Question about practice options/state of psychology

[MustIReallyThough]

Hi all, quick questions from a soon to be psychology graduate. After researching the practice options after a PhD/Psy.D, I've seemingly come across a consensus that psychology is trending towards specialty practice (neuro, addictions, forensic, right?) and that traditional therapy jobs are being passed on to the masters level. I'm wondering if this is still a trend. In a previous post, I mentioned my interest in SMI and one commenter noted that PhD's are very helpful in this setting. So, is SMI therapy considered a "specialty" practice or is this still going to be the purview of masters clinicians going forward?

My other question (that I actually came here to post) is how viable would it be to pursue specialty practice while also pursuing a generalist therapy private practice on the side unrelated to that specialty? Has anyone had any experience with this?

Thank you!! Every input helps, currently interviewing professionals at my school as well.

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[borne_before]

The vast majority or practicing psychologists are adult generalists conducting mostly therapy.

 

[WisNeuro]

The trend in my metro is that large healthcare organizations are hiring masters level therapists at a far greater clip than doctoral level. My last hospital did not have a psychologist in its outpatient MH clinic and only 1 psychologist between 4 inpatient MH units. There's always PP, but that depends on how saturated your area is. Here it's fairly saturated. I could get an intake within a week or two for a doctoral level psychologist pretty easily if I needed. If you want to be in a more rural area, where there are shortages, it'll be easier.

 

[MustIReallyThough]

The trend in my metro is that large healthcare organizations are hiring masters level therapists at a far greater clip than doctoral level. My last hospital did not have a psychologist in its outpatient MH clinic and only 1 psychologist between 4 inpatient MH units. There's always PP, but that depends on how saturated your area is. Here it's fairly saturated. I could get an intake within a week or two for a doctoral level psychologist pretty easily if I needed. If you want to be in a more rural area, where there are shortages, it'll be easier.

Would you be wary then of going into the field (or choosing this degree path) with a primary interest in the treatment of SMI? That trend is about what I expected, though I think I would like to stay rural. Always good to hear from you Wis, you're everywhere!

 

[WisNeuro]

Would you be wary then of going into the field (or choosing this degree path) with a primary interest in the treatment of SMI? That trend is about what I expected, though I think I would like to stay rural. Always good to hear from you Wis, you're everywhere!

I'd check out some areas that I planned on living/practicing in the future to see what the market conditions look like. SMI probably has a better outlook in saturated areas than general outpatient MH. As I said rural tends to fare better as they are always short of providers, so I think you;d have an easier go at it for most rural areas. Even those not too far outside of metros.

 

[JustNoticing]

Even if you wind up working as a generalist down the road, your SMI background will be valued. There is actually a movement right now to create an ABPP in SMI to make it a more formal specialty, though I don't think that is a needed step by our field. The ways that job options are limited in this area is that community mental health serves a lot of people with SMI and they generally don't want to pay for psychologists. VA, inpatient units, state hospitals, other healthcare systems, and correctional facilities will still want to hire people with SMI backgrounds. Another downside is that lots of folks with SMI don't have good insurance. However, in a big enough group practice, I'm sure they'd even love to have an SMI person and many people working in private practice do not want to/don't have the background to work with this population.

 

[AcronymAllergy]

SMI has a huge need for high-quality, evidence-based psychotherapeutic care. Whether or not it's ever appropriately (in my mind) reimbursed is another issue. But it's not a stretch to have a strong background in that population and to then use it to transition into other, related areas (e.g., state forensic facilities, which proportionally can see a good bit of SMI relating to competency to stand trial, etc.).

Employment-wise, a lot of the opportunities are related to state funding. The exception is VA, which is of course tied to federal funding, but is a bit more sheltered/stable in that respect than many states.

I would say most of the private practice psychologists I've seen/met would probably be classified as generalist. They typically supplement their therapy work with other stuff (e.g., assessment) if they're full-time PP, but I think it's still tenable to have a PP-based, generalist psychotherapy practice on the side, depending on your area. People in many areas are generally willing to pay for high-quality mental health care, and credentials (and, more importantly, marketing) can matter RE: initial impressions in that arena.

 

[PsyDr]

1) Law of averages. says that the market demand is driven by the most common mental disorders. The demand for psychotherapy for Major Depressive Disorder is higher than the demand for treatment of frotteurism. The demand for general psychotherapy is higher than the demand for neuropsychological assessment.

2) Demand is meaningless without an ability to pay (i.e., if they can't pay for service, it doesn't matter how much they need it).

3) Unfortunately, individuals with SMI have less ability to pay for services (i.e., the cashier with Downs syndrome at my local drug store is unlikely to have a few grand laying around).

4) The middle class is willing to pay for psychotherapy. Like psychoanalysis in the 1950s, getting psychotherapy seems to be fashionable right now.

5) In order of psydr rated importance, people will FIND the money to get: psychoeducational assessments for their children (everyone thinks their child is above average), custody evaluations, psychotherapy for their child after something troubling has happened, forensic evaluations that helps someone avoid responsibilities (e.g., criminal defense evaluations, disability, etc), marital therapy (risking half their assets), substance abuse treatment for adolescents, unlimited non-evidence based psychotherapy for general life complaints that usually blames someone else while not requiring any actual personal change, services that lead up to getting fun drugs, etc.

6) Balancing the appearance of your office is a key business move. You will lose higher end patients if your waiting room is full of individuals obviously suffering from SMI.

7) There are some VERY high end settings where VERY wealthy people pay an extreme premium for the treatment of their family member with SMI .

8) Your practice model is a commonly viable model . Many specialists offer more generalist services (e.g., several neuropsych journal editors regularly provide psychotherapy).

 

[foreverbull]

While most psychologists are generalists based on a range of training experiences, in the job market you really do need a niche/specialty to make you stand out, whether that be treating BPD, family therapy, eating disorders, gender & transition, geropsych, etc. It makes folks more hireable and will sometimes attract more clients and colleague referrals in private practice. A fair number of my clients specifically sought me out because of my experience working with a certain population/specialty (not the majority, but some).

SMI is a good niche; I’ve had to refer a few folks to colleagues who work with schizophrenia because I don’t have enough training in that area. Not every psychologist has experience working inpatient or in a setting in which you are trained to work with SMI.

 

[CheetahGirl]

Hi all, quick questions from a soon to be psychology graduate. After researching the practice options after a PhD/Psy.D, I've seemingly come across a consensus that psychology is trending towards specialty practice (neuro, addictions, forensic, right?) and that traditional therapy jobs are being passed on to the masters level. I'm wondering if this is still a trend. In a previous post, I mentioned my interest in SMI and one commenter noted that PhD's are very helpful in this setting. So, is SMI therapy considered a "specialty" practice or is this still going to be the purview of masters clinicians going forward?

My other question (that I actually came here to post) is how viable would it be to pursue specialty practice while also pursuing a generalist therapy private practice on the side unrelated to that specialty? Has anyone had any experience with this?

Thank you!! Every input helps, currently interviewing professionals at my school as well.

I am currently a clinical researcher at an AMC affiliated with a VAMC. My 'specialty-in-progress' is working with SMI (schizophrenia spectrum, personality disorders, PTSD/Trauma) in Veteran and civilian population, within the context of suicide prevention. Many of our patients and research participants are also dual diagnosis (SMI + comorbid substance use). I second what others have said about general practitioner training landing you what you need (although I did two-years in child training, which helps me work with adult survivors of abuse). In your doctoral program, you begin to narrow your interests with your research (research conference presentations/posters, masters thesis, dissertation) and practica (externships), then narrow your focus even more as you chose your internship and postdoctoral sites for training. Now, as post-fellowship/ early career professional, I'm working with this specific population to develop novel therapeutics. It's a fascinating position, keeps you on your toes, but also very competitive. It's also where you lean towards the higher salaries (if you're a well-producing academic + clinician), like many of my mentors and colleagues. I have a ceiling for my personal career goals, though...which helps keep things 'real' and not too lofty.

To answer one of your questions, I could branch out sometime in the future, (with the specialty training I've had) and go into generalist therapy private practice. I'm not there, yet....and keep that idea as more of an early retirement goal.

Hope this helps (PM if you have more specific questions). Good luck.

 

[Sanman]

IMO, specialty vs general practice really depends on your needs and situation. General outpatient adult PP is very common for psychologists. Usually cash pay and maybe limited insurance. The hard part can be volume of patients that are higher paying and benefits. If you have a spouse with a good w-2 job, it is easily viable full-time. There are many higher end practices in the larger metros that want psychologists. Finding an entry level w-2 job starting out can be difficult without a specialty. The most common viable model I tend to see is specialty practice for a w-2 job (Could be SMI, trauma, gero, health psych, etc.) with a general adult PP on the side (usually cash or 1 insurance taken). I don't know anyone with reasonable skills and a little marketing that cannot get 3-5 good paying clients. The trick becomes securing 20+ clients full-time.

 

[cara susanna]

In my city psychologists generally only seem to have supervisory positions or assessment-focused positions in the private community. I remember hearing a while back that the major healthcare systems transitioned to Masters-level clinicians to save money. There are still psychologists in some private practices doing therapy. That being said, the VA is always hiring psychologists and we do primarily therapy.

I don't think it ever hurts to specialize, but I would only recommend doing so if you really love the work. In my case, for instance, I much prefer specialty work in the area that I have received the bulk of my training in.

 

[MustIReallyThough]

Even if you wind up working as a generalist down the road, your SMI background will be valued. There is actually a movement right now to create an ABPP in SMI to make it a more formal specialty, though I don't think that is a needed step by our field. The ways that job options are limited in this area is that community mental health serves a lot of people with SMI and they generally don't want to pay for psychologists. VA, inpatient units, state hospitals, other healthcare systems, and correctional facilities will still want to hire people with SMI backgrounds. Another downside is that lots of folks with SMI don't have good insurance. However, in a big enough group practice, I'm sure they'd even love to have an SMI person and many people working in private practice do not want to/don't have the background to work with this population.

Wouldn't these institutions (besides the VA I understand) still look for masters folks to do this therapy rather than pay for a PhD? But really, the pay doesn't seem to be much different so...But yeah I think I'd very much enjoy this kind of employment (also looking at psychiatry). I actually think I'd like to be on call at a hospital for acute cases/crisis management. PP would also be fine.

 

[MustIReallyThough]

SMI has a huge need for high-quality, evidence-based psychotherapeutic care. Whether or not it's ever appropriately (in my mind) reimbursed is another issue. But it's not a stretch to have a strong background in that population and to then use it to transition into other, related areas (e.g., state forensic facilities, which proportionally can see a good bit of SMI relating to competency to stand trial, etc.).

Employment-wise, a lot of the opportunities are related to state funding. The exception is VA, which is of course tied to federal funding, but is a bit more sheltered/stable in that respect than many states.

I would say most of the private practice psychologists I've seen/met would probably be classified as generalist. They typically supplement their therapy work with other stuff (e.g., assessment) if they're full-time PP, but I think it's still tenable to have a PP-based, generalist psychotherapy practice on the side, depending on your area. People in many areas are generally willing to pay for high-quality mental health care, and credentials (and, more importantly, marketing) can matter RE: initial impressions in that arena.

How so? Does this relate to hospital type settings or PP insurance related concerns? I'm not as concerned about reimbursement I think. I'm willing to bust my ass to make a decent living and also to walk away from a psychiatrists pay if need be.

 

[MustIReallyThough]

Thank you all for the info so far, very helpful!!

 

[MustIReallyThough]

While most psychologists are generalists based on a range of training experiences, in the job market you really do need a niche/specialty to make you stand out, whether that be treating BPD, family therapy, eating disorders, gender & transition, geropsych, etc. It makes folks more hireable and will sometimes attract more clients and colleague referrals in private practice. A fair number of my clients specifically sought me out because of my experience working with a certain population/specialty (not the majority, but some).

SMI is a good niche; I’ve had to refer a few folks to colleagues who work with schizophrenia because I don’t have enough training in that area. Not every psychologist has experience working inpatient or in a setting in which you are trained to work with SMI.

Would I have to limit myself by specializing in specific SMI like schizophrenia or would it still be viable to see a wide range of SMI patients?

 

[MustIReallyThough]

IMO, specialty vs general practice really depends on your needs and situation. General outpatient adult PP is very common for psychologists. Usually cash pay and maybe limited insurance. The hard part can be volume of patients that are higher paying and benefits. If you have a spouse with a good w-2 job, it is easily viable full-time. There are many higher end practices in the larger metros that want psychologists. Finding an entry level w-2 job starting out can be difficult without a specialty. The most common viable model I tend to see is specialty practice for a w-2 job (Could be SMI, trauma, gero, health psych, etc.) with a general adult PP on the side (usually cash or 1 insurance taken). I don't know anyone with reasonable skills and a little marketing that cannot get 3-5 good paying clients. The trick becomes securing 20+ clients full-time.

This would be perfect for me honestly. I realize that may be a lot of stressful working hours, but I hope I could swing it. Have you or anyone else had experience with this model that they'd like to share?

 

[borne_before]

Would I have to limit myself by specializing in specific SMI like schizophrenia or would it still be viable to see a wide range of SMI patients?

It's not like a medical speciality and there is a lot of stuff generalizable from schizophrenia to other conditions.

As a personal example, I specialize in the assessment and treatment of the neurodevelopmental disorders. In my community, I've been identified as an autism specialist (both treatment and assessment). However, I would be lying if I said I started out with that plan. Autism and its associated niche largely found me. In fact, I have to be conscious about not making my job 100% autism or else I'd burn the hell out. I enjoy assessing autism and its treatment, and firmly believe in early intervention, but I do not "love" autism enough to make it my job 100%.

 

[borne_before]

I also want to add that I view the pursuit of the doctorate in a field of applied (clinical, counseling, school, neuro) psychology (e.g., PhD or PsyD) as being able to maximize options. For example, a ton of people teach, work in private practice doing counseling or assessments, and conduct research simultaneously. The field really does allow you to go into many different areas and interests.

 

[foreverbull]

Would I have to limit myself by specializing in specific SMI like schizophrenia or would it still be viable to see a wide range of SMI patients?

Being able to see a wide range of SMI would be great. I only highlighted schizophrenia because that is a disorder I recently referred out for.

That said, some folks get really burned out if they get too many clients in their niche (I have a DBT-trained colleague who was asking people to stop referring clients with BPD to her at one point and asked for general referrals because of the energy/time commitment of working with folks with BPD), so just make sure you understand whether a job requires that to be your almost whole focus or you have the flexibility to treat your everyday anxiety, depression, etc.

 

[cara susanna]

Being able to see a wide range of SMI would be great. I only highlighted schizophrenia because that is a disorder I recently referred out for.

That said, some folks get really burned out if they get too many clients in their niche (I have a DBT-trained colleague who was asking people to stop referring clients with BPD to her at one point and asked for general referrals because of the energy/time commitment of working with folks with BPD), so just make sure you understand whether a job requires that to be your almost whole focus or you have the flexibility to treat your everyday anxiety, depression, etc.

As someone who is also DBT-trained and known as the "BPD person," I feel this a lot.

 

[Sanman]

This would be perfect for me honestly. I realize that may be a lot of stressful working hours, but I hope I could swing it. Have you or anyone else had experience with this model that they'd like to share?

Early on in my career I did exactly this. I went to nursing homes and saw geriatric patients in the daytime and worked in a group practice part-time for cash three evenings per week. It is definitely doable. You just need to have the right set up with regard to commute times and some schedule flexibility is always nice. There was no set time I had to see my nursing home patients, so I could shift my schedule if I worked a split day. I had about 10-12 PP hours split over three evenings and was in facilities those mornings.

 

[Sanman]

As someone who is also DBT-trained and known as the "BPD person," I feel this a lot.

It is why we need physician style case complexity billing. Some cases are more difficult than others, there needs to be corresponding billables for that.

 

[ClinicalABA]

It's not like a medical speciality and there is a lot of stuff generalizable from schizophrenia to other conditions.

As a personal example, I specialize in the assessment and treatment of the neurodevelopmental disorders. In my community, I've been identified as an autism specialist (both treatment and assessment). However, I would be lying if I said I started out with that plan. Autism and its associated niche largely found me. In fact, I have to be conscious about not making my job 100% autism or else I'd burn the hell out. I enjoy assessing autism and its treatment, and firmly believe in early intervention, but I do not "love" autism enough to make it my job 100%.

I'm kind of the opposite, as far as my clinical practice goes. I only do ASD evals, and with a very small age range. I could see other stuff if I wanted, but I love what I do, am confident in my abilities with this population, and I'm reinforced well for doing it. It's a very comfortable gig, and I'm at a point in my career/life where I prioritize comfort. That said, I have been able to do a lot of different things, having been trained in general psychology (to the extent that there is such a thing), and doing the same thing day in and day out is maybe more tolerable when you know that you're doing so by choice, not necessity.

 

[WisNeuro]

It is why we need physician style case complexity billing. Some cases are more difficult than others, there needs to be corresponding billables for that.

That would definitely help. We kind of have that in neuro, to an extent. More complex cases will rewuire more time, which we can bill for, up to a reasonable extent in most cases. But yeah, I've definitely had to deal with a lot of extra unreimbursed time in some therapy contexts over the years.

 

[Sanman]

That would definitely help. We kind of have that in neuro, to an extent. More complex cases will rewuire more time, which we can bill for, up to a reasonable extent in most cases. But yeah, I've definitely had to deal with a lot of extra unreimbursed time in some therapy contexts over the years.

It is one of the reasons I went to VA. Good geriatrics work takes a lot of time that is not billable. Review chart, see patient, speak to staff, call family, integrate info and come up with behavioral/treatment/management plan. Then spend time figuring out how to bill all of this work in some way that makes it worth my while.

 

[WisNeuro]

It is one of the reasons I went to VA. Good geriatrics work takes a lot of time that is not billable. Review chart, see patient, speak to staff, call family, integrate info and come up with behavioral/treatment/management plan. Then spend time figuring out how to bill all of this work in some way that makes it worth my while.

As much as I dunk on the VA, I do agree that it's probably one of the best places you can be if you're in gero (non-neuropsych). Also by far teh best auxiliary resources I've had for gero pts (e.g., easy referrals for OT/PT, SW easy to access for elder services, etc).

 

[JustNoticing]

Wouldn't these institutions (besides the VA I understand) still look for masters folks to do this therapy rather than pay for a PhD? But really, the pay doesn't seem to be much different so...But yeah I think I'd very much enjoy this kind of employment (also looking at psychiatry). I actually think I'd like to be on call at a hospital for acute cases/crisis management. PP would also be fine.

There are jobs for psychologists in these settings, even if they hire master's folks too. The focus of the work may or may not differ from what they are hiring masters providers for. Think running a unit, supervisory positions, getting to do some testing/assessment, developing new programs/program eval, in addition to direct treatment roles.

 

[MustIReallyThough]

Early on in my career I did exactly this. I went to nursing homes and saw geriatric patients in the daytime and worked in a group practice part-time for cash three evenings per week. It is definitely doable. You just need to have the right set up with regard to commute times and some schedule flexibility is always nice. There was no set time I had to see my nursing home patients, so I could shift my schedule if I worked a split day. I had about 10-12 PP hours split over three evenings and was in facilities those mornings.

Awesome!! I admire the work ethic. What led you to stop this? Did you transition into PP full time?

 

[MustIReallyThough]

There are jobs for psychologists in these settings, even if they hire master's folks too. The focus of the work may or may not differ from what they are hiring masters providers for. Think running a unit, supervisory positions, getting to do some testing/assessment, developing new programs/program eval, in addition to direct treatment roles.

Ah right! Ok, that wouldn't be too bad. Do you think you could negotiate more direct treatment roles if you really wanted to do that?

 

[Sanman]

Awesome!! I admire the work ethic. What led you to stop this? Did you transition into PP full time?

Short answer, I stopped doing it because I moved to another state when my wife got a lucrative job offer. Longer answer, things like being eligible for board certification and being in need of benefits like health insurance more than money also played a role in moving to my current VA staff position. I will probably go back to private practice again in the future at some point.

 

[JustNoticing]

Ah right! Ok, that wouldn't be too bad. Do you think you could negotiate more direct treatment roles if you really wanted to do that?

yes, there's plenty of that.