everyone she knows who works in a hospital/CMHC has a PhD. The prof tried to correct her but student knows all. Even re: things with which she has no direct experience/knowledge.

Originally Posted by zzzz2

Look no further than the posters' usernames and signatures on this forum. It's important to them that they be called doctors regardless of how they get there.

If I can't be a doc in real life, at least I can be one on the internetz...

Originally Posted by Jon Snow

I agree. That's not going to happen. More likely, meaningful doctoral level mental health will require an MD. At some point, there will be a push back against the dumbing down of education.

Probably. I can see some of the assessment specialities hanging around because they are embedded more specifically in other areas or practice: e.g. forensic assessment, neuropsych assessment, etc. I think we will really lose out in regard to outcome research and advancing the field of we as a profession get pushed out of therapy services.

As a field we are already actively pushing away the best and brightest by our inability to protect our scope of practice. I know if I did it all over again I'd forego clinical psychology and go back to my original plan of doing an M.D. / Ph.D., at least that way I could have far easier mobility for clinical practice and still have the fallback of academic research.

Originally Posted by Therapist4Chnge

Probably. I can see some of the assessment specialities hanging around because they are embedded more specifically in other areas or practice: e.g. forensic assessment, neuropsych assessment, etc. I think we will really lose out in regard to outcome research and advancing the field of we as a profession get pushed out of therapy services.

As a field we are already actively pushing away the best and brightest by our inability to protect our scope of practice. I know if I did it all over again I'd forego clinical psychology and go back to my original plan of doing an M.D. / Ph.D., at least that way I could have far easier mobility for clinical practice and still have the fallback of academic research.

I agree that they will hang around, but I think encroachment and reimbursement is going to make things a lot tighter. I also think that how some of the work done in specialties is going to have to change to adapt to the health care environment and it's business model. Assessment is going to need to get more efficient on the whole, and people can't dilly-dally and take weeks/months before turning out a report ("product") to the consumer.

I still know of practices where a pediatric neuropsych report can take almost 6 months to get from start to finish (waiting list, testing, report writing). If I were bringing my child to get tested, this would simply be unacceptable. I think pointing at the high demand has been an excuse for these providers to not streamline certain things. In the long run, this hurts the field, as people will turn to alternatives to get their questions answered (enter encroachment) and that demand will not always exist. Why can't we be the best AND be efficient?

Originally Posted by paramour

since her end goal was to "do therapy." She attempted to explain that only folks with PhDs are allowed to work in CMHCs/hospital settings, which is where she wants to work.

Originally Posted by paramour

she could not possibly land the job of her dreams without a PhD. Because everyone she knows who works in a hospital/CMHC has a PhD.

Not only does she NEED to be called doctor, but the job of her dreams is to do therapy in a CMHC???!!

Originally Posted by Psychadelic2012

Not only does she NEED to be called doctor, but the job of her dreams is to do therapy in a CMHC???!!

hey now! CMHCs can use a lot of underpaid PhD work.

Originally Posted by Pragma

I agree that they will hang around, but I think encroachment and reimbursement is going to make things a lot tighter. I also think that how some of the work done in specialties is going to have to change to adapt to the health care environment and it's business model. Assessment is going to need to get more efficient on the whole, and people can't dilly-dally and take weeks/months before turning out a report ("product") to the consumer.

This has been happening...whether we want it to or not. I know in the neuropsych world the limits (set by insurance) on assessment time have really been cut back, so much so that many times a proper evaluation really isn't possible. The days of a 10-12hr+ battery are definitely dwindling. Most of the out-pt. work I've done uses batteries that are 3-5hrs (sometimes up to 7hrs) in length, with in-patient assessment being even less. All of my referrals come from physicians, and they want to know my impressions, recommendations, and if there is anything else they should know. I love the nitty-gritty of diganostic assessment, but at the end of the day the assessment needs to be functional and provide meaningful data and hopefully some recommendations. That is what will get consistantly paid.

Originally Posted by Pragma

I still know of practices where a pediatric neuropsych report can take almost 6 months to get from start to finish (waiting list, testing, report writing). If I were bringing my child to get tested, this would simply be unacceptable. I think pointing at the high demand has been an excuse for these providers to not streamline certain things. In the long run, this hurts the field, as people will turn to alternatives to get their questions answered (enter encroachment) and that demand will not always exist. Why can't we be the best AND be efficient?

Unfortunately there are many clinicans (doctorally trained and not), who are willing to take the work...whether they are competent or not to actually do it. I have a few years of assessment (research & clinical) experience working with pediatrics, and I still am hesitant to consult on any pediatric case that isn't clearly within my prior niche area of research...and even then I am very careful to qualify anything I say.

Originally Posted by Psychadelic2012

Not only does she NEED to be called doctor, but the job of her dreams is to do therapy in a CMHC???!!

Originally Posted by Therapist4Chnge

That is uhm....special. There are some wonderful CMHC clinicians who do great work, but that is generally a really rough place to work on a daily basis.

She is indeed a special duck. I suspect her deep-rooted desire to work in such a place has more to do with her overwhelming need to restrict herself to a certain geographical area. This particular setting is the only place which she could potentially work within that geographically restricted area, soooo, of course this is where she has always, always, always wanted to work. Even though she has no experience in such a setting.

T4C, I find it interesting that you mention CMHCs are generally rough to work at on a daily basis. I had to jump quite a few hoops to get a "voluntary" practicum approved at the local CMHC (we had a paid practicum there once upon a time 'til they dropped us). My dept then expressed concerns because they knew people who "burned out" quickly there, but they seemed to be attributing it to the site itself rather than it being a CMHC. During my interview with the director, however, I received the impression that the work-load/stress was not restricted or 'special' to this specific CMHC. I guess I'll find out what I'm in for once I get there next month (hopefully it's better since I've restricted myself primarily to evaluations/assessments?).

Originally Posted by paramour

T4C, I find it interesting that you mention CMHCs are generally rough to work at on a daily basis.

CMHCs generally struggle with funding, have more patients than they can see, and the typical caseload is chock full of complex cases that require more resources than are available. Some people thrive in that kind of environment, though I know I'd just pull my hair out after awhile. I work at a publically-funded hospital that gets steered all of the toughest cases, but we at least have resources to attempt to help. Obviously there are still many limitations, but I feel like our patients at least have a shot, whereas my (limited) experience with CMHCs felt more like a revolving door of patients who really need more help than is available.

Originally Posted by Therapist4Chnge

This has been happening...whether we want it to or not. I know in the neuropsych world the limits (set by insurance) on assessment time have really been cut back, so much so that many times a proper evaluation really isn't possible. The days of a 10-12hr+ battery are definitely dwindling. Most of the out-pt. work I've done uses batteries that are 3-5hrs (sometimes up to 7hrs) in length, with in-patient assessment being even less. All of my referrals come from physicians, and they want to know my impressions, recommendations, and if there is anything else they should know. I love the nitty-gritty of diganostic assessment, but at the end of the day the assessment needs to be functional and provide meaningful data and hopefully some recommendations. That is what will get consistantly paid.



Unfortunately there are many clinicans (doctorally trained and not), who are willing to take the work...whether they are competent or not to actually do it. I have a few years of assessment (research & clinical) experience working with pediatrics, and I still am hesitant to consult on any pediatric case that isn't clearly within my prior niche area of research...and even then I am very careful to qualify anything I say.

Right. To be honest, our reports are often very boring and overdetailed. I question who we are writing for at times: ourselves or the actual referral source?

I don't do peds but that is what I have heard here. I can just see some of the specialties (like neuropsych) becoming less relevant if it remains too elitist (i.e., the same rules don't apply to me that apply to all of your health care providers because I am special, so give me as much time as I need to get it done).

Originally Posted by Pragma

Right. To be honest, our reports are often very boring and overdetailed. I question who we are writing for at times: ourselves or the actual referral source?

I don't do peds but that is what I have heard here. I can just see some of the specialties (like neuropsych) becoming less relevant if it remains too elitist (i.e., the same rules don't apply to me that apply to all of your health care providers because I am special, so give me as much time as I need to get it done).

It might just be my own limited experiences, but I've definitely seen a push for faster neuropsych report turnarounds in both the VA and academic medicine. Don't get me wrong, I still have the occasional supervisor who's ok with the report taking two weeks to get back, although this is usually due to the pt not being scheduled to return to the hospital for a month or two. But in general, I've had multiple times where same-week turnaround was the goal, and I personally aimed for same-day when possible.

I wonder if most of the holdout is happening in private practice, particularly self-pay private practice? I know (again, in my own limited experience) this is where I saw most of the multi-day evals and subsequent 15+ page reports coming from.

Originally Posted by AcronymAllergy

It might just be my own limited experiences, but I've definitely seen a push for faster neuropsych report turnarounds in both the VA and academic medicine. Don't get me wrong, I still have the occasional supervisor who's ok with the report taking two weeks to get back, although this is usually due to the pt not being scheduled to return to the hospital for a month or two. But in general, I've had multiple times where same-week turnaround was the goal, and I personally aimed for same-day when possible.

I wonder if most of the holdout is happening in private practice, particularly self-pay private practice? I know (again, in my own limited experience) this is where I saw most of the multi-day evals and subsequent 15+ page reports coming from.

Not sure exactly...I have seen some of the holdovers within academic medicine. I am a same-day or next day type of person usually myself, but have had to be flexibile about that if I have needed to see several patients in a row without time to write because of extra referrals. But I hear about the really long delays more on the peds side of things, mostly because of obtaining records and getting collateral reports, as well as writing in a lot more detail.

I think where I see it within academic medicine, you have little bubbles where there are plenty of captive referrals within a system (e.g., HMO) or enough prestige for the institution such that the neuropsychs leverage that to do things the way they have always done them.

I am not saying that people haven't made it more brief or user-friendly everywhere. But it is pretty sad that the ABPP-CN boarding evaluators literally have to evaluate whether people "answered the referral question." There is something fundamentally wrong with things if a common problem is people getting too caught up in irrelevant details.

Originally Posted by AcronymAllergy

It might just be my own limited experiences, but I've definitely seen a push for faster neuropsych report turnarounds in both the VA and academic medicine. Don't get me wrong, I still have the occasional supervisor who's ok with the report taking two weeks to get back, although this is usually due to the pt not being scheduled to return to the hospital for a month or two. But in general, I've had multiple times where same-week turnaround was the goal, and I personally aimed for same-day when possible.

This has been my experience as well. When I was in the VA system the goal was <1 week. It was common to have a 3-4+ mon waiting list for neuro evals, so my mentor really pushed for clear referral questions (typically differential dx) and we tried to write clear and concise reports. We would talk about the data in depth during supervision because that was what was needed for my training, though the actual written report was much more to the point and focused on providing a Dx (and if applicable we also included functional recommendations for the patient and clinical recommendations for the referring physician.)

Originally Posted by AcronymAllergy

I wonder if most of the holdout is happening in private practice, particularly self-pay private practice? I know (again, in my own limited experience) this is where I saw most of the multi-day evals and subsequent 15+ page reports coming from.

More and more neuropsychologists are opting out of Medicare and private insurance plans because there is a disconnect between what is needed and what is being reimbursed. Most insurance cap at 6-8 hours...for everything. Additional hours can be requested, but most insurance companies require you to do backflips to get them, and even then they will look for reasons to deny them. This can be wholy insufficient to answer many of the typical referral questions being asked. Sadly this all reduces down to: Fast, Cheap, or High Quality scenario...whereas you are limited to choosing 2 of the 3 options.

I don't know how taking insurance makes fiscal sense for most clinicans at some of the rates that I have been quoted and the time associated with billing problems. Even when a 3rd party billing service is utilized by a clinican, billing issues can still eat up an inordinate amount of time. I strongly encourage all students and early career clinicians to speak to people in private practice about billing because it is a far more complex issue than most realize, and NONE of the issues are covered during training.

I personally am not considering taking any insurance when I finally branch off into private practice, as I'd rather practice in a different area than deal with the BS I constantly hear about on the npsych and mhbilling listservs. Some clinicians offer to write up a summary of information for the patient so they can seek out-of-network benefits from their insurance, but even that invites more headaches into the equation.

There are a % of practices that mostly/only do medicolegal evaluations, which tend to be extensive and very expensive. It is a different ballgame because the payor is typically a lawyer and the $ at risk to the case is often 6-7+ figures. They will always be the exception because there is just too much $ involved.

Originally Posted by Therapist4Chnge

I don't know how taking insurance makes fiscal sense for most clinicans at some of the rates that I have been quoted and the time associated with billing problems. Even when a 3rd party billing service is utilized by a clinican, billing issues can still eat up an inordinate amount of time. I strongly encourage all students and early career clinicians to speak to people in private practice about billing because it is a far more complex issue than most realize, and NONE of the issues are covered during training.

I personally am not considering taking any insurance when I finally branch off into private practice, as I'd rather practice in a different area than deal with the BS I constantly hear about on the npsych and mhbilling listservs. Some clinicians offer to write up a summary of information for the patient so they can seek out-of-network benefits from their insurance, but even that invites more headaches into the equation.

There are a % of practices that mostly/only do medicolegal evaluations, which tend to be extensive and very expensive. It is a different ballgame because the payor is typically a lawyer and the $ at risk to the case is often 6-7+ figures. They will always be the exception because there is just too much $ involved.

Oh, don't get me wrong, I'm not saying that private pay = inefficient and/or superfluous practice. Just that if you're going to do a three-day eval and write up a 15-page report, as you've mentioned, there's absolutely no way insurance is going to reimburse you for even half of that. Perhaps this perceived inefficiency is one of the reasons insurance companies have bucked against neuropsych and swung so far in the other direction; that, and our own relatively poor self-advocacy efforts.

I do think there's room for improvement in many practices, and perhaps that's one of the good things to be gleaned from our increased dealings with insurance companies. Obviously part of the trouble is that our tests aren't always good at providing clear answers in short amounts of time; sometimes, it takes administering a good number of them to get a clear idea of what's going on. We need to keep improving our tests and methods, but we also need to keep proving to other healthcare professionals that we can answer their questions, and provide meaningful and useful input, with the tests we've currently got.

Originally Posted by AcronymAllergy

Oh, don't get me wrong, I'm not saying that private pay = inefficient and/or superfluous practice. Just that if you're going to do a three-day eval and write up a 15-page report, as you've mentioned, there's absolutely no way insurance is going to reimburse you for even half of that. Perhaps this perceived inefficiency is one of the reasons insurance companies have bucked against neuropsych and swung so far in the other direction; that, and our own relatively poor self-advocacy efforts.

I do think there's room for improvement in many practices, and perhaps that's one of the good things to be gleaned from our increased dealings with insurance companies. Obviously part of the trouble is that our tests aren't always good at providing clear answers in short amounts of time; sometimes, it takes administering a good number of them to get a clear idea of what's going on. We need to keep improving our tests and methods, but we also need to keep proving to other healthcare professionals that we can answer their questions, and provide meaningful and useful input, with the tests we've currently got.

People like heuristics. If we are constantly convoluted and indecisive about things, all the while taking a long time to give those qualified answers, then our perceived value goes down as a whole. Sure, sometimes we can't tell or we get referrals that are really tough. But we need to educate our referral sources about what we can and can't do, not just take those cases and respond with "Bla bla bla.....bla bla bla..., IDK."

Given how things are in health care, I have never once heard a supervisor suggest that we should ask people NOT to send us certain things, or for us to suggest that we might not be great at answering certain questions. Although this may be taboo, I think neuropsychologists really need to evaluate if we actually ARE reducing the costs of healthcare in the long term through our work, or if we use that argument in an empty manner whilst folks in actuality are trying to make a buck.

Generally insurance companies have a reason for limiting services based on data. To not take insurance is not something I would ever consider, but that is just me and my own values. I also don't know anyone rich enough to pay out of pocket for that sort of thing, and am not interested in serving that subgroup of the population. Good thing I am not going into full time clinical work

Originally Posted by Pragma

People like heuristics. If we are constantly convoluted and indecisive about things, all the while taking a long time to give those qualified answers, then our perceived value goes down as a whole. Sure, sometimes we can't tell or we get referrals that are really tough. But we need to educate our referral sources about what we can and can't do, not just take those cases and respond with "Bla bla bla.....bla bla bla..., IDK."

Given how things are in health care, I have never once heard a supervisor suggest that we should ask people NOT to send us certain things, or for us to suggest that we might not be great at answering certain questions. Although this may be taboo, I think neuropsychologists really need to evaluate if we actually ARE reducing the costs of healthcare in the long term through our work, or if we use that argument in an empty manner whilst folks in actuality are trying to make a buck.

Generally insurance companies have a reason for limiting services based on data. To not take insurance is not something I would ever consider, but that is just me and my own values. I also don't know anyone rich enough to pay out of pocket for that sort of thing, and am not interested in serving that subgroup of the population. Good thing I am not going into full time clinical work

I, for one, definitely support the outcomes-related research that's being pushed and sponsored by neuropsych professional orgs at the moment. I don't know that reducing healthcare costs should be our only, or perhaps even paramount, goal (not saying you suggested this, btw), but we certainly can't sit with our heads in the sand and tell the rest of the healthcare juggernaut, "costs? who cares about costs, we're psychologists, we're different, that's not what we worry about." The costs of our services to our patients definitely needs to be taken into consideration, as does the whole cost-benefit decision-making process.

Originally Posted by paramour

She is indeed a special duck. I suspect her deep-rooted desire to work in such a place has more to do with her overwhelming need to restrict herself to a certain geographical area. This particular setting is the only place which she could potentially work within that geographically restricted area, soooo, of course this is where she has always, always, always wanted to work. Even though she has no experience in such a setting.

T4C, I find it interesting that you mention CMHCs are generally rough to work at on a daily basis. I had to jump quite a few hoops to get a "voluntary" practicum approved at the local CMHC (we had a paid practicum there once upon a time 'til they dropped us). My dept then expressed concerns because they knew people who "burned out" quickly there, but they seemed to be attributing it to the site itself rather than it being a CMHC. During my interview with the director, however, I received the impression that the work-load/stress was not restricted or 'special' to this specific CMHC. I guess I'll find out what I'm in for once I get there next month (hopefully it's better since I've restricted myself primarily to evaluations/assessments?).

I am relatively new to this forum, and I assume CMHC stands for Community Mental Health Clinic. If that is the case then the impression you received is correct. I am a Master's level clinician and I have been working at one for only a year and it is rough. Aside from being overwhelmed with clients, the majority of them are on Medicaid/Medicare with considerable limitations on transportation and when they can meet for sessions, and given that my CMHC also receives some state funding the paper work is even more crippling than at a typical private practice (or so I have been told). Also, given that many providers in my area have backed away from Medicaid/Medicare, many people are limited to our clinic only, putting clinicians in the position that they take on clients with issues that stretch the limits of their ability or have those clients be simply dropped and not seen by anyone.

Additionally I have had to negotiate clients that are coming in to get their children diagnosed simply to attain disability status and receive government assistance. My first day in the waiting room I heard a client say "I'm bored. I wanna go." The parent responded with "Well, if you go you know you don't get your check." The client replied that they didn't care, and they left. I have also had children who, when I meet with them 1:1 without parents, tell me that their parent wanted them to lie about voices in their head/out of control behaviors, or to simply act 'crazy' until they left my office.We have little to no access for assessments, client families can't pay out of pocket, and I am not allowed to be reimbursed by the insurance companies intakes and sessions that last longer than a certain period of time, so I have to take a client's word for it.

I've even had to call insurance companies to justify billing crisis evaluations on clients who were 1013'd by my supervisor. You have to fight just to get paid for your services. I don't know if this is poor lobbying on behalf of mental health in general, or maybe that mental health services aren't seen as useful by insurance at large, or both. It certainly doesn't help having a slew of degree acronyms.

It seems to me like a bidding war where the insurance will reimburse whoever is willing to take the lowest amount, then force all other to bend to that amount or not be paid at all.

Originally Posted by AcronymAllergy

I, for one, definitely support the outcomes-related research that's being pushed and sponsored by neuropsych professional orgs at the moment. I don't know that reducing healthcare costs should be our only, or perhaps even paramount, goal (not saying you suggested this, btw), but we certainly can't sit with our heads in the sand and tell the rest of the healthcare juggernaut, "costs? who cares about costs, we're psychologists, we're different, that's not what we worry about." The costs of our services to our patients definitely needs to be taken into consideration, as does the whole cost-benefit decision-making process.

Yeah it is great that there are some small foundation grants promoting such research. One would think we'd have a lot of outcome research by now, and since we don't have so much I think that is why were are at a crossroads without sufficient evidence to help us make an argument for funding agencies.

But now look, the thread is derailed!

Originally Posted by zensouth

I am relatively new to this forum, and I assume CMHC stands for Community Mental Health Clinic. If that is the case then the impression you received is correct. I am a Master's level clinician and I have been working at one for only a year and it is rough. Aside from being overwhelmed with clients, the majority of them are on Medicaid/Medicare with considerable limitations on transportation and when they can meet for sessions, and given that my CMHC also receives some state funding the paper work is even more crippling than at a typical private practice (or so I have been told). Also, given that many providers in my area have backed away from Medicaid/Medicare, many people are limited to our clinic only, putting clinicians in the position that they take on clients with issues that stretch the limits of their ability or have those clients be simply dropped and not seen by anyone.

Additionally I have had to negotiate clients that are coming in to get their children diagnosed simply to attain disability status and receive government assistance. My first day in the waiting room I heard a client say "I'm bored. I wanna go." The parent responded with "Well, if you go you know you don't get your check." The client replied that they didn't care, and they left. I have also had children who, when I meet with them 1:1 without parents, tell me that their parent wanted them to lie about voices in their head/out of control behaviors, or to simply act 'crazy' until they left my office.We have little to no access for assessments, client families can't pay out of pocket, and I am not allowed to be reimbursed by the insurance companies intakes and sessions that last longer than a certain period of time, so I have to take a client's word for it.

I've even had to call insurance companies to justify billing crisis evaluations on clients who were 1013'd by my supervisor. You have to fight just to get paid for your services. I don't know if this is poor lobbying on behalf of mental health in general, or maybe that mental health services aren't seen as useful by insurance at large, or both. It certainly doesn't help having a slew of degree acronyms.

It seems to me like a bidding war where the insurance will reimburse whoever is willing to take the lowest amount, then force all other to bend to that amount or not be paid at all.

Yeah I spent some time in CMHCs before shifting to hospital settings, and still talk wtih some. The clients you will get tend to be some of the roughest ones with complicated histories (although the County gets the ones that are turned away from CMHCs...that's probably the last line of defense). Most of that case management is not going to be reimbursed. In my experience, folks who work at CMHCs tend to more focused on outcomes and what is needed than "that's not my job" so it works out.

When it comes to Medicare/Medicaid, at least you aren't talking about a for-profit company. Funding is an issue everywhere and these state/federal programs are stretched to the max. But people are getting paid less and less!

Originally Posted by Therapist4Chnge

CMHCs generally struggle with funding, have more patients than they can see, and the typical caseload is chock full of complex cases that require more resources than are available. Some people thrive in that kind of environment, though I know I'd just pull my hair out after awhile. I work at a publically-funded hospital that gets steered all of the toughest cases, but we at least have resources to attempt to help. Obviously there are still many limitations, but I feel like our patients at least have a shot, whereas my (limited) experience with CMHCs felt more like a revolving door of patients who really need more help than is available.

Originally Posted by zensouth

I am relatively new to this forum, and I assume CMHC stands for Community Mental Health Clinic. If that is the case then the impression you received is correct. I am a Master's level clinician and I have been working at one for only a year and it is rough. Aside from being overwhelmed with clients, the majority of them are on Medicaid/Medicare with considerable limitations on transportation and when they can meet for sessions, and given that my CMHC also receives some state funding the paper work is even more crippling than at a typical private practice (or so I have been told). Also, given that many providers in my area have backed away from Medicaid/Medicare, many people are limited to our clinic only, putting clinicians in the position that they take on clients with issues that stretch the limits of their ability or have those clients be simply dropped and not seen by anyone.

Additionally I have had to negotiate clients that are coming in to get their children diagnosed simply to attain disability status and receive government assistance. My first day in the waiting room I heard a client say "I'm bored. I wanna go." The parent responded with "Well, if you go you know you don't get your check." The client replied that they didn't care, and they left. I have also had children who, when I meet with them 1:1 without parents, tell me that their parent wanted them to lie about voices in their head/out of control behaviors, or to simply act 'crazy' until they left my office.We have little to no access for assessments, client families can't pay out of pocket, and I am not allowed to be reimbursed by the insurance companies intakes and sessions that last longer than a certain period of time, so I have to take a client's word for it.

I've even had to call insurance companies to justify billing crisis evaluations on clients who were 1013'd by my supervisor. You have to fight just to get paid for your services. I don't know if this is poor lobbying on behalf of mental health in general, or maybe that mental health services aren't seen as useful by insurance at large, or both. It certainly doesn't help having a slew of degree acronyms.

It seems to me like a bidding war where the insurance will reimburse whoever is willing to take the lowest amount, then force all other to bend to that amount or not be paid at all.

Originally Posted by Pragma

Yeah I spent some time in CMHCs before shifting to hospital settings, and still talk wtih some. The clients you will get tend to be some of the roughest ones with complicated histories (although the County gets the ones that are turned away from CMHCs...that's probably the last line of defense). Most of that case management is not going to be reimbursed. In my experience, folks who work at CMHCs tend to more focused on outcomes and what is needed than "that's not my job" so it works out.

When it comes to Medicare/Medicaid, at least you aren't talking about a for-profit company. Funding is an issue everywhere and these state/federal programs are stretched to the max. But people are getting paid less and less!

This all seems to mesh with my understanding of our local CMHC. Unfortunately, it is plagued by those neverending funding issues as well. Additionally, we're in an area that has an abysmal lack of mental health care of any kind from any type of provider. Then, the county hospital shut down their psych floor a few years ago. The closest inpatient services are currently 1.5 hours away, buuut the ambulance folks typically dislike driving across county lines (in addition to the time it takes) to get people there... and news indicates that it's about to shut down soon anyway (so the state is allegedly going to funnel some of its funding to the local CMHC). Everyone goes to the CMHC because they hear that it "can't turn them away" due to funding it receives from other sources, but that funding is limited and can't be available for every person who walks through the door.

Anyway, thanks for the info, folks! Good to know that the local CMHC isn't the only one like this (and to be expected basically). I suspected that there were a select few in my dept merely attempting to use this information to dissuade me from working there. Hopefully I don't start hearing voices in the waiting room over the next year!

Originally Posted by Jon Snow

Quite the shift for you, Flutter.

I believe this was the direct result of working my ass off for 7 years to complete the training I needed to ethically call myself a neuropsychologist, while classmates of mine were out the door in 4 years, no APA internship, and setting up private practices in which they conduct "neuropsychological assessments" as part of their offerings. It's just not right. I have always been a strong Psy.D. proponent, but after going through a rigorous internship and postdoc experience, I just can't justify the 4-year in and out method of graduating Psy.D's from professional schools. It's not beneficial to anyone but the institution that collects the checks.

Originally Posted by Flutterbyu

I believe this was the direct result of working my ass off for 7 years to complete the training I needed to ethically call myself a neuropsychologist, while classmates of mine were out the door in 4 years, no APA internship, and setting up private practices in which they conduct "neuropsychological assessments" as part of their offerings. It's just not right. I have always been a strong Psy.D. proponent, but after going through a rigorous internship and postdoc experience, I just can't justify the 4-year in and out method of graduating Psy.D's from professional schools. It's not beneficial to anyone but the institution that collects the checks.

+1.

I took a very similar path (but 8 years) and my position has become much more rigid about training standards and what should be considered the bare minimum for competency.

Originally Posted by 4410

The MD and DO shows some similarities with PhD and PsyD and now there are some PsyD programs that are actually administered by Osteopathic medicine schools. In this date in time there is not any difference between MD and DO programs and a DO is considered to be equivalent to the MD degree. With RxP legislation in the next 20 years most psychologists will be licensed by the State Board of Medical Examiners or rather the psychology board will be merged with the medical board. LPC's will take over the more traditional mental health treatment and psychologists will be considered a medical specialty and readily be accepted in Hospital and medical settings. I could see psychologists training having the degree designation of MD or DO with training being provided in medical schools with the designation of MD or DO degree psychologists and the PhD and PsyD degree will become something such as MD-PhD psychologists or DO-PsyD psychologists but we will have either the MD or DO degree designation.

Ask your md/do friends and see. While most md's will concede that there are top flight DO schools, they will also point to the wide number that are not and the differences in training. It is almost perfectly analogous to the Phd v Psyd debate.

Most MDs will vigorously disagree that they are the "same" as a DO. Try telling one that.

M

I would just like to point out that if you substituted PhD and PsyD with racial, ethnic or other group names, we would have a discussion that represents our history with in-group vs out-group tensions. It's very interesting. It's interesting how even at the doctoral level in psychology we still seek to label and classify in broad terms.

I have been studying psychology for 7 years (psych major from day one of undergrad) and have grown to really see our society's individualistic tendencies. There seems to be this mentality, in multiple contexts, that we need to eliminate certain group to maintain resources. I'm starting to think, almost believe, we need a collectivism in our culture. Why don't we start forum on how we can value multiple training perspectives and work together towards common goal.

As psychologists (or soon-to-be), our energy would best be spent on brainstorming and using our critical thinking abilities to advocate for the field of psychology (and behavioral health in general). There is so much work to be done for psychology as a profession.

I'll stop there, for now, and wait for responses

Originally Posted by ClinicStudent

It's interesting how even at the doctoral level in psychology we still seek to label and classify in broad terms.

Why is that interesting? Because doctors should not want to classify people? Come on, dude...

I do not think this debate (Psy.D vs Ph.D) is taking place in any meaningful way in the real world. I think quality of training is, and I think that important. Poorly trained vs well-trained. Its an important distinction to make ("classify) whether you believe it to be or not.

I think erg has a point- that "well trained vs. poorly trained" should be the debate, instead of Ph.D. vs. Psy.D. Many of us Psy.D.'s (or Psy.D. students) have the same concerns voiced by Ph.D.'s (or Ph.D. students)- that there be rigor in the academic and clinical training process.

Originally Posted by ClinicStudent

I would just like to point out that if you substituted PhD and PsyD with racial, ethnic or other group names, we would have a discussion that represents our history with in-group vs out-group tensions. It's very interesting. It's interesting how even at the doctoral level in psychology we still seek to label and classify in broad terms.

I have been studying psychology for 7 years (psych major from day one of undergrad) and have grown to really see our society's individualistic tendencies. There seems to be this mentality, in multiple contexts, that we need to eliminate certain group to maintain resources. I'm starting to think, almost believe, we need a collectivism in our culture. Why don't we start forum on how we can value multiple training perspectives and work together towards common goal.

As psychologists (or soon-to-be), our energy would best be spent on brainstorming and using our critical thinking abilities to advocate for the field of psychology (and behavioral health in general). There is so much work to be done for psychology as a profession.

I'll stop there, for now, and wait for responses

Ehh to me your comparison smacks of sophistry. Two groups in conflict doesn't mean we can find the solution in the civil rights struggle or social psych research. Advocating for our field includes maintaining high academic standards to keep up our reputation, not to mention our salaries. Criticism of some Psy.D. programs only intensified when they doubled and tripled their class sizes, admitting under qualified applicants which substantially accelerated the internship crisis. Now we have their advocates wanting to water down the already minimum standards for accreditation. Sometimes the "let's just get along" sentiment is really an obfuscation. A group of for-profit education executives created a problem for our field by chasing the federal student loan fairy and here we are dealing with the consequences. Denying that reality cuts off the obvious path out of this mess: clamp down on the offending programs. That's how I'd like to advocate for psychology.

There seems to be this mentality, in multiple contexts, that we need to eliminate certain group to maintain resources.

No one wants to eliminate the outgroup, we want birth control so we don't go over the carrying capacity of our ecosystem.

Originally Posted by ClinPsychEnthus

I think erg has a point- that "well trained vs. poorly trained" should be the debate, instead of Ph.D. vs. Psy.D. Many of us Psy.D.'s (or Psy.D. students) have the same concerns voiced by Ph.D.'s (or Ph.D. students)- that there be rigor in the academic and clinical training process.

Agreed. On this board, at least, the argument is much more often about adequately- vs. inadequately-trained than it is Ph.D. vs. Psy.D. In the "real world," when the latter comes up, at least in my experiences, the underlying issue is the same (i.e., adequacy of training). However, because the number of questionable-quality Psy.D. programs seems to be outpacing the number of reputable training institutions, there's definitely a misunderstanding/generalization propogated by this outpacing that Psy.D. = poor training.

Anyone read this article?

http://blogmaverick.com/2012/05/13/t...any-time-soon/

I wonder how this may affect PsyD students in the future.

Originally Posted by roubs

A group of for-profit education executives created a problem for our field by chasing the federal student loan fairy and here we are dealing with the consequences. Denying that reality cuts off the obvious path out of this mess: clamp down on the offending programs. That's how I'd like to advocate for psychology.

The "obvious" path is to kill the federal student loan fairy as it stands to today, which would in a heartbeat probably cause at least a third of these questionable programs to disappear.

Originally Posted by ClinPsychEnthus

I think erg has a point- that "well trained vs. poorly trained" should be the debate, instead of Ph.D. vs. Psy.D. Many of us Psy.D.'s (or Psy.D. students) have the same concerns voiced by Ph.D.'s (or Ph.D. students)- that there be rigor in the academic and clinical training process.

Yes- this is all well and good. Obviously, the argument should be about good vs. bad training. However, when the degrees has been exploited and contributes overwhelmingly to the poor training of doctoral level psychologists, it would not be a complete argument without mentioning the degree.

Originally Posted by JeyRo

The "obvious" path is to kill the federal student loan fairy as it stands to today, which would in a heartbeat probably cause at least a third of these questionable programs to disappear.

All federally backed student loans or just the fairy part where the for-profits get something for nothing? The former would, imo, be a ridiculously blunt instrument solution. The existence of federally backed student loans enables upward mobility and without it even the possibility of higher education would become out of reach for many many people. This is a classic example of abuse of a system where the for-profit world takes in the student loan dollars but does not give back a quality product enabling the higher salary which would make loan repayment possible. This can and has been quantified. In a globally competitive labor market we should take pains not to kneecap ourselves when fixing problems like this. This for-profit mess is an immediate disaster that needs to be addressed, trying to do so while cutting off higher education access too much would be a slow motion trainwreck.

Agree with the above - we can stand on the deck of the titanic singing kumbaya or we can patch the holes. That doesn't mean diversity in training isn't valuable, but the whole point is that what might have been originally intended as "different" has turned into "bad". Different isn't always equal, and it seems foolish to pretend it is. If it seemed graduates of these programs got equivalent training, I doubt you'd see the level of backlash you do see. Instead, you have people calling themselves doctors of psychology who can barely understand studies in the major journals of the field, let alone run one of them, seem to offer few to no advantages (e.g. despite being purportedly "clinically-focused" are graduating people with fewer average clinical hours). Learning less is learning less. A bachelor's in psychology is certainly different, but not "equal" to a doctorate. Pretending it is for the sake of "unity" seems short-sighted. I don't view this situation as any different.

Originally Posted by erg923

Why is that interesting? Because doctors should not want to classify people? Come on, dude...

I do not think this debate (Psy.D vs Ph.D) is taking place in any meaningful way in the real world. I think quality of training is, and I think that important. Poorly trained vs well-trained. Its an important distinction to make ("classify) whether you believe it to be or not.

It's interesting because as I read through this thread I did not see much productive discussion on how to improve the quality of training all around. I certainly do not support the credentialing of under/poorly trained psychologists. Are there students that get admitted to PsyD programs that probably are not a good fit for the field? Yes. Are there students that get admitted to PhD programs that are not a good fit for the field. Yes.
Unfortunately, it is very difficult to identify whether or not someone will make a quality psychologist. Sometimes it's obvious at the application stage (either they are a strikingly good candidate or not), but most times it's rather difficult to predict.

Regarding the training program: there certainly ought to be standards and competencies that need to be met. I like to believe I have faith that the APA accreditation process does a suitable job of upholding these standards without trying to create a cookie cutter protocol. But we should always seek to improve training procedures.

What courses are required to be taken? What is included in the clinical training? I've heard some horror stories about both types of programs. I've heard of students taking courses in assessment without ever actually administering a WAIS. I've heard of students saying their goal is to graduate and then transition into a full-time faculty position, instructing clinical courses (yet they will have never had a full-time clinical position).

Simply blaming the PsyD programs for poorly trained psychology students is not the answer. There are programs on both sides of the aisle that provide inadequate training. I have had professors at every level of training with PsyDs and PhDs. My cohorts consensus was that their degree did not seem to be predictors of the quality of instruction. Of course, going into some of the courses, we assumed professors with a PhD would be much more knowledgeable. My point, there are high-quality PhD programs and PsyD programs. There are poor-quality PhD programs and PsyD programs. Let's focus on how we can improve both.

Originally Posted by ClinicStudent

It's interesting because as I read through this thread I did not see much productive discussion on how to improve the quality of training all around. I certainly do not support the credentialing of under/poorly trained psychologists. Are there students that get admitted to PsyD programs that probably are not a good fit for the field? Yes. Are there students that get admitted to PhD programs that are not a good fit for the field. Yes.
Unfortunately, it is very difficult to identify whether or not someone will make a quality psychologist. Sometimes it's obvious at the application stage (either they are a strikingly good candidate or not), but most times it's rather difficult to predict.

Regarding the training program: there certainly ought to be standards and competencies that need to be met. I like to believe I have faith that the APA accreditation process does a suitable job of upholding these standards without trying to create a cookie cutter protocol. But we should always seek to improve training procedures.

What courses are required to be taken? What is included in the clinical training? I've heard some horror stories about both types of programs. I've heard of students taking courses in assessment without ever actually administering a WAIS. I've heard of students saying their goal is to graduate and then transition into a full-time faculty position, instructing clinical courses (yet they will have never had a full-time clinical position).

Simply blaming the PsyD programs for poorly trained psychology students is not the answer. There are programs on both sides of the aisle that provide inadequate training. I have had professors at every level of training with PsyDs and PhDs. My cohorts consensus was that their degree did not seem to be predictors of the quality of instruction. Of course, going into some of the courses, we assumed professors with a PhD would be much more knowledgeable. My point, there are high-quality PhD programs and PsyD programs. There are poor-quality PhD programs and PsyD programs. Let's focus on how we can improve both.

Free-standing professional schools are too far gone to be improved and also happen to disproportionately contribute to the number of poorly trained folks being dumped into the field. Fixing that problem alone would put us miles and miles ahead.

This may be true. I think a rigorous exploration into specific schools would be worthwhile. Of course, we would need to define what is "quality." I'd suggest the following
-Evaluate what are the requirements of the core courses within the curriculum.
-Evaluate how the programs evaluate their students.
-What is the sequence of clinical training.

I find my program to be very comprehensive and rigorous. There are a series of comprehensive evaluations (objective, written and clinical). In general, writing is highly emphasized from day one. First year is heavy in theory, research and writing. Year two courses are geared towards clinical skill development and assessment training. Year three is practicum, electives, and dissertation focused. Year four similar to year three with new practicum placement. year 5 Internship. Comps before year three and 4. I only provide this info because I feel it has been effective for me.

Originally Posted by ClinicStudent

This may be true. I think a rigorous exploration into specific schools would be worthwhile. Of course, we would need to define what is "quality." I'd suggest the following
-Evaluate what are the requirements of the core courses within the curriculum.
-Evaluate how the programs evaluate their students.
-What is the sequence of clinical training.

I find my program to be very comprehensive and rigorous. There are a series of comprehensive evaluations (objective, written and clinical). In general, writing is highly emphasized from day one. First year is heavy in theory, research and writing. Year two courses are geared towards clinical skill development and assessment training. Year three is practicum, electives, and dissertation focused. Year four similar to year three with new practicum placement. year 5 Internship. Comps before year three and 4. I only provide this info because I feel it has been effective for me.

The program I'm in runs similarly, and I love it. I think its set up in a logical way to build a solid knowledge-base, then continue to build leading up to advanced practice and internship.