Jul 29, 2010
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So here in Texas there is a firestorm brewing over a movement to grant independent practice privileges for Licensed Psychological Associates (LPAs). The following is an excerpt from The Behavioral Medicine Report, by Christopher Fisher, PhD.

"In a potential major, controversial development for Texas psychology and those who hold a Master’s degree in psychology, Texas Association Of Psychological Associates (TAPA) announced their intention to seek, and file a lawsuit if necessary, independent practice status for Licensed Psychological Associates (LPAs). LPA is a Texas licensure designation that requires a Master’s degree in psychology and allows LPAs to work with patients under the supervision of a Licensed Psychologist. Check the end of this report for a link to the publicly available TAPA letter that explains their position."
http://txapa.net/uploads/Izzo_and_Board_ltr.pdf

I just wanted to share this information to my fellow psychologists in training. I find this action to be rather disturbing in that it has the potential to lower the level of training required to provide services to patients. I'm just not sure how this in any way benefits the public. I am also put-off by the attitude that people can choose to stop short of the degree and training required for a certain level of practice and demand the same rights that others work very hard for. If this keeps up, I am not sure exactly what psychologists will have to offer in clinical practice anymore. Bleh... I'm becoming jaded and I'm still an intern. :(
 
Sep 16, 2010
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Interesting. I wonder who is next? Will paralegals ask to be grandfathered into lawyers? Or perhaps career RAs will decide they have had enough research experience to considered for PIs in their own labs. I am not diminishing the work experience of any of these professionals, but there are plenty of avenues to independent practice for LPAs and psychometrists. Why not pursue an LCSW, PsyD, PhD, Ed, etc?
 

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Interesting. I wonder who is next? Will paralegals ask to be grandfathered into lawyers? Or perhaps career RAs will decide they have had enough research experience to considered for PIs in their own labs. I am not diminishing the work experience of any of these professionals, but there are plenty of avenues to independent practice for LPAs and psychometrists. Why not pursue an LCSW, PsyD, PhD, Ed, etc?
Exactly. I think part of the problem rests in the general public not understanding the training model for clinical psychology, and how it differs from other master's-level mental health professionals. Much of the responsibility for this lack of understanding falls on our shoulders (as a field).
 

edieb

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I urge you to join the texas and american psychological associations. if these organizations don't have enough money from membership dues, they cannot fight these encroachments on our scope of practice.
 
OP
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I urge you to join the texas and american psychological associations. if these organizations don't have enough money from membership dues, they cannot fight these encroachments on our scope of practice.
Absolutely!!!

Turns out the lawsuit has been filed. Not sure I can join as I am still a trainee, but we here at my internship site are trying to raise awareness.
 

Neuropsych2be

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Interesting. I wonder who is next? Will paralegals ask to be grandfathered into lawyers? Or perhaps career RAs will decide they have had enough research experience to considered for PIs in their own labs. I am not diminishing the work experience of any of these professionals, but there are plenty of avenues to independent practice for LPAs and psychometrists. Why not pursue an LCSW, PsyD, PhD, Ed, etc?

I don't get this. Persons with an MS in psychology can probably become licensed as LPC's in Texas with the appropriate amount of post-graduate supervision and can thereby work independently . LPC's have the advantage of having their own professional board and national professional organization the ACA. This makes no sense!
 
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True. LPC is yet another option. I really hope this doesn't go anywhere, but since it has already moved to an official lawsuit, we can't dismiss this altogether. It does seem very entitled and nonsensical to knowingly take on a position (LPA) that requires supervision and then whine about it. Give. Me. A. Break. Either take the steps to complete training or stay put. :rolleyes:
 
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What is the difference between an LPA and an LPC or LHMC?
LPCs and LHMC are closer in terms of their scope of practice. They can practice independently as professional counselors. LPAs, however, (a term which I'm not sure exists in all states) are professional assistants. The number of supervised clinical contact hours to obtain an LPA are far less as they are expected to work for a psychologist. It only makes sense in my mind to frame it this way, an LPA is to a clinical setting (typically private practice) what a psychometrist is to an assessment setting.

It is all confusing and getting to be a tad bit ridiculous...
 
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Thanks, I just renewed my TPA membership because of your posting!
Sweet!!! I sure hope more will join you as I suspect the tactic for this lawsuit is to simply out-spend counting on low membership numbers and limited funds from dues for the TPA to keep fighting it.
 

psich

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If it ain't broke, why fix it? It doesn't seem to make sense at all to give LPAs these privileges. If LPCs/LMHCs can practice independently, then a person who wants to do so should just follow these already-existing professions.
 
Dec 31, 2010
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In a land and time not so far far away, psychiatrists were the only professionals "qualified" to diagnose. They frequently wrote position papers decrying the "lesser" training of psychologists.

Encroachment of practice is the closest statement of the real issue. This is, and has always been, about identity crisis, not about qualifications. And while doctoral psychologists (and interns) quibble about this, life coaches, FNP's, MSW's, LPC's, pastoral counselors, etc. are treating people independently, and being reimbursed at increasing rates. Yes, these "lesser" professionals are treating (taking away) "your" "doctoral level" clients.

The benefit, among others, to the public by allowing LPA's to practice more independently (I say more because in my state one can practice with one hour of supervision per month) is that it provides additional evidence-based mental health professionals trained in psychology, charging lower fees (increasing access), particularly in rural areas where there are few, if any, doctoral-level psychologists (see APA report or the state of rural practice).

Isn't that the mission of the APA? To promote the science of psychology and its application to helping people access and receive much needed mental health services? Or is it to ensure PhD's get what they "deserve?" Sadly, if this ridiculous turf war continues, our profession surely will (continue to) suffer. And all the other providers will laugh all the way to the bank.

.02
 
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LPCs and LHMC are closer in terms of their scope of practice. They can practice independently as professional counselors. LPAs, however, (a term which I'm not sure exists in all states) are professional assistants. The number of supervised clinical contact hours to obtain an LPA are far less as they are expected to work for a psychologist. It only makes sense in my mind to frame it this way, an LPA is to a clinical setting (typically private practice) what a psychometrist is to an assessment setting.
This is not accurate. LPA's are not expected to work for a doctoral psychologist, and are not, in fact, professional assistants (akin to paralegals). That term, including psychometrist, is reserved for unlicensed individuals providing ancillary services. LPA's are engaged in the practice of psychology.

All else being equal, to practice "independently." LPA's must obtain a minimum of 5 calendar years and 7500 hours before being able to practice at a level of one hour of supervision by a doctoral-level psychologist per month. Thus, LPA's must obtain nearly four times the number of supervised hours prior to being able to practice quasi-independently compared to doctoral-level psychologists (2000 hours), not to mention LPC's, MSW's, etc. In fact, LPC's are required to obtain 3000 post graduate hours in my state, which is more than doctoral psychologists are required to have.

.02
 
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The benefit, among others, to the public by allowing LPA's to practice more independently (I say more because in my state one can practice with one hour of supervision per month) is that it provides additional evidence-based mental health professionals trained in psychology, charging lower fees (increasing access), particularly in rural areas where there are few, if any, doctoral-level psychologists (see APA report or the state of rural practice).
I would agree with this, except I'm not convinced that the training is evidence-based. Of course, you can say this of the doctoral level programs too, but my feeling is that master's programs are even more variable across programs in terms of teaching evidence-based therapies. I think that if APA would stop pandering to membership that opposes evidence-based practice by remaining lukewarm on the issue and would actually regulate the type of training people get, then your above comment would be the reality and it would be good for mental healthcare as a whole.
 

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One potentially interesting development would be for master's programs to become more specifically directed toward certain evidence based practices and--if this had correspondingly good standards around limiting scope of practice to your speciality area--this could be good all around. I actually think some MA programs do a better job of teaching basic clinical skills than some PsyD/PhD programs that teach a little bit of everything but not enough of the basics in any one area and this problem is driven by the scope of things accreditation requires programs to demonstrate within the program. Sometimes less is better if you want competence.
 
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I would argue that I know of no Master's-level program in psychology not organized and administered by psychologists.

Hence, to argue against LPA's on the basis that there is variability in the training of Master's-level psychologists such that some are not trained to practice based on the basic tenants (e.g. scientifically-informed practice) of psychology requires that those psychologists who are training them are not acting in accordance with the APA Ethics Code governing the conduct of psychologists.

LPA's have the same professional orientation and fundamental training in the biological, social, affective, and physiological bases of behavior as doctoral psychologists. If doctoral psychologists feel as though this orientation and training is what separates the practice of psychology from, say, the practice of social work or counseling, then the argument against LPA's is clearly visceral, not logical.

.02
 

Therapist4Chnge

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All else being equal, to practice "independently." LPA's must obtain a minimum of 5 calendar years and 7500 hours before being able to practice at a level of one hour of supervision by a doctoral-level psychologist per month. Thus, LPA's must obtain nearly four times the number of supervised hours prior to being able to practice quasi-independently compared to doctoral-level psychologists (2000 hours), not to mention LPC's, MSW's, etc. In fact, LPC's are required to obtain 3000 post graduate hours in my state, which is more than doctoral psychologists are required to have.
Uhm....you need to do more research into doctoral training. The average internship applicant has 1000 hrs of practica hours, 2000 hrs from internship, another 1500-2000 hrs post-doctorally, etc. This is on top of the thousands of more hours of classes, research mentorship, teaching, etc. This is done full-time, with a large portion of training coming OUTSIDE of classes, typically averaging 50-60+ hours a week for 6-8 years. Competent practice of talk therapy is more than learning some basic theories and approaches. I don't think MA/MS level practitioners should be allowed to practice anything but supportive therapy without additional significant supervision and training.


LPA's have the same professional orientation and fundamental training in the biological, social, affective, and physiological bases of behavior as doctoral psychologists.
If doctoral psychologists feel as though this orientation and training is what separates the practice of psychology from, say, the practice of social work or counseling, then the argument against LPA's is clearly visceral, not logical.
As a psychologist who has taught in both masters and doctoral level classes....there are large differences in the breadth and depth of the classes, as well as the requirements of each respective class. I'm not talking about statistics or research classes, which often get cited by MA/MS level students as "the only difference in training", but in core classes like adult psychopathology, psychopharmacology, assessment, etc. The classes aren't even remotely comparable, nor should they be.
 
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I must have come across as diminishing the training of doctoral-level psychologists. If so, that was a mistake on my part. I did not intend to do so. I want to make it clear that I do not equate MA/MS training in psychology to that of PhD training in psychology. I've heard that argument before by individuals who simply did not pursue one degree or another and wish to simply justify that their current training is "basically the same." I don't agree.

I would love to have an intelligent discussion about the empirical basis for some doctoral psychologists' strong disdain for master's-level psychologists (but ironically, not for master's-level counselors or social workers).

Answer this: If PhD/PsyD trained clinical/counseling psychologists are the only ones adequately trained to do talk therapy, as you assert, based on the rigor, breadth, and depth of training they receive, then why are doctoral psychologists not asserting that clients are being put in jeopardy each and every day in community mental health centers across the country when they are assigned to an LCSW or LPC?

Is there some assumption that social workers and counselors will not dare "treat" severe persistent mental illness? I don't know if you have ever worked in community mental health, but I'll tell you that they do not turn these clients away or refer them to their clinical/counseling psychology superiors. Why does this acrimonious relationship exist between doctoral-level and master's-level scientist practitioners?

As a final note, the literature has generally failed to support the hypothesis that doctoral-level psychologists achieve any better outcomes on any of the major psychotherapy outcome variables compared to master's-level psychologists, or any other master's-level clinician for that matter.


.02
 
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... the literature has generally failed to support the hypothesis that doctoral-level psychologists achieve any better outcomes on any of the major psychotherapy outcome variables compared to master's-level psychologists, or any other master's-level clinician for that matter.
The research on this issue that I am aware (and directly involved in) has found no difference in outcomes between doctoral level therapists (in our case postdoctoral fellows) and master's level therapists who are supervised by doctoral level therapists. I'm sure a number of other studies have looked at outcomes for independent master's level clinicians as well. And yes, there is a need for more clinicians providing services in rural/under-served areas where recruitment of PhD's is just difficult.

With that said, there are still valid concerns from the ever-broadening net of individuals under a wide variety of titles being unleashed upon the public. LPA-level clinicians alone are called 7 different titles across states: Psychological Technician (Alabama), Psychological Assistant (California), Licensed Clinical Psychotherapist (Kansas), Licensed Psychological Practitioner (Minnesota), Licensed Behavioral Practitioner (Oklahoma), Licensed Psychological Associate (North Carolina) or Psychological Examiner (Tennessee).

I have not found information on the actual number of hours required for LPAs in the state where I reside, but have found California information here: http://www.psychboard.ca.gov/licensee/sup-psych-assist.shtml

What I am gathering is that this is trade off of receiving less formal education in lieu of learning directly in the field, which is great to an extent. That is exactly what we do through practica, internship, and post-doctoral supervision. But are all of these LPA (or whatever title it is called in your neck of the woods) supervision hours occurring in the context of accredited training? Is there any oversight into where this supervision is occurring and what is being covered? It doesn't sound like it with clauses like this:


"Every supervisor of a psychological assistant shall be responsible for ensuring that the extent, kind, and quality of the psychological services performed by the assistant are consistent with his/her training and experience and with the education, training, and experience of the supervisor .(Regulation sections 1391.6).". [see link above]


So if each LPA ‘s ultimate skill-set can be determined by a few (perhaps only one) supervisors with little-no quality control, then yes, I have great concerns about simply unleashing these variably trained individuals on a public that is now inundated with a zillion different types of professionals who can call themselves "therapists."
 
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Thank you for responding so thoughtfully. I note, however, that your quotation of the CA regulation is out of context. The regulation is specifying that a psychologist cannot provide supervision of services outside the scope of his training and experience. This is the same requirement for any supervision provided by a psychologist (including that performed during APA accredited pre-doctoral internship training). It is only saying that a psychological assistant who performs, let's say xyz services, should be supervised by a psychologists with training and expertise in xyz services (pick your area/specialty).

I agree completely with your points, particularly concerning the inundation of the mental health field by myriad "professionals" with myriad titles and equally myriad training backgrounds.

I'd love to hear your response to the questions I posed previously. Furthermore, realizing that these "lesser" professionals ARE practicing independently, treating individuals with serious mental health issues, would you rather the master's-level clinician be a life coach, counselor, social worker, or master's-level psychologist? Do you see my point?

How would you propose to improve the situation?
 
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Thank you for responding so thoughtfully. I note, however, that your quotation of the CA regulation is out of context. The regulation is specifying that a psychologist cannot provide supervision of services outside the scope of his training and experience. This is the same requirement for any supervision provided by a psychologist (including that performed during APA accredited pre-doctoral internship training). It is only saying that a psychological assistant who performs, let's say xyz services, should be supervised by a psychologists with training and expertise in xyz services (pick your area/specialty).

I agree completely with your points, particularly concerning the inundation of the mental health field by myriad "professionals" with myriad titles and equally myriad training backgrounds.

I'd love to hear your response to the questions I posed previously. Furthermore, realizing that these "lesser" professionals ARE practicing independently, treating individuals with serious mental health issues, would you rather the master's-level clinician be a life coach, counselor, social worker, or master's-level psychologist? Do you see my point?

How would you propose to improve the situation?
What is a "masters-level psychologist?" This sounds like an oxy moron. One can only be licensed as a clinical or counseling psychologist with a doctoral degree, correct?
 
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Thank you for responding so thoughtfully. I note, however, that your quotation of the CA regulation is out of context. The regulation is specifying that a psychologist cannot provide supervision of services outside the scope of his training and experience. This is the same requirement for any supervision provided by a psychologist (including that performed during APA accredited pre-doctoral internship training). It is only saying that a psychological assistant who performs, let's say xyz services, should be supervised by a psychologists with training and expertise in xyz services (pick your area/specialty).
I see and it was not my intention to take the information out of context. Rendering these services is in effect, the LPA's training. My understanding is that this experience occurs after the terminal master's is awarded. The PA completes 2 years of coursework, receives a degree, and then finds a job/supervisor and starts accruing hours to become an LPA. So is it safe to say that there is little-no oversight into the quality of the training received? Are there training workshops and other didactics available? Once the hours are accumulated, are there any designations in the license that places limits on what the LPA is actually qualified to do? If not, an LPA that trained under a X-oriented supervisor could practice independently using Y-orientation and who's to stop them as an independent clinician? Yes, this could happen with a psychologist as well, but you'd have to admit there is far too much wiggle room for substandard or severely limited training with this approach.

How would you propose to improve the situation?
Fair question, given the amount of bitching that I engage in. :laugh:

Let me start by saying that I believe mental health care should be delivered through interdisciplary teams and that things have gotten so far out of hand that everyone involved in MH care will have to re-brand.

Psychiatrists need to accept the fact that they are not qualified to provide therapy or conduct research without pursuing at least a 2-year fellowship in that area.

Psychologists need to dwindle in numbers and define our identity. I believe our defining criteria is our scientist-practitioner approach. Thus programs that diminish this aspect of our training should be de-accredited if admissions and training standards are not raised, enrollment caps are not adopted, and scientific training is not incorporated. Then I could see psychologists functioning primarily as PIs, administrators, psychotherapy supervisors (for trainees and master's level clinicians) and in specialty assessment roles (e.g. neuropsych, bariatric/surgery, developmental disorders, learning disabilities, and forensic evaluations). Along these lines, I think that psychologists who wish to perform primarily clinical duties should be required to seek board certification in their area of interest.

Persons interested in providing therapy without all the hassle of research, administrative, or specialty duties should pursue a streamlined master's level therapy degree. This is where I see a lot of people who would have gone the professional school/PsyD route landing. I believe that there should be options toward independent licensure including PRE-degree practicum experiences followed by post-degree supervised experiences in specialty areas so that there can be a similar board-comparable designation to the license (e.g. licensed marriage and family therapist, licensed child and adolescent therapist, licensed addictions therapist, licensed cognitive behavioral therapist, licensed psychodynamic therapist).

Social workers should stick to just that--social work (e.g. helping link people with community resources). Which is EXTREMELY valuable. If they want to be therapists they should pursue the route described above.

And then for people who majored in psychology in undergrad and don't even want to bother with all of this specialty licensing rigamorol, there should be non-license-eligible assistant positions (research assistant, psychometrist, psychological assistant, etc.)

That is the ideal clinical world according to O Gurl :D
 
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AcronymAllergy

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I see and it was not my intention to take the information out of context. Rendering these services is in effect, the LPA's training. My understanding is that this experience occurs after the terminal master's is awarded. The PA completes 2 years of coursework, receives a degree, and then finds a job/supervisor and starts accruing hours to become an LPA. So is it safe to say that there is little-no oversight into the quality of the training received? Are there training workshops and other didactics available? Once the hours are accumulated, are there any designations in the license that places limits on what the LPA is actually qualified to do? If not, an LPA that trained under a X-oriented supervisor could practice independently using Y-orientation and who's to stop them as an independent clinician? Yes, this could happen with a psychologist as well, but you'd have to admit there is far too much wiggle room for substandard or severely limited training with this approach.



Fair question, given the amount of bitching that I engage in. :laugh:

Let me start by saying that I believe mental health care should be delivered through interdisciplary teams and that things have gotten so far out of hand that everyone involved in MH care will have to re-brand.

Psychiatrists need to accept the fact that they are not qualified to provide therapy or conduct research without pursuing at least a 2-year fellowship in that area.

Psychologists need to dwindle in numbers and define our identity. I believe our defining criteria is our scientist-practitioner approach. Thus programs that diminish this aspect of our training should be de-accredited if admissions and training standards are not raised, enrollment caps are not adopted, and scientific training is not incorporated. Then I could see psychologists functioning primarily as PIs, administrators, psychotherapy supervisors (for trainees and master's level clinicians) and in specialty assessment roles (e.g. neuropsych, bariatric/surgery, developmental disorders, learning disabilities, and forensic evaluations). Along these lines, I think that psychologists who wish to perform primarily clinical duties should be required to seek board certification in their area of interest.

Persons interested in providing therapy without all the hassle of research, administrative, or specialty duties should pursue a streamlined master's level therapy degree. This is where I see a lot of people who would have gone the professional school/PsyD route landing. I believe that there should be options toward independent licensure including PRE-degree practicum experiences followed by post-degree supervised experiences in specialty areas so that there can be a similar board-comparable designation to the license (e.g. licensed marriage and family therapist, licensed child and adolescent therapist, licensed addictions therapist, licensed cognitive behavioral therapist, licensed psychodynamic therapist).

Social workers should stick to just that--social work (e.g. helping link people with community resources). Which is EXTREMELY valuable. If they want to be therapists they should pursue the route described above.

And then for people who majored in psychology in undergrad and don't even want to bother with all of this specialty licensing rigamorol, there should be non-license-eligible assistant positions (research assistant, psychometrist, psychological assistant, etc.)

That is the ideal clinical world according to O Gurl :D
You've essentially (and rather eloquently) summed up my exact thoughts on this entire matter as well. Excellent response.

As for master's-level clinicians practicing in community mental health centers, I've worked in one such setting, and thus can speak to my experiences (which may or may not generalize) in that area. Hardly any of the LCSWs I worked with were providing any sort of therapy beyond supportive check-ins. Those who tried to do so, from my understanding, had limited (if any) training in the area, and were essentially attempting "CBT-lite." Perhaps the biggest issue was that these "workers" (as they preferred to be called), because of their HUGE case loads, were only able to see clients once a month at most. I know of no evidence-supported treatments that work in such a context.

Conversely, the workers focused quite heavily on providing social work-related support, such as general community advocacy and assisting clients in obtaining social services (disability, vocational rehabilitation, etc.). As these individuals were predominantly LCSWs rather than LPCs, that would make sense. And by working largely in the areas in which they (and no one else in that clinic) had received appropriate training and supervision, they meshed excellently with the the other care providers (psychiatrists and other physicians, psychologists, nurses).
 
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What is a "masters-level psychologist?" This sounds like an oxy moron. One can only be licensed as a clinical or counseling psychologist with a doctoral degree, correct?
Here in VT, one can practice as a psychologist (and bill insurance comapines) with only a Masters degree in psych. From what I understand, one may also practice under the title "psychologist" with a MA/MS while working as a GS employee (DoD, VA, etc).

Also, what is stopping the public from equating receiving services from an LPA in private practice in mental health, to a LNP in private practice in the medical field? Many people are misinformed about training, services, etc... and are already confused by the different professional titles for mental health clinicians.
 
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BSWdavid

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You've essentially (and rather eloquently) summed up my exact thoughts on this entire matter as well. Excellent response.

As for master's-level clinicians practicing in community mental health centers, I've worked in one such setting, and thus can speak to my experiences (which may or may not generalize) in that area. Hardly any of the LCSWs I worked with were providing any sort of therapy beyond supportive check-ins. Those who tried to do so, from my understanding, had limited (if any) training in the area, and were essentially attempting "CBT-lite." Perhaps the biggest issue was that these "workers" (as they preferred to be called), because of their HUGE case loads, were only able to see clients once a month at most. I know of no evidence-supported treatments that work in such a context.

Conversely, the workers focused quite heavily on providing social work-related support, such as general community advocacy and assisting clients in obtaining social services (disability, vocational rehabilitation, etc.). As these individuals were predominantly LCSWs rather than LPCs, that would make sense. And by working largely in the areas in which they (and no one else in that clinic) had received appropriate training and supervision, they meshed excellently with the the other care providers (psychiatrists and other physicians, psychologists, nurses).
Perhaps this is your experience but certainly isn't the norm. LCSW's are trained to provide psychotherapy. In fact, most cmhc's in my area don't hire psychologists to provide psychotherapy.
 

BSWdavid

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I see and it was not my intention to take the information out of context. Rendering these services is in effect, the LPA's training. My understanding is that this experience occurs after the terminal master's is awarded. The PA completes 2 years of coursework, receives a degree, and then finds a job/supervisor and starts accruing hours to become an LPA. So is it safe to say that there is little-no oversight into the quality of the training received? Are there training workshops and other didactics available? Once the hours are accumulated, are there any designations in the license that places limits on what the LPA is actually qualified to do? If not, an LPA that trained under a X-oriented supervisor could practice independently using Y-orientation and who's to stop them as an independent clinician? Yes, this could happen with a psychologist as well, but you'd have to admit there is far too much wiggle room for substandard or severely limited training with this approach.



Fair question, given the amount of bitching that I engage in. :laugh:

Let me start by saying that I believe mental health care should be delivered through interdisciplary teams and that things have gotten so far out of hand that everyone involved in MH care will have to re-brand.

Psychiatrists need to accept the fact that they are not qualified to provide therapy or conduct research without pursuing at least a 2-year fellowship in that area.

Psychologists need to dwindle in numbers and define our identity. I believe our defining criteria is our scientist-practitioner approach. Thus programs that diminish this aspect of our training should be de-accredited if admissions and training standards are not raised, enrollment caps are not adopted, and scientific training is not incorporated. Then I could see psychologists functioning primarily as PIs, administrators, psychotherapy supervisors (for trainees and master's level clinicians) and in specialty assessment roles (e.g. neuropsych, bariatric/surgery, developmental disorders, learning disabilities, and forensic evaluations). Along these lines, I think that psychologists who wish to perform primarily clinical duties should be required to seek board certification in their area of interest.

Persons interested in providing therapy without all the hassle of research, administrative, or specialty duties should pursue a streamlined master's level therapy degree. This is where I see a lot of people who would have gone the professional school/PsyD route landing. I believe that there should be options toward independent licensure including PRE-degree practicum experiences followed by post-degree supervised experiences in specialty areas so that there can be a similar board-comparable designation to the license (e.g. licensed marriage and family therapist, licensed child and adolescent therapist, licensed addictions therapist, licensed cognitive behavioral therapist, licensed psychodynamic therapist).

Social workers should stick to just that--social work (e.g. helping link people with community resources). Which is EXTREMELY valuable. If they want to be therapists they should pursue the route described above.

And then for people who majored in psychology in undergrad and don't even want to bother with all of this specialty licensing rigamorol, there should be non-license-eligible assistant positions (research assistant, psychometrist, psychological assistant, etc.)

That is the ideal clinical world according to O Gurl :D
This is quite absurd! Social work does NOT = resource management. Why do you think that psychologists are the only professionals qualified to provide psychotherapy? Oh, let me guess, you are either a psychologist or budding psychologist? Your argument is quite self-serving. Please provide the research to support your hypothesis that psychologist's elicit superior outcomes to other mental health professionals (as your post implies).
 
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This is quite absurd! Social work does NOT = resource management. Why do you think that psychologists are the only professionals qualified to provide psychotherapy? Oh, let me guess, you are either a psychologist or budding psychologist? Your argument is quite self-serving. Please provide the research to support your hypothesis that psychologist's elicit superior outcomes to other mental health professionals (as your post implies).
I never said psychologists are the only ones who can provide therapy. I said that people trained in psychology are the only ones who should. I was asked for my opinion of how to fix the current hot mess that is mental health care and I believe it should start with all professionals taking a step back to define who and what we are. When it comes to psychotherapy, it is most firmly rooted in principles of psychology whether you like it or not. Loosely defined, psychology is the study of human processes like thoughts and behaviors. In order to provide psychotherapy, ideally one would be able to 1) identify the nature of the problem, and sorry, without any training in assessment a professional is limited in doing so; 2) select and provide the most effective treatment possible and be able to modify accordingly; 3) be able to set measurable goals and monitor changes; and 4) understand larger factors impacting the patient (physiological, environmental, cultural). Looking at those factors, I would say that psychology best prepares people to do this. Let me clarify that my hypothetical model does not state that a doctoral level psychologists are the only ones who should do therapy or that should be our primary role. In fact, I think that would be a waste of a broad skill set. I am totally for master's level professionals providing the services. I just think therapeutic practices should condense under one global discipline so that people know what the hell a "therapist" is.
 

edieb

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This is quite absurd! Social work does NOT = resource management. Why do you think that psychologists are the only professionals qualified to provide psychotherapy? Oh, let me guess, you are either a psychologist or budding psychologist? Your argument is quite self-serving. Please provide the research to support your hypothesis that psychologist's elicit superior outcomes to other mental health professionals (as your post implies).
Why is it absurd for only psychologists to provide treatment? Is it because we have the MOST rigorous and extensive training in assessment and treatment of any other mental health profession? Is it because our programs have the most rigorous admissions requirements? Is it because we can interpret and add to scientific research regarding psychopathology?

Who would you rather be treated by?
 

edieb

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This is quite absurd! Social work does NOT = resource management. Why do you think that psychologists are the only professionals qualified to provide psychotherapy? Oh, let me guess, you are either a psychologist or budding psychologist? Your argument is quite self-serving. Please provide the research to support your hypothesis that psychologist's elicit superior outcomes to other mental health professionals (as your post implies).
Why is it absurd for only psychologists to provide treatment? Is it because we have the MOST rigorous and extensive training in assessment and treatment of any other mental health profession? Is it because our programs have the most rigorous admissions requirements? Is it because we can interpret and add to scientific research regarding psychopathology?

By whom would you rather be treated? Someone with 2 years of graduate education, most of which focuses on social justice or somone with 7 years of education solely dedicated to the assessment and treatment of mental illness... As far as I am concerned, I would rather a psychologist prescribe my medications, too After all, we know the patient the best and have more knowledge of psychopathology than a psychiatrist..
 

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Why is it absurd for only psychologists to provide treatment? Is it because we have the MOST rigorous and extensive training in assessment and treatment of any other mental health profession? Is it because our programs have the most rigorous admissions requirements? Is it because we can interpret and add to scientific research regarding psychopathology?

Who would you rather be treated by?
What you have failed to prove is that your "superior training", which is a somewhat premature assertion on your part, translates in superior clinical outcomes. Just because a program takes longer to complete, has a more selective admissions process, and provides more scientific training doesn't mean it necessarily produces better clinicians. You are under the assumption that more = better but you don't have the statistics to support your claim. Therefore, until you can support your claim with empirical evidence, I have to assume that your personal bias is driving your post. Ironically though, you support psychologist RxP rights even though it is fair to assume that psychiatrists have better training in medicine than psychologists. I ask you, who would you rather go to for medication management?
 

edieb

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What you have failed to prove is that your "superior training", which is a somewhat premature assertion on your part, translates in superior clinical outcomes. Just because a program takes longer to complete, has a more selective admissions process, and provides more scientific training doesn't mean it necessarily produces better clinicians. You are under the assumption that more = better but you don't have the statistics to support your claim. Therefore, until you can support your claim with empirical evidence, I have to assume that your personal bias is driving your post. Ironically though, you support psychologist RxP rights even though it is fair to assume that psychiatrists have better training in medicine than psychologists. I ask you, who would you rather go to for medication management?
do you realize how silly you sound? Anybody would rather be seen by someone with more rigorous and abundant training than someone with less... Even if there were research showing superior outcomes, you would not be able to understand it...
 

BSWdavid

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Why is it absurd for only psychologists to provide treatment? Is it because we have the MOST rigorous and extensive training in assessment and treatment of any other mental health profession? Is it because our programs have the most rigorous admissions requirements? Is it because we can interpret and add to scientific research regarding psychopathology?

By whom would you rather be treated? Someone with 2 years of graduate education, most of which focuses on social justice or somone with 7 years of education solely dedicated to the assessment and treatment of mental illness... As far as I am concerned, I would rather a psychologist prescribe my medications, too After all, we know the patient the best and have more knowledge of psychopathology than a psychiatrist..
After all, we know the patient the best and have more knowledge of psychopathology than a psychiatrists.
Hmm, seems a little bit egocentric and opinionated. For someone that is so well versed in science, you seem to have a difficult time providing an empirically supported argument. I imagine there are many psychiatrists that would disagree with your claim.
 

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do you realize how silly you sound? Anybody would rather be seen by someone with more rigorous and abundant training than someone with less... Even if there were research showing superior outcomes, you would not be able to understand it...
What seems logical on the surface doesn't always translate into empirical evidence. You of all people should know that. How would you know what I can or cannot understand?
 

BSWdavid

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What seems logical on the surface doesn't always translate into empirical evidence. You of all people should know that. How would you know what I can or cannot understand?
So why wouldn't one want to be seen by a psychiatrist that has the most rigorous training in medicine? Based on your argument, psychiatrists should be the only providers to prescribe simply because they have superior medical training.
 

BSWdavid

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What you have failed to prove is that your "superior training", which is a somewhat premature assertion on your part, translates in superior clinical outcomes. Just because a program takes longer to complete, has a more selective admissions process, and provides more scientific training doesn't mean it necessarily produces better clinicians. You are under the assumption that more = better but you don't have the statistics to support your claim. Therefore, until you can support your claim with empirical evidence, I have to assume that your personal bias is driving your post. Ironically though, you support psychologist RxP rights even though it is fair to assume that psychiatrists have better training in medicine than psychologists. I ask you, who would you rather go to for medication management?
Just for the record, I have very little "social justice" training. Clinical programs are just that, clinical.
 
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Once again, Gurl has made her point in a rational, sophisticated manner. I think given that she was the OP and clearly is open about her opposition to the original issue, we have much to learn from her ability to engage professionally and rationally in a discussion about such a controversial topic.

That said, edieb made a good point(s), as did BSW, actually. I think edie was correct. Sort of. I think BSW was correct. Sort of.

I think in terms of some issues (helping someone transition to college, to a divorce, financial stress, phase of life problems), it is silly for a client to pay a PhD fee when social workers and counselors are excellent in providing supportive therapy. I think, however, that individuals suffering from significant distress/dysfunction should be referred to a psychologist. It is incomprehensible that someone with SPMI would be "supported" by a counselor or social worker. Not because these professionals "aren't as good." Rather, it is because more chronic and severe problems in one's thinking, feeling, and behaving are squarely (and necessarily) in the realm of a professional extensively trained in the foundation of human behavior (broadly).

I think the very emotional turf war and struggle for professional identity and solvency in unstable times, in the overall context of a disorganized and inefficient mental health system are clouding our judgment. We will survive. But will we do harm to the people who need help? They depend on our professionalism, because they surely have absolutely no idea the difference between a psychologist (PhD/PsyD), psychiatrist, LPA, LCSW, LCAS, LNP, LPC, CMHC, etc. etc. in terms of how these myriad folks can help them. They just want help. It would be nice if they would just stratify themselves, wouldn't it? Except that with no uniformity among practitioners across counties, let alone states, how would they? This mess is partly our fault. And to top it off, as long as we let our emotions stubbornly lead the way, the wolf (managed care) is at the door ready to chew us to bits while we're busy squabbling.

.02
 
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I realize I am a habitual offender in terms of forum etiquette. I do apologize for the incredibly long posts. :)
 
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I think the very emotional turf war and struggle for professional identity and solvency in unstable times, in the overall context of a disorganized and inefficient mental health system are clouding our judgment. We will survive. But will we do harm to the people who need help? They depend on our professionalism, because they surely have absolutely no idea the difference between a psychologist (PhD/PsyD), psychiatrist, LPA, LCSW, LCAS, LNP, LPC, CMHC, etc. etc. in terms of how these myriad folks can help them. They just want help. It would be nice if they would just stratify themselves, wouldn't it?
Agreed. Can you imagine seeking services in this mess? We as trainees and professionals cannot even keep it straight. That is why I stand by a simplified model of psychiatrists, psychologists (academic and in board certified specialties), licensed therapists (by specialty), social workers, and non-license eligible assistants. Egos and self-interests are definitely getting in the way of doing what is right for the patients.
 

Therapist4Chnge

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As for master's-level clinicians practicing in community mental health centers, I've worked in one such setting, and thus can speak to my experiences (which may or may not generalize) in that area. Hardly any of the LCSWs I worked with were providing any sort of therapy beyond supportive check-ins. Those who tried to do so, from my understanding, had limited (if any) training in the area, and were essentially attempting "CBT-lite." Perhaps the biggest issue was that these "workers" (as they preferred to be called), because of their HUGE case loads, were only able to see clients once a month at most. I know of no evidence-supported treatments that work in such a context.
This is one of the biggest issues I have with many providers (mostly non-doctoral)...they attempt a "lite" version of whatever the popular EBT method is at the time, without realizing that this is not sufficient. "CBT is effective for treating depression" is the response, but without good data and rationale after that. They have the gist of the basics, but the underlying methodology, treatment selection, treatment rationalization, case conceptualization, etc are not sufficiently developed. Trying to inquire about these things is usually met by, "I know how to do XYZ intervention".

The vast majority of providers who claim to be practicing CBT, DBT, ACT, etc...are really not. They are taking aspects of approaches and throwing them together the best they can. Eclecticism is claimed, but then there are vital tenants that are being violated by mixing interventions. All of those extra years of training and thousands of hours of training are in place to provide a greater depth of understanding so that these approaches can be properly understood and implemented.

Here in VT, one can practice as a psychologist (and bill insurance comapines) with only a Masters degree in psych. From what I understand, one may also practice under the title "psychologist" with a MA/MS while working as a GS employee (DoD, VA, etc).
VT is an exception, as that allowance was made because a number of long-practicing providers were grandfathered in. For all intents and purposes, psychologist = doctoral level provider.

This is quite absurd! Social work does NOT = resource management. Why do you think that psychologists are the only professionals qualified to provide psychotherapy? Oh, let me guess, you are either a psychologist or budding psychologist? Your argument is quite self-serving. Please provide the research to support your hypothesis that psychologist's elicit superior outcomes to other mental health professionals (as your post implies).
Non-doctoral level people always fall back on the, "why isn't there research on this?!" and the practical answer is that no one who typically offers funding to psychologists wants that research to be done. The gov't, insurance companies, hospitals, CMHCs, etc...they all want the cheapest options available, and proving a clinical psychologist provides better outcomes will cost them more money. Psychologists are also busy trying to treat their patients, as there is an endless supply of misdiagnosed patients in need of treatment.
 
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Therapist4Chnge

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I don't want to get this off-topic talking about psychiatry, but I wanted to address this comment:

So why wouldn't one want to be seen by a psychiatrist that has the most rigorous training in medicine? Based on your argument, psychiatrists should be the only providers to prescribe simply because they have superior medical training.
They don't have the most rigorous training in medicine, though they probably have a better shot at getting things right compared to most of the prescribers out there. Their approach is limited by their training, as most still function under the medical model, and they fail to utilize other approaches to confirm/deny their hypothesis of the cause(s) of the patient's symptoms. I still believe a properly training prescribing psychologist will provide better care to their patient because they are better equipped to provide assessment to ensure the patient was properly diagnosed, and they can follow up more frequently to ensure the patient is doing well with the provided interventions (medication + therapy, etc).
 
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As far as I am concerned, I would rather a psychologist prescribe my medications, too After all, we know the patient the best and have more knowledge of psychopathology than a psychiatrist..
This is incredibly arrogant. Clinical Psychologists do not have the appropriate training to evaluate medical conditions.

Any physician out there will turn your arguments right back around - psychologists have even less (read zero) training in pathophysiology and pharmacology than MSWs have in assessment and psychopathology. And ya know what? This is exactly why psychologists with prescription rights are supervised by physicians.

Even if you had one or two neuroscience classes, your understanding of physiology and pathology pales to the lowest class rank psychiatrist. Are you are aware that a psychiatrists have gone through med school, completed rotations in the areas of pediatrics, surgery, neurology, emergency medicine, oncology, etc?

Part of any good psychiatric evaluation involves screening for non-mental illness causes as everything from diet to cancer can mimic depression. And there is the whole thing about medication interactions that require both a physician and pharmacist to monitor. And if a physician alone can't avoid all dangerous interactions (and pharmacists catch them messing up quite often), then psychologists have no business writing prescriptions.

Yea, yea clinical psychology grad programs are more competitive than med school, but that doesn't mean your psychology major course were anything close to what a pre-med goes through to get his 3.8. More competitive =/= smarter or more difficult.

And don't assume even for a second that assessing personal adjustment and specific psychopathology diagnoses is harder than interpreting MRIs, blood test results, and tissue biopsy results. No, these aren't used in day to day psychiatric evaluations, but they are 100% relevant to other conditions. By the way, all physicians are trained in basic psychopathology and evaluation methods.

You might know the patient better, but that isn't worth much in the grand scheme of medicine. Physician visits are usually only 10-15 minutes for a good reason - it's all the time you need for 90% of cases. Yea, there is some trial and error involved with mental health prescriptions, but all the knowledge in the world about personal assessment and psychopathology can't make medicine a perfect science. It's absolutely ridiculous that you think the "superior" training of psychologists is worth anything related to prescriptions and medicine maintenance.

LPAs, LACs, and MSWs are infinitely more qualified to do psychotherapy than psychologists are to write and manage prescriptions. And that won't change until psychology Ph.D. programs also require their graduates to attend 4 years of med school and become licensed physicians.

No, I'm not a med student or pre-med.
 

StudentBsMs11

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As a psychologist who has taught in both masters and doctoral level classes....there are large differences in the breadth and depth of the classes, as well as the requirements of each respective class. I'm not talking about statistics or research classes, which often get cited by MA/MS level students as "the only difference in training", but in core classes like adult psychopathology, psychopharmacology, assessment, etc. The classes aren't even remotely comparable, nor should they be.
I hesitate to jump into this rather heated discussion, but I feel like I have something to add to this point here. I'm sure that we are in different states with different standards, but the program which I attend is very different from what you are describing here. It is a master's level program, yes, but it is in the same department as another (behaviorally focused) master's program and a doctoral Ph.D program in clinical psychology. The classes are generally not stratified by 'level'; we all take the same classes, often with the accompanying cohort from the other 'level', and we all take the same exams, complete the same assignments. Also, I believe someone else mentioned the need for a pre-graduation practicum experience: we have that too. I'm completing mine at the moment. What we, as master's level students, miss out on is the in-house practicum experience that the doctoral students undertake while we conduct our first practicum experience externally; primarily, this is a pain because it can be very difficult to find said practicum experience. After graduating, we would go on to get a temporary limited license, allowing us to clock enough hours to get a limited license. In both cases, there is a requirement of (I believe) one hour of supervision a week/per 40 hours of work, which decreases to half that once you have 10 years of experience in the field. So you're never totally 'independent', but you don't need to be working 'for' a psychologist, either. Unfortunately, the requirements are not the same (and, I believe, less rigorous) for LCSWs, so my path is a poor choice for someone who just wants to do therapy and practice independently here.

However, I'm not sure how this is relevant to other master's level training, since the vast majority of my cohort-mates and I are all hoping to go on and complete a Ph.D, rather than practicing at the master's level. So it's possible that my training here is different from the training in other programs. Just my two cents.
 

edieb

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This is incredibly arrogant. Clinical Psychologists do not have the appropriate training to evaluate medical conditions.

Any physician out there will turn your arguments right back around - psychologists have even less (read zero) training in pathophysiology and pharmacology than MSWs have in assessment and psychopathology. And ya know what? This is exactly why psychologists with prescription rights are supervised by physicians.

Even if you had one or two neuroscience classes, your understanding of physiology and pathology pales to the lowest class rank psychiatrist. Are you are aware that a psychiatrists have gone through med school, completed rotations in the areas of pediatrics, surgery, neurology, emergency medicine, oncology, etc?

Part of any good psychiatric evaluation involves screening for non-mental illness causes as everything from diet to cancer can mimic depression. And there is the whole thing about medication interactions that require both a physician and pharmacist to monitor. And if a physician alone can't avoid all dangerous interactions (and pharmacists catch them messing up quite often), then psychologists have no business writing prescriptions.

Yea, yea clinical psychology grad programs are more competitive than med school, but that doesn't mean your psychology major course were anything close to what a pre-med goes through to get his 3.8. More competitive =/= smarter or more difficult.

And don't assume even for a second that assessing personal adjustment and specific psychopathology diagnoses is harder than interpreting MRIs, blood test results, and tissue biopsy results. No, these aren't used in day to day psychiatric evaluations, but they are 100% relevant to other conditions. By the way, all physicians are trained in basic psychopathology and evaluation methods.

You might know the patient better, but that isn't worth much in the grand scheme of medicine. Physician visits are usually only 10-15 minutes for a good reason - it's all the time you need for 90% of cases. Yea, there is some trial and error involved with mental health prescriptions, but all the knowledge in the world about personal assessment and psychopathology can't make medicine a perfect science. It's absolutely ridiculous that you think the "superior" training of psychologists is worth anything related to prescriptions and medicine maintenance.

LPAs, LACs, and MSWs are infinitely more qualified to do psychotherapy than psychologists are to write and manage prescriptions. And that won't change until psychology Ph.D. programs also require their graduates to attend 4 years of med school and become licensed physicians.

No, I'm not a med student or pre-med.
'

As a student in the New Mexico State classroom based psychopharmacology program, I can tell you that we are learning how-to order and interpret EKGs, labs, perform physical examinations, etc. The professors teaching us are M.D.s who work at medical schools and are supportive of prescriptive authority for psychologists.

Since these professors are not paid much money for teaching and face reprisal from their M.D. colleagues for being involved in this movemen, I can only imagine they are teaching these classes because they think psychologists can do as good of a job as psychiatrists.

The standard of care for most psychological disorders (exept some of the somatoform and PDs) is medication + psychotherapy. However, there are not enough prescribers who can provide medications. Furthermore, there are not enough providers who can provide EBTs, proper assessment of treatment response, etc. Psychologists are the only providers in the position to do this.

Imagine you have a patient w/ a cluster A personality disorder, with an associated mood disorders. Do you think that patient is going to open up re: med side effects, treatment response, etc. to a psychiatrist who sees this patient once/3 months for 10 minutes? Do you think the patient is much more likely to open up regarding these sensitive issues with a provider who has established collaboratively empirical relationship with the patient.

Yes, there are medical issues we need to be aware of. However, we collaborate with the M.D. when prescribing. Furthermore, we are trained in pathophysiology, etc. Finally, the data show that no complaints have been filed against RxP psychologists in NM or LA. Other states are starting to see the benefits of prescribing psychologists. The DoD has reopened their program and are now allowing newly trained RxP psychologists to prescribe. Oregon almost passed a bill last year and is going to try again this year. Montana looks promising, too...

I think presciribing + therapy + proper assessment is a way in which psychology can differentiate itself from other professions and, at the same time, provide superior patient care
 

loveoforganic

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Since these professors are not paid much money for teaching and face reprisal from their M.D. colleagues for being involved in this movemen, I can only imagine they are teaching these classes because they think psychologists can do as good of a job as psychiatrists.
Or they recognize the need you mention in the paragraph you type below this one and believe they can do an adequate job of providing a needed tx to an underserved population.

Imagine you have a patient w/ a cluster A personality disorder, with an associated mood disorders. Do you think that patient is going to open up re: med side effects, treatment response, etc. to a psychiatrist who sees this patient once/3 months for 10 minutes? Do you think the patient is much more likely to open up regarding these sensitive issues with a provider who has established collaboratively empirical relationship with the patient.
I'm not sure where you're drawing this from. In pp, time allowed is a function of the provider's preference, not a function of training. Outside of pp, you're working in multidisciplinary teams, and it only makes sense to divide up the tasks by relative expertise.

Finally, the data show that no complaints have been filed against RxP psychologists in NM or LA.
FWIW, without a source to cite, I've heard psychiatry is one of the least sued medical specialties. As far as the DoD study, IIRC, some providers had restricted formularies, and all of them had close sustained relationships with a psychiatrist in most cases and a physician in the other cases. Proposed civilian psychologist rx training and supervision also seems to be considerably lighter than what took place in the DoD study.
 
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nitemagi

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After all, we know the patient the best and have more knowledge of psychopathology than a psychiatrist..
:laugh::laugh::laugh::laugh::laugh::laugh::laugh:

Please, check your ego, buddy.

And as for the not sued individuals in NM, there's only 16 registered prescribing psychologists in the whole state! Get a bigger N first before you use that safety record to generalize to all potential providers. I'd call it more of a pilot program than anything else. See the many other posts on prescribing psychologists, and the differences in clinical hours of training (psychiatry has far more even in the most conservative estimates) in the many other threads on the topic here, here, and here.
 
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edieb

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:laugh::laugh::laugh::laugh::laugh::laugh::laugh:

Please, check your ego, buddy.
Not really ego, just the facts: An average psychologist receives 7 years of training in psychopathology. Psychiatrists do not even really receive much exposure to psychiatry-related coursework until their residency, and much of this is very informal, on the job training.

In fact, when Governor Johnson (NM) signed the RxP bill, he also indicated that psychologists have more training in the assessment and tx of mental illness than any other mental health profession. Therefore, it is not just "ego" but a statement agreed upon by other persons when they see the facts.
 

nitemagi

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Not really ego, just the facts: An average psychologist receives 7 years of training in psychopathology. Psychiatrists do not even really receive much exposure to psychiatry-related coursework until their residency, and much of this is very informal, on the job training.

In fact, when Governor Johnson (NM) signed the RxP bill, he also indicated that psychologists have more training in the assessment and tx of mental illness than any other mental health profession. Therefore, it is not just "ego" but a statement agreed upon by other persons when they see the facts.
Yes, let's definitely leave it to the politicians to assess who has the highest level of expertise. The same one-sided argument led to that that now is leading to this issue in Texas with Masters level providers. :rolleyes:

Psychiatrists have thousands of more hours of direct patient exposure and clinical training than psychologists. Our clinical hours in the first year and a half of residency equals all of the require psychology clinical hours for licensure. Sure you can go do fellowship, to buff your numbers. And I always hear this 7-year figure thrown around. I'd really appreciate a source to show the average period of schooling for a Ph.D. psychologist to confirm this. The reading I've done is 7-years is on the upper limit of normal and 5-6 is more average. Believe what you want (you obviously do), but I have yet to see any arguments in this kind of debate from psychologists that didn't seem like a further lashing out at all other providers due to your own identity crises, stemming from the flooded market and a desire to be king of the hill. Sure you have better training in therapy during your doctoral training. But to generalize that to a superior training in med management even with a 2-year course is simply ridiculous.
 
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