Independent practice for LPAs?

[FuturePhD2]

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

The point was clear 20 years ago. Training in all areas evolves over time. I'm not sure a review article that looks at studies before the 80's really makes your point here.

Assuming adequate training in evidence-based therapies (and adherence to said training), there is no difference among disciplines, in general. Otherwise, there are discrepancies. I haven't seen any studies that look at this, but my feeling is also that those with more training are probably more competent in handling treatment resistant and refractory types of clients (e.g., psychiatrists and psychologists). These kinds of cases go a little bit beyond teaching a master's level person CBT for standard mood and anxiety disorders.

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[KayJay85]

I'm not sure a review article that looks at studies before the 80's really makes your point here.

I certainly don't want to dismiss the findings without even reading what went into the investigation, but on first glance at the abstract alone, it does appear to be a review of 1980s studies. I am still interested to see what populations were treated and what outcomes they looked at. I don't think any psychologist or psychiatrist would argue that other disciplines could not handle straightforward cases of therapy. Heck, that was the whole point of developing treatment manuals. However, those of us in the field, regardless of discipline, can point to a number of cases where one has to go outside the typical bag of tricks and manage a number of variables. But who can or will ever design and execute an impartial investigation into the treatment of those cases?

 

[KayJay85]

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.

But if oversight or training accreditation is warranted in order to prepare everyone for equal licensing standards, then what discipline should be in charge? I'm more than a little confused by the movement into psychology by social workers while balking anything that remotely looks like authority from psychology.

 

[BSWdavid]

I tried to upload the pdf and got the message, "Your file of 1.43 MB bytes exceeds the forum's limit of 856.3 KB for this filetype."

 

[BSWdavid]

The point was clear 20 years ago. Training in all areas evolves over time. I'm not sure a review article that looks at studies before the 80's really makes your point here.

Assuming adequate training in evidence-based therapies (and adherence to said training), there is no difference among disciplines, in general. Otherwise, there are discrepancies. I haven't seen any studies that look at this, but my feeling is also that those with more training are probably more competent in handling treatment resistant and refractory types of clients (e.g., psychiatrists and psychologists). These kinds of cases go a little bit beyond teaching a master's level person CBT for standard mood and anxiety disorders.

I'm struggling to find recent solid research. It seems much of the research was completed 20+ years ago. I will keep looking.

 

[FuturePhD2]

I'm struggling to find recent solid research. It seems much of the research was completed 20+ years ago. I will keep looking.

I already cited research in an earlier post that found no differences between therapists of varying experience levels assuming they had the same training in ESTs and adhered to that training. This is a little different than what you are looking for, saying that all disciplines produce equal outcomes in general (which I don't think research would support currently, given that the same set of studies that I cited earlier found that when therapists did not adhere to evidence-based practice there WERE discrepancies in outcome based on experience).

 

[DrGero]

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.

The Dodo Bird effect for professions..... snort. I'll order that one from my medical library later today if I remember.

 

[FuturePhD2]

The Dodo Bird effect for professions..... snort. I'll order that one from my medical library later today if I remember.

The Dodo Bird is extinct.

 

[nitemagi]

Effect or verdict?

 

[O Gurl]

I already cited research in an earlier post that found no differences between therapists of varying experience levels assuming they had the same training in ESTs and adhered to that training. This is a little different than what you are looking for, saying that all disciplines produce equal outcomes in general (which I don't think research would support currently, given that the same set of studies that I cited earlier found that when therapists did not adhere to evidence-based practice there WERE discrepancies in outcome based on experience).

I agree wholeheartedly, along with this point from the Wiki link provided by nitemagi: "The significance of the figure of 0.2 (DoDo) is then an artifact of grouping problems and therapies in a non-meaningful way."

It is funny how people can point to a limited/confounded set of outcome data (published in a social justice journal no less) that looks at limited circumstances and expect to generalize it into a finding that the level of expertise or professional orientation of the therapist is a nonfactor. That is absurd.

Only in the world of psychotherapy do people with either less training (master's level) or training in a spin-off area (clinical social work) have the audacity to continually diminish the training of those who pursued the top level of training in the field. That is not to sound snooty, but doctoral is the top level of academic training in the U.S. Funny how physician's assistants and nurses don't seem to balk at medical doctors. I have to step back and wonder where this comes from? It is really based in an idea that because we are not dealing with visible and tangible illness (a virus, a broken bone, a cancer cell) that advanced training is null? After all, all we do is talk to people, right?

 

[PsyDetective]

Emotions run high on this issue, clearly.

PhD's have every right to be proud of their accomplishments. I personally have diminished that accomplishment, or the value of their training. Although the same is clearly, and unfortunately, not true on this forum in the reverse. Some doctoral-level psychologists/students (overrepresented here) have almost no regard and little actual knowledge about the training of master's-level psychologists (the original topic), let alone the hard work and dedication it takes to pursue that degree in such a hostile environment. A rational examination of the issue is not to be had here, I'm afraid. Narcissus will not be pulled from the pool.

This thread reads like a Monty Python skit.

It would be great if any of the self-purported intellectual superiors were willing to engage in a mutually-respectful, intelligent discussion of the issue and proposals for the solution that did not start with, "not to sound snooty."

 

[loveoforganic]

I'm not sure I'd use the doctor/nurse example OGurl

 

[nitemagi]

And to continue the theme of humility, I see part of the issue here as a sense of undermining of hard work via undermining credentials. Most people on this forum have experience in their discipline alone, with a few exceptions (people who have cross-trained with multiple degrees).

No one wants to hear that their hard work is worthless, or worth less than others. Not Ph.D.'s or Master's level providers and speaking from my side of the camp not M.D.'s. Citing sources that both speak to the benefit of experience, and the benefit of following a manual, there does Not seem to be a consensus in the literature stating that any 1 factor leads to best outcomes for psychotherapy in general, nor for a particular psychopathology. FuturePhD gave a nice link (though it is a self-published blog, thus not peer reviewed, it cites and summarizes some good articles). So we're much more prone to seek out evidence that supports our own self-interest. That must be accounted for when reading any literature, and I believe we must question our own need to be proven superior or worthy as potentially clouding our ability to help others, and to connect with our colleagues.

And if you want to prove a point, do a study in it. Because I'm looking and I'm not finding a wealth of evidence to show anyone is superior to everyone else in their therapeutic skills, despite our years of training and many thousands of dollars of investment, and whatever we have to tell ourselves to sleep at night.

I'll keep working on my N of 1.

 

[BSWdavid]

I agree wholeheartedly, along with this point from the Wiki link provided by nitemagi: "The significance of the figure of 0.2 (DoDo) is then an artifact of grouping problems and therapies in a non-meaningful way."

It is funny how people can point to a limited/confounded set of outcome data (published in a social justice journal no less) that looks at limited circumstances and expect to generalize it into a finding that the level of expertise or professional orientation of the therapist is a nonfactor. That is absurd.

Only in the world of psychotherapy do people with either less training (master's level) or training in a spin-off area (clinical social work) have the audacity to continually diminish the training of those who pursued the top level of training in the field. That is not to sound snooty, but doctoral is the top level of academic training in the U.S. Funny how physician's assistants and nurses don't seem to balk at medical doctors. I have to step back and wonder where this comes from? It is really based in an idea that because we are not dealing with visible and tangible illness (a virus, a broken bone, a cancer cell) that advanced training is null? After all, all we do is talk to people, right?

"published in a social justice journal no less" You really do have a problem with social workers, don't you? I think the fragile ego might be your issue!

Master level clinicians/social workers are not the "nurses" of psychology!

 

[BSWdavid]

Emotions run high on this issue, clearly.

PhD's have every right to be proud of their accomplishments. I personally have diminished that accomplishment, or the value of their training. Although the same is clearly, and unfortunately, not true on this forum in the reverse. Some doctoral-level psychologists/students (overrepresented here) have almost no regard and little actual knowledge about the training of master's-level psychologists (the original topic), let alone the hard work and dedication it takes to pursue that degree in such a hostile environment. A rational examination of the issue is not to be had here, I'm afraid. Narcissus will not be pulled from the pool.

This thread reads like a Monty Python skit.

It would be great if any of the self-purported intellectual superiors were willing to engage in a mutually-respectful, intelligent discussion of the issue and proposals for the solution that did not start with, "not to sound snooty."

I think this is an important point. Some posters clearly believe that their hard work has been diminished by masters level clinicians, however, I think the reverse is also true.

 

[O Gurl]

"published in a social justice journal no less" You really do have a problem with social workers, don't you? I think the fragile ego might be your issue!

Sorry. Seriously. What I meant by that is the study was published in the journal with an audience that stands to gain from a review that suggests therapist credentials are not important.

Master level clinicians/social workers are not the "nurses" of psychology!

I'm not sure how that would be an unfair comparison. I am talking about the tiers of training. Physician's assistants/ Nurses: Medical Doctor seems to parallel Master's Psychology/Clinical Social Worker: Doctor of Psychology. I am speaking in terms of degree of post graduate training in the science (medicine to psychology).

 

[O Gurl]

No one wants to hear that their hard work is worthless, or worth less than others. Not Ph.D.'s or Master's level providers and speaking from my side of the camp not M.D.'s. Citing sources that both speak to the benefit of experience, and the benefit of following a manual, there does Not seem to be a consensus in the literature stating that any 1 factor leads to best outcomes for psychotherapy in general, nor for a particular psychopathology. FuturePhD gave a nice link (though it is a self-published blog, thus not peer reviewed, it cites and summarizes some good articles). So we're much more prone to seek out evidence that supports our own self-interest. That must be accounted for when reading any literature, and I believe we must question our own need to be proven superior or worthy as potentially clouding our ability to help others, and to connect with our colleagues.

And if you want to prove a point, do a study in it. Because I'm looking and I'm not finding a wealth of evidence to show anyone is superior to everyone else in their therapeutic skills, despite our years of training and many thousands of dollars of investment, and whatever we have to tell ourselves to sleep at night.

I'll keep working on my N of 1.

I already dread opening this can of worms, but when was the last time you reviewed RCTs of the major classes of psychotropic medications? The effect sizes are not that impressive. So yes, the science to support the value of one discipline or another is not always easy to find. Yet I am stunned by this challenge to show a comprehensive study across all mental health presentations in all settings across all modalities that shows that people with more training are better trained. Would anyone demand to see an all-encompassing study of treatment outcomes across medical conditions between doctors, pharmacists, nurses, and physician's assistants?

I just have to ask, what do you guys think are the training differences between a doctor of psychology and a master's of psychology and a social worker?

 

[O Gurl]

I'm not sure I'd use the doctor/nurse example OGurl

I am picking up what you are putting down.

But really, can you imagine a group of non-doctoral medical professionals, let's take nurses for example, going into the MD/DO forum and saying: "well I have a study here showing that a sample of HTN or influenza patients had similar outcomes whether they were treated by a doctor or a nurse". F*ck the patients with HTN+ diabetes+ stroke history... oh, and with a questionable nodule found on their lungs.

 

[PsyDetective]

I can see your point. Although your logic fails because of your fundamental misunderstanding about the training of "nurses" (a broad term which encompasses many different areas and typically requires a BSN or Associate's degree, as opposed to graduate training), I think it is useful for something.

Why do you think you DON'T hear of MD's on their forum trying to tear apart PA's? Why are they not asserting with such audacity and arrogance their superiority and trying to destroy the entire profession of PA's? I'm very serious. This actually gets at my original point, and I think it could spawn a useful discussion. I'd really love to hear from any members on that side of the house as well.

 

[O Gurl]

I can see your point. Although your logic fails because of your fundamental misunderstanding about the training of "nurses" (a broad term which encompasses many different areas and typically requires a BSN or Associate's degree, as opposed to graduate training), I think it is useful for something.

Why do you think you DON'T hear of MD's on their forum trying to tear apart PA's? Why are they not asserting with such audacity and arrogance their superiority and trying to destroy the entire profession of PA's? I'm very serious. This actually gets at my original point, and I think it could spawn a useful discussion. I'd really love to hear from any members on that side of the house as well.

Let me be clearer then: registered nurse. My point still stands. You don't hear registered nurses or PA's outright dismissing the doctoral degree in their field of medicine.

And I am not in anyway trying to destroy the profession of clinical social workers or master's level therapists. I have already spelled out my position in which a master's level psychology degree would be in place and any person who wishes to call his/herself a therapist would have to complete an accredited program, meet a set of training criteria, and pass board-comparable licensing standards that denote wtf they are qualified to do, such as licensed marriage and family therapist, licensed child and adolescent therapist, licensed addictions therapist, and so on. *Aside: I am also a strong proponent of board certification for psychologists*

Why do you not see a zillion different degrees (like MSW, LPC LCSW, LMHC, MFT, so on) fighting to independently practice medicine? Someone please answer this?

 

[nitemagi]

I already dread opening this can of worms, but when was the last time you reviewed RCTs of the major classes of psychotropic medications? The effect sizes are not that impressive. So yes, the science to support the value of one discipline or another is not always easy to find.

1. You misunderstand my statement. I wasn't asking for a study that looks globally at all pathology rolled into one.
2. We all have investment in what we're trained in. Many psychiatrists will fight for the death that meds are very very effective. Many of them are unfortunately swayed by the substantial number of pharma sponsored studies.

So have you read through the bias of your own education? How many of your EST's are definitively shown to be superior to other psychotherapies in head to head comparisons? Some are, don't get me wrong. Check my link for the example with DBT (no follow-up studies, etc.).

I am quite aware of the low effect size of many antidepressants (usually around 0.3).
3. And my statement was not a challenge at all. Fascinating how you read these statements as anything other than a statement.
To quote myself:

there does Not seem to be a consensus in the literature stating that any 1 factor leads to best outcomes for psychotherapy in general, nor for a particular psychopathology.

My point was a lack of consensus on what makes a therapy or therapist superior to another.

But then we turn to more evidence:
"However, they conclude that the relationship between therapist competence and reduction of depressive symptoms was “not as strong or consistent as expected” (from one of the studies reviewed).
"...a classification of ‘extensive training’ was given to studies with more than 137 h of training for therapists,"
"It is perhaps not surprising that extensive training for inexperienced therapists yielded significant effects."
"If close monitoring with feedback on actual clinical performance is crucial during the stage of training in which therapist competence is consolidated ... then practice cases would seem to serve the same function as supervision."
"This dynamic might suggest that adherence is a precursor to competent clinical skill."
"The existing literature suggests that more extensive training variably leads to increased therapist competence, which is positively related to better patient outcome."

So there's evidence to support all camps.

But as the review authors point out, there is no consensus on how much training is sufficient to make a competent therapist that actually correlates with better clinical outcome.

 

[KayJay85]

And I am not in anyway trying to destroy the profession of clinical social workers or master's level therapists. I have already spelled out my position in which a master's level psychology degree would be in place and any person who wishes to call his/herself a therapist would have to complete an accredited program, meet a set of training criteria, and pass board-comparable licensing standards that denote wtf they are qualified to do, such as licensed marriage and family therapist, licensed child and adolescent therapist, licensed addictions therapist, and so on. *Aside: I am also a strong proponent of board certification for psychologists*

Sounds fair. My understanding of obtaining a license for independent practice of psychology is that a professional is able to hang a shingle and then take on primary responsibility for whoever or whatever comes through their door. I am familiar with both a private practice and residential treatment facility for eating disorders where one of my former clinical supervisors (PhD Clinical Psychologist) is the clinical director. Within that practice are LPCs, LCSWs, and other psychologists and by all accounts, they achieve excellent results. However I would be terrified to refer a patient to an independent practice with no doctoral level psychologist in the picture. Looking at eating disorders in particular, there are far too many variables at play, from personality disorders, to substance abuse, to suicide/self-injury, to family intervention, to assume the risk that someone without the most thorough training possible will be equipped to handle each case. Specialty licenses would go a long way toward easing the minds of many skeptics, I think.

Why do you not see a zillion different degrees (like MSW, LPC LCSW, LMHC, MFT, so on) fighting to independently practice medicine? Someone please answer this?

I am also waiting on pins and needles for the answer to this question.

 

[AcronymAllergy]

Why do you think you DON'T hear of MD's on their forum trying to tear apart PA's? Why are they not asserting with such audacity and arrogance their superiority and trying to destroy the entire profession of PA's? I'm very serious. This actually gets at my original point, and I think it could spawn a useful discussion. I'd really love to hear from any members on that side of the house as well.

To address this point specifically--I don't have any thread links handy at the moment, but I've seen quite a few individuals from the MD/DO camp (students, residents, attendings) who've criticized certain suggestions/efforts by PAs to expand the latter's scope of practice into areas the physicians deemed inappropriate due to inadequate training. I definitely recall the general tones of the posts and threads being quite similar to those between doctoral-level and master's-level practitioners, and between psychologists and psychiatrists with respect to prescription privileges.

 

[BSWdavid]

Sounds fair. My understanding of obtaining a license for independent practice of psychology is that a professional is able to hang a shingle and then take on primary responsibility for whoever or whatever comes through their door. I am familiar with both a private practice and residential treatment facility for eating disorders where one of my former clinical supervisors (PhD Clinical Psychologist) is the clinical director. Within that practice are LPCs, LCSWs, and other psychologists and by all accounts, they achieve excellent results. However I would be terrified to refer a patient to an independent practice with no doctoral level psychologist in the picture. Looking at eating disorders in particular, there are far too many variables at play, from personality disorders, to substance abuse, to suicide/self-injury, to family intervention, to assume the risk that someone without the most thorough training possible will be equipped to handle each case. Specialty licenses would go a long way toward easing the minds of many skeptics, I think.



I am also waiting on pins and needles for the answer to this question.

I am also aware of clinics that have LCSWs as their clinical director. Heck, our dept of psychiatry has an LCSW as the Chief Operating Officer.

You assume that just because someone is a PhD psychologist automatically they have the training and skills necessary to treat more complex cases. I would rather refer to someone who specializes in the area, regardless of the degree.

 

[loveoforganic]

Why do you not see a zillion different degrees (like MSW, LPC LCSW, LMHC, MFT, so on) fighting to independently practice medicine? Someone please answer this?

Again, you DO see it (NP's, NMW's, CRNA's) but it's certainly not to the same degree that occurs with psychology. I think it's a virtue of ease of regulation. There are distinct procedures in medicine. It's harder to draw a regulatory distinction between talk and therapy.

 

[KayJay85]

My point was a lack of consensus on what makes a therapy or therapist superior to another.

But then we turn to more evidence:
"However, they conclude that the relationship between therapist competence and reduction of depressive symptoms was “not as strong or consistent as expected” (from one of the studies reviewed).
"...a classification of ‘extensive training’ was given to studies with more than 137 h of training for therapists,"
"It is perhaps not surprising that extensive training for inexperienced therapists yielded significant effects."
"If close monitoring with feedback on actual clinical performance is crucial during the stage of training in which therapist competence is consolidated ... then practice cases would seem to serve the same function as supervision."
"This dynamic might suggest that adherence is a precursor to competent clinical skill."
"The existing literature suggests that more extensive training variably leads to increased therapist competence, which is positively related to better patient outcome."

So there's evidence to support all camps.

But as the review authors point out, there is no consensus on how much training is sufficient to make a competent therapist that actually correlates with better clinical outcome.

I cannot access the full-text from home (again! argh!) but in just scanning the abstract and your selected quotes, this fall directly into what FuturePhD and O Gurl have already addressed in terms of sanitized, isolated, and non-generalizable studies of "therapist expertise" and outcomes. I use that term very loosely, as do the authors apparently. Seriously, 137 hours? What an arbitrary cut-off for declaring someone an "expert therapist". Oh, and only expert in treating one type of disorder (depression) with one manualized therapy (CBT).

 

[Therapist4Chnge]

You assume that just because someone is a PhD psychologist automatically they have the training and skills necessary to treat more complex cases. I would rather refer to someone who specializes in the area, regardless of the degree.

They have a much better foundation of training (breadth and depth), which would allow a good basis from which to build upon. With that being said, there are definitely certain areas that require specialized training, and a clinical psychologist off the street would struggle with special populations (eating disorders is the first thing that came to mind).

 

[BSWdavid]

So, the argument boils down to this: clinical social workers shouldn't practice psychotherapy because that would be in fact practicing psychology; however, it is OK for clinical psychologists to prescribe medication, and even perform "physical exams, order and interpret EKGs and labs, etc" (which one poster noted). How is the former wrong and the latter somehow ok? Why should clinical social workers, with the proper training, be banned from practicing psychology, but psychologists be permitted to practice medicine?

 

[nitemagi]

I cannot access the full-text from home (again! argh!) but in just scanning the abstract and your selected quotes, this fall directly into what FuturePhD and O Gurl have already addressed in terms of sanitized, isolated, and non-generalizable studies of "therapist expertise" and outcomes. I use that term very loosely, as do the authors apparently. Seriously, 137 hours? What an arbitrary cut-off for declaring someone an "expert therapist". Oh, and only expert in treating one type of disorder (depression) with one manualized therapy (CBT).

They use the term "competent," not expert. You should probably read more than the abstract before criticizing it as "sanitized, isolated, and non-generalizable."

I posted the link because it was a review article actually looking at studies on training and outcomes. A major issue cited in the study is that there's little solid research on this area. So again without good evidence to back opinions, they're still just opinions. If you have articles to cite in response, actual evidence, I'd like to see them.

But read the article. As I said, it actually gives evidence for all camps in this argument.

 

[Therapist4Chnge]

So, the argument boils down to this: clinical social workers shouldn't practice psychotherapy because that would be in fact practicing psychology; however, it is OK for clinical psychologists to prescribe medication, and even perform "physical exams, order and interpret EKGs and labs, etc" (which one poster noted). How is the former wrong and the latter somehow ok? Why should clinical social workers, with the proper training, be banned from practicing psychology, but psychologists be permitted to practice medicine?

The bolded part is why.

The psychologist wishing to prescribe has to take 2 additional years of classes, receive supervision from a physician, sit for a national exam, and then have a consultative relationship with a physician.....compared to a social worker who says, "I have enough training", with no additional training. The RxP training leaves something to be desired, but it is at least an attempt to provide additional training.

If a social worker wants to do talk therapy they should complete a minimum of the LCSW requirements (supervised therapy hours after licensure, etc).

 

[BSWdavid]

They have a much better foundation of training (breadth and depth), which would allow a good basis from which to build upon.

Isn't this a bit presumptuous though? "Much better" is an opinion, not a fact. Also, where does experience play a role? With this logic, a recently licensed psychologist would be better equipped to handle a crisis than a 20+ year clinical social work veteran. Come on; surely you can't believe this. I experienced a similar situation a couple of months ago where we had a patient that came into the clinic with suicidal and homicidal ideation, compounded by several other issues. The psychology extern she had been assigned to had no idea what to do; however, my LCSW supervisor, who had been practicing for 33 years, stepped in and quickly handled the situation. Based on this theory, the PhD extern should have been able to handle this better than the LCSW simply based on her "much better foundation of training (breadth and depth)." Do you not see the problem with this line of thinking?

 

[BSWdavid]

The bolded part is why.

The psychologist wishing to prescribe has to take 2 additional years of classes, receive supervision from a physician, sit for a national exam, and then have a consultative relationship with a physician.....compared to a social worker who says, "I have enough training", with no additional training. The RxP training leaves something to be desired, but it is at least an attempt to provide additional training.

If a social worker wants to do talk therapy they should complete a minimum of the LCSW requirements (supervised therapy hours after licensure, etc).

So you are implying that two additional years of training equates the training of medical school?

 

[KayJay85]

Again, you DO see it (NP's, NMW's, CRNA's) but it's certainly not to the same degree that occurs with psychology. I think it's a virtue of ease of regulation. There are distinct procedures in medicine. It's harder to draw a regulatory distinction between talk and therapy.

People can't bill for simply talking. Seems simple enough to distinguish between that and what is supposed to be psychotherapy. But I see your point in terms of limitations on ordering certain procedures and prescribing meds which prevents people without proper credentials from doing so. While no one can stop someone from hanging the proverbial shingle and talking, they sure can stop reimbursing for it... but hey, he who charges the least....

You assume that just because someone is a PhD psychologist automatically they have the training and skills necessary to treat more complex cases. I would rather refer to someone who specializes in the area, regardless of the degree.

Yep. People with a more advanced degree in the field in question get my vote. Of course I would prefer to see evidence of expertise in area (e.g. board certification) but it is not unreasonable to seek care from the most rigorously and comprehensively trained professional possible. Yes, in vivo training should mean something, but when that training and supervision could have occurred in an accredited training environment (APA approved practicum, internship, postdoc) or under one provider in the field with no oversight (as is the case with LPAs) then I'm sticking with the more rigorous standard.

 

[AcronymAllergy]

Isn't this a bit presumptuous though? "Much better" is an opinion, not a fact. Also, where does experience play a role? With this logic, a recently licensed psychologist would be better equipped to handle a crisis than a 20+ year clinical social work veteran. Come on; surely you can't believe this. I experienced a similar situation a couple of months ago where we had a patient that came into the clinic with suicidal and homicidal ideation, compounded by several other issues. The psychology extern she had been assigned to had no idea what to do; however, my LCSW supervisor, who had been practicing for 33 years, stepped in and quickly handled the situation. Based on this theory, the PhD extern should have been able to handle this better than the LCSW simply based on her "much better foundation of training (breadth and depth)." Do you not see the problem with this line of thinking?

The same could potentially be said of a newly-minted MD/DO resident (or, as you use the extern example, an actual medical student) vs. an RN or NP with 30+ years of experience.

 

[BSWdavid]

People can't bill for simply talking. Seems simple enough to distinguish between that and what is supposed to be psychotherapy. But I see your point in terms of limitations on ordering certain procedures and prescribing meds which prevents people without proper credentials from doing so. While no one can stop someone from hanging the proverbial shingle and talking, they sure can stop reimbursing for it... but hey, he who charges the least....



Yep. People with a more advanced degree in the field in question get my vote. Of course I would prefer to see evidence of expertise in area (e.g. board certification) but it is not unreasonable to seek care from the most rigorously and comprehensively trained professional possible. Yes, in vivo training should mean something, but when that training and supervision could have occurred in an accredited training environment (APA approved practicum, internship, postdoc) or under one provider in the field with no oversight (as is the case with LPAs) then I'm sticking with the more rigorous standard.

From my understanding, from reading other posts, APA standards are minimal and questionable. After all, they do accredit programs like Argosy.

 

[AcronymAllergy]

So you are implying that two additional years of training equates the training of medical school?

The argument by those supporting RxP is that the two additional years of training, when combined with the qualifying exam, the period of supervised practice, and the existing knowledge obtained in the clinical psychology doctoral training paradigm, would allow one to appropriately prescribe a limited array of medications in a limited array of circumstances. Or something along those lines.

 

[BSWdavid]

The same could potentially be said of a newly-minted MD/DO resident (or, as you use the extern example, an actual medical student) vs. an RN or NP with 30+ years of experience.

I'm at a psychiatric clinic which refers to post-doc psychologists as externs (prior to licensing). I think it depends on the situation, but I have no doubt that there are some things a veteran RN can perform better than a freshly minted MD/DO.

 

[AcronymAllergy]

I'm at a psychiatric clinic which refers to post-doc psychologists as externs (prior to licensing). I think it depends on the situation, but I have no doubt that there are some things a veteran RN can perform better than a freshly minted MD/DO.

I'd agree that there are likely some things a veteran RN can do better than a newly-minted MD/DO. However, that generally hasn't caused RNs to lobby that they can all independently and appropriately practice in those areas. Having worked in a multitude of medical settings, my anecdotal experience has been that while RNs and physicians don't always have the greatest working relationships, the RNs--when it comes down to it--will recognize the more in-depth training that physicians receive. The same can be said for NPs and PAs; again, at least in my (limited) experience.

 

[Therapist4Chnge]

Isn't this a bit presumptuous though? "Much better" is an opinion, not a fact. Also, where does experience play a role? With this logic, a recently licensed psychologist would be better equipped to handle a crisis than a 20+ year clinical social work veteran. Come on; surely you can't believe this.

This is the same argument 20+ yr nurses use with 1st year residents. Sure their 20+ years give them a lot of experience to pull from during the first few months, but the resident will quickly catch up because they have....[barney stinson voice] wait for it.....[/barney stinson voice] more breadth and depth of training.

So you are implying that two additional years of training equates the training of medical school?

Absolutely not. I am saying that the 2 years of training, supervised hours, national exam, and collaborative agreement....ON TOP OF the pre-existing doctoral training is sufficient to prescribe a limited set of meds. Compare the training to that of an NP (independent practitioner in many states), and it isn't close, and they have independent practice!

From my understanding, from reading other posts, APA standards are minimal and questionable. After all, they do accredit programs like Argosy.

They are indeed THE MINIMUM qualifications, which is all the more reason anything less than them should not be considered adequate.

 

[KayJay85]

They use the term "competent," not expert. You should probably read more than the abstract before criticizing it as "sanitized, isolated, and non-generalizable."

I posted the link because it was a review article actually looking at studies on training and outcomes. A major issue cited in the study is that there's little solid research on this area. So again without good evidence to back opinions, they're still just opinions. If you have articles to cite in response, actual evidence, I'd like to see them.

But read the article. As I said, it actually gives evidence for all camps in this argument.

"This review examines what can be learned from existing research into the efficacy and effectiveness of CBT training. Due to the paucity of research specifically investigating CBT training, CBT effectiveness and dissemination studies are also examined to glean information about potentially effective training practices. In order to draw conclusions about effective training practices, comparisons are drawn between studies according to the clinical outcomes that they achieved."

Looking at effectiveness of training for CBT delivery in a research setting is sanitized and non-generalizable to the world of private practice. It is a manualized intervention. Who can't be taught to follow a manual? What happens when these "competently trained" therapists are stuck in an office with a bipolar, non-literate patient with alcohol dependence? Unless you know of people sustaining practices by treating ideal CBT candidates (literate and organized enough to complete homework) with depressive disorders only, this finding is not germane to this debate.

 

[BSWdavid]

I'd agree that there are likely some things a veteran RN can do better than a newly-minted MD/DO. However, that generally hasn't caused RNs to lobby that they can all independently and appropriately practice in those areas. Having worked in a multitude of medical settings, my anecdotal experience has been that while RNs and physicians don't always have the greatest working relationships, the RNs--when it comes down to it--will recognize the more in-depth training that physicians receive. The same can be said for NPs and PAs; again, at least in my (limited) experience.

And I would agree psychologists receive more in-depth training than clinical social workers, however, how much in-depth training is necessary? Np's, in many states, can practice independently but I don't think the argument has been made that their training equals that of an MD/DO. But that doesn't mean they can't perform their duties adequately.

 

[AcronymAllergy]

And I would agree psychologists receive more in-depth training than clinical social workers, however, how much in-depth training is necessary? Np's, in many states, can practice independently but I don't think the argument has been made that their training equals that of an MD/DO. But that doesn't mean they can't perform their duties adequately.

Similarly, I don't know if anyone (in this thread, at least) has explicitly said that social workers shouldn't be allowed to perform psychotherapy--just that it must be demonstrated they're receiving adequate training to do so.

One of the issues unique to psychology vs. medicine is that, given the youth of the discipline, even experts in the field have trouble agreeing on what makes a competent practitioner, or where our discipline stands in terms of its clinical effectiveness. These ideas were central to the Ph.D./Psy.D. debates (i.e., do we even know enough about applied practice to be able to create a professional degree in the field?). Thus, if we're still figuring out what our doctoral-level practitioners need to know, how can we hope to extend appropriate training and standard of care guidelines to master's-level practitioners?

Then again, I might just be delirious from my recent dissertationing binge.

 

[KayJay85]

From my understanding, from reading other posts, APA standards are minimal and questionable. After all, they do accredit programs like Argosy.

The professional school, buy-a-degree crowd is quite the exception. Besides, you mentioned PhD, did you not?

Thus I would indeed argue that a PhD clinician who accrued supervised hours in accredited programs is more rigorously trained than an LPA who only had to have one on-the-job supervisor with no training criteria.

 

[BSWdavid]

Similarly, I don't know if anyone (in this thread, at least) has explicitly said that social worker's shouldn't be allowed to perform psychotherapy--just that it must be demonstrated they're receiving adequate training to do so.

One of the issues unique to psychology vs. medicine is that, given the youth of the discipline, even experts in the field have trouble agreeing on what makes a competent practitioner, or where our discipline stands in terms of its clinical effectiveness. These ideas were central to the Ph.D./Psy.D. debates (i.e., do we even know enough about applied practice to be able to create a professional degree in the field?). Thus, if we're still figuring out what our doctoral-level practitioners need to know, how can we hope to extend appropriate training and standard of care guidelines to master's-level practitioners?

Then again, I might just be delirious from my recent dissertationing binge.

Absolutely fair that we prove we are receiving adequate training. And I do recall one poster referring to social workers as nothing more than "social justice workers" that have no place in clinical work. I am paraphrasing of course. The problem is, how can we prove we are adequately trained when it seems that even psychologists have trouble with the issue? There isn't a single empirical study that proves that clinical social workers receive inferior training to clinical psychologists. It may not be the SAME training, but that doesn't mean it is inferior. And perhaps it is inferior, I don't know. But the current research suggests otherwise.

 

[KayJay85]

Isn't this a bit presumptuous though? "Much better" is an opinion, not a fact. Also, where does experience play a role? With this logic, a recently licensed psychologist would be better equipped to handle a crisis than a 20+ year clinical social work veteran. Come on; surely you can't believe this. I experienced a similar situation a couple of months ago where we had a patient that came into the clinic with suicidal and homicidal ideation, compounded by several other issues. The psychology extern she had been assigned to had no idea what to do; however, my LCSW supervisor, who had been practicing for 33 years, stepped in and quickly handled the situation. Based on this theory, the PhD extern should have been able to handle this better than the LCSW simply based on her "much better foundation of training (breadth and depth)." Do you not see the problem with this line of thinking?

Experience certainly is important, but surely you have read several accounts of LCSWs who skate by on supportive check-ins and resource management for YEARS. In your example comparing an extern to a supervisor rolleyes I would certainly hope that someone with 3 decades of MH experience could at least manage safety planning/suicide intervention over someone with a couple years. I would wager to say that many an extern could more appropriately manage cases where veiled neurocognitive decline, late life discovery developmental delays, or personality disorders played a key part because we are actually trained to factor in and assess for these issues.

 

[BSWdavid]

Experience certainly is important, but surely you have read several accounts of LCSWs who skate by on supportive check-ins and resource management for YEARS.

I admit this does happen, but I don't think this is universal to social work.

 

[futureapppsy2]

Just something interesting to throw out there: My department explicitly excludes masters students (mainly school counseling students are interested, as they are the only real clinical/applied masters program the department offers) from taking child therapy classes in the department. The reasoning is that the masters level students simply don't have the level of training or scientific knowledge at that level of training to be able to effectively and competently use the EBTs we are taught in those courses. *Not* my wording or reasoning, but that is the official department policy, FWIW.

Are there masters-level folks who are very, very good, very competent clinicians? Certainly. Do they provide invaluable help to clients and their families? Yes. Can they play a role in training doctoral-level psychologists? Depending on the situation, yes. Is their depth and breadth of training the same? No. I don't see any conceivable way that you could fit the curriculum from my program into 2-3 years, either if you cut out the upper-level stats classes (I'm assuming you would still want some baseline level of graduate stats training in there). My friends in other disciplines are amazed by how much coursework we have and how are research, except for our dissertation, is considered a "mandatory extra"--i.e., we don't get course credit for it. Also, our coursework really is rooted in the science of it all--our therapy class, for example, has almost-weekly article critiques built in, and our behavioral assessment class does the same. Granted, I've never been in a masters level program and so have no direct basis for comparison, but it doesn't seem like the type of training my friends in MSW and MA programs received. Not that they received bad training, but just that philosophy of the training was different.

 

[BSWdavid]

Just something interesting to throw out there: My department explicitly excludes masters students (mainly school counseling students are interested, as they are the only real clinical/applied masters program the department offers) from taking child therapy classes in the department. The reasoning is that the masters level students simply don't have the level of training or scientific knowledge at that level of training to be able to effectively and competently use the EBTs we are taught in those courses. *Not* my wording or reasoning, but that is the official department policy, FWIW.

Are there masters-level folks who are very, very good, very competent clinicians? Certainly. Do they provide invaluable help to clients and their families? Yes. Can they play a role in training doctoral-level psychologists? Depending on the situation, yes. Is their depth and breadth of training the same? No. I don't see any conceivable way that you could fit the curriculum from my program into 2-3 years, either if you cut out the upper-level stats classes (I'm assuming you would still want some baseline level of graduate stats training in there). My friends in other disciplines are amazed by how much coursework we have and how are research, except for our dissertation, is considered a "mandatory extra"--i.e., we don't get course credit for it. Also, our coursework really is rooted in the science of it all--our therapy class, for example, has almost-weekly article critiques built in, and our behavioral assessment class does the same. Granted, I've never been in a masters level program and so have no direct basis for comparison, but it doesn't seem like the type of training my friends in MSW and MA programs received. Not that they received bad training, but just that philosophy of the training was different.

But there is the issue at hand. You are assuming that your training model is superior and therefore if other programs don't meet those requirements, they are inadequate. Just because one spends more time in school doesn't automatically make one a better clinician. I understand though how this is a hard pill to swallow. If I had spent 6 or more years in school, I would be vested in the idea that my training was superior; after all, if it wasn't better than my time would have been wasted.

As a side note, while I believe that my training and education thus far has been solid, I do desire a more in-depth education and more solid research exposure, which is why I am pursing a PhD. However, I don't think this has much to do with social work; I think it has more to do with the limits of a masters degree in general. But I don't buy into the idea that more = better, nor do I believe that psychology has a superior training model. But hey, what do I know, after all I'm just a social justice worker

 

[nitemagi]

Looking at effectiveness of training for CBT delivery in a research setting is sanitized and non-generalizable to the world of private practice. It is a manualized intervention. Who can't be taught to follow a manual? What happens when these "competently trained" therapists are stuck in an office with a bipolar, non-literate patient with alcohol dependence? Unless you know of people sustaining practices by treating ideal CBT candidates (literate and organized enough to complete homework) with depressive disorders only, this finding is not germane to this debate.

I'm not quite sure of your point here - since manualized CBT doesn't fit real world practice situations, we can't learn anything from looking at how much training in a manualized therapy actually helps lead to competency and efficacy in that manualized therapy? That's your argument? Ignore any actual research on the topic? Just go with heated shouting?

I'm starting to feel like the only one actually reading the literature in this argument and not shouting from my pulpit.

 

[futureapppsy2]

But there is the issue at hand. You are assuming that your training model is superior and therefore if other programs don't meet those requirements, they are inadequate. Just because one spends more time in school doesn't automatically make one a better clinician. I understand though how this is a hard pill to swallow. If I had spent 6 or more years in school, I would be vested in the idea that my training was superior; after all, if it wasn't better than my time would have been wasted.

As a side note, while I believe that my training and education thus far has been solid, I do desire a more in-depth education and more solid research exposure, which is why I am pursing a PhD. However, I don't think this has much to do with social work; I think it has more to do with the limits of a masters degree in general. But I don't buy into the idea that more = better, nor do I believe that psychology has a superior training model. But hey, what do I know, after all I'm just a social justice worker

I never said that more=better. There are certainly incompetent psychologists out there, no doubt! I said the depth, breadth, and model of training is different. FWIW and in my limited experience, I do think the psychology *model* is better *for clinical work*, esp. diagnosis. For things like working with disenfranchised populations, social work probably has the edge. Prior to grad school, I worked in an area (DV/IPV in a socially disenfranchised group) where social justice plays a HUGE role and having someone with a social work background is INVALUABLE. A mentor/colleague of mine has a PhD in social work, and I have nothing but the utmost respect for her as a researcher and as a social justice professional (our work is entirely research, so I can't speak to her skills as a clinician, but I trust they're probably very good).

My clinical supervisor in undergrad, an MSW, was a very, very good clinician, and again, I have nothing but respect for her. My other clinical supervisor was an LPC--again, same thing. But their training is still fundamentally different from that of psychologists--in the population they were working with (lots of phase of life issues), that very well may have been to their advantage or at least given them a good background for that population. So, I'm not knocking social work at all. In fact, I have a BSW!

You seem to think anyone who advocates for psychology or our training model is either (a) bashing social work, (b) has a fragile ego and needs to puff it up by getting a PhD, (c) disregards all social workers and Masters level clinicians, or (d) has no exposure to social work. On the same hand, you same to be denying that the psychology training model has ANY good to it and that the little good it does have simply duplicates social work.