Watering down standards weakens training, especially when you consider the wider variance in training across psych doctoral programs (as compared to physician training). It's one thing if the hours in training were equal to hours on internship or post-doc/fellowship...but they aren't. In school, mentorship and supervision were plentiful (or should be in a program), and as a student progresses, they become more independent. On internship, it should be pretty close to that. If a trainee was only doing therapy in a private practice setting, maybe they wouldn't benefit as much from the additional year of training, but the average trainee isn't going to be a generalist. Look at how people identify on various surveys....generalist isn't 80%+, I'd be surprised if it was 40%-50%.
My responses are long but hopefully add to a quite spirited discussion and debate.
Perhaps we need to stop comparing ourselves to physicians. The hours of training , according to some state boards are now equal. I do agree we should want to see more rigorous hours and training as continue to move towards no post doc licensures, the solution there is establishing better standards and holding programs to higher standards to provide that. As for surveys, can guarantee people are claiming to be specialists because of a mix of actual experience, perceived experience, and preference. Ever browse Psychology Today? I'm not saying they're doing the right thing by claiming specialities in many areas, but I imagine many are. I'd hope most have enough common sense to avoid labeling themselves a specific specialist (aka titles that board certifications state). I would imagine there's plenty of generalists who are experts in their own eyes. And maybe many of them do have the experience to back it up but don't label themselves on their business cards as such or sign up to be board certified.
As for post-doc, I know experiences can vary greatly, which is its own problem. Can a generalist skip post-doc, probably. Should a generalist do it....I don't think so. Should a specialist do it...heck no. I learned more on 2yr of fellowship than I did in 5 years of schooling and a 1yr internship. The increased independence was helpful too. How many students truly graduate as generalists? What usually happens is they graduate, and then they want to do [x speciality work] "on the side". That sets that person up for a potential world of hurt, and I'd rather that not happen.
Please don't take this the wrong way, but I'd question the rigor and standards of a program where one felt they learned more in 2 years in a supervised training position than in 5 years of doctoral study and internship. Not pointing figures, but I read that and would wonder what's wrong with a program that leaves people feeling like they learned more in 2 years after the program than during the program.
As for the speciality work and worlds of hurt, it depends. Can the person back up their competency to do the thing they're doing? Can their education and training experiences back it up? Most clinical psychologists can, with solid competency, administer, interpret, and provide feedback on a wide range of psychological tests and assessments. Some probably call themselves experts in ADHD evaluations, in psychoeducational assessments, in personality testing. But are they wrong? Or right? I mean they have the training, they have the experience, they understand it on some level we've deemed competent. There's a lot "generalists" are trained to do competently. I agree there's definitely caution here, but at the same time most of us in reputable clinical psychology programs have a nice breadth of training and have met competency standards set by accrediting organizations.
It shouldn't even be a debate though because the content covered and hours spent are vastly different, so watering down training is what makes the debate more valid. Doctoral training is more than just classes and accruing hours. Specializing is something that most psychologists do and substituting some weekend seminars and online classes is not the same as completing a formal post-doc or fellowship.
As someone who has worked with a state licensing board on setting training standards for psychologists, I can tell you that those hours *are* viewed differently. My work was specific to psychologist v. neuropsychologist, but it could also apply to health psych too. Seeing a patient as a prac student v. a post-doc or fellow *is* different. Your understanding, responsibilities, and quality of work *are* different. Trying to pretend the hours are the same does a disservice to the clinician and also the community.
But it is a debate , as it should be. If some state boards, filled with psychologists, who consult with experts in both generalist and specialists areas, have determined practicum hours can be substituted for post doc hours....well there's obviously some reasons for that. I know a good mix of generalists, or integrated psychologists, and board certified neuropsychologists. I know experts in autism, I know experts in EMDR, I had professors board certified in clinical psychology and neuropsychology. Most were advocates for reducing semantic hoops regarding licensure requirements. They advocated for clear standards across states. Many worked hard to further programs so that people went in and came out with a well rounded set of competencies to make them competitive in a range of settings and roles without specialization. We aren't medical doctors, we aren't in the same system. Maybe that's our fault as a profession, but we're also kidding ourselves if we think people need as much training and supervision pre-licensure as a surgeon or a cardiologist to be competent effective psychologists. Maybe some of the jaded ones would say "isn't that what CEs are for?"
I totally agree, the experience of a prac student vs post doc is different and it should be. But, again, if this concerns some in the field, ask the state boards who decided the hours are more similar than dissimilar why these decisions were made?
Where is the field going....more towards specializing or less? The answer is more....so if more people are specializing, why do you want to REDUCE training hours?
I never suggested reducing hours. Some state boards simple accept other hours instead of post doc hours. I agree with you on maintaining an adequate number of hours. Concerns about loss of post docs is going to have an impact across the field for sure. Less incentive or need to offer post doc positions except for very specific specialities. A solution is , again, standardizing. A sufficient number of hours accrued over the course of a program and internship. Maybe develop higher requirements for these hours to get them more in line with the post doc hours being different and more rigorous.
A bit off topic, but I used to want to be a pharmacist. I was a pharmacy tech many years ago during the changes where suddenly pharmacists needed to be doctors of pharmacy. It created a massive shortage for a few years. It created then an influx of frankly over educated pharmacists who often came into it thinking it was like medicine when it wasn't. It created a lot of disgruntled pharmacists and also created a lot of bright minds who weren't actually applying or using the extra years of "doctoral" study 99% of the time. Now there's a lack of pharmacist jobs and PharmD programs pumping out people who memorized medications and chemistry and end up restocking a pharmacy shelf or ringing up a cash register, refilling auto dispensers, and calling doctors for prior auths. Most of what they do, a tech can do. Why? Who decided pharmacists needed more training? Plenty did fine, did well, didn't put the public at risk before this. My point with this story is that sometimes enough is sufficient. There's nothing wrong with people wanting to specialize and get 2 year formal post docs to become specialized board certified practitioners in areas that really do benefit from it. But there's also nothing wrong with good programs producing good psychologists who can do good work competently without more, more more before they can begin their career as a licensed professional.
As a profession, we have already yielding a lot of our areas of work to mid-levels, and they will continue to erode our practice areas because they have more to gain, and most psychologists are passive in regard to advocacy; they want everyone else to do the work and then get mad when we lose ground. Just talk with your state-level psych association and the vast majority will tell you the same.
It's true. It's been happening for years. You know another reason there's more mid-levels, as you call I guess I assume masters level clinicians? Because they can go to school in a shorter amount of time, learn enough to do their work competently enough. Sure they don't get the depth and breadth that you and I learned and they don't get competencies in assessment and testing. They don't get the rigor of thousands of hours of supervised experience in school. They get it after they graduate , in the workforce, in the field too. You're right, a lot of psychologists are passive on advocacy because they're doing work in the field. I know plenty of psychologist who live and breath psychology, who want to be board certified in many areas, want to get published, want to make a name for themselves. But there's also plenty of us that just want to work a fulfilling job and do our work. That aren't worried about losing ground because we 1.) have other competencies and skill sets we can fall back on that masters level clinicians don't have and 2.) there's plenty of demand of mental health providers out there. There's nothing wrong with either approach to one's career.
Anyone can get on their soapbox and lament psychologists being second rung, to many people , to psychiatrists, or what have you. But it's clear the current fragmented system where a psychologist can't go to another state and apply for a license without ease because of different standards while most psychiatrists and medical doctors can, is a HUGE part of the problem. We're going to continue to lose ground until the cliche ivory tower approach to demanding more and more requirements on students of the profession realizes we need less fragmenting of the profession when it comes to licensed psychologists.
The "more years accruing hours" makes sense when specializing. I don't think training as a generalist will serve most students in training now. Allowing a student to graduate as a generalist isn't going to make them more competitive in the market. Straight therapy jobs are mostly going to mid-levels because they are cheaper and are more willing to accept lower pay. It is bad for the profession to have clinicians taking generalist positions that pay mid-level salaries. Commercial insurance has been degrading us for years, and decreasing standards just gives them more ammunition to keep doing it.
I assume you've been licensed for quite some time given your tags and history on this forum. More recently, at least my experience and many of my peers has been that the minute we got licensed: doors opened and opportunities opened. So much so in recent years, I had a close mentor, Ivy league PhD licensed psychologist, decades in the field that mentors and guides many in grad school, simply say "get the license, the doors then open."
Most well rounded reputable programs can and do train good clinical psychologists. And most of those graduates can justify and back up much of the work they're doing today because they have the receipts so to speak. The documented proof of training, experience, and supervision in the work they're doing whether assessment or therapy. I know some generalists doing fine in straight therapy, and I know many that do a mix of assessment and therapy. I know plenty working in health care facilities as part of interdisciplinary teams. I know some who teach, some who supervise, some who publish.
This isn't about decreasing standards, it's about building better standards.
I'm not sure where you are in your training/career, but there are very good reasons why commercial insurance companies panel push psych through a behavioral health carve out and it is because they can. They crammed psychologists in there because that's where they stuck all of the mid-levels. They can add hoops and decrease reimbursements, arguing "you are doing the same job." Contrast that with paneling on the medical side. On the medical side, there are less hoops and higher reimbursements because mid-levels CANNOT panel there because there are things they cannot do.
Licensed in the past year but have been in the field for about 12 years, first as a master level clinician, then went back to school. I agree these insurance companies push and will continue to push. Sometimes in my work I feel like I can't get dressed in the morning without a "medical doctors" order authorization for a service, you know. But that's the reality of the field of behavioral health. Trust me, I've heard the "you're doing the same job" thing a lot in past jobs and training experiences. Sometimes we are, sometimes were aren't. Most I know simply do private practice on the side or charge cash. Many are tired of the hoops and opted out. Others just took salaried jobs in larger companies or agencies becoming part of interdisciplinary teams at health care facilities.
Who do we blame for the atrocious state of psychological testing and neuropsychological testing and many insurances outright refusing to cover it at all? If anything makes us different than "mid-levels" (new term to me) it's our training and competency in assessment and diagnosis. And yet here we are in many cases, needing medical doctors to authorize it or oversee it, or insurance panels denying it based on their "own" research and "experts."
It's sad because there's so much infighting in the profession. And while it's mostly healthy and much needed spirited debate, the argument for keeping fragmented licensing systems isn't helping.
A good family friend is a long time insurance claims adjuster for an auto and home insurance company. Comes to me one day and says "no offense but we don't go to psychologists or neuropsychologists when we need what we need to prove or disprove a brain injury or a cognitive impairment due to an accident, we go to real doctors like neurologists." To be fair I educated him on what neuropsychologists do and how they can be valuable consult in these situations even though I'm not a neuropsychologist. He thought about it and said "I'd love to learn more, and even beyond that what clinical psychologists do, maybe there's something we're missing out on here." Grassroots advocacy works maybe. But that's the state of things as others look at our field.
Had a clinical psych professor once say, "we do great work but one day science will allow for brain scans that diagnose things like depression , anxiety, bipolar with precision and there will be computers or even AI that reads those results, issues and interprets tests and a pill that solves the problem. Testing and assessment will one day be done by brain scans and computer administered and interpreted assessments with a physician overseeing it, but it'll be a long time until computers are good enough to provide the human connection and experience of a good therapist."
These are small snippets of thoughts of others. I'm sure there's many more. Insurance panels I'm sure know this and think this way too. But hey, insurances will likely always go for the "cheaper" route.
You want to lower the bar, when it already has been lowered over the years. Instead, we need to push specializing and push differentiating our skillset from other clinicians. FWIW, I almost never refer to a generalist because they don't know what they don't know. Sure, they can pick things up as they go, but I'd rather trust someone who went through a formal training program for post-doc because there at least is some standard from which to rely on. My typical head injury patient tends to be a challenge for a generalist, but a health psych/rehab psych/neuropsych....they can handle them fine. I know not everyone sees medically complex cases, but the typical patient walking through the door isn't going to be in perfect health and the less training the clinician has, the more likely they are going to get in over their heads. I don't have time for that, and the clinician who referred that patient to me is going to judge me by how that generalist handles the case.
It's not about lowering the bar, it's about, as I've said, setting standards. Your comment here about generalists exposes a very big problem in our field, and not blaming you personally of course. The academic system , often found by some , has this sense of being out of touch built into that world. There's plenty of generalist clinical psychs that know quite a bit, know where their competency begins and ends, but aren't afraid to lean on their competencies to do the work. Maybe I'm fortunate I went to a program that highlighted this and worked hard to instill this.
On the "formal training program for a post doc" thought, there's things wrong with it. Why aren't programs formal enough? Why isn't 5 years of training, education, theory, comps, practicums, and a year of internship enough? But more importantly, do people not realize not everyone has the luxury of just grinding out years of low paid work because some feel they did it so the rest have to? Not everyone comes from a background or experience where they can or need to take on even more debt, more time, etc to be a good psychologist. Frankly that's how it comes across, no offense. Let's not forget many of us worked, at least part time, while in school in clinical roles under supervision and within regulations and most of those hours "didn't count" because of some arbitrary rule one state might have vs another. And that was alongside the thousands of hours that "did count." I mean there's state boards with things that sound as absurd as "the hours must equal X hours per week when the moon is half full for those who started their second year prior to the summer of 2004 but if you started your third year in the spring of 2007 , the moon rule does not apply and the hours can be of any amount a week as long as they are completed within 6.6 years of the last time Halloween fell on a Friday."
I have experience, training, and knowledge in brain injuries and in rehab psych. I have a CV full of experiences in areas as broad as partial hospitalization programs to neuropsych assessments. And a lot in between. I'm a generalist because I didn't do a formal two year post doc in "pick one speciality please" mentality. I don't know everything and I don't bill myself as a neuropsychologist or as a specialist. Because I don't need to. I know where my competency begins and ends and I strive to make that known when it needs to be said. Because of my training and experience.
If anything wanting MORE specialists is worse by this logic. Most patients walking through the door especially in first contact, depending on the setting, want what's akin to a family doctor. If it makes the practitioner feel better, throw up that diploma on the wall, it does mean something. A person well versed enough in broad enough areas to provide treatment or know what to recognize to treat or refer. And do the specialists want more competition? That's a cold but hard reality in modern health care. And if the clinician who refers people to you is pedantic enough to judge you , then we should all have bigger concerns. I have enough training and common sense to recognize when I'm presented with a case beyond what I know. Part of that was because I was trained to be able to recognize that. A post doc isn't going to solve problems at the program level if people aren't being trained properly. Also someone else mentioned income and business being good in one big speciality, will it remain that way once more and more are specialized in that speciality and insurers and those seeking the service can push down the asking prices of the service?
As you can tell I'm quite passionate about a realistic and pragmatic approach to our profession. I'm also one who wants to focus on the work and see others also succeed in their goals in the field. Many are. Many aren't apathetic, they're just tired of the semantics. Most are well trained and competent. Many are just busy doing work. There's a huge need for our services and a lot of mental health services, many of my colleagues are LPCs, LCSWS, and I often work closely with other healthcare professionals. I don't spend my time losing sleep over whether they're taking my work or my income because they're not. I spend my time doing what I can to help people and work with other professionals when needed to serve and help the patient. I'm not saying you or others don't, but damn if I don't get a bit annoyed watching people decry the "degrading" of our field because pragmatic approaches to licensing are finally happening. Because accessibility is finally happening. And because we're starting to realize there's a point where enough is sufficient, ethical, practical, and useful to become a competent psychologist. In layman's terms, many of us don't have the time for the nonsense, we have a job to do. Perhaps a small positive side effect of managed care, consolidated organizations and facilities is that more people across professions come together for patient care. I'm sure we've all met medical professionals with the same no nonsense approach.
At the end of the day the answer isn't push for post docs for everyone as the field moves away from it. The answer is better standards for programs so they can provide the experience and training you and others cite. Built in. Standardized number of hours and standards for what those hours entail. Like we have now but improved. Cut the semantics of when the hours occur and the state by state arbitrary totals. Recognize we aren't medical doctors, we don't need more residencies and post doc hours to be competent. Add in better advocacy from our professional organizations, not to enforce more hoops, but to provide clearer pictures of what we do.
Board certified specialists and generalists can co-exist. But one has to wonder, if it's up to the insurance panels are the generalists going to be the "mid levels" to the specialists and if so why pay the specialists if the mid level has most of what the insurance panels think is enough? After all, many of the people making these policies and decisions don't really understand the nuances and figure, eh a psychologist is a psychologist and a state board issued a license. How many of us have had medical doctors and just the general public go "isn't that what you do?" in regard to whatever it is they think we do. Devils advocate approach perhaps.
Again, it's a great discussion and a much needed one. We all can do our part to advocate and further our profession. There are still huge untapped areas and populations that can benefit from all we have to offer.
At the end of the day you, I, many others on here don't have to worry about all this much. We don't have to sweat or worry about hoops to jump through. We checked off the boxes and got licensed. But let's think about those trying to reach their goals, their careers, their opening of doors. To the OP post that started this discussion, are we really in 2022 with people still wondering if they're stuck in one state or can move to another state because one state decided X hours and another state decided Y hours? Good grief.
Just this past week, I had to turn away 3 cases because I don't have the time.
