The psychotherapy subreddit has gone Private. What are everyone’s thoughts on this?

[AcronymAllergy]

How does one get into that area, though? Cold contacting health insurance companies? Are there websites, tutorials? Over the holidays I tried to do some online searches and came up empty.

Probably varies by area, but there are companies that will contract providers to perform IMEs, review records, etc., in a variety of contexts; that's how most folks I know got into it initially. Maybe ask around on state and other professional listservs and/or with local colleagues to see if anyone does the type of assessments you'd be interested in and ask if they have any recommendations for contacts you could reach out to? In neuro, once you're boarded, you'll start getting random emails as well.

I'm sure other folks have some better suggestions that me as well.

This would be more for civil-type work, btw. For criminal work, your best bet may be going through the court system's websites to see what types of credentialing/registration they require and how you can go about getting certified with them, etc. Typically, in my experience, the court has a list of providers they'll use for things like mandated evaluations, but again, I suspect that can vary by area.

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[WisNeuro]

How does one get into that area, though? Cold contacting health insurance companies? Are there websites, tutorials? Over the holidays I tried to do some online searches and came up empty.

Depends on your area a little bit. Easiest way is probably to find one of the good IME companies and credential with them. Don't have to deal directly with lawyers and you get paid promptly. May be able to make a little more working direct with law firms, but then you also burn more admin time. May also help to talk to some colleagues who do it in your local area to get the lay of the land. Also pretty helpful to see some de-identified samples to see how these may differ from clinical reports.

 

[cara susanna]

I've learned over the past few years that my program provided us particularly strong training in assessment (especially compared to some psychologists I've met)--apparently we are even known in the field for our assessment training. I am SO appreciative of that now. I'm not a math person, quite the opposite, but I actually really love psychometrics. I found all of that stuff really interesting and still use it today. Specificity, sensitiivty, and predictive power have been very useful with COVID too!

 

[PsyDr]

Different story for IME work, though. Our area could use some good psych assessment, particularly in the PTSD area. The plaintiff shills are pretty locked in, but there's a shortage of people who will do a real objective eval for civil work.

That doesn't matter. Increased risk= increased reward. IT guys who work in McMurdo Station probably charge more than the IT guys in your city.

What matters is that the perceived value of 13hrs of treatment is less than the perceived value of 9 hours of assessment. That's a substantial issue. It 's like 10 years ago when US ranchers culled the US pork herd, the price of pork went up, and then restaurants started selling pork like it was fine dining. The perception doesn't match the real value.

 

[Justanothergrad]

It's a wide gamut, but most programs should give students ~100 assessment hours minimum (psych and neuro assessment combined) even for generalists. My program probably tended on the higher side as everyone in the program learned assessment in our in-house LD/ADHD assessment clinic, and between that and other assessment opportunities in-house, most people had at least 10 integrated reports and a decent number of hours even without external practica. Nowadays, we can commonly see people with 1-2 integrated reports when applying to internship. Sad to see what's happening.

I gave 450 BDI. That counts as ~100 hours of assessment, right??

 

[WisNeuro]

I gave 450 BDI. That counts as ~100 hours of assessment, right??

That's not far off from what applicants have actually done. Had one application where the person was claiming notes that they had written with an MMSE and a PHQ9 were all "integrated reports."

 

[Justanothergrad]

That's not far off from what applicants have actually done. Had one application where the person was claiming notes that they had written with an MMSE and a PHQ9 were all "integrated reports."

Oh I know. It pisses me off so much. I saw one applicant years ago who reported 1000 integrated reports because they had given PHQ9's and put them in their therapy files.


Also.

Yeah, especially when you get to Sp/Sn/NPV/PPV/etc. Just seems like you wouldn't want to limit your earning potential. Lot of money out there for people skilled in various assessments. Ceiling is much higher in assessment than it is in therapy only.

When "X + Y / Z" is scary math, we have a broad problem.

 

[WisNeuro]

Oh I know. It pisses me off so much. I saw one applicant years ago who reported 1000 integrated reports because they had given PHQ9's and put them in their therapy files.

I always have to wonder, are they just ignorant, or do they think we won't notice? And, which one is worse?

 

[Justanothergrad]

I always have to wonder, are they just ignorant, or do they think we won't notice? And, which one is worse?

I always want to invite folks who do things like that to interview just so that I can ask them.

To date, my morbid curiosity has never won out over the ethics of my colleagues.

 

[WisNeuro]

I always want to invite folks who do things like that to interview just so that I can ask them.

To date, my morbid curiosity has never won out over the ethics of my colleagues.

Yeah, in almost all of these situations, the rest of the application is pretty terrible, so I have not been able to do that either.

 

[ClinicalABA]

I always have to wonder, are they just ignorant, or do they think we won't notice? And, which one is worse?

All I do in my clinical position is conduct assessments and write integrated reports. Working an average of ~50 hours per week, 45 weeks per year over the past five years, I've barely exceeded 1000 integrated reports. I call BS on any student who says they've done even a fraction of that during their training.

 

[WisNeuro]

All I do in my clinical position is conduct assessments and write integrated reports. Working an average of ~50 hours per week, 45 weeks per year over the past five years, I've barely exceeded 1000 integrated reports. I call BS on any student who says they've done even a fraction of that during their training.

At the pre-internship level that is tough. But, my postdoc was 3-4 full evals a week and ~3 inpt evals. 48 weeks times. let's say an average of 6 reports a week is about 288/year. I had over a hundred going into internship apps, but we also had an in house assessment clinic and I also did 2 years of prac at an AMCs neuropsych department.

 

[Indiana_Jane]

That's not far off from what applicants have actually done. Had one application where the person was claiming notes that they had written with an MMSE and a PHQ9 were all "integrated reports."

I had the lowest number of integrated reports in my internship cohort, and I intensely sought out assessment opportunities (granted, not neuropsych). I cannot wrap my head around how someone could do the number of “integrated reports” claimed if they counted them as rigorously as my program did. I’m talking over 100 integrated reports, not neuro, mostly correctional and psychodynamic therapy experiences.

 

[PsyDr]

There's no shame in gaming the system. If you read the instructions, the old application said to list "supervision hours including group supervision" under intervention hours. A few interviewers were annoyed when I explained my answers. But what were they gonna do? Say "this guy followed the instructions when no one else did?".

But I had a guaranteed spot at an internship site, so I could afford to screw around.

 

[psych.meout]

I have over 200 assessment split between neuro and psych assessment and I think about 25 integrated reports. Will internship sites look at it negatively that I have a good bit more tests/measures administered than those just for those 25 reports because there were patients beyond that 25 where the post doc wrote the report instead of me (though all were still encompassed by those 200 or so hours)? I still did the interview, testing/scoring, and co-facilitated the feedback sessions and did supervision with both the post doc and psychologist if that makes a difference. Also, I'm not interested in a neuropsych career but I do like other kinds of assessment I've done, which has come in handy at other prac sites.

 

[WisNeuro]

I have over 200 assessment split between neuro and psych assessment and I think about 25 integrated reports. Will internship sites look at it negatively that I have a good bit more tests/measures administered than those just for those 25 reports because there were patients beyond that 25 where the post doc wrote the report instead of me (though all were still encompassed by those 200 or so hours)? I still did the interview, testing/scoring, and co-facilitated the feedback sessions and did supervision with both the post doc and psychologist if that makes a difference. Also, I'm not interested in a neuropsych career but I do like other kinds of assessment I've done, which has come in handy at other prac sites.

You'll be ok, especially for generalist sites when it comes to that kind of assessment experience. Also, people generally should have more testing administration experience than integrated reports as many sites has you essentially work as a psychometrist first while you are learning the ropes before you get a crack at report writing.

 

[calimich]

r/psychotherapy is now Private as of about 3 months ago. In order to obtain membership, you must be a licensed and practicing professional. The application process requires you to submit a photocopy of your ID, psychotherapy license, and your graduate school transcripts in order to obtain access.

What are your thoughts about one of the major public online spaces for therapist discussion going this route?

I was verified last week and maybe things changed since this post was made, but transcripts nor ID were required, and membership is open to students. I did have to submit a copy of my license, with name and # redacted, and my reddit username handwritten instead. There are over 100k members and lots of active threads. I'm appreciating the mutual accountability and level of discourse. Come on over, the water is nice!

 

[psych.meout]

I was verified last week and maybe things changed since this post was made, but transcripts nor ID were required, and membership is open to students. I did have to submit a copy of my license, with name and # redacted, and my reddit username handwritten instead. There are over 100k members and lots of active threads. I'm appreciating the mutual accountability and level of discourse. Come on over, the water is nice!

Huh, maybe going private has been for the best...

 

[BuckeyeLove]

Different story for IME work, though. Our area could use some good psych assessment, particularly in the PTSD area. The plaintiff shills are pretty locked in, but there's a shortage of people who will do a real objective eval for civil work.

This market is wide open in Cleveland. Like insanely wide open. The objective eval work that is. The shills are a dime a dozen. My best friend is a PI/labor attorney, and he has been begging me for the last 2 years to move there and hang a shingle and start sending cases my way. They've essentially got 3 guys who are respectable. The rest are guns who get paid 10-15k a case and diagnose everyone with PTSD and somehow still keep getting work even after humiliating depos. I say all that to say...you're right...there's a need.

 

[psych.meout]

This market is wide open in Cleveland. Like insanely wide open. The objective eval work that is. The shills are a dime a dozen. My best friend is a PI/labor attorney, and he has been begging me for the last 2 years to move there and hang a shingle and start sending cases my way. They've essentially got 3 guys who are respectable. The rest are guns who get paid 10-15k a case and diagnose everyone with PTSD and somehow still keep getting work even after humiliating depos. I say all that to say...you're right...there's a need.

Geez, if they're getting $10-15k per case, how much would good evals pull in?

 

[WisNeuro]

Geez, if they're getting $10-15k per case, how much would good evals pull in?

I imagine the shills can charge more, as the lawyers are paying for a specific diagnosis. For those of us with integrity, we're paid for our time, not to parrot what the client wants.

 

[psych.meout]

I imagine the shills can charge more, as the lawyers are paying for a specific diagnosis. For those of us with integrity, we're paid for our time, not to parrot what the client wants.

Ah, I see. I thought maybe the shortage of those willing to do good work would at least receive parity, but I get what you're saying about buying a result instead of paying for quality work regardless of the outcome.

 

[BuckeyeLove]

Ah, I see. I thought maybe the shortage of those willing to do good work would at least receive parity, but I get what you're saying about buying a result instead of paying for quality work regardless of the outcome.

I'll never forget when I was on fellowship, I went to watch my supervisor testify in a criminal case, I think it was felonious assault or something like that. Might have been a kidnapping thrown in there too. The dude was pleading NGRI, and my supervisor's report, which was as thorough as it could be (approx. 30ish pages, all necessary), all indicated dude was not ill when he did it. His attorney, obviously displeased, hired an 88 year old psychologist to provide a 2nd opinion. This dude went on the give the Rorschach, TAT, and house tree person tests, all which were used to formulate his opinion that dude was insane at the time. The report itself was approximately 7 pages. The prosecutor asked how much he was paid, to which he responded, "10 thousand for the evaluation and report and 2k for my time here today." The dude was found guilty, but I left there learning that it's all just a game. All of it. Some are better at others at walking that line. Some make careers out of walking that line. Found out later the psych had a history of board complaints for a variety of things over the years.

 

[cara susanna]

I joined that testing FB group and, man, you'd think that EMDR is the only trauma therapy out there if you read it.

 

[AcronymAllergy]

I joined that testing FB group and, man, you'd think that EMDR is the only trauma therapy out there if you read it.

I often wonder if one of the reasons EMDR seems to be so popular is because it makes the therapist feel like they're doing more. Rather than "just' talking, it maybe feels more procedural, and therefore more substantial. Same with things like therapeutic touch (or whatever VA is calling it these days; healing touch maybe? can't remember), reiki, etc., that and the whole alternative healing aspect.

 

[WisNeuro]

I joined that testing FB group and, man, you'd think that EMDR is the only trauma therapy out there if you read it.

It's hard to find treatment for PTSD round here from a provider who doesn't list EMDR as one of their methods, of which I refuse to refer out to those people as they clearly do not know how to evaluate research.

I often wonder if one of the reasons EMDR seems to be so popular is because it makes the therapist feel like they're doing more. Rather than "just' talking, it maybe feels more procedural, and therefore more substantial. Same with things like therapeutic touch (or whatever VA is calling it these days; healing touch maybe? can't remember), reiki, etc., that and the whole alternative healing aspect.

I think that can be part of it, also, people who don't know any better like the pseudo neuro jargon involved. I think some of these people also just got very poor training in therapy or never learned how manualized therapy works and don't know how to apply anything outside of a protocol.

 

[Fan_of_Meehl]

I often wonder if one of the reasons EMDR seems to be so popular is because it makes the therapist feel like they're doing more. Rather than "just' talking, it maybe feels more procedural, and therefore more substantial. Same with things like therapeutic touch (or whatever VA is calling it these days; healing touch maybe? can't remember), reiki, etc., that and the whole alternative healing aspect.

"Paging Anton Mesmer.... Dr. Mesmer...."

Agreed. All else being equal, everyone wants to be a wizard. 'Behavioral consultant' is much less 'sexy' an archetype. In some sense--to the masses--the promise of 'magic' to fix their lives is far more appealing than redirecting them to the cold hard truth that, for their lives to improve, behavior change is essential.

 

[Sanman]

Ah, I see. I thought maybe the shortage of those willing to do good work would at least receive parity, but I get what you're saying about buying a result instead of paying for quality work regardless of the outcome.

Not really any different than clinical work. You can make a perfectly fine living dxing anyone who wants some adderall with ADHD and writing bs emotional support dog letters right up until someone reports you to the board. Then the headaches start. Plenty of docs got rich prescribing opioids as well.

 

[R. Matey]

"Paging Anton Mesmer.... Dr. Mesmer...."

Agreed. All else being equal, everyone wants to be a wizard. 'Behavioral consultant' is much less 'sexy' an archetype. In some sense--to the masses--the promise of 'magic' to fix their lives is far more appealing than redirecting them to the cold hard truth that, for their lives to improve, behavior change is essential.

This. 100%. People love mysterious cures for whatever's troubling them as much as charlatans like money. Evidenced-based psychotherapy, by contrast, is like going to the gym: It's good for you, but it's hard and not very mysterious and not very fun.

 

[cara susanna]

I often wonder if one of the reasons EMDR seems to be so popular is because it makes the therapist feel like they're doing more. Rather than "just' talking, it maybe feels more procedural, and therefore more substantial. Same with things like therapeutic touch (or whatever VA is calling it these days; healing touch maybe? can't remember), reiki, etc., that and the whole alternative healing aspect.

For sure. EMDR isn't contingent on the patient feeling distress like PE (and CPT to a lesser extent). I think a lot of the "floofiness" in trauma treatment is fragilizing patients and not wanting to cause them distress.

 

[AbnormalPsych]

I often wonder if one of the reasons EMDR seems to be so popular is because it makes the therapist feel like they're doing more. Rather than "just' talking, it maybe feels more procedural, and therefore more substantial. Same with things like therapeutic touch (or whatever VA is calling it these days; healing touch maybe? can't remember), reiki, etc., that and the whole alternative healing aspect.

My hunch, people like it when you use tools to fix things, especially when they are paying. Just so happens EMDR uses actual tangible tools and even in the verbage (i'm guessing, I don't know emdr) is percevied more practical and like something is being done rather than 'just talking'.

 

[Way Too B-- A--]

>One of my big criticisms of Psychology is that there is a lot of elitism and very little transparency


Im glad it is not just me. Saw it 20 years ago in training. Hoped i would see more change over time than I have.

 

[PsyDr]

>One of my big criticisms of Psychology is that there is a lot of elitism and very little transparency


Im glad it is not just me. Saw it 20 years ago in training. Hoped i would see more change over time than I have.

It's juvenile competitiveness, divorced from results.

 

[WisNeuro]

I am against the psychotherapy forum becoming private. In this way, trust between the client and the psychologist is lost. When the forum was public, everyone felt part of one big family.

How so?

 

[psych.meout]

I am against the psychotherapy forum becoming private. In this way, trust between the client and the psychologist is lost. When the forum was public, everyone felt part of one big family.

Lol, are you talking about a different sub?

 

[smalltownpsych]

I visited an open psychotherapy forum once. After reading about all the clients sexual fantasies about their therapists, I became way too uncomfortable and never went back. I like this site. Sometimes we get into spirited debates, but it has always been respectful and appropriate.

 

[PsySeeker]

I think the assessment phase is the sign psychologists are screwed. The average assessment is what? 7 hrs? If you’re just doing EBTs for strict diagnosis based treatment, you’re billing 13hrs. That’s a net loss of billable hours. So why are people flocking to assessment?

I believe it’s because there are cheaper options for psychotherapy, and that pills, or some form of excuse for responsibility, are a preferable option. That should tell you something about the general narcissistic character structures of society. That should be terrifying for us. People see us as less valuable. Questions of “what’s wrong with me?”; are responded to, and perceived to reflect, “there’s no changing me!”. That’s bad news from a business sense.

And I lost interest in reddit when they banned the peerage subreddit…. Because narcissistic observations are reciprocal.

You seem to be connecting a lot of dots to confirm a bias/fear of your own here and then making a very broad prognosis from your scribbles.

 

[Justanothergrad]

You seem to be connecting a lot of dots to confirm a bias/fear of your own here and then making a very broad prognosis from your scribbles.

I dont think he's necessarily wrong that assessment is not the answer. Its not the answer because the problem is so much broader and more complex. In many instances, there is a net loss relative to full completers of therapy with a higher material cost / risk of liability. Thats not an ideal outlet to prove worth as a field. HOWEVER, the fact that we have yet to prove unique worth in psychotherapy is a reason folks flock to assessment - at least the competition is smaller compared to therapy (e.g., no MSW, LPC, etc. to compete with). Many assessment needs, including those which are some of the most common referrals (e.g., ADHD), have limited coverage under insurance and so there is a discrepant treatment in how folks gain access to therapy versus assessment. There is money to be made in assessment because people aren't effective at it / don't understand how to do it with quality, so those psychologists flock to therapy. Regardless of if you agree with his reasoning, PsyDr's prognosis at the broadest level of the declining influence of psychology is very real - as is his understanding that the spaces in which there is a unique and competitive market belonging for psychologists is also declining. I don't think we're at risk of being 'screwed' per se because of the assessment focus (its far less pronounced at the trainee/ECP level than I think it seems on here - folks here are very business savvy and highly successful relative to the field standards), but it is an area that I am aware of having potential problems, speaking as a researcher and clinician who specializes in assessment and as an elected board member in various assessment and clinical societies.

 

[PsyDr]

You seem to be connecting a lot of dots to confirm a bias/fear of your own here and then making a very broad prognosis from your scribbles.

Most readers would see my use of the word "belief", and note that these are my beliefs, stated as such, rather than facts.

Why say "scribbles"? You seem to be alluding to something.

 

[Sanman]

I dont think he's necessarily wrong that assessment is not the answer. Its not the answer because the problem is so much broader and more complex. In many instances, there is a net loss relative to full completers of therapy with a higher material cost / risk of liability. Thats not an ideal outlet to prove worth as a field. HOWEVER, the fact that we have yet to prove unique worth in psychotherapy is a reason folks flock to assessment - at least the competition is smaller compared to therapy (e.g., no MSW, LPC, etc. to compete with). Many assessment needs, including those which are some of the most common referrals (e.g., ADHD), have limited coverage under insurance and so there is a discrepant treatment in how folks gain access to therapy versus assessment. There is money to be made in assessment because people aren't effective at it / don't understand how to do it with quality, so those psychologists flock to therapy. Regardless of if you agree with his reasoning, PsyDr's prognosis at the broadest level of the declining influence of psychology is very real - as is his understanding that the spaces in which there is a unique and competitive market belonging for psychologists is also declining. I don't think we're at risk of being 'screwed' per se because of the assessment focus (its far less pronounced at the trainee/ECP level than I think it seems on here - folks here are very business savvy and highly successful relative to the field standards), but it is an area that I am aware of having potential problems, speaking as a researcher and clinician who specializes in assessment and as an elected board member in various assessment and clinical societies.

I do agree with the bolded and I have a feeling that has a lot to do with our state of affairs. The lack of business or even basic billing knowledge is quite appalling generally. Even seasoned psychologists I know are not aware of some of the basics. I feel like that more than therapy vs assessment drives problems. Everyone wants to copy each other and there is little business savvy in the industry. A few people end up making a lot and the rest have no idea they are getting ripped off.

 

[Justanothergrad]

I do agree with the bolded and I have a feeling that has a lot to do with our state of affairs. The lack of business or even basic billing knowledge is quite appalling generally. Even seasoned psychologists I know are not aware of some of the basics. I feel like that more than therapy vs assessment drives problems. Everyone wants to copy each other and there is little business savvy in the industry. A few people end up making a lot and the rest have no idea they are getting ripped off.

100%.

 

[psych.meout]

I do agree with the bolded and I have a feeling that has a lot to do with our state of affairs. The lack of business or even basic billing knowledge is quite appalling generally. Even seasoned psychologists I know are not aware of some of the basics. I feel like that more than therapy vs assessment drives problems. Everyone wants to copy each other and there is little business savvy in the industry. A few people end up making a lot and the rest have no idea they are getting ripped off.

As someone who isn't practicing yet but has seen those who have discuss the issues, it seems like two themes are unfolding that impact this area.

1. Lack of business skills, strategy, and savvy. This rings true for my program which, being clinical science and with faculty hyperfocusing on research, intentionally eschews this side of things and PP in general. They provide (or at least "provided") very little instruction or mentoring in this area. Apparently it's only been since I've been in the program that students have finally been able to get some movement in this area (e.g., proseminar talks from some psychologists in PP). It seems like some programs just neglect this area while others intentionally avoid it. The latter seems like the "business and money are icky" analogue to "stats and research are icky" from applicants to diploma mills.

2. Avoiding the larger systemic issues, like CMS rates, changes, etc.; protecting psychologist scope of practice; broadening healthcare coverage so more people have access to mental healthcare; and so on. I know it's difficult to address a lot of these on an individual level, but it strikes me as a bit like the PCSAS issue. Rather than getting involved in the APA and trying to reform it, some psychologists and programs are picking up their ball and going home. It's not really helping the profession by bifurcating it like this and reducing solidarity.

Maybe I'm wrong about these and I'm probably missing some, but it just seems like these are (at least some of) the themes from what I've seen others discuss.

 

[thebalmofhurtminds]

I will also add that the complexity of healthcare and billing and the de-coupling of service and direct profit/billing makes it more difficult to wrap your head around what you're worth in many settings. In the VA, there's the obvious removal. In AMCs and hospitals, RVUs make it pretty difficult to accurately calculate the impact of budget changes and especially your individual cost center. That's not to say that you can't collect information about what your agreement is with different insurance providers, average cost of an RVU for your service, etc., but it does make it more challenging to get to when you're part of a larger system. When you add in things like payor mix, hospital adjustments, and billing errors, the excel docs start to look ridiculous.

I wouldn't say I'm particularly business-minded at all, but I think it's important to become familiar with, especially when your institution is not likely to hand over the information letting you know you're worth much more than they're offering. We've started to incorporate that into our intern's training and hopefully that helps, but the intentional complexity does often lead to learned helplessness and I can see why.

 

[smalltownpsych]

Are you guys posting in the right topic? Or maybe I missed the connection from business savvy and assessment to the Reddit user forum. Not that I mind tangents, you should see me and my clients wandering all over the place at times.

 

[PsySeeker]

Most readers would see my use of the word "belief", and note that these are my beliefs, stated as such, rather than facts.

Why say "scribbles"? You seem to be alluding to something.

Just a fun play on words doc, nothing more.