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Reminds me of an article I just read about women attending universities in Nigeria...
Dismissal from CSPP's PsyD program
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Reminds me of an article I just read about women attending universities in Nigeria...
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Are the Chunkendales still around and hiring?? I may need to do the Fully Monty thing at some point.
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If someone is more Farley than Swayze....you can dance for baseball tickets as a, "Manatee" (Florida Marlin's plus-sized male cheerleading squad.)
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lmfao
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Wow, this thread took a really interesting turn.
To throw another wrench in the discussion, from what I've heard from MSW graduates, the market's pretty flooded for them as well... Maybe we're just all screwed?
To throw another wrench in the discussion, from what I've heard from MSW graduates, the market's pretty flooded for them as well... Maybe we're just all screwed?
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Wow, this thread took a really interesting turn.
To throw another wrench in the discussion, from what I've heard from MSW graduates, the market's pretty flooded for them as well... Maybe we're just all screwed?
People need to work harder and smarter to be a therapist in today's market. Good business skills will trump good clinical skills....so if you want to be a therapist, make sure to have a good plan.
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It doesn't surprise me, I know so many MSWs it isn't funny.
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Wow, this thread took a really interesting turn.
To throw another wrench in the discussion, from what I've heard from MSW graduates, the market's pretty flooded for them as well... Maybe we're just all screwed?
Yep, i've been seeing/hearing this about MSWs also.
I DID have a good plan ahead because my father is a psychiatrist and he and all his colleaugues are reaching retirement soon and would have me as their main source of referral for psychotherapy for their patients. Unfortunately, I blew it, but Im not giving up. I'm just trying to find as many outlets as possible right now.
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Ahh...and we are back to joust again, T.
Good business skills will not float the ship! They are vital, but not sufficient and will not "trump" clinical skills.
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The clinician just needs to be "good enough". The great clinicians are often some of the worst business people. They are usually too focused on their work, to the detriment of their business. Many will sacrifice additional revenue to avoid feeling too much like a business person (waive no-show fees, not charge for otherwise billable services). When you leave that kind of $ on the table, you can't just make it up by being a superior clinician. In my prior consulting career I worked with a few boutique medical practices that offered therapy services. Their business model allowed for plenty of internal referrals, and their therapists only had to be good enough so the pt would stick around for med management and related services.
Look at some of the most successful "pop psychology" people:
-Dr. Phil: He hit it big because he ran a forensic consulting practice (read: business savvy), and he is pretty much a hack psychotherapy. He surrendered his TX license after a patient complaint for inappropriate conduct.
-Dr. Laura: Her Ph.D. is in Physiology, and only later did she go back for an MFT certificate. She marketed the heck out of herself with no formal training or clinical skills.
Even Dr. Linehan. She is primarily a researcher. She was able to develop and market DBT to all of psychology. She founded Behavior Tech and charges $2400/pp for her DBT training seminar. She obviously has great clinical skills too, but so do many other clinicians....none of whom rake in the same kind of $$. 😀
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You're bringing up some pop-culture phenoms...not entirely related, but I guess I can see the extreme comparison.
My point is that a poor clinician will not prosper even with good bus. skills.
...this means that neither trump eachother. You need to be a good clinician in order to have business.
Moreover, those you mention that waive fees etc and don;t charge...not likely that they are "good" as that's pretty oedipal to invert the cost.
"Good enough" has some depth to it, if you mean it in a Winnicott kinda way.
My point is that a poor clinician will not prosper even with good bus. skills.
...this means that neither trump eachother. You need to be a good clinician in order to have business.
Moreover, those you mention that waive fees etc and don;t charge...not likely that they are "good" as that's pretty oedipal to invert the cost.
"Good enough" has some depth to it, if you mean it in a Winnicott kinda way.
Well it may depend on what you define as as being a good clinician. Here in NYC there are many therapists with limited training, who practice obscure forms of therapy with no empirical support, some of which, such as recovered memory therapy, are even considered to be potentially harmfull and warned against by the APA. This doesn't necesarilly stop them from being wildly succesfull. You can get pretty far with just good people skills and charisma.
Wow, this thread took a really interesting turn.
To throw another wrench in the discussion, from what I've heard from MSW graduates, the market's pretty flooded for them as well... Maybe we're just all screwed?
Majority of people who are solely trained to do therapy are screwed if they are graduating these days. Mental health is just the first thing that gets cut and is not valued. If you look at any other profession in the health care field they are continuing to do well and many trump the salaries of psychologists, including NP, RN, OT, PA, Psychiatry. Its primarily mental health (especially therapy services) that are suffering the most these days (psychologists, MFT's, and social workers). MFT graduates take on unpaid full-time internships after they graduate. Some of our graduates take on unpaid post-docs. I have never heard of this unpaid BS in other fields that require graduate education.
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That makes sense to me. Since we're talking about being economically successful, not therapeutically effective, it would seem like what's at stake might not be good clinical skills, but what patients THINK good clinical skills are or what they think productive (or enjoyable) therapy sessions should be like (based on past experience, TV). Or what they think a good therapist should be like (or not be like). I wonder what the empirical literature says about why clients/patients continue to come back and who "succeeds" in the business of psychotherapy.
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I have worked at group practices and networked with lots of people in private practice who are successful and unsuccessful. This is purely anecdotal, but the only people that i've met who were able to charge $200 plus and have a full practice (sometimes no open spots) tended to be leaders in the field and had name recognition, excellent business skills, great clinical training, and often supervised/trained many psychologists. They also wrote books and published throughout their career, and had additional certifications (Academy of Cognitive Therapy, ABPP, trainings with famous people in the field). They also went to good programs and tended to have lots of prestigious names on their CV for internship and fellowship training. I have not met one single person who was able to command this type of money and actually have a full practice with just charisma or good business skills alone. I think all 3 are needed to be financially successful, including excellent clinical training, business skills, and name recognition (e.g. books, publications or some attachment to a prestigious institute/school). People who can spend $150-250 per session are not getting therapy from someone who went to some shabby school and just has charisma. They want to pay for someone who is a leader in his/her area.
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I won't quibble with the above, as that too makes sense (and why would I? You've demonstrated you know what you're talking about on numerous threads). But how then to explain what Faded C is reporting re: the wildly successful quacks (my term, not FC's) in New York? It sounds like perhaps both arguments are true to some extent, depending on context?
I guess I'm always suspicious of the assumption that people (in this case patients/clients) make rational, well-informed decisions. And I know wealthy people who seek to acquire "the best" in a variety of areas of life, but I'm not convinced that the individuals I'm thinking about are actually smart enough to discern what "the best" is. I know a lotta folks with more money than brains.
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NYC is a bit of a zebra amongst horses....certain things fly there that do not in 98% of the country. For instance, psychoanalytic and psychodynamic providers are much more abundant in NYC, though it doesn't generalize to other places in the country. Fees are also quite a bit higher on average in NYC....though sqft/$ is also ridiculous.
A flashy website, the right office, and a few well placed contacts can go a long way. 2012PhD is correct in that the vast majority of folks who charge $200/hr have the pedigree to back it up.
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Interesting--thanks. I like "zebra amongst horses" too--never heard that one before!
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To chime with regard to the recent posts, I thought it best to consider the following issue: Marketing in Clinical Psychology.
Generally speaking, clinical psychology does a poor job marketing itself as a field to the public at large. One of the reasons obscure, poorly researched, and ineffective treatments still continue to be practiced is because we have not found an effective way to inform consumers about what psychotherapy should entail, what forms of efficacious treatment exist, how they are purported to work, and how to find competent providers that offer them within the community.
Even when we do make attempts to inform the public, the message is not as accessible to consumers in comparison to pharmacotherapy. For example, "Take pill X, it works via neurotransmitter Y, leading to outcome Z in studies A, B, and C." While I realize that psychiatric medications and the practice of psychiatry is far more more complex than what I have just written, the complexities can be distilled into this type of message in order to be user friendly. Moreover, pharmaceutical companies have an enormous operating budget that can spread the word. Unfortunately, outcomes in therapy are much more difficult to explain and the evidence appears as less "scientific" and "compelling"to consumers. We also do not have a large operating budget to get the message out.
As a field, we need to consider how to market our "product" and explain the "why" and the "how" in a way that makes sense and is more digestible. What we do is valuable and can help better people's lives, and while we know that, no everyone does and/or believes it to be true. Keeping this in mind, I think the "product" we promote needs to be an empirically supported treatment. While I am biased in terms of my theoretical orientation and believe in evidence based practice, I am not sure that treatment approaches lacking efficacy studies will be well received by the community, if for no other reason than people will want to know that it has been well researched in comparison to medications. Not all approaches, despite their clinical usefulness, rich histories, and longstanding contributions to the field, have this form of support.
Taking this a step further, if we consider success of psychotherapists within this context, it makes perfectly logical sense that an individual who publishes books, seeks out certification by boards within the field (e.g., ABPP), and is able to explain how they are competent in ways that are easy to discern for the public (i.e., educational background, training at prestigious institutions, etc.), they will be more successful than those who do not have said credentials or savvy. If they can explicate how their treatment is effective, citing research in a way that is digestible to the average client, things look even better with respect to success as a professional.
To that end, I think being able to explain the "how" and "why" is critical and it is something our field needs to do on a large-scale basis and something all psychologists need to do on an individual basis in order to make a reasonable living. After all, none of us are in this for the money (i.e., wealth), if we were, we would not be doing it in the first place.
I don't know who you guys are referring to when you mention "wildly successful quacks." I honestly have not run into these folks because they don't supervise graduate students and don't publish or attend conferences. They are certainly not the "experts" who are charging $250 from my experience. Even the psychodynamic therapists who are successful went to good universities and studied at prestigious training institutes.
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Even when I do tell my clients what the most efficacious treatment is, they still don't want to do it if they perceive that it's a lot of work. It's a lot easier to convince people to take a pill IMO.
These are the types of psychologists that can typically charge $200 plus per session and have a full schedule:
http://www.sfbacct.com/index.php?option=com_content&view=category&layout=blog&id=32&Itemid=55
None of the center's psychologist went to a professional school as you can see.
I disagree that rich people don't care about where you went to school or what the "best" treatment is. From my experience, these clients are the most demanding and want people who hold prestigious posts or went to prestigious training institutes. One of my supervisors, for example, gets a ton of private practice referrals and can command $250 because he has a director position at a prestigious medical school. Clients often ask for him because they want to meet with the director of the program and want to pay for treatment from a renowned expert who publishes widely and directs a program in his specialty. How did he get to this post? Specialized fellowship at a top medical school and tons of grants/publications in his area of specialty. You may think that prestige doesn't equate with quality or good clinical outcomes. However, the people that land these posts generally went through rigorous and reputable internships/fellowships, publish frequently, and are leaders in their area so its unlikely that they would be really incompetent.
http://www.sfbacct.com/index.php?option=com_content&view=category&layout=blog&id=32&Itemid=55
None of the center's psychologist went to a professional school as you can see.
I disagree that rich people don't care about where you went to school or what the "best" treatment is. From my experience, these clients are the most demanding and want people who hold prestigious posts or went to prestigious training institutes. One of my supervisors, for example, gets a ton of private practice referrals and can command $250 because he has a director position at a prestigious medical school. Clients often ask for him because they want to meet with the director of the program and want to pay for treatment from a renowned expert who publishes widely and directs a program in his specialty. How did he get to this post? Specialized fellowship at a top medical school and tons of grants/publications in his area of specialty. You may think that prestige doesn't equate with quality or good clinical outcomes. However, the people that land these posts generally went through rigorous and reputable internships/fellowships, publish frequently, and are leaders in their area so its unlikely that they would be really incompetent.
I suppose part of this depends on who you consider "successful" and what their patient population is. I have no doubts its possible to have an incredibly busy practice that is booked solid all day, even if you have no idea what on earth you are doing. We get referrals to our clinic all the time from people who have been in therapy for years seeing these folks and never gotten quality care. I'm sure if I looked into it I could find a huge percentage of full practices staffed with predominantly inept/incompetent staff. For the most part though, these are people taking insurance and not cash which (generally) means they aren't making anywhere near $250/hour. However, if someone is director/owner of a sizable clinic, has additional streams of passive income, it wouldn't surprise me if this person was doing as well or better than someone who took cash only and charged a lot more but was completely independent.
On the other hand, there are also plenty of people who charge large sums of money, cash-only, who work predominantly with the "worried-well" doing long-term "therapy" (I use the term loosely). While I'm sure this is great financially if one came pull it off, its certainly a qualitatively different type of practice than I think many going into the field expect or desire. Think 1950's old-school psychoanalyst stereotype...the ranks have thinned, but those practices aren't gone by any means. This sort of thing I'm not convinced one needs to be truly GOOD to do - in fact they are often mutually exclusive in my eyes.
I've also encountered some of the folks 2012 describes. These folks are often running specialized clinics, and can charge whatever they want. One even has folks who fly in and stay at a hotel for a few weeks of "intensive treatment". These are (as described above) leaders in the field, using evidence-based practices and pushing the field forward.
This is all out there. I think any of them can lead to a successful practice, though the latter is the only one I really think of as a great psychologist. The first one I have no problems with, but their primary revenue stream doesn't seem to come from psychology-related activities.
On the other hand, there are also plenty of people who charge large sums of money, cash-only, who work predominantly with the "worried-well" doing long-term "therapy" (I use the term loosely). While I'm sure this is great financially if one came pull it off, its certainly a qualitatively different type of practice than I think many going into the field expect or desire. Think 1950's old-school psychoanalyst stereotype...the ranks have thinned, but those practices aren't gone by any means. This sort of thing I'm not convinced one needs to be truly GOOD to do - in fact they are often mutually exclusive in my eyes.
I've also encountered some of the folks 2012 describes. These folks are often running specialized clinics, and can charge whatever they want. One even has folks who fly in and stay at a hotel for a few weeks of "intensive treatment". These are (as described above) leaders in the field, using evidence-based practices and pushing the field forward.
This is all out there. I think any of them can lead to a successful practice, though the latter is the only one I really think of as a great psychologist. The first one I have no problems with, but their primary revenue stream doesn't seem to come from psychology-related activities.
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I have had the opposite experience with clients who are either in college or have college degrees. They generally don't want to take pills because they dont want to become dependent, can't tolerate side effects, or believe that pills don't solve their problems. Many Educated people are also very interested in reading about treatments and will follow up regarding journal articles and books that i have recommended to them. I usually inform my clients about the effectiveness of various treatments compared to SSRI's and what the advantages/disadvantages are of each. They are usually interested in trying therapy first. It generally wins out.
It's very true. One of my professors used the anology that trying to get rid of a psychological practice in the United States is like wringing a wash cloth to get rid of the water. You grab it in the middle and squeeze everything out, but there's always a little water left at the very ends. In this case the ends are NYC and parts of Cali.
Or to put it in less folksy terms, NYC is the last stand for any unpopular or discredited therapy. Apparently there are some projective tests like the TAT which are much more popular here then elsewhere too.
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Thank you very much for posting this. Interesting to note that the director, Dr. Persons (great name!), probably wouldn't be a competitive candidate for academic jobs in today's market. No pubs prior to graduation--in fact, first peer-reviewed pub came out 5 years AFTER earning the PhD and concurrent with first academic appointment. Only a single grant way back in 1992 (<$41,000). I have a co-author (okay, s/he's in social psych, not clinical) from a top school with about 18 refereed pubs, more on the way, and 6 figures in competitive grants. Best job s/he could land in today's market was 1 year VAP gig in the boondocks.
What I'm wondering, if anyone wants to chime in, is how many hours does a Dr. Persons put in as a clinician in PP/her institute, while simultaneously publishing at a reasonable rate and serving as clinical prof at Cal??
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I cant resist, so here we go.
My biggest problem with the TAT was the first thing I thought of when I was exposed to the test.
The professor showed me a card and proceeded to tell a very interesting, somewhat macabre story. I then told her that the story I actually told her was from a book I was reading. When she told me there was no instruction to the examinee not to do this sort of thing...or at least a queery regarding the origin of the examinee's story (TV, book, happened to a friend of there's 10 years ago), I quit paying attention to the thing.
How anybody could actually put interpetation and conclusions in a legal report without even bothering to ask such basic questions was beyond me.
My understanding is that the TAT has any number of serious issues that prevent if from being a remotely valid form of psychometric measurement. My professor had said that he though it was fine to use it as a way to build a rapport with a child and get them talking, but that it should never ever be used for assessment.
But you will still see the TAT used here in NYC with a much higher frequency then the rest of the country.
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There are people out there who believe it is a valid assessment to use in forensic cases. I have used the TAT in training, to get some 'grist for the mill', though I don't feel comfortable using it in any formal assessment.
My understanding is that that the TAT has no reliability so it can never be a valid test as far as psychometrics go. But there will always be people who aren't as concerned about that type of thing. Don't see anything wrong with using for non assessment purposes though.
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This is a very interesting situation. There is an uncanny resemblance between our situations. Almost the exact same thing happened to my in my program for almost the exact same reasons. I am at a standstill in my schooling as well. I wonder if we could contact a bunch of students this has happened to, and bring some legal help into the situation? Behavioral health schools should not dismiss students went going through a rough time. There should be some sort of remediation or reappeal process. Hopefully someone out there can help us with this.
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This is why I am pumped I have two little boys.... no girls.... now I just have to worry about them knocking up a girl during HS. eeeyyaaa
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I actually just sat in on a case where a psychiatrist used this test and the opposing expert ripped him a new one. The test is generally NOT accepted even in NYC courts, as quirky as this place may seem. Even the Rorshach is generally only used to determine psychosis OR in some, albeit rarer circumstances used in collaboration with a personality measure (PAI, MMPI etc).
Also, although there are some PhD programs in NYC that still adhere to strictly psychodynamic psychotherapy, I think this is a huge misnomer because A) almost all of the PhD programs are object relations and not some classical psychoanalytic or ego theory driven and B) the people doing more traditional psychoanalytic or egopsych come from psychiatry residencies and tend to be much older.
Though I dont necessarily agree with object relations theory, it is definitely better than classic psychoanalysis. In fact one of the best institutes for this, Cornell, trains some really bright, insightful, yet critical therapists. Tale Otto Kernberg for instance. And MANY of the Cornell psychodynamic adherents do treatment trial research.
just putting that out there... not all of them (in fact I would say most are not) quacky
D
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It's VERY limited validity doesn't mean that it is not useful. The TAT could be useful in cases of malingered or factitious disorders and in cases where a thought disorder or psychosis is present. How you use it is more important than if you use it. It's a data point with limited validity, but combined with other measures, it can be useful.
FWIW, I am not a fan of the TAT, and I would never hang my hat on it in a court room, but I wouldn't have a problem including it as one additional measure. Interpreting the findings and describing the strength of those findings is what gets people in trouble.
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I think the TAT and Rorschach take far more effort to admin/score than they're worth.
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The Rorschach is great for psychosis that is not overtly obvious. Once you ask them to say what they see, white spaces and wacked out descriptions galore.
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Is that psychosis? Or someone being creative? Or just random noise/variation?
What would you do with that information? Encourage them to start treating a disorder you think they have that doesn't manifest unless they look at random inkblots?
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Right, you can get psychosis from an interview and then you don't have to worry about the stupid determinants, content, location, etc. I HATE scoring the Rorschach and we have a computer program. 😉
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It is a pain to score, but you can't always get a clear read on psychosis from an interview. 80% of the time a Rorschach is not necessary to dx thought disorder, but it is really helpful in the remaining 20%. It is also a nice way to corroborate a finding of no psychosis when there is a lot riding on the determination.
Here is a pretty typical presentation we had on inpatient where the Rorschach was vital. A guy in his mid 20s is brought in by the police after attempting suicide. At the time of the attempt, he was highly intoxicated/under the influence of drugs. During the initial intake he says some pretty strange things that sound paranoid, but the intake occurs while he is still under the influence. On the unit he is quiet, mildly disorganized, dysphoric, and socially isolated. Responses to questions from staff are vague, but he disavows the paranoid statements he made at intake. Also, he is being held as an involuntary admission, and it is clear he would like to be released.
A clinical interview is probably not going to resolve the question of whether or not the disorganization and putative paranoia can be explained as secondary to intoxication and major depression. Unless he discloses positive symptoms during an interview, the two possibilities will remain. He is unlikely to disclose positive symptoms even if they are present because he would like to be sent home.
MMPI-2/PAI are also unlikely to be dispositive. MMPI-2 is almost certain to be invalid or nearly impossible to interpret due to a K elevation, and any elevation on the relevant scales might still be explained by disorganization secondary to the cognitive effects of depression. You could look at subscales to see if the positive symptom subscales are elevated, but these groups of questions are awfully face-valid and not very reliable. An elevation or an absence of an elevation on one of the subscales would not be a very good basis for dx.
This leaves the Rorschach. The parts of it that are sensitive to psychosis are relatively unaffected by defensiveness, and disorganization secondary to cognitive effects of depression look very different from disorganization secondary to psychosis in the results.
IMO, the TAT is much more deserving of the general criticisms of projectives. It seems to me that the interpretation of TAT answers always leads to data that confirms the report writer's hypothesis whatever that hypothesis might be. For years I have promised a drink to the first psychologist who can show me a report in which there is a discrepancy reported between the results of the TAT and the interpretive findings on other measures. So far the drink has not been awarded.
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If one pics up what they perceive to be psychosis ONLY on the Rorschach...what the hell do you do with that clinically? Inform the person that they might have a full psychotic break somewhere down the line and to just watch out?
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If one pics up what they perceive to be psychosis ONLY on the Rorschach...what the hell do you do with that clinically? Inform the person that they might have a full psychotic break somewhere down the line and to just watch out?
I cant imagine ANYONE ONLY basing ANYTHING on the Rorschach, not even Exner himself (though he may roll in his grave for my comment, who knows). Its always in the context of other information.
Also the person before me gave a great example. But literally the responses would be something like "the white, that shape, the shape there, its edges, its __________ (insert comment about some sort of mythical creature or violent referent)" Its not just a creative thing, its a little more clear than that.
Also, I dont think many places use the Exner norms anymore but lots of places use the updated International norms that ACTUALLY compared scores to clinical populations and not just to people training on the Rorschach.
But of course I share your reservations... I of all people have them too. But its different when you actually use it in a forensic psychiatric setting. NOT often at all (maybe once or twice a year?) Nevertheless, it can have its uses as long as you can cut through the heavily psychodynamic weighted rubbish.
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But all the rorchach ppl always talk about how good it is for detecting subtle psychosis that isnt illicited elsewhere or by other measures (MMPI). Does this not make the assumption that these people are concluding that there is some kind of disorder (psychosis) based on only ONE test? That's kinda what it sounds like to me anyway.
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If one pics up what they perceive to be psychosis ONLY on the Rorschach...what the hell do you do with that clinically? Inform the person that they might have a full psychotic break somewhere down the line and to just watch out?
Well, you could do that, or you could let the treating psychiatrist know that psychosis is present so that it could be effectively treated. I'd go with the latter option myself, since that is the one that avoids lawsuits for negligent discharge.
Also, what part of the hypothetical stated above suggests that the potential psychotic disorganization is present only in response to the Rorschach? It is potentially observable in all three assessment techniques. The problem is that neither the interview nor the objective measures are unambiguous enough to lead to a diagnosis.
Your comment's analysis is based upon a faulty understanding and the tone is oddly hostile despite the laughing smiley face. Revise and resubmit.
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Well, what would the diagnosis be in the above stated scenario? What exactly is there to treat?
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I for one have never seen someone produce a high Wsum6 without also spiking Scale 8.
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But have you seen a spiked 8, spiked f-scales, and high Wsum6/f-%? Unfortunately, I see this in about half of the cases where r/o psychosis is part of the referral question. The MMPI-2 would always be an easier way to reach a diagnosis if it weren't questionably valid a lot of the time.
The MMPI-2 also can't be given in every instance. People have remarkably low reading levels.
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- Oct 29, 2004
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- 189
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- 3
Who cares what the specific diagnosis happens to be in cases like these. It might be presumptive MDD with psychotic features, schizoaffective d/o, schizophrenia, whatever. The critical question isn't one of assigning a diagnostic label; it is one of treatment approach. If someone is psychotic and being treated inpatient, it is probably a good idea to make sure they are taking an anti-psychotic medication before they are released. If someone is not psychotic, but is disorganized secondary to MDD, then perscribing an anti-psychotic may make the disorganization worse.
I am not arguing that the Rorschach is without its problems, but it has saved a lot of clinicians from having to take a guess and hope for the best when it is really, really important to know if someone is psychotic.
