LMHC or PsyD? (specific question)

[MustIReallyThough]

Hello! Please help!

After countless hours of research (and thank you all for your previous posts on this topic) I'm still heavily debating a grad school path. My primary interest is in working with SMI populations and staying abreast with any scientific advances in therapy. I would like for my niche to be in this area (or perhaps child/adolescent therapy) and would pursue whatever it took outside of my degree to be as competent as possible.

I'm torn between a masters and a doctorate. I currently have next to no interest in teaching or conducting my own research though. I merely want to be well informed and able to introduce contemporary psychological research into my own practice. The only thing I would probably enjoy about a PhD is the job freedom (though I'm envisioning PP) and assessment ability. Yet from what I've read, doctorate education is a bit more geared towards therapy with SMI populations.

What do you guys think? Will a LMHC get me where I want? Or should I bite the bullet and incur more debt with a PsyD in the hopes that it pays off practice wise?

P.S: I do know the financial risk accompanying even a partially funded PsyD. I'm also not considering a LCSW at this time despite the lobbying power or psychiatry.

If anyone reads this, thanks a bunch.

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[JustNoticing]

Why aren't you considering an MSW? You will have more employment opportunities, particularly in places that heavily serve SMI populations, such as community MH agencies. I say this as someone who got a counseling masters before my phd. Doctorate education and how much it exposes you to SMI populations is going to vary widely by program emphasis and what types of practica and internships you complete. You could always look up some type of place you might want to work down the road in your state and try and get a sense of what types of clinicians they employ. If you know you want to do private practice therapy, you'll save time and money with a masters. You can still be well informed if you chose to be and work in places that value that.

 

[smalltownpsych]

Last few jobs I have had I made double to triple compared to what the Masters folks made. Even with my high student loan payments, I am still doing better than if I had gone just the masters route. That being said, there are a lot of PsyD people who make only a little more than the masters people. Especially the ones that attended the large cohort schools. Also, I know of three people who went to these questionable type schools who cannot pass the eppp. No pass, no license, no money. If you want the quickest and safest route to start working in the field, then the licensed counselor is the route to go. I just don’t think very many make much money doing that.

 

[summerbabe]

Also wondering why you are closed off to a MSW.

I’ve worked in this field (within the VA healthcare system) and the truth is that everybody does a lot of case management and people never trained in therapy (think RNs, NPs, and PAs) will provide a bunch of therapy.

You might have a therapy apt booked with a patient but sometimes, they will be in no state to engage in therapy but have significant case management needs. Or you’re a medical provider who just wants to give them their monthly long acting injection but find yourself pressed into having what feels like a mini therapy session based on the patient’s needs.

Is it possible to work in this field as an LMHC? Yes. But I think you increase your odds and also receive lots of relevant training as an LCSW.

Do you have to have a doctorate? No but it can help you gain improved assessment experience and potentially help with advancing in leadership roles, depending on your organization/politics.

Is the extra cost worth it? I don’t know. Doing this type of community mental health work means you’re earning ceiling will likely be capped (versus a cash pay private practice type setting that has a lot more room for growth) so whatever debt load you take on may feel more burdensome.

PEPPNET and EPINET focus on early psychosis intervention. You can get more info on this career path, as well as see what types of degrees individuals working at these organizations are likely to have. Good luck!

 

[BuckeyeLove]

I remember doing a practicum at a CMHC over 10 years ago. All of the therapists there (a confluence of LMHC's, LSW's, LCDC's, LISW's, etc.) all hated life. Like they might have enjoyed the job at first but got burnt out roughly 1 yearish in due to having to constantly worry about meeting productivity requirements with really difficult populations, spend-down stuff, and a whole bunch of other garbage. And it really did feel like most of them felt stuck because they couldnt really do much more with the degree and license they had, there was a legit ceiling. It really made me think about where i wanted to be and what i wanted to do in mental health more than any point in my training.

 

[Sanman]

My thoughts are this, while there are exceptions I tend to see the LMHC targeted more at outpatient counseling. I can see the the LCSW having more opportunity in an inpatient or step down setting (psychiatric hospital, HUDVASH, VA Domicilliary, etc) as there is a lot of case management that needs to be done with this population. Therapy is not doing much for you if you are homeless, can't eat, etc. A PsyD can get you where you are going, but it will be dependent on the program and access you have to SMI populations/rotations. That said, look at salaries. If you are thinking community mental health or similar, the salaries are low and the stress burden is high. Adding a big debt load to a small salary means that you may be struggling financially as well.

 

[cotn_psych]

As someone who focused on SMI populations in a doctorate, you will not be doing a lot of traditional CBT right off the bat with most folks. Most of therapy with this population is case management. If you do end up with long term and high functioning people, you will still have times when you need to do a lot of case management and can intersperse more talk therapy during stable times. I trained with masters level therapists in community mental health, VA, and inpatient settings and we did pretty much the same thing (even co-led groups together). The only difference was that when I finished with clinical work for the day I went back to doing research.

 

[MustIReallyThough]

I may have given the wrong impression (still figuring out the nuances). I'm not sure I'd last any longer than anyone else in a CMHC. But I see how that would be the financial reality of that population sadly.

I mostly envision private or group practice. With my niche being that I'd want to study and specialize in the more severe disorders.

As far as social work goes, I just feel like I'd get more out of a counseling curriculum. Even though I know social work is a great field with more opportunity. I'm focused more on individuals and the theories behind therapy than macro level considerations. Also I don't have much interest in social work type jobs (medical, school, etc.)

I attempted to major in social work at first actually but just really missed my psych classes

 

[MustIReallyThough]

Why aren't you considering an MSW? You will have more employment opportunities, particularly in places that heavily serve SMI populations, such as community MH agencies. I say this as someone who got a counseling masters before my phd. Doctorate education and how much it exposes you to SMI populations is going to vary widely by program emphasis and what types of practica and internships you complete. You could always look up some type of place you might want to work down the road in your state and try and get a sense of what types of clinicians they employ. If you know you want to do private practice therapy, you'll save time and money with a masters. You can still be well informed if you chose to be and work in places that value that.

Good info! Can you speak a little more about why you went from a counseling masters to a doctorate? I'm a bit afraid that if I do go for just a masters I'm going to end up unsatisfied in the long run and go back for the PhD anyway. Which wouldn't be the most graceful path, especially if I went from counseling to psychology, but it'd give me much needed time to think things over.

Anyone else had this experience?

 

[MustIReallyThough]

I remember doing a practicum at a CMHC over 10 years ago. All of the therapists there (a confluence of LMHC's, LSW's, LCDC's, LISW's, etc.) all hated life. Like they might have enjoyed the job at first but got burnt out roughly 1 yearish in due to having to constantly worry about meeting productivity requirements with really difficult populations, spend-down stuff, and a whole bunch of other garbage. And it really did feel like most of them felt stuck because they couldnt really do much more with the degree and license they had, there was a legit ceiling. It really made me think about where i wanted to be and what i wanted to do in mental health more than any point in my training.

This is exactly what I'm afraid of. Being limited and then regretting my degree. I read somewhere once that job freedom = satisfaction. What about private practice? Couldn't they branch out that way eventually?

And what were your specific thoughts about where you wanted to be and do, if I may ask?

 

[Sanman]

This is exactly what I'm afraid of. Being limited and then regretting my degree. I read somewhere once that job freedom = satisfaction. What about private practice? Couldn't they branch out that way eventually?

And what were your specific thoughts about where you wanted to be and do, if I may ask?

Depends, do you want to work with only SMI pops in PP or are you willing to give up working with that population? Also, do you need a steady paycheck or is that not a problem?

 

[MustIReallyThough]

Depends, do you want to work with only SMI pops in PP or are you willing to give up working with that population? Also, do you need a steady paycheck or is that not a problem?

I'd probably burnout eventually if it was 100 percent that pop in PP. And I'm definitely interested in the full gamut as well. Just want an idea of a solid business model beforehand that includes specialization (and marketing as such). As well as being driven by the belief that these folks need the best, most informed care.

I'd definitely need a steady paycheck. So I guess that'd mean an agency job and side PP for some years?

 

[MustIReallyThough]

Last few jobs I have had I made double to triple compared to what the Masters folks made. Even with my high student loan payments, I am still doing better than if I had gone just the masters route. That being said, there are a lot of PsyD people who make only a little more than the masters people. Especially the ones that attended the large cohort schools. Also, I know of three people who went to these questionable type schools who cannot pass the eppp. No pass, no license, no money. If you want the quickest and safest route to start working in the field, then the licensed counselor is the route to go. I just don’t think very many make much money doing that.

Money is definitely a concern, though I'm not quite sure I'm cut out for the jobs that pay better. I'm guessing like director and supervisor roles.

I don't think I'd consider doctorate education unless I got into a really good program to avoid what you spoke of. I suppose my best bet is to get a masters, practice, and see about doing some research on the side to beef up future applications, just in case.

smalltownpsych- I distinctly remember reading about your decision to pursue doctorate education because it gave you options. Do you think you'd have regretted stopping at a masters? Any regrets in general?

 

[smalltownpsych]

Money is definitely a concern, though I'm not quite sure I'm cut out for the jobs that pay better. I'm guessing like director and supervisor roles.

I don't think I'd consider doctorate education unless I got into a really good program to avoid what you spoke of. I suppose my best bet is to get a masters, practice, and see about doing some research on the side to beef up future applications, just in case.

smalltownpsych- I distinctly remember reading about your decision to pursue doctorate education because it gave you options. Do you think you'd have regretted stopping at a masters? Any regrets in general?

I don’t really have any regrets about the path I have chosen. I could say in hindsight, I would have made more effort into a funded program and looked at making a geographic move earlier. Not sure if my life would have been the same though as I got married in the second year of my doctoral program. I have a lot of experience working with severe mental illness and there is definitely room to challenge the current mental health system and make money too.

I have started my own group practice and one goal is to keep people with serious mental health issues out of the revolving door of psychiatric hospitals and other aspects of the system that seem to work pretty poorly in many ways. I have found that there are people or families with more resources that are willing to pay for a higher standard of care. I had another one of those walk into my office just today. It is challenging because as a society we don’t seem to understand what is needed for early intervention to ameliorate and treat serious mental illness. Here’s one hint, medications are not the answer and the over-reliance on them and compliance is part of why our outcomes in this country are so poor.

I talk about this stuff because I strongly believe that psychologists have a lot to contribute to the issues of severe mental illness and I don’t think enough of us get involved in that. The last few years I worked hand in hand with a psychiatrist that saw what skilled and experienced psychologists can bring to the table and he had been working with two of them for almost 15 years before he brought me in to the mix since they were retiring. Now it is for me to pick up where that left off. About 3/4 of my patients have a hx of psychiatric hospitalizations and half have long term and complex mental health issues. It’s not exactly the worried well. In other words, I know that there is a role for psychologists to provide treatment and oversee the case managment and mentor support aspects becuase it’s what I do.

 

[AcronymAllergy]

Popping in to quickly say (which may have been mentioned above) that, unfortunately, it'd probably be pretty tough to work primarily with SMI in a private practice setting, depending. Many of those folks are underserved due in no small part to economic limitations, hence the heavy reliance on community mental health. And if they can afford anything relating to private practice, they/their families will probably prioritize psychiatry first.

Although there's always the possibility of working full-time or thereabouts in a CMHC and then having a private practice on the side.

 

[Sanman]

Money is definitely a concern, though I'm not quite sure I'm cut out for the jobs that pay better. I'm guessing like director and supervisor roles.

I don't think I'd consider doctorate education unless I got into a really good program to avoid what you spoke of. I suppose my best bet is to get a masters, practice, and see about doing some research on the side to beef up future applications, just in case.

smalltownpsych- I distinctly remember reading about your decision to pursue doctorate education because it gave you options. Do you think you'd have regretted stopping at a masters? Any regrets in general?

This is where reality needs to leak into your decisions. You have a choice here. Many PP psychologists/therapists tend to work with upper middle class or rich patients and families in order the make more money (better insurance or cash). There are many MA level therapists that end up as supervisors or directors in CMHCs due to the low pay in those positions. SMI often don't have money and are on the low end of the payscale. Which preference are you are most likely to give up for the others? That may help you choose your path. There are state hospital or Veterans Affairs positions that may pay better. I would suggest looking at the job openings for positions that interest you and see the income and educational requirements listed.

 

[MustIReallyThough]

I don’t really have any regrets about the path I have chosen. I could say in hindsight, I would have made more effort into a funded program and looked at making a geographic move earlier. Not sure if my life would have been the same though as I got married in the second year of my doctoral program. I have a lot of experience working with severe mental illness and there is definitely room to challenge the current mental health system and make money too.

I have started my own group practice and one goal is to keep people with serious mental health issues out of the revolving door of psychiatric hospitals and other aspects of the system that seem to work pretty poorly in many ways. I have found that there are people or families with more resources that are willing to pay for a higher standard of care. I had another one of those walk into my office just today. It is challenging because as a society we don’t seem to understand what is needed for early intervention to ameliorate and treat serious mental illness. Here’s one hint, medications are not the answer and the over-reliance on them and compliance is part of why our outcomes in this country are so poor.

I talk about this stuff because I strongly believe that psychologists have a lot to contribute to the issues of severe mental illness and I don’t think enough of us get involved in that. The last few years I worked hand in hand with a psychiatrist that saw what skilled and experienced psychologists can bring to the table and he had been working with two of them for almost 15 years before he brought me in to the mix since they were retiring. Now it is for me to pick up where that left off. About 3/4 of my patients have a hx of psychiatric hospitalizations and half have long term and complex mental health issues. It’s not exactly the worried well. In other words, I know that there is a role for psychologists to provide treatment and oversee the case managment and mentor support aspects becuase it’s what I do.

Thank you so much for sharing that! I love the passion you have for the specific issues this population faces. It's easy to see how the system is broken in many ways. I currently manage a large food pantry in a very rural, poor county and see first hand how much folks struggle, especially with rampant mental illness that simple isn't feasible to treat given lacks in transportation services.

I think having a practice like yours would be my perfect end goal. I'd want to be part of the solution in providing a high standard of care at a reasonable price, not just medication. And I get the feeling from what you wrote that there's room to balance making a decent living and seeing disadvantaged clients, though it may require some sacrifices.

Given what I've said, do you think a PhD would be a better fit for the specifics I have in mind? How has it helped you within this context?

 

[MustIReallyThough]

This is where reality needs to leak into your decisions. You have a choice here. Many PP psychologists/therapists tend to work with upper middle class or rich patients and families in order the make more money (better insurance or cash). There are many MA level therapists that end up as supervisors or directors in CMHCs due to the low pay in those positions. SMI often don't have money and are on the low end of the payscale. Which preference are you are most likely to give up for the others? That may help you choose your path. There are state hospital or Veterans Affairs positions that may pay better. I would suggest looking at the job openings for positions that interest you and see the income and educational requirements listed.

Yep, unless I can eventually swing a niche practice like smalltown has I see what you mean. I'm not quite sure which preference I'd end up giving up.

I do envision a PP of some sort as soon as I'm able to make that viable. I'm a pretty solitary person and would like the peace of just seeing clients and maybe doing some supervison. Being a director would be a nightmare I think.

And I do think I'd still be fulfilled in generalist PP, even if I only got the occasional client with complex issues. Barring niche success, I envision the specialization as a marketing tool as well as being something I'm passionate about researching in-depth anyway (just not my own research). Although I might end up juggling both CMHC and PP like some seem to do.

I'll definitely look up some other job options though. You never know where you're going to end up in this field it seems. Thanks a lot for your continued input!!

 

[JustNoticing]

Good info! Can you speak a little more about why you went from a counseling masters to a doctorate? I'm a bit afraid that if I do go for just a masters I'm going to end up unsatisfied in the long run and go back for the PhD anyway. Which wouldn't be the most graceful path, especially if I went from counseling to psychology, but it'd give me much needed time to think things over.

Anyone else had this experience?

Sure. I didn't have much research experience in undergrad, in part because I did the math on the cost of a psyd a little late in the game and was afraid of committing fully to the phd route at the time. I went with the counseling masters to hedge my bets. In hindsight, taking a year or two to work in research (what I did later anyway) would have been a better use of my time and money. Ultimately there was still a lot I wanted to learn in the field, which some of my ambitious peers handled through post-grad therapy institutes. I was interested enough in research, and was curious about things like psych assessment, and wanted more flexibility to do things like teaching. Another contributing factor was that at that time, my counseling masters did not make me a particularly attractive job candidate for the jobs I was looking for after graduation compared to those with MSWs, so I took it as a sign and decided to pursue the phd.

 

[smalltownpsych]

Thank you so much for sharing that! I love the passion you have for the specific issues this population faces. It's easy to see how the system is broken in many ways. I currently manage a large food pantry in a very rural, poor county and see first hand how much folks struggle, especially with rampant mental illness that simple isn't feasible to treat given lacks in transportation services.

I think having a practice like yours would be my perfect end goal. I'd want to be part of the solution in providing a high standard of care at a reasonable price, not just medication. And I get the feeling from what you wrote that there's room to balance making a decent living and seeing disadvantaged clients, though it may require some sacrifices.

Given what I've said, do you think a PhD would be a better fit for the specifics I have in mind? How has it helped you within this context?

In my experience, becoming a psychologist has provided me with more flexibility and credibility. This is mainly due to the breadth of experience and the foundation in science and the title psychologist is fairly well-established and respected. I get that many people with serious mental illness are impoverished, but I actually believe that the downward drift and trajectory can be impacted most effectively with the late adolescent to early adulthood population and that families might have some resources at that point to pay for effective care. The last five years I have been working with this population completely outside of the insurance and state-funded system. The state systems also seem to be run by social workers more so not as much room for psychologists in that and not as much compensation either.