Thanks for posting. Always good to be kept abreast of the latest ideas and developments in the field.
One immediate concern I'd have is a practical one, namely, what is the current (and expected future) actual demand in MH organizations/hospitals for the prototype non-licensed and non-practicing 'clinical psychologists' they're envisioning? With budgets typically stretched thin in such organizations, is there realistically going to be a great demand for these types of professionals?
This was on my mind the entire time I was reading it. Where are the jobs for psychologists in this model? Who would be paying them to do these things and why wouldn't these organizations and employers just hire someone cheaper (e.g., MPH) or with another more specialized degree (e.g., biostatistics or epidemiology PhD), ? They mention various hypothetical settings (e.g., schools, NGOs), but why would they hire an expensive psychologist who is trying to be a jack-of-all-trades-but-master-of-none, as opposed to expanding the scopes of their existing employees or hiring someone with the specific skills they need?
And if a psychologist wanted to get into other areas and settings, why shouldn't they just go get an MPH or other relevant degree to add to their repertoire or even some training without a degree? Why change the entire system for small minority of psychologists?
Also, if the mental health burden is so high partially because of the "treatment gap," won't siphoning off some psychologists to do this other work through their (yet unproven) model make the problem worse?
Here's what they envision as the scope of psychologists under this model:
If such an approach were to be employed more broadly, clinical psychologists could contribute to reducing mental health burdens in a wide variety of ways, including: (a) continuing to directly deliver evidence-based treatments to people who have already developed mental health conditions; (b) leading and training others to deliver evidence-based prevention programs and treatments; (c) developing, implementing, and disseminating more effective and efficient evidence-based interventions; (d) conducting research intended to lead to the development of improved interventions, especially those that extend beyond oneto-one, in-person interventions in traditional settings, such as direct-to-user digital interventions; (e) developing and implementing improved means of identifying those at highest risk for mental health conditions; (f) working to develop and implement prevention efforts in non-clinical/medical settings, ranging from barber shops and hair salons (see Victor et al., 2018) to social media platforms and embedded sensors in personal computing devices; and (g) using clinical psychological science to inform public policy.
They never really establish how or why existing psychologists trained in the current system can't do these things, or why it's better to fundamentally change the current system instead of just having psychologists collaborate with professionals from other fields.
For example,
- "A" and "B" are basic parts of any accredited doctoral program
- Without getting into too much detail, "C" and "D" are explicitly part of my mentor's primary research program and those of many other faculty.
- Other labs in my program are doing "E" with various populations, risk factors, perspectives, etc., including SMI and health psych.
- I know a lab in a clinical program which focuses on implementing DBT-derived interventions in schools for prevention and behavior management purposes, which would seem to fit with their description of "F."
And for something like "G," how is their model superior to, say, a psychologist being hired as a consultant to an organization staffed with public policy analysts, epidemiologists, and other professionals with whom they will be directly collaborating?
The other concern I'd have is the degradation of a clinical/scientific profession into one largely composed of non-practicing 'excellentologists' and 'expertologists' churning out endlessly complex rules, policies, procedures, 'best' practices, PowerPoint trainings, etc. to overcomplicate the lives of the actual clinical practitioners on the front lines with caseloads of 100+ clients. These non-practicing clinical psychologists who, nonetheless, are busy'shaping/directing' clinical policies/procedures without 'skin in the game' or without the perspective of what it's like to try to IMPLEMENT all those great new ideas on the ground (rather than at 30,000ft) with individual clients...I dunno, I think we have enough of that kind of thing already making life hell for practitioners in clinical service settings. I think we need far LESS of that sort of thing, not more.
Exactly. It's more people in the bloated professional managerial class who are detached from the concerns and lives of the average person or practitioner.
As someone who prepared for a research career and ended up in almost (75%) full time clinical practice, I'm not convinced that this model would work for everyone. A lot of us don't know exactly what setting or role we want to be in. Yes, our training is a huge pain, but it does give us maximum flexibility.
That's what so perplexing about this article. They repeatedly talk about how their model would increase "flexibility" (using it 22 times throughout), but they don't at all reckon with the incredible loss of flexibility that comes from not being able to be licensed at the doctoral level. They do implicitly try to address this by claiming that students who complete even just the "initial Foundational Knowledge and Competency Phase" could get licensed at the master's level, but, as I'm sure everyone here knows, that's far different in so many ways than being a licensed psychologist. I certainly wouldn't take that bargain regardless of how great the "NGO internship" was.
And again, they're not really addressing how just getting a master's level licensure and a separate master's degree (e.g., MPH) is not equivalent to what they're advocating.
Furthermore, I always think of something I've read on this board: if you're arguing that training needs to be less arduous because there need to be more psychologists to help people with mental health issues, don't you need to show that there's an actual shortage? As we've discussed, isn't the problem more disparity in rural vs. urban and general clustering of psychologists in highly populated areas?
That's the other part that's perplexing and frustrating. They keep using the geographic disparities in mental health (i.e., the US vs. most of the rest of the world) as justification for why the change is needed, but never really acknowledge that the effects would be mostly limited to the US or that the "shortages" in the US are based on geography as well, not an absolute shortage.
They pay the tiniest lip service to this by saying that psychologists under their new model could join an NGO and go abroad to improve mental health, but fail to to flesh out the gigantic questions this entails or any of the problems it would entail (e.g., white saviorism, cultural chauvinism). More egregiously, they deflect as to the actual reasons for many of these disparities, especially cultural stigma surrounding mental health. I don't know that a bunch of American intelligentsia coming into a country and telling people how to address their mental health and fundamentally change their culture is going to work the way they think it is.
There is robust evidence that when antipsychotics are used for approved conditions in the general population, their prolonged use shortens lifespans by an average of 25 years. They also shrink the white matter of the brain, result in metabolic syndrome, and massive weight gain. Dr. Nancy Andreason’s work at the University of Iowa, demonstrated definitively that it is the anti-psychotic itself and not the illness being treated that is associated with brain shrinkage. Even with schizophrenia, good medicine calls for the briefest possible exposure to antipsychotics, at the lowest dose needed to stabilize. Countries other than the United States, that offer psychosocial alternatives to treat psychosis, have much better outcomes and quality of life for those so diagnosed.
Is this true? I attended a conference on psychosis that mentioned the brain shrinkage but indicated that was related to unmedicated episodes. Can any psychiatrists who visit this board weigh in?
I can't answer that, but I don't think the bolded section is even close to correct, nor do I think any differences in outcomes across countries is reducible to the usage of antipsychotics vs other treatments. There are so many other factors (e.g., multigenerational households, cultural differences in explaining psychotic experiences) involved.
