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Here come the Master's-level therapists!

Discussion in 'Psychology [Psy.D. / Ph.D.]' started by PublicHealth, Nov 14, 2005.

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  2. psych101

    psych101 Member
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    Interesting. This is already happening in my state and I can attest to the fact that it has made it increasingly difficult to find a decent job. Why hire a doctoral-level psychologist when a master's level psychologist can be licensed -- to test independently and do therapy--- especially since you can hire them and pay them less?? And, in many cases, licensed social workers are selected for positions traditionally held by psychologists since they can work completely independently. Managed care and agency work certainly doesn't value the doctoral-level education or quality of care provided overall. It's all about money -- billing the most for clinical work using the most poorly-paid clinicians.
     
  3. Jon Snow

    Jon Snow Senior Member
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    This is all about lowering the standard of care. We already have social workers, with one year of therapy education (maybe), expanding their services, claiming expertise where they have none, and vying for jobs formerly held by doctorate level clinicians. Hopefully, APA is strong enough to stop this. Imagine what it would be like if nurses could increasingly have independence from physicians. Not good at all.
     
  4. Logic Prevails

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    I can see this being an issue of distain for those already holding a PhD, I think it's going to happen in time regardless. Masters level psychologists have been practicing in Canada for some time now. When you register, you are required to state your area of competence and not work outside of this area. Most provinces also require a minimum of 5 years supervision post graduation. Although I'd agree that most people with a degree in SW should not practice therapy (b/c I've never heard of their programs providing much therapy/intervention coursework or supervision), I don't think that this should include MSc psychologists (although I'm biased b/c that's the route I'm taking).

    There have been several studies showing that degree (PhD vs. Masters) does not predict the quality of treatment clients receive in outpatient settings. There is also so much variation by university training. Keep in mind that while a Masters degree (on the way to receiving a PhD) might not be sufficient, while there are other programs (as those in Canada) specifically designed to train MSc psychologists. I think many of you will admit that most PhD programs prepare individuals for academic careers. In my own opinion, I think I could have done without the thesis, publicaitions, research methods and stats courses in terms of what they would offer someone training to be a clinician.

    - My biased opinion (off with my head! :) )
     
  5. Jon Snow

    Jon Snow Senior Member
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    There really aren't that many good outcome studies comparing treatment selection, degree type, and disorder.
    Partly, but that is not the complete story. The Ph.D. programs are still applied (e.g., clinical or counseling psychology).

    Maybe, but I think that such work promotes greater depth of understanding of the field, how things interrelate, and general clinical issues. Lowering the bar continually is doing more than just allowing people that don't have research training associated with doctoral programs to conduct therapy and assessments. The qualifications and training exposures are completely different in terminal masters programs. I think a masters level therapist should be able to do things like supportive therapy and behavioral analysis (provided they attended the proper program). Beyond that, I'm very skeptical.
     
  6. Logic Prevails

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    "Partly, but that is not the complete story. The Ph.D. programs are still applied (e.g., clinical or counseling psychology)."

    A program labeled 'clinical' may simply mean that it teaches clinical skills above and beyond an academically focused degree. I am in such a program, the 'clinical' focus is minimal. Students are more concerned about getting publications and theses completed than getting the most out of clinical coursework and supervision.

    "Maybe, but I think that such work promotes greater depth of understanding of the field, how things interrelate, and general clinical issues. Lowering the bar continually is doing more than just allowing people that don't have research training associated with doctoral programs to conduct therapy and assessments."

    This is just the same slippery slope argument that has been around forever for not allowing masters level psychologists to practice. Let us not lower that bar! Honestly, are publications, theses, statistics and methods courses going to significantly add to an individuals clinical ability? Realize that MSc programs still have stats courses, offer assessment & intervention coursework and require practica; just not to the same degree.

    "The qualifications and training exposures are completely different in terminal masters programs. I think a masters level therapist should be able to do things like supportive therapy and behavioral analysis (provided they attended the proper program). Beyond that, I'm very skeptical."

    I'll slightly agree with you here. There are things that a MSc psychologist should not do. Limiting practice to supportive therapy and behavioral analysis
    is a bit superficial though. A an individual should be limited on a case by case basis dependent on what they knowledge and skills they have acquired in a particular program. Just as you (assuming you are registered) are required to limit your own practice to those areas that you are deemed competent in. A regulatory board should make these decisions.
     
  7. PublicHealth

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    PhD/PsyD students need to start lobbying for prescriptive authority in their respective states! Expansion of practice scope is the key to success in today's healthcare market for nonphysician providers!
     
  8. Jon Snow

    Jon Snow Senior Member
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    That may be, but they still have internship and fellowship requirements if they wish to be licensed and practice psychology and school should be about theory and research. Psychology is not a trade, it is a purported science.


    I think the argument is quite valid and certainly not a slippery slope.

    Absolutely. What are the best hospitals in the country?

    See, now there's a slippery slope. We (psychology) need to push for stronger boards (specialty and general). It's difficult enough for folks to agree on doctoral level boards. I don't see how adding the complexity of masters level boards is going to do anything but further blur the lines between what is and is not acceptable. We already have enough morons doing thought-field therapy.
     
  9. Logic Prevails

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    "That may be, but they still have internship and fellowship requirements if they wish to be licensed"

    Yes; and Masters psychologists will have the practica and supervision requirements that should be more than enough to permit them to practice within certain areas in which they are competent.

    "and practice psychology and school should be about theory and research."

    Why? Because they always have been.. so they must continue to be? Masters programs still require 1 or 2 graduate stats courses and a thesis. Is it really essential to therapy that they get a publication, learn how to use canonical correlations etc. in their research, and do a dissertation?

    "Psychology is not a trade, it is a purported science."

    Depending on how you use it. We can also argue that in therapy it is an art. Yes, it is important to understand (as much as needed) the underlying science of the dicipline, but we don't need therapists to get the knowledge one might have in order to teach the subject.

    "I think the argument is quite valid and certainly not a slippery slope."

    Okay...

    "See, now there's a slippery slope. We (psychology) need to push for stronger boards (specialty and general). It's difficult enough for folks to agree on doctoral level boards. I don't see how adding the complexity of masters level boards is going to do anything but further blur the lines between what is and is not acceptable."

    Okay, so you don't get the slippery slope idea. There's nothing slippery about my argument at all. I'm saying "Yes, put up a block on what individuals can do as a psychologist!" But you're basing this decision on your 'fancy-pants' degree, while I'm basing it on (perhaps more fairly) as a restriction on what the individual is competent at. Don't tell me that we should not have Masters boards because it makes more work for those on the board or that they will disagree from time to time. Are you suggsting that they should 'wave' the board entirely for individuals such as yourself, assuming you have your golden PhD degree?

    It seems you like to use the 'slippery elevator' in your arguing, so let us continue on that path and see where it leads... What if we say that no.. a PhD as it sits right now is not sufficient to be the 'best psychologist' that we can be. Let us say that these individuals should also have at least minor in Philosophy so that they might learn to reason rationally (add another 2 years)... and it would be also good to learn several other languages... and on and on.

    I'll end it with this: Who is it to decide what we need in terms of education? We can always be better or learn more. The questoin is whether we will have what is required to provide therapy that is benefiting the client and that is ethical and within our level of competence - is it not?



    "We already have enough morons doing thought-field therapy."

    Don't assume that only Master's level psychologists would do such things. There's plenty of "moron" PhD individuals out there as well.
     
  10. Jon Snow

    Jon Snow Senior Member
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    How else is one going to learn the science behind the application? If school becomes supervision of clinical work, that's not really going to foster much conceptual sophistication.

    No, it's essential that people be consumers of research and think analytically, and in an informed way, about their cases. I don't think masters level training is generally enough to do that.


    That's really wrong-headed thinking in my opinion. Art? No.



    Okay, so you don't get the slippery slope idea. There's nothing slippery about my argument at all. I'm saying "Yes, put up a block on what individuals can do as a psychologist!"

    Apparently you're confused.

    I'm using the slippery slope argument to denote that it appears likely that we will continue in a negative direction by allowing more priv. for masters level practitioners, in other words an erosion of what it means to be a psychologist which will lead to an erosion in pay, patient care, and field cohesion. That's is the quintessential "slippery slope."

    What I'm saying is that, in my opinion, the Masters board would lead to a further erosion of standards for practicing aspects of psychology. Who would run a masters board? Other people with masters degrees? Naturally, I'm sure they will believe they aren't qualified to do certain things (e.g., neuropsychological assessment). Yeah, sure they will. I'd expect that the board have exactly the same requirements as ABPP to be a licensed psychologist. Unfortunately, that would mean getting a doctorate.

    Politicians apparently. Ideally, the professional boards and major professional societies would decide. I don't think psychology practice should be shifted without approval by APA and ABPP. However, this current proposal circumvents that.

    I'm aware. We don't need more.
     
  11. 50960

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    Snow, I am going to smack you.... There is nothing in this legislation that would creat a MA level psychologist. It is only to allow already licensed MFT and LPC's to get medicare reimbursement, and we should have no problem with that. LCSW's have been doing it for years, and have not replaced us. Really man you are a walking Rorschach!!!

    cheers
     
  12. Logic Prevails

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    Damn, I think some of you would loose your minds if you were to practice in Canada where we have Masters level "Psychologists" (yes, I said psychologist and not "therapist") practicing in most provinces (with some supervision of course).

    "What! they're practicing psychology with a WHAT!!??? My god the incompetence must be overflowing at the borders of every province."

    I'm sure this disease of professional practice will eventually make it south of the boarder at some point.
     
  13. Jon Snow

    Jon Snow Senior Member
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    Eh? I resemble that remark, though the point I'm making is not that there would be masters level psychologists, but that we (psychologists) would be ceding part of our scope of practice to non-psychologists with lesser training, in essence redefining in a narrower fashion the scope of practice for psychologists.

    Probably so, given the socialist healthcare system Canada has.
     
  14. Heath82371

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    Who really cares? Do PhD trained psychologist really want to work with the dredges of society doing home visits or working with indigent people? My guess is no. I doubt any sane PhD trained licensed psychologist would work for the 32k that my last job paid me. I should point out that I am a LMHC (Licensed Mental Health Counselor) and I have a masters degree in clinicial psychology. My last job was in the state hospital and my title was Clinician III. Interestingly enough I wanted to get my PhD at one point. Luckily I have left the field.

    Just thought I would clarify a few things that were incorrectly stated on this website (though not necessarily this thread). Individuals with Masters degrees in certain fields may obtain licensure as therapists by the state they reside in (I live in Florida). These individuals must have a masters in psychology, counseling, or mental health and after 2 years of supervised experience and passing boards they will be licensed as LMHC (Licensed Mental Health Counselor). If they did graduate work in the field social work they will be a LCSW (Licensed Clinical Social Worker), or if they studied marriage and family therapy, they will be licensed as a LMFT (Licensed Marriage and Family Therapist).

    I am in nursing school and though, I personally will not do this, I could become a ARNP (Advanced Registered Nurse Practitioner) and I could effective prescribe meds to the oh-so-fun mental health clients I have left behind. I know there is a big push for pscyhologists to have Rx rights. Guess I could do this (prescribe Rxs), and do therapy and still never do a doctorate in psych or complete post doc in psychopharm. Am I more or less qualified than a PhD....who cares? Actually, I am actually leaning towards nurse anesthesia or FNP at this point. If you entering the field of psychology for the money...RUN....or change your specialization ASAP. Listening to people complain is not all that it is cracked up to be. Jobs are few and far between and the burn out rate is high for a reason.

    I am sorry if it upsets some that once we (LMHCs) complete our supervision and pass boards we are independently licensed, can accept third party reimbursement, and can "hang a shingle." It's just a part life and it happens in all aspect of healthcare.
     
  15. deuist

    deuist Stealthfully Sarcastic
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    If that were true, all medical students would be required to do research and write a thesis in order to become better physicians. While some schools (e.g., Duke et al.) have these requirements, the vast majority of other universities have done just fine in graduating high quality doctors without ever forcing them to take stats or making them do original research.
     
  16. psych101

    psych101 Member
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  17. sasevan

    sasevan Senior Member
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    I'm interested in knowing others' perspective on the above post.

    My own views tend toward seeing the field continuing to diversify with a minority of clinical psychologists in teaching and research, another minority in assessment (neuro, forensic, educational) and the majority in treatment.

    I believe that those in teaching, research, and assessment are going to be fine but those in treatment may not be unless they sub-specialize.

    My hope is that clinical psychologists exclusively or primarily involved in providing therapy will become more interested in health psychology (primary care) and medical psychology (psychopharm).

    I guess the bottom line for me is that if psychology becomes more like medicine (e.g., doctoral level practitioners, sub-specialization, prescriptive authority) the future of the field is a bright one. However, I agree with the sentiment that if it remains in large part in competition for therapy patients with LCSW, LMHC, and LMFT it may in fact risk that aforementioned future.

    Peace.
     
  18. Jon Snow

    Jon Snow Senior Member
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    I agree with you.

    I'm not sure where the lower rate for assessment comes from that Psych 101 is referring to. Must be the kind of assessment being done.

    There are many issues in clinical psych and in medicine that are a bit scary from an economic perspective. On the surface, it seems like we're training too many psychologists. Those that earn low incomes are generally primarily therapists seeing poor patients. This, in my opinion, puts higher yield specialties in danger because of the temptation of those earning low incomes to switch. Unfortunately, because of the lack of strong board control, it is relatively easy for a therapy-only psychologist to start doing specialty work. My hope is that the boards, such as the American Board of Clinical Neuropsychology, continue to strengthen and define specialty training and standards for practice. That is the key, in my opinion, to keeping clinical psychology viable.
     
  19. Jon Snow

    Jon Snow Senior Member
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    Would they? I don't think that's practical. The schools that do require it tend to be among the better respected universities. University medical centers tend to offer higher quality care. Do you disagree?
     
  20. psych101

    psych101 Member
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    I agree with sasevan and jon snow – both analyses seem accurate. I guess I just get frustrated because the job of a psychologist is so often dictated by bigger entities like reimbursement sources and business people who run agencies but don’t understand clinical work. I get frustrated because, in many cases, we have to get creative and specialize and find a new way to change ourselves in response to external forces in the mental health field. Why is it that we have to constantly change instead of doing a better job at protecting our turf and advocating for ourselves? In addition to outside entities controlling the type of work we do (or are reimbursed for doing and at what rate), we are also contributing to our own self-destruction by overpopulating the field with psychologists. I wish I knew how to solve these problems.

    Yes, the population I was initially referring to regarding assessments is the low-income population – Medicaid. In my state, a fully licensed doctoral level psychologist is reimbursed for services by Medicaid at the following rates: $141 for an intake, $92 per hour for individual therapy, $108 per hour for family therapy, $30 per event for group therapy, and $88 per hour for testing (defined as “psychological testing, neurobehavioral exam, or neuropsychological testing” – so pretty much any kind of testing). I find the testing reimbursement rate to be RIDICULOUS considering the level of training required to do a competent evaluation and the valuable recommendations that can be provided based on the evaluation. It’s also ridiculous when you think of the non-billable time it takes to score, interpret, and write a report summarizing test results. Agencies begin to think it is, overall, a waste of time for a psychologist to do that type of work when they could be billing more for therapy or intakes. Even psychologists start to avoid much testing because it doesn’t pay well for all the time and energy that goes into it. Incidentally, in my state, the master’s level (i.e., LCSW, LPC, master’s level psychologist) reimbursement rate is as follows: $106 for an intake, $68 per hour for individual therapy, $81 for family therapy, $23 per event for group therapy, and $66 per hour for testing (defined as “psychological testing, neurobehavioral exam, or neuropsychological testing”).

    I do find myself thinking of other alternatives such as private practice or specialization. I find myself hoping I can “stick it out” with the low-income population, even if only to obtain licensure hours. But what a shame that so many of us end up framing such work in these terms while the low-income population remains so underserved. I don’t have the answers, I just hope that we can find a better way of advocating for ourselves and the people who could benefit from what we do.
     
  21. sasevan

    sasevan Senior Member
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    Hi psych101,
    I think I know what you mean.
    I was recently offered a forensic psych job at a state hosp for 55k (it is a 40+ hrs, 50 cases job involving competency assessments, restoration treatment, expert testimony, and supervision of interns/externs).
    When I was completing my psychology residency I was looking at jobs that were offering even less. My colleagues completing their psychiatry residency were being recruited for 80-100k for 20 hrs. I have a friend who graduated from a med school in the Caribbean and who did his psych resiency here in Florida who took two of those 100k jobs and is now making well over 200k as he has plenty of time to do private practice on the side.
    And its not just salary.
    A friend of mine, currently completing an informal post-doc fellowship (getting paid 35K), has for her immediate supervisor an unlicensed mid-level provider who routinely introduces her at community outreach programs by her first name.
    So I think I can relate to your frustration.
    In fact, when I realized the constant and permanent challenges that I was going to have to face in psychology (e.g., salary, status, scope issues) I decided to pursue psychiatry.
    Having said that, I also know that there are many doctors in our field who are doing fine.
    My two mentors (clinical and forensic) both make about 120k (combining teaching, supervising, assessing, and treating services). They've both been in the field for about 15 years and work more than 40 hrs but they are content.
    I also have another friend, completing a pre-doc internship, who is very confident that after residency he'll get a job as a researcher at a pharmaceutical company probably making 70-80k.
    I guess my bottom line is that while our field has a lot of challenges (low salaries, limited scope) it also has a lot of opportunities for those willing to adapt to the ever-changing environment.
    I believe that once someone is licensed (if s/he is willing to move) s/he will be able to get a job that pays ok and will be able to eventually establish a practice that is fulfilling.
    Best of luck to you; keep the faith. :)
    P.S. Alternatively, you could join me in psychiatry; just a thought. ;)
     
  22. Jon Snow

    Jon Snow Senior Member
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    Interesting post. MD incomes are very high in general. Some perspective. . . The average PhD holder across all disciplines makes somewhere in the 60s.
    Working with poor patients who cannot pay and are on government programs such as medicaid will never be profitable.

    Regarding your friend who is being supervised by an unlicensed midlevel (social worker?) on an informal postdoc. . . I am under the impression that won't count for postdoctoral hours? The rule is generally that supervision by a licensed clinical psychologist is required. 35K for a post-doc is not bad. That's not much different than a medical residency and it's shorter. There's also huge variability. I have a friend who is making 70K on their post-doc.

    Regarding money. . . In my opinion the way to do clinical psychology if you want to be a clinician is. . .

    Go to a Ph.D. program with full-funding (0 debt upon graduation). Go to a competitive research based program. Get an internship at an established academic medical center or VA. Networking is the name of the game. Get a post-doc in a professional position, academic medical center, or VA. Specialize, specialize, specialize. General therapy with people who can't pay is not going to do you any good.

    0 debt + good training + good networking + specializtion = good income and financial situation. It also helps with the status issue.

    Clinical psychology is not a sure thing like medicine is, but, as far as careers go, the potential is high to be successful. It is necessary to plan and carefully weigh options and decisions. Unlike medicine, just getting in to graduate school is not enough. Going in with that attitude may get you burned.
     
  23. sasevan

    sasevan Senior Member
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    Hi Jon Snow,

    I've asked my friend about this and she's informed that while her immediate supervisor (i.e., her boss at the branch) is an unlicensed social worker she also has another supervisor (i.e., a colleague at headquarters) who is a licensed psychologist with whom she meets with for 2-3 hrs/weekly for individual/group supervision. She assures me that this arrangement is acceptable to the Board of Psychology.

    Peace.

    P.S. I've enjoyed your posts in the various threads here and in the psychiatry forum; especially the point that psycheval and you (as well as others) have made about all clinical psychologists needing to be better trained in neuroanatomy, pathophysiology, pharmacology, etc. in order to be able to provide efficient diagnostic et al. services. I couldn't agree more. I also liked the point that you made regarding the posibility that medical psychologists who have to collaborate with physicians (by law) may appear to be mid-level providers. I don't agree but I liked the point nonetheless; something to at least think about, perhaps resulting in a different RxP model. I am, however, really curious as to why you believe that psychologists shouldn't prescribe medications. What if med psych were trained in a more rigorous manner than currently proposed psychopharm programs (something akin to the DoD project)? What about increasing patient access to pharmacotherapy? What about expanding scope for psychology in order to improve status/salary?
    I grew in tremendous appreciation of the biological dimension of mental illness during my psychology residency and as a result of that became interested in pharmacotherapy and have since begun to pursue psychiatry but given the success of the med psychs from the DoD project (and now NM and LA) I don't see why cl psychs shouldn't prescribe and I believe that this will be a benefit both for patients as well as for psychology. Your thoughts will be very appreciated. Thanks in advance. :)
     
  24. Jon Snow

    Jon Snow Senior Member
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    That will work, though I don't know why she bothers meeting with the social worker. It doesn't count.

    Thanks, others haven't been so pleased. :)
    I am concerned about how it would change the field. The midlevel point I've alread made, but it goes beyond that. Money is one issue. Will prescribing psychologists make materially more than non-prescribing psychologists? If so, what will that do to the numbers of prescribing psychologists? Will most psychologists pursue prescription rights? Will training programs adjust and make prescription training part of graduate school? If that becomes the case, what will be replaced? Also, how will malpractice insurance rates for the field be affected? Right now, they're low. If psychology adds prescription priv, how much will they increase? Will it affect psychologists who choose not to pursue prescription rights? Further, expertise issues come into play. At the moment, clinical psychology is very good at assessment (neuropsych, psychosocial, health, behavior analyses, developmental - asperger's, autism, adhd, etc. . .) and non-pharm treatment. Will clinical psychology shift to mirror psychiatry if it gets prescription priv? How much of a blitz will drug companies put on psychology? There are alot more clinical psychologists than psychiatrists. I would think the blitz would be strong. Would the field shift in terms of research?

    I have some problems with the medical model as practiced by psychiatrists. My perception is that they throw pills at nearly every problem that walks through their office. This is not a strategy supported by research in my opinion. There are many conditions that responsd just as well or better with specific types of psychotherapy.

    I think there is a potential for psychology to lose its identity and become psychiatry-lite if prescription priv become wide spread. I don't think that's good for patients. I don't think it's good for our understanding of the human condition (something that I think psychology has a better handle on than psychiatry both from research and clinical vantage points).

    At the moment, psychology is distinct from psychiatry. It does alot of things that psychiatry does not do and it does them well. It does things that neurology does not do and it does them well. I think what we have is a bunch of clinical psychologists who want to be psychotherapists and from their vantage-point, adding prescription priv sounds like a good idea.
     
  25. PsychEval

    PsychEval Senior Member
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  26. Jon Snow

    Jon Snow Senior Member
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    One more point, then I need to stop stalling and get some work done. Psychology is a diverse field. My entire training from undergrad, to grad school, through internship and postdoc has focused on biological dimensions of mental illness and human behavior. I went into grad school with the intent to specialize in neuroscience/neuropsychology and I did that from the start. Everything I've done from my research to my clinical work has focused on physiology, pathophysiology, and brain-behavior relationships. I don't think my course of training is unique either. There are lots of psychologists that have taken a similar path. There is no reason to shift to psychiatry to pursue biological underpinnings of mental illness.
     
  27. sasevan

    sasevan Senior Member
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    Hi PsychEval,
    I really liked your posts in the psychiatry forum; like you I support all clinical psychologists being trained in the biological dimension of mental illness in order to increase diagnostic skills (e.g., differentials, triage) as well as a sub-specialty of medical psychologists having RxP.
    I considered a post-doc MS in psychopharm or going the route of a psych NP but in the end decided to become a psych MD/DO.
    My passion is really clinical work, especially intervention strategies. I don't know much about neuroradiology but it sounds to me to be a branch of diagnostic radiology; if so I don't think I'd be interested. I see myself in the future as a psych PsyD-MD or PsyD-DO providing direct service to both outpatient and inpatient populations.
    Peace. :)
     
  28. sasevan

    sasevan Senior Member
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    Hi Jon Snow,
    Thanks for the response. Again you make some very good points. Allow me to suggest some counter-points.

    Don't neuropsychs and forensic psychs already make on avg much more than cl psychs? Are most cl psychs sub-specializing in neuro or forensic? I may be wrong but my impression is that the answer is "no."
    What about making med psych a concentration in psych school (just like neuro, forensic, health, pedi) with a 3 yr residency (just like neuro)-1 yr internship and 2 yr fellowship?

    Have NP/CNS insurance rates skyrocketed after these providers acquired RxP? Again, my impression is "no."

    APA has suggested that med psych would have a different model for prescribing than psychiatry, e.g., psychopharmacotherapy in the context of psychological treatment (psychodynamic psychotherapy, CBT, behavioral therapy) not exclusively med mgm (especially the often reported 15-20 min psychiatric evals and 10 min med checks) and close consultation with the PCP.

    I totally agree. I think that that is why the APA is advocating for a psychological model for med psych as opposed to the med model of psychiatry. I think that the implementation of this model would offer patients a viable alternative and maybe even inspire psychiatry to reconsider its current approach to pharmacotherapy.

    I agree that there is this potential but perhaps it can be guarded against by faithful implementation of APA's proposed psychological model of RxP (pre-doc training as currently established with med psych reserved for post-doc training).

    Again, I totally agree. I believe, though, that most cl psychs won't specialize in med psych and RxP will be limited to a sub-set that will not usurp psychology's identity but only add to its diversity and continued development from an exclusively academic discipline to a mental heath profession and now more and more to a healthcare one.

    Peace.
     
  29. PublicHealth

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    If you don't mind my asking, where did you complete your PhD/PsyD? Did your clinical training REALLY focus on physiology, pathophysiology, and brain-behavior relationships? I find this hard to believe, given the emphasis on cognitive-behavioral models of treatment that seem to be in vogue at most clinical psychology programs.
     
  30. sasevan

    sasevan Senior Member
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  31. PublicHealth

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    Hi, sasevan.

    I applaud your effort to pursue MD/DO and psychiatry. There's a long road ahead. MS1 is rough and MS2 is comparably difficult. I have several friends in clinical psych PhD programs who seem to be having a MUCH better time than me -- more free time, interesting research, no debt, etc. Nevertheless, I'm committed to sticking it out in favor of comprehensive medical training and a ticket to a good psychiatric residency.

    That said, it seems like psychologist RxP efforts have really picked up in several states. Have you considered moving to Louisiana to pursue certification as a "medical psychologist?" Given that you currently live in Florida -- two states away from Louisiana -- this seems like a highly time efficient and cost effective option. I'm not sure what it's like to live in Louisiana, though! Last I heard, RxP efforts in Florida have been stalled. A number of southern states -- Tennessee, Georgia, Alabama, Mississippi -- look like they may pass psychologist RxP legislation over the next few years, as they have been lobbying hard lately. I sincerely believe that it's only a matter of time before this happens in most US states.

    As a medical student with an interest in psychology and psychiatry, I embrace wholeheartedly the "biopsychosocial model" of pharmacotherapy, with integrate pharmacotherapy and psychotherapy. Psychiatry has pretty much abandoned this integrative practice in favor of primary pharmacotherapy a number of years ago, and is now moving toward a tighter integration in medicine -- psychosomatics. This has been a longstanding interest of Dr. Michelle Riba, current President of the American Psychiatric Association. It's also a good way to convince policymakers that psychologists are not physicians and do not understand the intricacies of clinical medicine and its interaction with psychiatry.

    We should try to carry on a dialogue in this forum. I'm curious to hear everyone's responses.
     
  32. PublicHealth

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  33. Jon Snow

    Jon Snow Senior Member
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    Cognitive-behavioral and social learning theory were definitely present. But, like many clinical programs, mine allowed individual tracking beyond core courses. Within the core, bio-specific courses were available. Outside of that, electives could be anywhere. Example elective courses might include psychophysiology, frontal lobe development, cognitive neuroscience - attention, cognitive neuroscience - imaging and EEG, behavioral genetics, neuro-ethology, and neuroanatomy, etc. . . Outside of classes, directed individual study was allowed (topic to be determined by student), research projects were required, of course (e.g., masters and dissertation). Most people do projects beyond that, as did I . For me, all of these were psychophysiology/cognitive neuroscience research projects. Teaching can also be a learning method in graduate school (e.g., teach biopsych courses).

    Practicums:
    Many programs offer neuropsychology practicums yearly. Externships are required. There are formal externship programs for neuropsychology at places like the University of North Carolina, Duke, VAs, and so on. . .

    In addition:

    at the internship level, if you go to a division 40 certified program at an academic medical center you might experience:

    wada testing as part of epilepsy surgery
    neuropathology - brain cuttings - (many programs require interns to attend this weekly throughout the year).
    psychiatry grand rounds
    neurology grand rounds

    some programs require/offer interns to do neurological exams under the supervision of a neurologist as a rotation

    Then, there is post-doc.. . .
     
  34. sasevan

    sasevan Senior Member
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    Hi PublicHealth,

    Thanks and congrats on being an MS2; that is really awesome. :clap:
    I considered for about a year all possible options (including moving to NM or LA) and finally decided on going the psychiatry route when I concluded that RxP will come to FL (where I want to live and practice) only at the very end (FMA and FPS are very influential in FL to the point that this State is one of only six that does not permit psych NP-eventhough they need to have a collaborative agreement with a psych MD/DO-to Rx controlled substances like benzos and stimulants).
    Besides I believe that getting legislative approval for RxP is only half the battle as insurance coverage for med psych also has to be garnered and efforts at this are now just starting in NM.
    So, while I support this development in cl psych I believe it will be a long-time coming (at least on a national scale).
    I also believe that while medical psychology will provide a very neccessary service to patients (especially increasing access to integrated psych treatment for the outpatient population) I continue to believe that psychiatry will still be the gold standard in pharmacotherapy. I envision that medical psychologists will be the primary mental health providers of the future (as opposed to PCPs) but that they will refer to psychiatrists the harder to treat cases (e.g., treatment resistant, polypharmacy, inpatient).
    I'm also very interested in psychosomatics.
    Bottom line, I'm very much in support of this development in psychology but its current status and what I foresee as its ultimate unfolding do not fully respond to my professional aspirations.
    Peace.
    P.S. Can't wait to be in med school. Congrats again. BTW,
    NYCOM is still one of my top choices; especially because of its clerkships in The City and awesome residency matches. :thumbup:
     
  35. PublicHealth

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    If you don't mind my asking, where did you train?
     
  36. Jon Snow

    Jon Snow Senior Member
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    I think we'll find that there are more people specializing in neuro now. I don't have any empirical evidence to back that up, but I am aware that many professional schools are pushing students into these areas so that they may have a shot of paying off their debt.


    That would be the way I would do it.
    I don't know.


    I don't have confidence that would remain the case for long. I think the current model of psychiatry evolved because of reimbursement rates not because of benefit to the patient. Psychology would face the same pressures.



    I think med psych would be more tempting than you think to a large number of cl psychs. Many people in cl psych go into it with the notion of being a psychotherapist. Many people go in not that interested in science (especially with the prof schools) and more interested in therapy. If RxP allowed cl psychs to do psychotherapy as their primary vocation and earn at a reasonable level (unlike now), it would be a big golden carrot. Neuropsychology and forensics are not fun if you it isn't what you want to do and it's hard. I think this (RxP) would be much more tempting to all those eclectic therapists out there.
     
  37. PsychEval

    PsychEval Senior Member
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    I appreciate and applaud anyone who has a passion for knowledge. And as we know, there are many diverse formats to obtain knowledge. Furthermore, I have always appreciated your posts, and do not mean to be discouraging, but from a practical standpoint completing two years of pre med, four years of medical school, four years of residency, accruing 200,000 more in debt on top of your Psy.D. degree, not to mention 10 years of not making your full income as a psychologist, and when it’s all over you will receive a 20-25% pay raise, just doesn’t seem practical. In fact, you will likely make less money over your lifetime because of your decision to pursue psychiatry considering your background and current skills. You’re a smart guy and have probably crunched the numbers and are aware of this. There is absolutely nothing wrong with going to medical school after becoming a psychologist. In fact, I respect your level of dedication and discipline. However, from a practical standpoint, the only way a career in medicine seems sensible after completion of doctoral training in psychology would be to select a specialty that pays well (300 +). In my area, psychiatrists start out at $125,000 in the local community mental health center. I know several psychologists in private practice in my area who make around $130,000. I would love to be a forest ranger or be a lifeguard and look at pretty girls all day, the only problem is that there is no money in it. I don’t think it is healthy to be preoccupied with money, but when there are money concerns folks can become resentful and unhappy. I remember reading months ago Dr. Focker saying something like….two hundred thousand in debt, and old car, and no home ownership, yes I am concerned about psychologists prescribing. I have the utmost respect for you for continuing your education. I hope as you enter medical school and later become a physician, that you would keep an open mind about what your specialty will be.

    About the neuroradiology…..I am increasingly involved in neuroscience. Among the professionals involved in interdisciplinary neuroscience, I interact with neurologists, neuropsychologists, neurosurgeons, neuroradiologists, residents, and medical students (unfortunately psychiatry only on occasion, and I don’t know why they are not more involved). The neuroradiologists are an impressive group, and steal the show at various case conferences. They are some of the most skilled diagnosticians, contribute to patient care, have excellent economic compensation, and even a better quality of life.
     
  38. PublicHealth

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    I disagree. Nearly all of the private practice psychotherapists (all PhDs) with whom I have discussed RxP have no interest whatsoever in prescribing. They respect the complexities of medical/psychiatric treatment and would much rather refer their patients to psychiatrists than pursue additional years of psychopharmacology training and liability concerns. Of course, all of these psychologists practice in an fairly affluent region of the country with ready access to psychiatrists. I'm sure this is not the case in other states.
     
  39. Jon Snow

    Jon Snow Senior Member
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    Sure, but they've already done the internship, post-doc thing. Let's say, RxP, at the very least, puts incomes on par with neuropsychology (~$100,000+). You don't think professional schools would jump on that. I'm sure we'd immediately see Pharm tracks, Pharm internships, and Pharm postdocs (they've already done the same for neuropsychology and forensics, something that you don't really see in PhD academic programs in the same way).
     
  40. sasevan

    sasevan Senior Member
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    Hi PsychEval,

    Thanks.
    I've always appreciated your posts as well; very well thought out and respectful. I think you have been an excellent psychology ambassador in the psychiatry forum. :thumbup:
    I decided to pursue psychiatry at the beginning of my post-doc fellowship in the Fall of 2003 and began to take the pre-med reqs in the Spring of 2004. I'll be finished with all courses by Summer 2006 and hope to start med school in the Fall of 2007. I'm already well along this course and have only become more committed to it as it has unfolded. As you can tell, I've only been a professional psychologist since the Fall of 2004 so money wise I'm not making the most amount (probably 50k annually for 30 hrs/weekly-gives me flexibility for pre-med) and not having this current income during my med school years doesn't bother me very much. I also hope to finance my med edu through the National Health Services Corp so maybe I won't have that 200k debt. Of course, I'll probably be earning 45k annually during the residency years so all in all I think I'll be financially ok. When I become a professional psychiatrist in 2015 I'll still have about 30 working years where hopefully I'll make enough (I'm thinking 150k) to enjoy a slight upgrade to my current modest but comfortable lifestyle (as you can see I've become habituated to my working student status...LOL).
    Seriously, though, I did crunch the numbers (and consulted with a couple of psychologists-psychiatrists) and financially, even in the worst case scenario (200k debt, 120k annual salary), it still made sense.

    This is very interesting and I will look into it. I'm also going to pass on this info to a friend who is very interested in neuroscience but who is considering dentistry instead of medicine because of quality of life issues.
    I'm really committed to psychiatry as my preferred med spec but I guess I'd be ultimately open to any med spec that can be built on my psychology background. You never know. If not, then maybe I can at least find a place as a psychologist-psychiatrist in the interdisciplinary neuroscience team. ;)

    Thanks again. Peace. :)

    P.S. Any other info on neuroradiology (e.g., what role you've seen it play, how that has been translated to patient care, is it a neuro or rad sub-spec, does it require a fellowship) would be awesome.
     
  41. sasevan

    sasevan Senior Member
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    Hi Jon Snow,

    Cool.

    No doubt its definitely a risk. But wouldn't the worst case scenario be that medical psychologists would end up taking the place of PCPs providing front line med mgm? On the other hand, the best case scenario could be increasing patient access to integrated mental health services (i.e., doctoral-level mental health clinicians providing both psychotherapy and primary psychopharmacotherpy). This could result in PCPs being free of this responsibility, mid-level providers engaged in counseling, and psychiatrists providing secondary psychopharmacotherapy to the harder to treat cases and continuing to develop and implement other medical interventions such as ECT and VNS. Its a risk but isn't it worth taking?

    I agree, but wouldn't it still be better for patients to have increased access to doctoral level mental health clinicians that could provide them integraded treatment as opposed to seeing a PCP (or psychiatrist when available) exclusively for med mgm and perhaps sometimes (rarely?) also seeing a mid-level provider or psychologist for therapy?

    Could you support the development of PhD/PsyDs having RxP if med psych were limited to a pre-doc concentration and a rigorous post-doc training (akin to neuropsych) and certification standards were established and safeguarded by a Board of Medical Psychology? Wouldn't that at least decrease the risk of the sub-specialty overrunning cl psych?

    Peace.
     
  42. PublicHealth

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    This sounds like optometry and ophthalmology -- ODs providing primary eye care (eye exams, primary vision care) and MDs providing more intensive treatments, including surgery.
     
  43. sasevan

    sasevan Senior Member
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    Hi PH,
    What's your take on something like that?
    To me it sounds like a way to expand psychology's practice scope while safeguarding psychiatry's medical pre-eminence.
    This could also reduce the risk of the over-medicalizing of psychology while increasing patient access to integrated mental health treatment.
    Peace.
     
  44. PublicHealth

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    :thumbup: :thumbup:
     
  45. Logic Prevails

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    <<Originally Posted by PublicHealth
    This sounds like optometry and ophthalmology -- ODs providing primary eye care (eye exams, primary vision care) and MDs providing more intensive treatments, including surgery.>>

    The argument that you're trying to make here is the same as the argument I've been making for masters level practitioners. By the logic of some people on this board we would argue that Ophthalmologists don't have the same qualifications as the Optometrists and provide sub-par care for patients. This means that allowing Opthalmologists to continue caring for those with eye problems is undermining the field of eye care. Similarly, psychologists who seek RxP will be providing sub-par tx (as compared to Psychiatrists) and undermine the field of Psychiatry.

    (P.S. I don't necessarily believe anything that I just wrote - I'm just trying to make a point that has been missed in the past few pages of this thread and steer the topic closer to the title of the thread)
     
  46. sasevan

    sasevan Senior Member
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    Hey Brad3117,
    I think you were confusing Opthalmologists with Optometrists and vice versa; the former are the MD/DOs while the latter are the ODs but I get your point.
    I wasn't considering medical psychologists, in comparison to psychiatrists, as providers of sub-par patient care. I believe that psych PhD/PsyDs that are trained/certified in a post-doc MS psychopharm program will be able to provide primary pharmacological treatment equal to a psych MD/DO (and probably superior to PCPs, the current primary psychopharmacologists). However, I don't believe that medical psychologists will be equal to psychiatrists when it comes to medically managing the more complex cases (just like PCPs aren't equal to psychiatrists in that regard).
    I guess the model that I envision will have medical psychologists taking over the role of PCPs in providing basic psychopharmacological treatment (primary care) and psychiatrists continuing to provide more sophisticated treatment when warranted (specialty care).
    I think that such a model would serve the needs of all the stakeholders: patients would have increased access to integrated primary mental health treatment (remember that psych PhD/PsyDs will be providing pharmacological interventions in the context of psychological services); psychology will expand its scope of practice; psychiatry's current medical pre-eminence in mental health will not be threatened; and PCPs will be relieved (I believe) to not have to medically managed the majority of the mentally ill.
    What do you think?
    Peace. :)

    P.S. Please clarify your point regarding the masters level providers. :confused:
     
  47. Logic Prevails

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    Yup, my bad.

    I know you weren't - I was making this comparison to highlight my point about Master's level practitioners. I've argued throughout this thread that Master's level practitioners should be permitted to take on some roles that had been previously (and are currently in some places) reserved for PhD level Psychologists. In Canada, there are only 2-3 provinces that require a PhD in order to practice. In Many provinces we have Master's level Psychologists or "Psychological Associates/Assistants," who might do assessments or therapy as long as they are practicing within their area of competence (though often with supervision). I know registration is different in the U.S., but it has been this way in Canada for quite some time with few problems.

    Anyway, another user on this board went on a lengthy rant about how allowing Masters level practitioners to provide services (even limited services) would be undermining the field of Psychology (following from the logic that PhD psychologists would have more education and could have provided better services). I don't agree at all (as this applies to limited types of services), but have extended his logic to this discussion about PhD psychologists who might do additional training to provide pharmacological treatment. Following the same logic, we would have to say that PhD Psychologists would provide sub-par services (even if these services were limited and generally applied) compared to their Psychiatric counterparts (who would have a larger background in medicine). ;)

    In providing primary pharmacological treatment, I certainly agree. :)

    Sounds good to me, but this is the same argument that I've been making for Master's level practitioners providing certain types of services.

    I think some people on this board dislike the idea of Master's level practitioners taking over positions that they might have otherwise filled (even though MSW's have already done so). I think if this were to happen (which I believe it should), PhD Psychologists should expand their area of expertise so that the dicipline remains in good health and the public benefits. I think this will happen by having more PhD psychologists moving to supervisory positions and further specializing (in ways such as what you've been outlining here).

    I think this makes a lot of sense. I would only worry about the extra training it would require. I think if this were to happen, you would need to seriously reassess the PhD/PsyD programs that we have already. Many schools on paper take 5-6 years to complete a MSc/PhD plus internship. In reality, it often takes longer (i.e. 7-8 years average at my school). I would worry about additional training taxing the student too much in terms of what they can be an "expert" in. I think they would be spreading themselves too thin, emotionally, cognitively, and financially.

    I think in general you're on the right track here. I believe the PhD programs that we currently have in place need some serious restructuring before anything else were to happen (we don't really have PsyD programs in Canada, but I believe they are the right way to go for clinical training). I believe these changes will happen eventually, and likely as a result of changing roles for those working outside of the Universities.

    My 2 cents
     
  48. Jon Snow

    Jon Snow Senior Member
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    Brad,

    To what level do we take that argument? Shall we have stipulations for:

    PhD level psychologists
    PsyD level psychologists
    Masters level psychotherapists
    Bachelors level psychotherapists
    high school level psychotherapists
    GED level psychotherapists

    etc. . .


    I think your analogy of psychologists trying to get RxP compared with the expansion of roles for masters level practitioners (including the woefully undertrained social workers) is apt. It also bears mentioning that the proposed training for RxP for clinical psychology is more education than a masters level person receives in the mental health field to do anything.
     
  49. PublicHealth

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    I agree that restructuring at the predoctoral-level is inevitable. However, this will have to been done in a way that is sensitive to those who seek more traditional training in clinical psychology and those who wish to pursue more medical/psychiatric training.

    Many clinical psychology programs have specialty tracks (e.g., neuropsychology, geropsychology, etc). No one talks about these tracks as having required "serious restructuring." They were simply specializations within the broad field of clinical psychology. A good move for the field if you ask me, as it allows students to begin to specialize at the predoctoral level. Why not simply add a "medical/prescribing psychology" track to existing doctoral programs in clinical psychology?

    Why is adding medical/psychopharmacology training at the predoctoral level viewed as such a dramatic change that requires such "serious restructuring" when it is simply a track to prepare students for further training in psychopharmacology and integrated behavioral healthcare? There are multiple levels in clinical psychology training -- predoctoral, internship, postdoctoral, continuing education -- that we need to consider when discussing the incorporation of medical/psychiatric training into predoctoral clinical psychology curricula.
     
  50. sasevan

    sasevan Senior Member
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    Hi,

    Sorry for taking so long to reply; I've been swamped with work and school (finals next week :eek: )

    Not just in Canada. I believe in many nations psychologists are masters level; Colombia and Venezuela come to mind.
    I think that in the US the APA made the decision long ago that psychologists (at least clinical and counseling ones not neccessarily school ones) would be doctoral level and has labored since to ensure that. It has also labored to restrict the use of terms such as "psychologist" and even "psychological" to those practitioners regulated by the pertinent State Board of Psychology; e.g., after I got my M.S. in Psychology I worked at a State prison under the title of "Psychological Specialist" (and under the supervision of Licensed Psychologists-i.e., PhD/PsyDs).This was a position open to anyone with a masters degree in psychology, social work, or counseling. Eventually, the FL legislature, after lobbying from FPA, prohibited its use and the title is now "Mental Health Specialist." So I believe that the issue is pretty much settled here.

    Nonetheless, I think that your main point is that masters level practitioners should be able to expand their scope of practice into therapy/testing just as psychologists want to expand their's into RxP. In principle I would, generally, agree. I say generally because when we're talking about masters level practitioners we're talking about different fields, i.e., MA/MS psychology, LCSW, LMHC, and LMFT. I don't see why someone with an MA/MS in psychology (Psychological Assistant?) could not function as a Physician Assistant does in medicine: i.e., providing limited assessment/treatment under the supervision of a psychologist. This was basically what I was doing when I was a "Psychological Specialist." Is this what you're proposing?
    But as far as LCSWs, etc I don't know enough to offer much of opinion except to suggest that all of these different disciplines certainly have a role to play in the delivery of psychosocial interventions but probably not in the administration of psychometric measures (not that they couldn't/shouldn't but that they're not trained to do so and don't appear to be too interested in so being).

    I defenitely agree that PhD/PsyDs should be doing much more supervising of masters level practitioners (and even possibly of MD/DOs) in the area of therapy (and testing where applicable).

    I think you've raised an important point but I think, as PublicHealth stated, that a concentration in med psych and a 3 yr residency (1 yr intern/2 yr fellow) would ensure adequate training for RxP whithout needing to alter the current model of cl psych. Although, to be perfectly honest, I think that the current curriculum could benefit from some alterations such as increased exposure to neuroscience, pathophysiology, psychopharmacology, etc.

    Thanks. I believe you are too.

    Peace. :)
     

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