Independent practice for LPAs?

[edieb]

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.

Actually, that is outdated data. Per NMSU, there are now 30 in NM and around 70 in Louisiana. In addition, there are psychologists prescribing in the IHS and DoD.

I think that M.D.s/D.O.s are starting to feel threatened because the legislatures are starting to see through the "M.D. = omniscient" argument. Look at the rapid expansion of other medical professions' scopes of practice (NP, PA).

This explains the crazy bills and initiatives the AMA is endorsing(e.g., trying to restrict the use of the term "doctor", trying to limit psychologists' hospital admitting privileges, etc)

While M.D.s are the experts in medicine, they are not the master of every other domain outside of it. Psychiatry is paricularly unique because it is partially divorced from medicine in that it is forced by the evidence regarding the etiology and maintenance of mental illness (diathesis-stress, EE, etc) to delve into the psychosocial aspects of illness more than other areas of medicine.

Therefore, knowledege of general anatomy, physiology, histology, et cetera, is not enough to make it the preeminent profession in the mental health arena. Psychologists are fighting to expand their scope of practice with additional training and while maintainting a collaborative relationship with a PCP.

Compared to other professions, professional psychology is expanding its scope of practice the right way: through standardized extra training and passage of a standardized exam. Other professions, like social work and counseling, want to conduct psychological testing, etc. without any extra standardized training. However, despite all this and the documented shortage of prescribers, medicine STILL resists. I think it's psychiatry's ego that's the problem.

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[BSWdavid]

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.

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.

Thank-you!

 

[nitemagi]

Actually, that is outdated data. Per NMSU, there are now 30 in NM and around 70 in Louisiana. In addition, there are psychologists prescribing in the IHS and DoD.

I think that M.D.s/D.O.s are starting to feel threatened because the legislatures are starting to see through the "M.D. = omniscient" argument. Look at the rapid expansion of other medical professions' scopes of practice (NP, PA).

This explains the crazy bills the AMA is trying to pass (e.g., trying to restrict the use of the term "doctor", trying to limit psychologists' hospital admitting privileges, etc)

While M.D.s are the experts in medicine, they are not the master of every other domain outside of it. Psychiatry is paricularly unique because it is partially divorced from medicine in that it is forced by the evidence regarding the etiology and maintenance of mental illness (diathesis-stress, EE, etc) to delve into the psychosocial aspects of illness more than other areas of medicine.

Therefore, knowledege of general anatomy, physiology, histology, et cetera, is not enough to make it the preeminent profession in the mental health arena. Psychologist are asking to expand their scope of practice with additional training and while maintainting a collaborative relationship with a PCP.

Compared to other professions, professional psychology is expanding its scope of practice the right way: through standardized extra training and passage of a standardized exam. Other professions, like social work and counseling, want to conduct psychological testing, etc. without any extra standardized training. However, despite all this and the documented shortage of prescribers, medicine STILL resists. I think it's psychiatry's ego that's the problem.

My data comes from the NM psychology board. Sounds more reputable than your university source.

And sorry to burst your bubble, but 1. I'm not threatened, 2. psychosocial factors play heavily into every area of medicine. Not having any medical training, though you wouldn't know that. The medical field has been working in the biopsychosocial model for over 30 years.

And I have yet to have any psychological or neuropsychological testing that added any useful information. And I challenge you to please provide data that such testing is superior to a trained skilled clinician interview.

 

[BSWdavid]

BTW, psychologists ordering and interpreting EKGs and providing physical exams? That appears to be quite beyond the scope of psychological practice. How is this appropriate?

 

[PsyDetective]

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.

No one wants the research done? Psychologists are too busy? It's a conspiracy? T4C, I've read many of your posts on this forum, and I know you to be a very dedicated, intelligent, and thoughtful person. But, this whole statement is...I don't know, ridiculous coming from a psychologist. I'm not attacking you, so relax. But really?

You act as if PhD psychologists are uniform in their knowledge and use of interventions (conceptualization, selection, rationalization, etc.). They most certainly are not. They are just as likely to be "eclectic" as anyone else.

And I note that this outcome research HAS been done. It has generally been found not to support your hypothesis that PhD's get it "right" because they take 7 years to complete their program while everyone else get it so "wrong" because they didn't.

You don't give enough credit to master's-level folks (trained by licensed psychologists who also completed APA-accredited programs). We sit in the same classes you do (I have, others who have posted also have), take the same licensing exam you do. Moreover, I can attest that in my program, we also spent 50-60 hours per week managing research, practica, coursework, assistantships, etc. We just did it with less respect and funding. We also completed nearly 1000 hours of practica before having to complete a 1000- hour psychologist-supervised clinical internship.

Your fervor is blinding your scientist-practitioner perspective on this issue, I believe.

And what of the questions I posed before? Does no PhD have a response? Perhaps that should serve as an indication that your opinions are not based on fact, but indoctrination.

 

[Therapist4Chnge]

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.

Because cramming in 80hr/wk doing a variety of other things in addition to clinical contact hours yields the same level of training for each hour.

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.

How can someone get through with 5 years? 4 years of full-time work in the classroom/lab/etc is the quickest a student will get, though most tend to take more. Add in a year for internship, and at least 1 year for post-doc...and you are at 6 with doing the absolute minimum....which is not common, nor recommended. It is akin to someone going through a primary care training in med school 4+3. More likely it is 5+1+1, and anyone who does a fellowship like neuropsych, research, etc. is 5 (or more) +1+2.

 

[edieb]

My data comes from the NM psychology board. Sounds more reputable than your university source.

And sorry to burst your bubble, but 1. I'm not threatened, 2. psychosocial factors play heavily into every area of medicine. Not having any medical training, though you wouldn't know that. The medical field has been working in the biopsychosocial model for over 30 years.

And I have yet to have any psychological or neuropsychological testing that added any useful information. And I challenge you to please provide data that such testing is superior to a trained skilled clinician interview.

1 -The NM Psychology Board does not update their online information regularly. I imagine my source, the director of New Mexico State University's psychopharmacology program and the President of the NMSU Board of Psychology is a little more accurate than a website that's updated a few times/year.

2 - It is beyond argument that psychosocial factors play a larger role in the onset and maintenance of PSYCHOLOGICAL/PSYCHIATRIC illness than they do in let's say, a person who has contracted influenza. While psychosocial issues play a role in almost all illness, the degree to which these factors are at play varies...


3 - In regards to psychological testing, I am not arguing that it does or does not consistently provide valuable data. My point is that while these other professions want to do testing, etc, without any additional training, at least psychologists are willing to receive more training to gain an expansion of practice.

However, I admire your ability to diagnose MR without an IQ test, especially since the DSM, the guidebook of the American Psychiatric Association, requires an IQ test be conducted for a diagnosis of intellectual disbility (along with measures of adaptive bx), lol

 

[nitemagi]

1 -The NM Psychology Board does not update their online information regularly. I imagine my source, the director of New Mexico State University's psychopharmacology program and the President of the NMSU Board of Psychology is a little more accurate than a website that's updated a few times/year.

2 - It is beyond argument that psychosocial factors play a larger role in the onset and maintenance of PSYCHOLOGICAL/PSYCHIATRIC illness than they do in let's say, a person who has contracted influenza. While psychosocial issues play a role in almost all illness, the degree to which these factors are at play varies...


3 - In regards to psychological testing, I am not arguing that it does or does not consistently provide valuable data. My point is that while these other professions want to do testing, etc, without any additional training, at least psychologists are willing to receive more training to gain an expansion of practice.

However, I admire your ability to diagnose MR without an IQ test, especially since the DSM, the guidebook of the American Psychiatric Association, requires an IQ test be conducted for a diagnosis of intellectual disbility (along with measures of adaptive bx), lol

Patients don't come to a doctor for treatment of their MR.

For other physicians (non-psychiatrists) we don't treat influenza, either. Unless it's reached the point of a severe pneumonia and they're requiring a ventilator or antibiotics to prevent a secondary infection.

But if you want to talk bread and butter, say hypertension. There's plenty of psychosocial factors in terms of stress, family dynamics, diet, medication compliance, compliance with exercise, that are exactly what doctors treat. So I say again, check your facts before speaking about a field in which you have no expertise.

And you didn't answer my question/challenge for data. If your skill and expertise is as superior as you say it is, please provide the data. Otherwise your opinion about psychology superiority is only that, an opinion.

 

[edieb]

Patients don't come to a doctor for treatment of their MR.

For other physicians (non-psychiatrists) we don't treat influenza, either. Unless it's reached the point of a severe pneumonia and they're requiring a ventilator or antibiotics to prevent a secondary infection.

But if you want to talk bread and butter, say hypertension. There's plenty of psychosocial factors in terms of stress, family dynamics, diet, medication compliance, compliance with exercise, that are exactly what doctors treat. So I say again, check your facts before speaking about a field in which you have no expertise.

And you didn't answer my question/challenge for data. If your skill and expertise is as superior as you say it is, please provide the data. Otherwise your opinion about psychology superiority is only that, an opinion.

You are so cute when you get angry!

 

[loveoforganic]

god, you're like a child

 

[O Gurl]

I have yet to have any psychological or neuropsychological testing that added any useful information. And I challenge you to please provide data that such testing is superior to a trained skilled clinician interview.

Really??? I wouldn't broadcast this if I were you. You mean to say that you are 100% confident in your ability to to detect things like axis-II traits, somatoform disorders, and early cognitive decline from an interview alone? This is especially eyebrow-raising giving the limited time and low frequency of medication checks that would provide further opportunities to observe red flags. I don't mean to be insulting, but such a claim could raise some serious doubts about your clinical judgment.

Let me state for the record that I am not a huge campaigner for Rx rights for psychologists, because I am all about streamlining disciplines and staying in our own lanes. That means, for me, a psychiatrist should never fancy themselves a researcher or psychotherapist without a fellowship in that area and psychologists should never dare to Rx meds without advanced training in the the area (at least 2-year minimum in all cases).

 

[FuturePhD2]

Because cramming in 80hr/wk doing a variety of other things in addition to clinical contact hours yields the same level of training for each hour.



How can someone get through with 5 years? 4 years of full-time work in the classroom/lab/etc is the quickest a student will get, though most tend to take more. Add in a year for internship, and at least 1 year for post-doc...and you are at 6 with doing the absolute minimum....which is not common, nor recommended. It is akin to someone going through a primary care training in med school 4+3. More likely it is 5+1+1, and anyone who does a fellowship like neuropsych, research, etc. is 5 (or more) +1+2.

In my Ph.D. program this is exactly what is recommended. I am on internship in my 5th year and will likely do a 2-year postdoc, so if you include that, it's 7 years. I've seen people take longer than 4 years before going on internship, but I wouldn't say that most programs recommend this. It just ends up happening due to research and/or getting an internship delays. No one wants to stay in grad school making beans for longer than they have to.

 

[nitemagi]

Really??? I wouldn't broadcast this if I were you. You mean to say that you are 100% confident in your ability to to detect things like axis-II traits, somatoform disorders, and early cognitive decline from an interview alone? This is especially eyebrow-raising giving the limited time and low frequency of medication checks that would provide further opportunities to observe red flags. I don't mean to be insulting, but such a claim could raise some serious doubts about your clinical judgment.

Let me state for the record that I am not a huge campaigner for Rx rights for psychologists, because I am all about streamlining disciplines and staying in our own lanes. That means, for me, a psychiatrist should never fancy themselves a researcher or psychotherapist without a fellowship in that area and psychologists should never dare to Rx meds without advanced training in the the area (at least 2-year minimum in all cases).

The most, frankly, I've ever gotten was confirmatory evidence that supported my diagnosis. But I do use some instruments in my own practice. Yes, in all those cases. More often, I get vague information that neither confirms or refutes a diagnosis. And especially with somatoform disorders. The best scales out there (and I am a researcher in this) don't have direct concordance with any diagnosis, but more often measures traits such as health anxiety (Whitely Index, Illness Attitude Scale, etc.). Even the PHQ-15 isn't diagnostic for anything. Currently somatoform disorders require ruling out medical causes of symptoms first.

And OGurl, I appreciate your even-mindedness on the debate. I wholly agree with you on many fronts. But certain medical schools do specific research training for a year of their schooling (Duke, for example), and some residencies have research tracks with additional training and empiric research done. Furthermore while psychiatrists have clearly swung away from therapy training towards majority of medication management, they are currently required in residency to have training (given that the level of training varies between programs) in 5 different psychotherapies (brief/short term therapy [of which there are of course many], psychodynamic, CBT, interpersonal, and group/family). Since psychiatrists developed most major therapies (including CBT, DBT is an exception), I think it's ridiculous to propose that they be required to do a fellowship in either beforehand.

 

[nitemagi]

You are so cute when you get angry!

Funny how you interpret counterarguments as angry. If you ask my family/friends/colleagues, I'm actually considered one of the more cool-headed individuals around. So again, sorry, but not angry.

 

[O Gurl]

No one wants the research done? Psychologists are too busy? It's a conspiracy? T4C, I've read many of your posts on this forum, and I know you to be a very dedicated, intelligent, and thoughtful person. But, this whole statement is...I don't know, ridiculous coming from a psychologist. I'm not attacking you, so relax. But really?

You act as if PhD psychologists are uniform in their knowledge and use of interventions (conceptualization, selection, rationalization, etc.). They most certainly are not. They are just as likely to be "eclectic" as anyone else.

I'm not aware that T4C is suggesting that at all. I believe the argument against having free-reign, independent practice rights for people with 2-3 years of post graduate education is the utter lack of quality control. Glancing over you self-purported level of training, it looks dubious at best:

I can attest that in my program, we also spent 50-60 hours per week managing research, practica, coursework, assistantships, etc. We just did it with less respect and funding. We also completed nearly 1000 hours of practica before having to complete a 1000- hour psychologist-supervised clinical internship.

Really? Because that is exactly what a PhD program looks like. You were able to squeeze it in in less than half of the time?

And in terms of all this outcome data that you are familiar with, would you mind posting references? All I've seen are comparisons of "therapist expertise" in highly controlled contexts such as those with supervision provided to the junior therapist or those examining discrete outcomes (e.g. decreased BDIs) using specific components of a manualized treatment. As we all know, the clinical world of private practice is far messier. I am curious to see if master's level clinicians in private practice are indeed producing equal outcomes as doctoral level clinicians.

 

[FuturePhD2]

You are so cute when you get angry!

I don't get the need for passive-aggressive comments just because someone doesn't agree with you. If you want to debate, then do so, but why lower the bar of the conversation with this kind of ridiculousness?

For what's it's worth, I'm in psychology (completing internship currently) and I am completely against the RxP movement. There is no way that a 2-year course is sufficient to have both the medical and pharmacological knowledge necessary to practice in this way. There is also no data to indicate that this is safe. A lack of lawsuits does not equal safety - there are many who receive shoddy (and sometimes harmful) treatment who never sue their providers. I think in our field, it's hard for patients to know this sometimes. It's easy when your surgeon leaves a towel in you. Not so easy when your therapist is doing psychoanalysis for your OCD.

I do agree with the idea that because meds + ESTs have found to be the best treatment for a lot of things, that it would be nice if there were one provider who could do both of these things. But to do that properly, I think you'd need a combined psychiatry/psychology MD/PhD program and a similarly hybrid residency to allow for that type of training.

In any case, what someone said earlier about Ph.D.'s being just as eclectic as master's level providers in their treatment, I believe to be true, especially those further out from grad school. If all Ph.D.'s were appropriately trained in evidence-based therapies, we wouldn't see the dissemination and access to care problems that we do currently. When I was in grad school, it was not uncommon to get a few referrals a year our program training clinic of people in other parts of the state who were willing to drive to our clinic because no one offered ESTs for their issue in their local area (most of which were not small towns or rural areas). We need standards of training enforced and a regulating body that will do something akin to what the FDA does in terms of determining safety of medical treatment in order to get there.

 

[Therapist4Chnge]

And I have yet to have any psychological or neuropsychological testing that added any useful information. And I challenge you to please provide data that such testing is superior to a trained skilled clinician interview.

Then you have a lot to learn. If all you are taught to use is a hammer, everything probably looks like a nail to you. Using objective assessment data allows for more information to support/refute clinical judgment. While you are taught to believe your hunches and judgments about a patient, as a scientist-practitioner & neuropsychologist, I was taught the value of gathering data from multiple sources.

 

[nitemagi]

Because cramming in 80hr/wk doing a variety of other things in addition to clinical contact hours yields the same level of training for each hour.

How can someone get through with 5 years? 4 years of full-time work in the classroom/lab/etc is the quickest a student will get, though most tend to take more. Add in a year for internship, and at least 1 year for post-doc...and you are at 6 with doing the absolute minimum....which is not common, nor recommended. It is akin to someone going through a primary care training in med school 4+3. More likely it is 5+1+1, and anyone who does a fellowship like neuropsych, research, etc. is 5 (or more) +1+2.

T4C,

I agree they're not apples for apples for hours. But when you add it up over 4 years of residency it's substantially more clinical time, which means more hours of patient observation, many more patients seen total (speaking of breadth of pathology), training in a wider variety of clinical settings (inpatient, emergency, subspecialty units, and clinics). I know of no psychologists that get that range of psychopathology exposure in training as a requirement. Psychiatrists have a lot of classroom time in medical school and book learning during residency, but it seems to me the hours for psychologists slant much more towards research and classroom time. But I'm not a psychologist. I can only speak to what I know about the required number of hours of clinical training for licensure of a psychologist, which is dwarfed very quickly by psychiatry residents in less than 2 years.

In this debate what gets me into the fray (rather than reading from the sidelines) is the lack of humility by everyone, on every side. I am very aware that psychiatry doesn't train in depth in everything. But when others pretend that their training makes them superior in all aspects of possible care, including areas clearly outside their scope of training, that's just propaganda. A training course in reading EKG's for a prescribing psychologist doesn't mean they understand the physiology or pathology of what they're reading, or what the significance is of non-psychiatric meds on that EKG, or how psychiatric meds can interact with non-psychiatric meds and then further change that EKG. The depth in training just isn't there. And those that want to convince themselves it is are sadly fooling themselves, IMHO.

Re: the hammer-nail comment, that's a fair point. But it rests on a presumption that psychological testing is a necessary information source. Rather than a trained clinical interview, gathering of info from collateral sources. I'd really like to see the data to show its utility. Seriously, I would. I'm actually open to discussion, if someone can show me the data. Flaunting the "scientist" component then I would appreciate the evidence to support it. Believe it or not physicians are trained in the scientific method. But everyone here acts as if psychologists have a monopoly on it.

 

[FuturePhD2]

Furthermore while psychiatrists have clearly swung away from therapy training towards majority of medication management, they are currently required in residency to have training (given that the level of training varies between programs) in 5 different psychotherapies (brief/short term therapy [of which there are of course many], psychodynamic, CBT, interpersonal, and group/family). Since psychiatrists developed most major therapies (including CBT, DBT is an exception), I think it's ridiculous to propose that they be required to do a fellowship in either beforehand.

They should, if they did not receive adequate training in evidence-based therapies. The residents at my hospital definitely do not receive real training in CBT (as you admitted, the training varies). It's more CBT-lite and they are taught to conceptualize from a psychodynamic perspective. This is not doing CBT and they would need additional training to be able to do real CBT after their residency.

I don't see how your argument that because another psychiatrist developed it, other psychiatrists shouldn't have to do rigorous training to be competent in it holds. A psychologist developed DBT, but any psychologist who wants to be competent in it needs rigorous training and that's going to be extra time if they didn't get that in grad school or on their internship.

 

[Therapist4Chnge]

And OGurl, I appreciate your even-mindedness on the debate. I wholly agree with you on many fronts. But certain medical schools do specific research training for a year of their schooling (Duke, for example), and some residencies have research tracks with additional training and empiric research done. Furthermore while psychiatrists have clearly swung away from therapy training towards majority of medication management, they are currently required in residency to have training (given that the level of training varies between programs) in 5 different psychotherapies (brief/short term therapy [of which there are of course many], psychodynamic, CBT, interpersonal, and group/family). Since psychiatrists developed most major therapies (including CBT, DBT is an exception), I think it's ridiculous to propose that they be required to do a fellowship in either beforehand.

The Devil is in the details...

Cherry-picking a more research-friendly residency program doesn't prove anything other than some psychiatrists may have more exposure to research than most of their counter-parts at other hospitals.

As for the therapy training...while it is "required", it is hardly a focus at most residency programs. There have been many posts over in the Psychiatry forum asking specifically about therapy-friendly programs, since there are so few programs that actually pay more than lip-service to the "requirement"....per the comments of many psychiatry residents.

 

[O Gurl]

The most, frankly, I've ever gotten was confirmatory evidence that supported my diagnosis. But I do use some instruments in my own practice. Yes, in all those cases. More often, I get vague information that neither confirms or refutes a diagnosis. And especially with somatoform disorders. The best scales out there (and I am a researcher in this) don't have direct concordance with any diagnosis, but more often measures traits such as health anxiety (Whitely Index, Illness Attitude Scale, etc.). Even the PHQ-15 isn't diagnostic for anything. Currently somatoform disorders require ruling out medical causes of symptoms first.

Well no measure (or imaging, in the case of neuro) is meant to be diagnostic alone. That is why we (clinicians) are needed, to synthesize the information while accounting for the context of the presentation. Also, unless you have a uniformly young and heart-healthy population, I am utterly shocked that questions of dementias (age related or vascular) do not come across your path. In terms of somatoform disorders, I have found the most useful tool to be the good old MMPI. Measures of health anxiety and health locus of control (which I have used for bariatric and pre-transplant evaluations) are merely suggestive, while thorough medical reviews and personality trait assessments are far more telling.

And OGurl, I appreciate your even-mindedness on the debate. I wholly agree with you on many fronts. But certain medical schools do specific research training for a year of their schooling (Duke, for example), and some residencies have research tracks with additional training and empiric research done. Furthermore while psychiatrists have clearly swung away from therapy training towards majority of medication management, they are currently required in residency to have training (given that the level of training varies between programs) in 5 different psychotherapies (brief/short term therapy [of which there are of course many], psychodynamic, CBT, interpersonal, and group/family). Since psychiatrists developed most major therapies (including CBT, DBT is an exception), I think it's ridiculous to propose that they be required to do a fellowship in either beforehand.

Certain schools and residences, but surely you are not arguing that most prepare psychiatrists for research?

Your bolded statement made me laugh out loud. So because Aaron Beck was a psychiatrist and coined cognitive theory (NOT CBT-- the applied treatment advanced by his daughter, Judith, a psychologist) then modern day psychiatrists should not have to go through rigorous training on how to provide psychotherapy??? 1 year of seminars in psychotherapeutic approaches is squat compared to supervised clinical intervention hours actually crafting the skill. We all know the patients who walk through your doors are not nearly as neat and clean as Judith Beck's sample cases in her videos. The real learning occurs in practice.

 

[nitemagi]

The Devil is in the details...

Cherry-picking a more research-friendly residency program doesn't prove anything other than some psychiatrists may have more exposure to research than most of their counter-parts at other hospitals.

As for the therapy training...while it is "required", it is hardly a focus at most residency programs. There have been many posts over in the Psychiatry forum asking specifically about therapy-friendly programs, since there are so few programs that actually pay more than lip-service to the "requirement"....per the comments of many psychiatry residents.

Agreed. Whereas 40 years ago it was the primary focus of residency, the pendulum has swung away from that. It's swinging back, though.

I was not arguing that psychiatrists shouldn't do additional training, but the requirement of it for practice is just impractical (at this point politically at least). My residency involves 2 therapy continuity cases during year 2, 4-5 during year 3, and 3-6 during year 4. Each case involves supervision and goes longitudinally through the year. Supervisors are either psychologists, or other trained practitioners depending on the modality used (such as psychiatrist psychoanalysts).
I greatly decry the minimal requirements in therapy training. For my own education (seriously), what are the required level of therapy training in most Ph.D. programs?

 

[FuturePhD2]

Agreed. Whereas 40 years ago it was the primary focus of residency, the pendulum has swung away from that. It's swinging back, though.

I greatly decry the minimal requirements in therapy training. For my own education (seriously), what are the required level of therapy training in most Ph.D. programs?

It is not uniform, which is a huge problem for the field. I would love for the APA to get it together and make rigorous EST training mandatory instead of paying lip service to it.

In my program (research emphasis, scientist-practitioner Ph.D.) most people go on internship with between 1500-2000 total hours (usually 800-1000 face-to-face hours). My program also exclusively trains in evidence-based therapies, so all of these hours include things like CBT, exposure therapy, DBT, etc.

I think most internships require a minimum of 500 to 800 face-to-face hours in grad school to be considered (depending on the place), so this is the best "standard" to really point to.

 

[Ollie123]

Don't have time to jump into this full force, but why does it seem like Albert Ellis never gets any credit? If I remember correctly, he beat Beck to the punch by at least a couple years....

 

[nitemagi]

It is not uniform, which is a huge problem for the field. I would love for the APA to get it together and make rigorous EST training mandatory instead of paying lip service to it.

In my program (research emphasis, scientist-practitioner Ph.D.) most people go on internship with between 1500-2000 total hours (usually 800-1000 face-to-face hours). My program also exclusively trains in evidence-based therapies, so all of these hours include things like CBT, exposure therapy, DBT, etc.

I think most internships require a minimum of 500 to 800 face-to-face hours in grad school to be considered (depending on the place), so this is the best "standard" to really point to.

So my program involved at minimum 450 hours of supervised therapy (psychodynamic, CBT, DBT primarily). But because some of it is psychodynamic therapy (which I'm presuming doesn't qualify as evidence based in psychologist circles despite studies like this) I should have to do a fellowship in some people's view to be able to practice psychotherapy at all?

 

[O Gurl]

Don't have time to jump into this full force, but why does it seem like Albert Ellis never gets any credit? If I remember correctly, he beat Beck to the punch by at least a couple years....

Anyhoot, I will say that the amount of passion shown across disciplines in this debate is encouraging. We all want to defend our science, which is what prompted this thread to begin with. I just hope we will eventually get to a point of true collaboration in a mental health care system that makes sense one day. I just don't see that happening if we continue to blur our lines of practice and muddy the waters by loosening criteria for independent practice of less rigorously trained individuals.

 

[FuturePhD2]

So my program involved at minimum 450 hours of supervised therapy (psychodynamic, CBT, DBT primarily). But because some of it is psychodynamic therapy (which I'm presuming doesn't qualify as evidence based in psychologist circles despite studies like this I should have to do a fellowship in some people's view to be able to practice psychotherapy at all?

I don't see how 450 hours split between 5 different types of therapies (so less than 100 hours per, if it were divided equally) provides competence in any of those therapies, so yes I think additional training would be warranted - maybe not a full fellowship, but there are ways to get further training and supervision (the Academy of Cognitive therapy has a nice model set up for professionals in practice wanting to gain competence in CBT, for example). I would also bet that psychodymanic folks would also say that 100 hours of therapy training is not sufficient for that type of therapy either (the psychoanalytic folks would be totally up in arms at the suggestion).

That particular study has a lot of methodological flaws, and has been widely discussed in academic circles. The problem is that so few people actually understand how to do a meta-analysis properly, that people look at the discussion and assume the study actually provides the evidence it claims. This study does not show that long-term psychodynamic therapy is superior to any of the ESTs. While short-term psychodynamic therapy is supported for depression and some transference-based therapies are supported for BPD, these effects are more modest than other types of therapy, and thus the standard of care in terms of preponderance of evidence is a form of CBT in most cases.

 

[nitemagi]

Anyhoot, I will say that the amount of passion shown across disciplines in this debate is encouraging. We all want to defend our science, which is what prompted this thread to begin with. I just hope we will eventually get to a point of true collaboration in a mental health care system that makes sense one day. I just don't see that happening if we continue to blur our lines of practice and muddy the waters by loosening criteria for independent practice of less rigorously trained individuals.

Fair enough. This has been an interesting way to burn up a sunday...

 

[O Gurl]

So my program involved at minimum 450 hours of supervised therapy (psychodynamic, CBT, DBT primarily). But because some of it is psychodynamic therapy (which I'm presuming doesn't qualify as evidence based in psychologist circles despite studies like this) I should have to do a fellowship in some people's view to be able to practice psychotherapy at all?

I would say yes. Not because psychodynamic is an invalid approach. It is simply not as feasible as the major ESTs in a medical environment. But mainly I would say a fellowship is warranted because 450 is just not enough exposure, IMO. I had a little over 1000 face to face hours prior to internship, will acquire at least 600 more while I am here and am still quivering a little about being out on my own soon. Well, after postdoc. Therapy is such a dynamic process that anyone who wagers to say that have nothing left to learn would have to be kidding to themselves.

 

[nitemagi]

I don't see how 450 hours split between 5 different types of therapies (so less than 100 hours per, if it were divided equally) provides competence in any of those therapies, so yes I think additional training would be warranted - maybe not a full fellowship, but there are ways to get further training and supervision (the Academy of Cognitive therapy has a nice model set up for professionals in practice wanting to gain competence in CBT, for example). I would also bet that psychodymanic folks would also say that 100 hours of therapy training is not sufficient for that type of therapy either (the psychoanalytic folks would be totally up in arms at the suggestion).

That particular study has a lot of methodological flaws, and has been widely discussed in academic circles. The problem is that so few people actually understand how to do a meta-analysis properly, that people look at the discussion and assume the study actually provides the evidence it claims. This study does not show that long-term psychodynamic therapy is superior to any of the ESTs. While short-term psychodynamic therapy is supported for depression and some transference-based therapies are supported for BPD, these effects are more modest than other types of therapy, and thus the standard of care in terms of preponderance of evidence is a form of CBT in most cases.

3 types. The 5 types to have "competence in" can most definitely fall into lectures at times as the sole teaching in it (IPT in our program, for example).

And you'd think that JAMA would've scrutinized the control groups a little closer before publishing that study. But alas, that's where political motivation behind science leads you, wouldn't you agree?

 

[Therapist4Chnge]

3 types. The 5 types to have "competence in" can most definitely fall into lectures at times as the sole teaching in it (IPT in our program, for example).

And you'd think that JAMA would've scrutinized the control groups a little closer before publishing that study. But alas, that's where political motivation behind science leads you, wouldn't you agree?

A rush to publication...those of us in clinical psychology know nothing about that!

 

[FuturePhD2]

3 types. The 5 types to have "competence in" can most definitely fall into lectures at times as the sole teaching in it (IPT in our program, for example).

And you'd think that JAMA would've scrutinized the control groups a little closer before publishing that study. But alas, that's where political motivation behind science leads you, wouldn't you agree?

It's encouraging that this camp is trying to empirically support their ideas, as historically they have been resistant to scientific scrutiny. Does psychodynamic therapy have an effect? Sure (for some disorders - it is contraindicated for some). Is it a larger effect than ESTs? There's no evidence for that at this time.

The problem I have with the study is that people try to use as evidence that psychodynamic is superior to current ESTs. By the very design of the study, it cannot provide this information.

 

[PsyDetective]

I'm not aware that T4C is suggesting that at all. I believe the argument against having free-reign, independent practice rights for people with 2-3 years of post graduate education is the utter lack of quality control. Glancing over you self-purported level of training, it looks dubious at best:

Really? Because that is exactly what a PhD program looks like. You were able to squeeze it in in less than half of the time?

Gurl, I was accurate in my mere repetition of T4C's comments. His assertion that psychotherapy outcome research actually showing support for doctoral supremacy doesn't exist because people don't want it done, that it violates a profit-motive, and that psychologists are too busy to conduct it. You must be kidding. These comments are ridiculous and unprofessional.

Furthermore, I take serious offense to your disrespectful insinuation that I have fabricated or exaggerated my training. That was an arrogant assertion based on nothing more than personal bias. You clearly know very little about master's-level training. Despite your lack of knowledge, you hold such strong opinions about its inadequacy. And that was my point all along.

I don't "purport" to be able to open the minds of those who have such a personal stake in keeping it closed.

 

[FuturePhD2]

Gurl, I was accurate in my mere repetition of T4C's comments. His assertion that psychotherapy outcome research actually showing support for doctoral supremacy doesn't exist because people don't want it done, that it violates a profit-motive, and that psychologists are too busy to conduct it. You must be kidding. These comments are ridiculous and unprofessional.

Furthermore, I take serious offense to your disrespectful insinuation that I have fabricated or exaggerated my training. That was an arrogant assertion based on nothing more than personal bias. You clearly know very little about master's-level training. Despite your lack of knowledge, you hold such strong opinions about its inadequacy. And that was my point all along.

I don't "purport" to be able to open the minds of those who have such a personal stake in keeping it closed.

I really think that programs are too variable in training to have a clear "one produces better outcomes" study in the real world. I would refer a client to a master's level person who was actually trained to deliver CBT before I referred them to a Ph.D. that either didn't or did some bastardization "eclectic" therapy.

There has been research that shows that as long as people are adherent with their evidence-based training, there is no significant difference in outcome among those with varying years of experience. This is encouraging to me, because if a master's level person can be trained in CBT and produce similar outcomes to a Ph.D., then this is good for patients.

The main problem is that training is not standardized. Some master's folks get great evidence-based training, and some definitely do not. The same is true for Ph.D. level folks, however.

 

[nitemagi]

I really think that programs are too variable in training to have a clear "one produces better outcomes" study in the real world. I would refer a client to a master's level person who was actually trained to deliver CBT before I referred them to a Ph.D. that either didn't or did some bastardization "eclectic" therapy.

There has been research that shows that as long as people are adherent with their evidence-based training, there is no significant difference in outcome among those with varying years of experience. This is encouraging to me, because if a master's level person can be trained in CBT and produce similar outcomes to a Ph.D., then this is good for patients.

The main problem is that training is not standardized. Some master's folks get great evidence-based training, and some definitely do not. The same is true for Ph.D. level folks, however.

That's interesting. I'd like to see the papers if you have any links. I'll have to find the study(s) but my understanding is that the evidence studying community providers is that the further one gets from training, the less they (any type of provider) sticks to the standardized/manualized form of therapy, especially in CBT. I'll try to find the paper(s).

FuturePhD2 - why do you list yourself as a resident if you're not in medicine?

 

[O Gurl]

I take serious offense to your disrespectful insinuation that I have fabricated or exaggerated my training. That was an arrogant assertion based on nothing more than personal bias. You clearly know very little about master's-level training. Despite your lack of knowledge, you hold such strong opinions about its inadequacy. And that was my point all along.

I don't "purport" to be able to open the minds of those who have such a personal stake in keeping it closed.

It was not my intent to insult you, but I am genuinely confused as to how one accumulates 1000 face to face hours and engages in more hours (as your reported it, 50-60 hours/week) of research in 2-3 years of master's study when people are unable to produce those numbers in 4-5 years of pre-internship doctoral study. I'm not saying you are lying, I am saying there certainly IS a piece to the puzzle that I am missing. Perhaps course loads are significantly lighter? I am open to hearing more.

 

[O Gurl]

FuturePhD2 - why do you list yourself as a resident if you're not in medicine?

I know you weren't asking me, but I have also listed myself as a resident as well. I did so b/c SDN has no option for "intern", but only "resident-all fields" which is the most congruent with our current stage of training. Also, in some settings (mainly military and DoD) interns are referred to as residents.

 

[nitemagi]

I know you weren't asking me, but I have also listed myself as a resident as well. I did so b/c SDN has no option for "intern", but only "resident-all fields" which is the most congruent with our current stage of training. Also, in some settings (mainly military and DoD) interns are referred to as residents.

Thanks for the clarification. That's an artifact I guess of SDN originally being just for physicians and med students.

 

[FuturePhD2]

That's interesting. I'd like to see the papers if you have any links. I'll have to find the study(s) but my understanding is that the evidence studying community providers is that the further one gets from training, the less they (any type of provider) sticks to the standardized/manualized form of therapy, especially in CBT. I'll try to find the paper(s).

FuturePhD2 - why do you list yourself as a resident if you're not in medicine?

A nice review of the literature in this area can be found here: http://www.psychotherapybrownbag.co...your-therapist-and-does-that-even-matter.html

About the community center thing, I've seen one of those studies, and anecdotally it would appear to be true, although I have seen community centers that value evidence-based treatments and this does not seem to be the case where there is an emphasis.

On that last question, because my internship classifies me as a "Psychology Resident". A lot of academic medical center internships do this. Also because of what OGurl said - there is no specific distinction for psychology internship and this best characterizes my level of training.

 

[BSWdavid]

While there is no doubt that various fields have different training philosophies, I think it is self-serving to claim that one filed is better than another. As has already been pointed out, without the evidence to support such a claim it really is just an opinion. Unfortunately, there will always be members of every profession that claim they are superior; however, without evidence to back up such claim, it is really hard to take seriously. After all, can we really be that objective when we have a personal stake in promoting a claim? I will admit that this has been quite a humbling experience. In the end, I hope I strive to become the best clinician I can become and avoid falling into the trap of "my training is better than your training".

 

[Therapist4Chnge]

Re: the hammer-nail comment, that's a fair point. But it rests on a presumption that psychological testing is a necessary information source. Rather than a trained clinical interview, gathering of info from collateral sources. I'd really like to see the data to show its utility. Seriously, I would. I'm actually open to discussion, if someone can show me the data. Flaunting the "scientist" component then I would appreciate the evidence to support it. Believe it or not physicians are trained in the scientific method. But everyone here acts as if psychologists have a monopoly on it.

I'm most familiar with neuropsychology....

Diagnosing:
-ADHD (neuro)
-Various dementias (neuro)
-Malingering (neuro, psych)
-Conversion Dx (psych)

etc.

 

[O Gurl]

While there is no doubt that various fields have different training philosophies, I think it is self-serving to claim that one filed is better than another. As has already been pointed out, without the evidence to support such a claim it really is just an opinion. Unfortunately, there will always be members of every profession that claim they are superior; however, without evidence to back up such claim, it is really hard to take seriously. After all, can we really be that objective when we have a personal stake in promoting a claim? I will admit that this has been quite a humbling experience. In the end, I hope I strive to become the best clinician I can become and avoid falling into the trap of "my training is better than your training".

If that is all that you gathered from this conversation then you should really step back and take your fragile ego out of the picture. The crux of this discussion is the muddled and nearly impossible to navigate landscape of mental health care as we know it. It is not hard to see how a person in need of services could get lost (or potentially harmed) in a sea of independent practitioners with varying levels of training and understanding of the philosophy and principles underlying psychotherapy. Do you wish to argue whether or not an understanding of psychology (learning models, theories of behavior, principles of human development, understanding psychometric properties of measures, ability to administer and interpret assessment data, and so on) is needed for providing therapy? I'm all ears. But in a land where a PhD, PsyD, MD, MSW, LCSW, LPC, LPA, MFT, and any other combination of the alphabet can claim the amorphous title of "therapist" and tinker with people's lives, I am seriously invested in defining who and what these individuals are. I am training to be a PhD clinical psychologist and cannot think of anyone who took this route to solely provide therapy so please stop with the accusations of a monopoly. I already said I think the bulk of therapy could/should be provided at the master's level, but how about actually setting a firm and consistent standard of training for therapists? Reducing these points to the oversimplified, victim retort of "you docs are just saying you are better" is slightly irritating, immature, and self-absorbed. It is not about YOU it is about the consumers/clients/patients. Do you think this current circus of providers with no quality control is good for THEM????

 

[BSWdavid]

If that is all that you gathered from this conversation then you should really step back and take your fragile ego out of the picture. The crux of this discussion is the muddled and nearly impossible to navigate landscape of mental health care as we know it. It is not hard to see how a person in need of services could get lost (or potentially harmed) in a sea of independent practitioners with varying levels of training and understanding of the philosophy and principles underlying psychotherapy. Do you wish to argue whether or not an understanding of psychology (learning models, theories of behavior, principles of human development, understanding psychometric properties of measures, ability to administer and interpret assessment data, and so on) is needed for providing therapy? I'm all ears. But in a land where a PhD, PsyD, MD, MSW, LCSW, LPC, LPA, MFT, and any other combination of the alphabet can claim the amorphous title of "therapist" and tinker with people's lives, I am seriously invested in defining who and what these individuals are. I am training to be a PhD clinical psychologist and cannot think of anyone who took this route to solely provide therapy so please stop with the accusations of a monopoly. I already said I think the bulk of therapy could/should be provided at the master's level, but how about actually setting a firm and consistent standard of training for therapists? Reducing these points to the oversimplified, victim retort of "you docs are just saying you are better" is slightly irritating, immature, and self-absorbed. It is not about YOU it is about the consumers/clients/patients. Do you think this current circus of providers with no quality control is good for THEM????

I'm not sure why you are making this personal, and if you come to such hasty conclusions about your clients as you have done about me (i.e my fragile ego), then I would be quite hesitant to refer anyone to you. I believe there should be more quality control, but I don't believe that this should equate to only psychology providers providing services.

 

[O Gurl]

Re: the hammer-nail comment, that's a fair point. But it rests on a presumption that psychological testing is a necessary information source. Rather than a trained clinical interview, gathering of info from collateral sources. I'd really like to see the data to show its utility. Seriously, I would. I'm actually open to discussion, if someone can show me the data. Flaunting the "scientist" component then I would appreciate the evidence to support it. Believe it or not physicians are trained in the scientific method. But everyone here acts as if psychologists have a monopoly on it.

Ok. You could maybe start in the field of conversion disorders and pseudoseizures with:

Drake, M.E., Pakalnis, A., and Phillips, B.B. (1992). Neuropsychological and psychiatric correlates of intractable pseudoseizures. Seizure, 1, 11-13.

Which found a strong correlation (0.9) b/t conversion V profiles on the MMPI and people who were actually diagnosed with psychogenic seizures (conversion manifestation of what looks like convulsive epilepsy). This is just a start, but you can search by measure and diagnosis or by broad categories (e.g. neuropsychological correlates of dementia). Now, will you find anything that says you CANNOT diagnose without this data, probably not. But any clinician worth their salt would want as much reliable data to support their diagnosis as possible.

 

[O Gurl]

I'm not sure why you are making this personal, and if you come to such hasty conclusions about your clients as you have done about me (i.e my fragile ego), then I would be quite hesitant to refer anyone to you.

What a sad response. So I take it you are just going to ignore substantive points in lieu of continuing to play victim? Nice. This is a professional forum and I am trying to advocate for protecting patients. Not you. You are not my patient.

I believe there should be more quality control, but I don't believe that this should equate to only psychology providers providing services.

Somehow my saying that firm standing in psychology is necessary for a psychotherapist is translating to you that people with primary training in other disciplines cannot practice. Wild. Anyway would you please provide an example of a single psychotherapeutic approach that could treat a patient with MDD based on social welfare, social change and social justice alone (sans psychology)?

 

[BSWdavid]

What a sad response. So I take it you are just going to ignore substantive points in lieu of continuing to play victim? Nice. This is a professional forum and I am trying to advocate for protecting patients. Not you. You are not my patient.



Somehow my saying that firm standing in psychology is necessary for a psychotherapist is translating to you that people with primary training in other disciplines cannot practice. Wild. Anyway would you please provide an example of a single psychotherapeutic approach that could treat a patient with MDD based on social welfare, social change and social justice alone (sans psychology)?

I don't feel like a victim at all. I just think its interesting how you so quickly turn this into a personal issue. Why can't you make a clear point without making things personal? "...you should really step back and take your fragile ego out of the picture"; is this really necessary? As a psychology resident I would assume that you are capable of making an argument without the need to presume to understand the strength of someone's ego.

Clinical social work practice is informed by psychology, just as medicine is informed by biology.

 

[O Gurl]

Clinical social work practice is informed by psychology, just as medicine is informed by biology.

Indeed. So if clinical social work branched from psychology (the foundation of the practice) and people are raising concerns about the level of training in the science that is actually getting translated, then that is a valid concern for the public. Not for our egos. Sadly, I (and others here) have encountered MSWs and LCSWs who seem not to grasp or integrate the principles of psychology beyond the CBT manual. Or those who focus primarily on resource management and supportive check-ins than actual therapy. Certainly this cannot be applied to all social workers, but it is a valid concern. So now the discussion becomes: what should be done? Perhaps one option is having APA accreditation for clinical social work programs, but that may not help b/c the APA is not even reigning in some of the crappy professional schools of psychology. I don't know the solution but would love to be of some assistance in sorting it out.

 

[BSWdavid]

Indeed. So if clinical social work branched from psychology (the foundation of the practice) and people are raising concerns about the level of training in the science that is actually getting translated, then that is a valid concern for the public. Not for our egos. Sadly, I (and others here) have encountered MSWs and LCSWs who seem not to grasp or integrate the principles of psychology beyond the CBT manual. Or those who focus primarily on resource management and supportive check-ins than actual therapy. Certainly this cannot be applied to all social workers, but it is a valid concern. So now the discussion becomes: what should be done? Perhaps one option is having APA accreditation for clinical social work programs, but that may not help b/c the APA is not even reigning in some of the crappy professional schools of psychology. I don't know the solution but would love to be of some assistance in sorting it out.

I absolutely agree with you - there needs to be more consistency across disciplines. Perhaps state licensing boards should have more consistent requirements for licensing (i.e. if you want to practice psychotherapy, then you need to have completed certain courses, regardless of profession). I don't think the APA should be in charge, as this would be quite unfair to all non-psychology practitioners, but I do believe that the licensing standards should be comparable across disciplines. My point from the beginning has been that just because someone is a social worker doesn't mean they have not been properly trained in psychotherapy. Conversely, just because someone is a psychologist doesn't mean they were properly trained either. I have objectively observed psychotherapists for many years, long before I became a social worker, and I haven't been consistently impressed with any one field.

 

[BSWdavid]

Interesting article, although somewhat dated, I think the point is clear. Research has failed to prove that therapists from any one profession achieve superior results over another.

Psychotherapeutic Outcome and Professional Affiliation
Vincent J. Giannetti, Richard A. Wells
The Social Service Review
Vol. 59, No. 1 (Mar., 1985), pp. 32-43
Published by: The University of Chicago Press
Stable URL: http://www.jstor.org/stable/30011784

 

[KayJay85]

Interesting article, although somewhat dated, I think the point is clear. Research has failed to prove that therapists from any one profession achieve superior results over another.

Psychotherapeutic Outcome and Professional Affiliation
Vincent J. Giannetti, Richard A. Wells
The Social Service Review
Vol. 59, No. 1 (Mar., 1985), pp. 32-43
Published by: The University of Chicago Press
Stable URL: http://www.jstor.org/stable/30011784

Interesting. I tried to access it through our school library, but this article is not indexed on PubMed. Do you have a pdf? I am certainly interested in reading it.