Discussion in 'Psychology [Psy.D. / Ph.D.]' started by 50960, Dec 6, 2005.
They're REALLY taking psychologist RxP seriously in CA! Folks in the psychiatry forum seem to think that it's not an issue. Meanwhile, a good percentage of the California Psychiatrist newsletter is about this very issue, with even a comic on it!
I wholeheartedly disagree with you when it comes to the PhD. I think the PsyD model should probably change, but that's not what you were talking about. If by change you mean to add a little more bio bases of behavior I would agree, but psychology doesn't need medicalization to the extent I think you are talking about. Or at least it shouoldn't be required. I (and a myriad other students) have very little interest in studying mental disorders from a biological base.
I've said it before and I'll say it again now, the study of the biological underpinnings of mental disorders is contingent on us having adequate constructs of what the disorders actually are. If not we are wasting our time looking at the pretty little MRI pictures.
Naurally this all needs to be reconciled with the attempt the field should be making at understanding disorders multidimensionaly.
No, what I am saying is how to rule out a needed referral for a pancreatic tumor, hypothyroidism, heart conditions etc. Most PhD;s haven't a clue of basic clinical medicine, and a little could go along way in this regard. I am not even getting into the ignorance most psychologist have over drugs/pharmacology.
"Or at least it shouoldn't be required. I (and a myriad other students) have very little interest in studying mental disorders from a biological base. "
No offense, but this is sorta like saying we should continue to study the flatness of the earth because we prefer it that way?? Psychology does not exist outside of physiology. Every thought, memory, feeling and experience has a well understood physiology in the CNS. You can't separate mind and body.
So there is a "well understood physiology in the CNS" for Uncle Tommy's experience as a hippie, his high school memories, his feelings toward his cousin Deirdre, and his thoughts regarding Milwaukee's Best beer?
Not at all. Or at least not how I see it. This is saying that mental functioning is a multi faceted construct, and I choose to focus most of my attention on one facet as opposed to others. Not to the exclusion of the others.
Agreed, I resent that you feel the need to point this out. I often remind people to avoid falling into the trap of the duality of mind and body.
Well understood? That is the boldest statement I have seen on this board. I would say hypothesized instead of well understood in that sentance.
Ultimately you can't, but there are useful ways to approach certain problems. Many of the mental disorders we study and attempt to daignose and thus treat are in need of a revision. This has big implications for biological work. How will you study the underpinnings of schizophrenia, if schizophrenia isn't the right construct to be studying.
"Every thought, memory, feeling and experience has a well understood physiology in the CNS."
The mechanisms are not hypothoses at all. What is a memory?
You tell me, if you are so confident. I'm not certain that the associated brain physiology, chemistry, location, etc. for a memory is well understood. Is there an assiociated physiology, chemistry, location, activation etc. associated with memories? Probably, but you tell me what, where, and how they occur with any level of certainty and I'll cede this argument to you.
My previous comment was just for memories since thye are what you chose to quiz me on. I would also like to know all of the same information for "Every thought, memory, feeling and experience". I also would suspect that if you were able to answer this at a level that could be deemed "well understood". You would be the richest and most revered man in the cognitive sciences. Are you such a man?
Psychology clearly needs more medicalization, this deficit is what makes most psychologists look ignorant during integrated patient care.
I would agree with you on this point. I'm in favor of any sort of training that would make better either treatment providers or researchers out of psychologists. But I'm not sure to what extent.
There are whole books written on just the biochemistry of memory, not to mention the neurophysiology etc... My point was alot of mental health providers see memories, and the psyche in general as some sort of almost metaphysical phenomenon. Memories, are neuronally strengthened networks connecting sense points in the brain of each part of the memory; smell, vision, touch, language etc. 90% of mental health people who argue these points believe a memory is a stored in a collective chunk in one location in the brain, and science has known this is not true for 20 yrs. That is a problem.....
Like you, I enjoy testing. This type of training would also make us better diagnosticians.
I agree I think it would be useful, but I don't know that everyone would require it. Obviously the more neuro, or health psych inclined might. And for assessment it would be invaluable.
That's a good answer. (And I feel the need to add that my conceptualization of memory is close to what you have just delineated.) I agree that those who want to mysticise all fo these processes are a bunch of mush heads. But I have a knee jerk reaction to those who want to biologize everything, it's not always the useful level of analysis, meds are only useful up to a point, and I think our discipline takes its richness in being able to reconcile bio-psych-social models. I get frustrated when when people go gaga over fMRI and similar stuff. Head shaped rainbows belong on greatful dead t-shirts.
We're only beginning to scratch the surface. And that's enough to win Nobel Prizes: http://www.erickandel.org/research_fr.html
I think it's pretty obnoxious that his website has a picture of his Nobel medal permanently etched on the left frame. You can't look at a single thing on his website without having the medal rubbed in your face. I'm glad he won it, but its a little tactless. Sorry for the diversion, I just had to point that out.
I hadn't noticed that. What an arrogant bastard! Probably some Internet design nerd thought it would look cool.
Arrogant? If I won the medal I'd show you arrogant. I'd stop wearing shirts and only wear my medal....and a fur cape......tiger fur.
You should also swing by the Kandel lab, run around the Aplysia, and yell, "WAAHOOOO!"
Look here is the thing with this whole medicalization of clinical psychology. Some, but not all disorders appear to have a primarily biological etiology. Of course all have some sort of physiological associations with them, but is that the useful level at which to approach them?
The increase of the medicalization, as I see it, would lead to an increase in medication treatment over all, I don't know that that is necessarily the right approach to take. I want to aknowledge that medication is a useful for of treatment, and sometimes the only viable option. But I would caution against making it the default treatment, and elevating the biological dimesnsion to the top of the pyramid.
We had recently discussed Hebb's law. Things like that are certainly informative, and should be required for all students of the cognitive sciences (psychology included). But the fact that nerons that fire together wire together is of limited clinical utitlity, IMO.
The truth is, if we want to be bona fide health care providers we need to step up. Most psychologists do not have a strong foundation in pathophysiology and neuroscience. Without this training, how can they pretend to have an understanding of the biopsychosocial model.
Opinionated, negativistic, elitist professors in psychology training programs are doing a disservice to their students. Far too many of these professors are stuck in the philosophy department (and yes I saying that as if it is a bad thing), engage in fluff qualitative social science research, then complain that hard science obtains the research dollars. It seems we need to make some radical changes in how we train psychologists (both clinicians/researchers).
I agree with you psycheval. I also want to add for psyclops and others that I do not feel we need to go MORE into the bio in a reductionist fashion, but how can even include it in our model if we don't know it to begin with. Also, knowing alot of bio, pathophys etc, does not mean one sees that as the etiology more, quite the opposite. Everything has bio component, but that does not mean it is caused by uncompromised biological processes. Up until very recently large amounts of good research have failed to show more than a 50% loading for genetics on any psychological condition. Environment changes bio as well. I have gained a much greater respect for experience, cognition and environmental effects on human behavior through my study of neurosciences and physiology than I even did in psychology school.
I've been thinking about this, and here are my current thoughts, this may clear up our current discussion, I don't know. So, if something has a pathophysiological etiology, or if they have a tumor, or whatever causing phsycholgical symptoms, they whould primarily be treated by a medical specialist in the area. I think everyone agrees with me on this point. Right? Maybe there would be some counseling if there was some distress and the patient was interested or requested it. Ok with me there?
But in the event that something appeared to be primarily psychological in nature or etiology, it would most likely best be treated by a psychologist/psychiatrist right?
Ok, so I assume you agree with me up until now. Now there are many d/o which have been shown to be alleviated by both psychological and medical (meaning ECT or psychopharm) intervention. And, as all of us enlightened ones know, there is no dualism. So ultimately most things can be found to be affected by medical intervention or at least to some extent. But why would we want as psychologists to reduce everything to the biological? Why would it be the best type of intervention be the pharmacological?
Well I was busy writing my previous post when this one comes out. I pretty much agree whole heartedly with this one. I just want to add, that as a hopeful psycholgist who plans to go at least into half research, I think that what psycholgisy does best is the psycho in the bio-psycho-social equation. So I would resist the pharm for our profession.
I do believe that we need to "medicalize" psychology. But this does not mean that mental illness should be reduced to the bio. I also don't believe it is generally helpful to dichotomize. It is not about biochemical versus psychosocial interventions but rather about what is the most appropriate treatment. Medicalization will help our discipline to truly be the gold standard in mental health diagnosis since it will compliment our current focus on the intrapsychic and interpersonal. Treatment comes from diagnosis. IMO, the question that psychologists should be asking is: what is the EBT for this condition(s)? and then being able to implement it. So, in this model we are not reducing everything to the bio or saying that the best intervention is always the pharm one. We are saying that to be a competent diagnostician we need to be better educated on the bio and that to be considered a comprehensive provider we need to have RxP-to continue, change, increase, decrease, discontinue pharm.
P.S. BTW, many times pharm is the most efficacious treatment to alleviate symptom distress that could interfere with a pt's gaining of insight and/or cog/beh skills that are necessary to prevent relapse post-pharm. As a psychologist now (and as a psychiatrist in the future?) I often favor this combination as the most efficient one.
Well said sas, thanks for chiming in.
its been a while since I last posted (org II and phy II ) but I'm really passionate about this need.
thanks; just echoing the mod
It should. It doesn't yet though. At least not to the extent it should.
Originally Posted by sasevan
Treatment comes from diagnosis.
This is where we will be particularly helpful. Dx Rx. Utilizing testing with good validity/reliability, provide an accurate diagnosis, then when needed, follow up with Evidenced Based Prescribing. We can save the medically complicated or the extremely difficult bi polar cases for the psychiatrists. This is what they do best.
I think this is a really interesting debate and I would like to learn more about it.
I think one of the problems that needs to be adressed is that in general NP's, OD's and other non-physician practitioners who have prescibing privellages are not prescibing the same type of drugs that psychologists want to.
What I mean by this is that psychotropic medications as a whole carry rather unfavorable side effect profiles. As opposed to the antibiotics and analgesics that are often prescibed by NP's and OD's.
For instance patients put on stimulants like methylphenidate need to have thier bp monitored, and thier cardiac function followed. The person prescibing the drugs should be to detect a bruit b4 prescibing or catch a murmur after treatment has begun.
Also, if the patient above does experience adverse side effects the presciber should be in the position to prescibe other classes of drugs to deal with these side effects.
A good example that comes to mind is beta-blocking, or diuresing a child who is mildly hypertensive after a regimen of a stimulant for ADHD. Other drugs like clozapine need frewuent blood draws, and someone who can order and interpert a differential blood count to make sure that there is no deraingment of hematopoeisis.
I think that if psychologists are to have prescribing privellages they will need to integrate more basic science into thier education process, as well as clinical rotations in other medical disciplines. Ideally a few months of internal medicine, neurology, psychiatry, and surgery would be great. I like the idea of psychopharm MA degrees, but I think they need to be more multidsciplinary, integrating various medical subspecialties.
Courses in basic physical diagnosis teaching how to use a stethescope and BP cuff, how to interpert a CBC, Chem-7, liver enzymes, etc.... should also be included.
My question is really though, why? As it stands now, I think the field of psychiatry is moving rapidly towards a totally organic view of mental illness. My inpatient psych rotation was all psychopharm. I saw no individual therapy, no psychodynamic testing, no analysis, no group therapy..... There is a huge void that I believe will evolve over the next few years as a result of psychiatry moving away from its traditional roots.
For instance, every week we had a session with a group of older psychiatrists who were no longer practiting. All of them were in thier mid 70's and some in thier 80's. These guys were awesome, but totally a diffrent breed than the residents and attendings that I was working with. These doctors all beleived in diffrent forms of psychoanalysis, thought that the residents over-prescibed and were not really treating the patients effectivley.
I think Psychologists are in an excellent position to really carve out a specialized niche. Why expand your scope of practice to pharmacological managment when as it stands now your traditional competition is (for all intents and purposes) leaving the field?
Just some thoughts I would love to hear what people think.
From a business perspective, our competition is not only psychiatrists. Our competition includes but is not limited to:
Licensed Clinical Social Workers
Licensed Professional Counselors
Marriage and Family Therapists
Those involved in Coaching or Peak Performance
Primary Care physicians and nurses-meds
Chiropractors-neck/back pain due to stress
Eye Doctors-headaches due to stress, not eye strain
Pain Doctors-particularly psychogenic pain (I hate that term).
Cosmetic Surgeons self esteem surgeons
The 1% of Physicians who practice Osteopathic Manipulative Therapy- neck/back pain due to stress
Massage Therapists or Spas back tension, or those needing to feel pampered.
well, it's not like psychologist just want rxp so they can start writing scripts like there is no tomorrow...it's not completely a business/competition thing, sure, in the real world, that is partially the case and to some extend that is the point behind all these arguments, but as a whole is a quality of treatment thing. I live and work in a very dense metropolitan area in the east coast and there are tons of psychiatrist, but yet, most of the psychiatrist's schedules are completely packed; even when they are already squeezing in 10-15 min sessions. Most of the patients that I worked with often complained about not being able to discuss their side effects, new prescriptions, adjusting dosages, loosing prescriptions and wanting another copy, unable to rescheduling their appointments with their psychiatrists; and even some patients actually complained of not feeling comfortable with their psychiatrists because of their psychiatrist's poor command of English. Regardless of the source of the argument, comprehensive treatment by a single provider is by far the most efficient and effective treatment modality than split treatment and that's the bottom line. The problem is that as mental health treatment stand now, it simply sucks... in very rare cases pts are receiving appropriate treatment, simply because there is not enough psychiatrists out there, which lends to an almost unethical provision of minimal time with their patients, which cascades into all sorts of issues (including egos, etc)...
As per your question regarding medical follow ups, psychologist who prescribe would have to collaborate with the pt's pcp so most of the medical complications should be covered by this collaboration. Ideally, sure it would be great if one provider could monitor everything and combine psychological treatment but that just won't exist. Keep in mind though, most medical issues are usually monitored and followed by the pt's pcp's, at least in my experience, psychiatrist more often then not refer their pt's right back to their pcp's for medical monitoring rather then doing them themselves... I'm not sure why, I suspect because they don't have time or is also possible that their medical training is not as adequate as other md's... also, for whatever reason (from my understanding) is that psychiatrist often practice in a vacumm and often do not collaborate with other md's (this was the reaction of family/internist docs in a conference that I attended)... this may be an md cultural factor, not sure but psychologist would have to collaborate if they were to be writing scripts...
so my point is not fully a need to carve out a nitch here, it's more providing the best/efficient treatment to patients. just curious, and I don't mean to put you on the spot, what specialty are you practicing/training. Would you feel 100% uncomfortable in referring one of your pts to an rxp psychologist? just curious as to what the rest of the md community really feel about this topic.
Is the collaborative practice agreement in place in NM? I recall reading somewhere that once some conditional prescribing period of two years was completed, psychologists there could practice independently without physician oversight. Is this the case? I know that the collaborative agreement is in place in LA.
I think you are right, as far as I know, NM can practice independently after they pass their conditional review; however, at least in my opinion, it would not be wise to do so even if legislature allows it... psychologist do need to continue their collaboration with physicians simply because there is so much that overlaps between psych and medicine...
also, any idea as to why there are only a handful of rxp psychs in NM as compared to Louisiana eventhough NM's bill was signed first?
I think it's the rigorousness of the requirements to prescribe in NM, such as the required practicum and conditional prescribing period. In LA, if you have an MS in clinical psychopharmacology, you can prescribe, as long as it's in collaboration with patients' primary care physicians. It may also depend on the number of psychologists who completed RxP training prior to pursuing legislation. In LA, I believe all of the 30 or so "medical psychologists" went to the same program -- Alliant International. This is a growing effort that will hopefully help address the critical need for comprehensive mental healthcare.
By the way, I'm a medical student who supports psychologist RxP. I am considering psychiatry, but also neurology and PM&R. I will definitely refer to prescribing psychologists if presented with patients who may benefit from a combined psychosocial/pharmacologic intervention. I am also aware of the high-quality assessment training that psychologists receive, especially neuropsychologists, and am interested in the incorporation of advanced assessment techniques--computer-based and traditional pencil-and-paper--in treatment selection and monitoring. I am hoping to use this type of approach in my own practice, focusing on empirically-supported assessment techniques (perhaps in collaboration with a psychologist/neuropsychologist) psychological interventions such as CBT and combined pharmacologic and psychological treatment approaches (if I decide on psychiatry, of course!).
We need more folks like you... just wondering has anybody actually taken any opinion polls from the various md specialties regarding their thoughts about rxp psych and whether they would, and how comfortable they would refer their pt to an rxp psych?
Great question. I know of several MDs/DOs who support psychologist RxP. Several have testified in support of it in NM, LA, HI, and TN. There is simply a need for it and primary care and psychiatry is not meeting it. I do not know of any formal survey that has been conducted to assess the proportion of physicians who support this effort. My guess would be that a majority would not support it because it threatens medicine's financial and political dominance.
California psychiatrists are getting concerned about psychologist RxP: http://www.calpsych.org/publications/newsletter/capinsigtspring06.pdf
If psychologists in CA get RxP, other states will likely move legislation a lot quicker.
Fear and Loathing in California:
It is really pathetic all the time, energy and press that is given to and showing, how scared psychiatrists are about this. ...for them.
Fear mongering. Probably the best approach to get psychiatry to do something about psychologist RxP. Psychiatrists are too lazy to give a sh*t. When you're making $200K/year and working 40 hrs/week, who really cares about the few handfuls of psychologists pursuing RxP?
By the way, what's the latest on the legal case involving RxP in CA?
It has passed some big hurdles, and is going strong. They are basing the case on the Americans with Disabilities Act.
Actually, psychiatrists make much less than $200,000 a year. Plus they have to be on call and take tougher cases than a psychologist will ever encounter.
Ok, $180K per year. There are many psychiatrists who only see outpatient "worried well" cases 40 hours per week, no call, so please do not think that they are all in the trenches with the floridly psychotic.
If you need evidence: http://www.healthecareers.com/candidate/search/index.asp?aff=APA&SPLD=APA&celgn=&email=
Does anybody know if psychologist with rxp training can actively prescribe in Indian reservations? I did a search online and found conflicting info...
I don't know where you're getting your information from. According to WashU's Residency Web, psychiatrists average $145,700. This number is in line with the AAMC's Careers in Medicine website that lists the middle 50% as earning between $139,000 and $190,000.* The link you gave only lists salaries for a few locations. I'm guessing that the ads that aren't listing salaries are paying less.
Yes, there are some psychiatrists that only work 40 hours a week and see easy patients. Landing such a job is pretty rare. Most people who go into the field understand that they'll have to take call and work with some psychotic patients.
* I can't post a link to Careers in Medicine because a login is required.
I think the WashU numbers are low. I'm quoting data from the U.S. Dept. of Labor. http://www.bls.gov/oco/ocos074.htm#earnings
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